key: cord-0737156-syxy67lm
authors: Mann, Erin M; Klosovsky, Alexander; Yen, Catherine; Olson, Andrew P J; Hoffman, Sarah J; Mamo, Blain; Frerich, Ellen A; Weinberg, Michelle; Mayali, Harith; McCoy, Molly; Prasad, Shailendra; Dunlop, Stephen J; Stauffer, William M
title: Health challenges in refugee resettlement: an innovative multi-sector partnership to improve the continuum of care for resettled refugees
date: 2020-06-24
journal: J Travel Med
DOI: 10.1093/jtm/taaa103
sha: f25a95419c407ffb47a203964efebcb1e21b2d0f
doc_id: 737156
cord_uid: syxy67lm

Refugee resettlement is a complex process relevant to migration medicine. A partnership between the International Organization for Migration, the US Centers for Disease Control and Prevention, and the University of Minnesota addresses medical needs of refugees and serves as a model for improving the continuum of care delivered to refugees.

Refugee resettlement is a highly complex process that may hold lessons for the larger realm of migration medicine. 1 As more and more people are displaced by war, climate change, political strife and economic disparities, migration medicine is becoming an increasingly important component of travel medicine. 2 A recent partnership between the International Organization for Migration/United Nations Agency for Migration (IOM), the US Centers for Disease Control and Prevention (CDC), the University of Minnesota (UMN) and other Minnesota-based organizations has evolved to address the medical needs of migrating refugees, particularly those with complex health needs. The goal of the partnership is to improve a fractured health system during the migration process and to build the capacity of IOM and US-based refugee clinicians to improve the continuum of care delivered to refugees. In this article, we describe our experience with this partnership, which may hold lessons for others developing programmes to improve the health of displaced populations during their migration journey.

Although many refugees are young, healthy and productive, some will have serious health conditions that can complicate their resettlement. For US-bound refugees, the initial resettlement medical examinations conducted by IOM may be the first comprehensive medical evaluation they have experienced. It is common for refugees to have newly identified health conditions, or conditions recognized but not managed. It is imperative for IOM clinicians to identify health conditions prior to migration, particularly those that may adversely affect a refugee's resettlement such as conditions exacerbated by air travel. Further, identifying health conditions prior to resettlement can facilitate appropriate services and preparation by the sponsoring agency and community. This examination can be challenging with the limited time and scope required. Making this even more challenging is that refugees may have a distrust of officials based on past experiences. Adding to this mistrust is the fact that refugees are aware that, when travelling to the USA as a family or group, identification of a serious health condition may delay the entire group. Any delay may permanently jeopardize resettlement. Therefore, there may be fear or mistrust of any person with the authority to delay or cancel their resettlement, including those providing their clinical care. This reality challenges the clinical encounter since patient trust is the cornerstone to obtaining a thorough and accurate medical history and soliciting important current complaints. Additional challenges include language barriers, lack of recall or missing medical history documentation, varying cultural understanding of health and disease and limited access to screening and diagnostic tools. Finally, the overall complexity of the migration process may inhibit effective communication of health information across providers.

The partnership began in 2012 when the UMN, Minnesota Department of Health (MDH) and IOM initiated an informal exchange programme. UMN medical residents and physicians performed short international rotations with IOM to understand the pre-departure process. In return, IOM clinicians visited Minnesota to understand the post-arrival process. The partnership was formalized and received funding in 2017 and activities have expanded significantly. The activities undertaken are at the request of the stakeholders and driven by needs identified by IOM.

A cornerstone of the partnership is in-person formal trainings. For example, a physical examination curriculum has been developed for physicians. IOM employs physicians trained across the world, leading to a wide array of physical examination techniques, styles and skills. The goal of this component of the programme is to standardize and strengthen physical examination, improve patient communication skills across cultures and address areas of particular needs (e.g. paediatric training). The programme uses a train-the-trainer model whereby UMN faculty work with IOM 'master trainers' to build their examination skills, training techniques and teaching and feedback skills. UMN faculty have also partnered with IOM nurses for in-person trainings that have focused on strengthening and standardizing clinical assessment skill sets relevant to the health assessment conducted immediately prior to refugee departure. To support the leadership development of IOM nurses, additional sessions focused on mentorship, feedback and debriefing were developed with input from with IOM nurse leaders.

Other workshops and trainings have been conducted with both physicians and nurses in attendance to promote an interprofessional environment. Workshop topics include aviation medicine, dermatology, haematology, paediatric neurology, patient rapport, interprofessional communication and working with interpreters. Another area of interprofessional training is a course in Comprehensive Advanced Life Support (CALS). 3 The CALS curriculum has been modified for unique situations that may be encountered by IOM such as health emergencies during travel (e.g. advanced life support skills to address an emergency in an aircraft cabin).

Minnesota hosts IOM staff to learn firsthand about domestic resettlement through visits to UMN, MDH and state and county public health programmes, shadowing of domestic refugee clinics, and meetings with former refugees through communitybased organizations. One of the most important aspects of the programme is relationship building between the IOM and their domestic counterparts. Frequently providers are unclear of processes that occur, including the limitations and difficulties that the 'other side' faces. These face-to-face meetings allow questions to be answered, exchange of knowledge and best practices and creation of networks that provide for clearer communication and improved care. Visiting US facilities supports IOM clinicians to understand the services provided and the challenges refugees may face and better prepare refugees for the resettlement process.

The partnership also facilitates support in diagnosing, managing or planning travel for refugees with complex medical needs. A unique and challenging aspect of the clinical care of refugees resettling to the USA is management of health during the actual movement period, including long-haul flights. Experts with experience working in varied and austere environments provide specialized advice for IOM clinicians regarding challenging patients. These consults help optimize the health of refugees before departure, minimize risk during travel and facilitate timely follow-up upon arrival.

In addition, UMN and partners contribute to the development of Standard Operating Procedures (SOPs) that IOM generates for their clinicians to guide the care of specific conditions before and during US resettlement. SOPs include topics frequently encountered by IOM such as sickle cell disease management; scabies detection, management and control; as well as diagnosis and management of splenomegaly.

Partnership activities are designed to improve the health of USbound refugees by focusing on various points in the continuum of care. Every patient and patient population needs tailored, comprehensive health advice and services along the continuum. 4,5,6 Take, for example, a child with scabies and anaemia. With a standard approach to physical examination, the clinicians performing pre-departure medical examinations may be more likely to identify subtle signs of scabies and the cause of underlying anaemia to be sickle cell disease. The SOPs for scabies can guide the treatment and the SOP for sickle cell disease can assist in the management, including preparation for travel. If a question arises, such as if they are unable to get the haemoglobin to a threshold safe for flight, the IOM clinician can solicit advice from UMN and other partner specialists. Further, if any of the IOM staff has visited the USA, they may be able to facilitate more appropriate follow-up and counsel the family regarding what to expect after arrival. The receiving physician in the USA, if they have participated in the partnership, will have a better understanding of the pre-departure management and the IOM documentation.

Migration health-by its nature-is fractured. It involves multiple providers seeing the same patient during their migration journey-often with incomplete information. Although our programme currently focuses on refugees resettled through the US Refugee Resettlement Programme, we believe this model holds lessons for working with displaced populations in other settings. First, points of contact during migration represent opportunities to improve the health of the individual. Second, although IOM's needs drive the relationship and activities, there are mutual benefits to US health professionals and systems that provide care to refugees. The networking and bilateral learning experiences are invaluable for all health care professionals and systems along the resettlement continuum. Third, the partnership has been designed to be highly collaborative. All partnership outputs have been developed through an iterative process that leverages the expertise of both IOM and Minnesota partners, with the help of CDC and other subject matter experts. This process has generated mutual ownership, respect and understanding. Fourth, the partnership supports development of critical interpersonal and interprofessional skills. These include leadership skills, workplace communication and feedback. Finally, the partnership has been designed to be sustainable and to build the capacity of IOM staff to engage in workforce development themselves.

The outbreak of coronavirus disease 2019 (COVID-19) is impacting individuals and organizations in an unprecedented way. Our partnership is no exception. Given that many of our activities previously relied on travel and face-to-face interaction, we are facing challenges shared by many around the world. In light of the logistical and operational challenges posed by COVID-19, our partners are working quickly to adapt our activities. For example, we are quickly shifting training activities to live, online platforms that use creative and innovative approaches to maintain the quality of learning and collaboration.

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Non-communicable diseases in migrants: an expert review

We would like to acknowledge our partners from the Center for International Health, the University of Minnesota Community-University Health Care Center, Ramsey County Public Health, Hennepin County Public Health, the Minnesota Council of Churches, the International Institute of Minnesota, the Mayo Clinic, HealthPartners, Hennepin Healthcare, the University of Washington and Makerere University. Additionally, we would like to acknowledge the many individuals who have served as instructors at trainings or provided subject matter expertise to the project. Finally, we would like to acknowledge IOM physicians, nurses, Medical Movement Coordinators and all others who work tirelessly to ensure the safe resettlement of refugees to the United States. 

The work was funded by the International Organization for Migration and the United States Centers for Disease Control and Prevention.

None declared.

The findings and conclusions of this report are those of the authors and do not necessarily reflect the official position of the Centers for Disease Control and Prevention.