Integrated Care of Refugees in a Primary Care Residency Clinic

Providing quality health care for refugees requires cross-cultural competence and unique medical knowledge.1,2 While the Society of General Internal Medicine called for the development of longitudinal training for residents in refugee care in 2004,3 most residents do not feel prepared to care for new immigrants.4 We describe the experience of the Yale Combined Internal Medicine-Pediatrics Residency Program in providing integrated care for a population of Burmese refugees. This model presented numerous challenges but we believe it represents a viable, rewarding alternative to one in which refugees are cared for in a distinct clinic. In 2007, our patient-centered medical home practice serving a multiethnic, largely poor and underserved community began caring for 66 newly resettled Burmese refugees, most of whom were members of the Karen ethnic minority. We developed 3 distinct interventions that helped us provide quality care to this group. We first organized an introductory community meeting that brought together faculty, residents, and office staff with representatives of the community. We held home visits during which we led health education discussions, reviewed common health concerns, and held pediatric acute care and catch-up immunization clinics. Connecticut, like many states, lacked comprehensive guidelines for refugee health care. Since our Karen patients were randomly distributed between physicians, we devised a standardized instrument to provide guidance during the initial visit. It prompted the clinician to gather information relevant to refugees and provide recommendations regarding infectious disease screening. The provision of efficient, quality care was limited by a vast cultural divide and by unreliable telephone interpretation. Taking medical histories, eliciting symptoms, and comprehending and following through on management plans were challenging. The extended time taken by visits with our Burmese patients affected patient flow and clinic efficiency. An integrated care model offers several advantages. Serving as a medical home to this population created a sense of trust between patients and providers. We focused on refugee-specific matters and general health issues concurrently and could effectively coordinate care with the resettlement agency and community. However, this model of care also presented distinct challenges. Varying degrees of cultural competence meant different levels of comfort in caring for this population. Our screening protocol was developed in parallel with home visits and ongoing primary care, limiting its effective, widespread implementation. We were faced with the question of when and how to shift the focus from fulfilling the needs of the newly arrived refugee to those of the primary care patient. Finally, though this vulnerable population merited special attention, we struggled with how to balance their needs with those of our other patients. With tens of thousands of refugees being resettled annually in the United States,5 exposure to their medical care needs is a vital component of residency training and one that fosters cultural competency. Our interventions provided structure and built trust as we cared for this population. Though rife with challenges, we believe a residency clinic can provide effective, comprehensive care to refugees.