OPTIMISE: Collaborative improvement of primary health care delivery to the Australian refugee community

Project Short Title
OPTIMISE

Project Number
RG160464

Project Status
Current

Chief investigators
Grant Russell, I-Hao Cheng (Monash University), Virginia Lewis (La Trobe University), Mark Harris (CPHCE, UNSW), Mitchell Smith (NSW Refugee Health Service), Keith McDonald, (South West Sydney Primary Health Network), Tadgh McMahon, (Settlement Services International), Amitabh Rajouria, (Settlement Services International), Hyun Song, (CPHCE, UNSW)

Rationale

Permanently resettled refugees have been a part of the fabric of Australian society since the end of the Second World War. Australia’s annual refugee intake will increase from 13,750 to 18,750 by 2018 [1]. Nearly all of these refugees face substantial health challenges – both from pre-migration trauma, and the demands of settling in a new and unfamiliar country.

 These challenges are compounded by the fact that, across the nation, organisations tasked with delivering specialised health services to refugees have reached capacity. Waiting times are long, transition of care from specialised services to mainstream general practice is inconsistent, and mainstream general practice is under-equipped to provide consistently high quality care to this vulnerable population [2].

 These systemic weaknesses contribute to poor health outcomes for refugees through missed opportunities for early intervention and continuity of care, especially for the prevention and management of long term physical and psychological conditions [3]. Emerging evidence shows limited access to refugee responsive primary health care contributes to an increase in physical and mental health morbidity in the refugee population [4, 5]. This in turn contributes to higher rates of emergency department and hospital admissions compared to the Australian-born population, and higher cost to Commonwealth funded health services and programs compared to skilled migrants [6, 7].

 To combat this issue, the health needs of refugee populations must be managed more effectively and at lower cost to the health system through community based primary health care (PHC) services such as mainstream general practice [8].

 OPTIMISE Project

The OPTIMISE Project, led by Monash University, is a unique network of 11 national, state and local organisations responsible for delivering community based care to refugees, with an international team of academics. The OPTIMISE research team works in partnership with refugee focussed health services and mainstream general practice to generate robust, regionally relevant improvements to systems of care for this vulnerable population. Its aims are to: a) build the capacity of existing staff in outreach practice facilitation, b) support practice-based quality improvement, c) enhance use of information and communication technology, and d) optimise the use of existing Commonwealth and state resources. 

Aims

The ultimate goal of the OPTIMISE Project is to develop and evaluate a model of integrated PHC for refugees suitable for uptake throughout Australia. To this end, the OPTIMISE team will implement a collaborative, system-oriented approach in three key regions of refugee resettlement in Australia, including in South West Sydney (SWS). 

Project design and method

The first phase aims to conduct a system mapping exercise in each study region to determine the contextual background and system-level barriers and enablers of refugee responsive PHC. The purpose of our system mapping work is: a) To understand the policy, population, program and service context in which the intervention will be set; b) To describe barriers and enablers affecting access to, transition between and quality of primary health care delivered to people of refugee background in each of the three intervention regions; and c) To identify priority gaps in the organisation of care in the region that may be amenable to change and improvement.   Key informant interviews will be conducted with a range of stakeholders involved in refugee health care in the region.  The findings will help inform improvements to service delivery for refugees in SWS in the future, and ultimately will contribute to the design of a quality improvement intervention in SWS.

The second phase of the study has multisite quasi experimental design with evaluation using mixed quantitative and qualitative methods to evaluate a model for primary health care access and continuity in the transition between specialised and mainstream services.  The intervention included the practice level quality improvement applying PDSA (Plan-Do-See Adjust) cycle focusing on four core areas identified in the first phase; namely a) Refugee patients identification, b) Use of Translation and Interpreting Services (TIS), c) Conducting comprehensive health assessment and d) Referral paths. A facilitator was recruited and trained from each regional refugee health focused service for facilitating this process, which took over a period of 6 months. Overall, 34 practices across 3 regions participated in the study which were allocated either to the “early” and “late intervention group.

The intervention phase was completed in Sep 2019, and the data are currently being analysed. Results will be published and disseminated via multiple channels in mid-2020.

In parallel, OPTIMISE also implemented small regional studies in two study regions. In SWS, NSW Refugee Health Service (RHS) implemented a quality improvement project aiming to improve communication with general practitioners by reducing the time between the patient’s assessment and delivering its results, and by sending a letter to let GPs know that patients attended RHS while waiting the assessment results can be compiled. Although the formal study has been completed, NSW-RHS continues these measures as they are integrated in their routine practice.

For the details of study protocol, please follow the link below.

Russell, G., Gunatillaka, N., Lewis, V. et al. The OPTIMISE project: protocol for a mixed methods, pragmatic, quasi-experimental trial to improve primary care delivery to refugees in Australia. BMC Health Serv Res 19, 396 (2019). https://doi.org/10.1186/s12913-019-4235-6