High-Quality Health Care For Resettled Refugees: A Sustainable Model

Like Sisyphus pushing the boulder to the top of the hill, efforts to end the Syrian civil war have been equally futile. According to the United Nations High Commissioner on Refugees, the violence in Syria has forced 4.8 million refugees to flee their country. Not since World War II have there been so many refugees and internally displaced people worldwide–in fact, the number of refugees worldwide has reached nearly 60 million.

Since 1975, more than 3 million refugees from all over the world have resettled in the United States, according to the US Department of State's website. After a lengthy vetting process that takes eighteen to twenty-four months, on average, refugees approved to enter the United States are typically resettled where other relatives are already living or placed in areas based on the best match between a community's resources and a refugee's needs.

New York State has traditionally accepted refugees into its communities over the years. Approximately 3,000–5,000 refugees per year have resettled in New York State, many in the upstate region. The proportion of refugees resettling upstate is growing each year. In 2006, 76 percent of New York's refugees were placed upstate; by 2008, that number had increased to 87 percent. Currently, 97 percent of refugees resettling in New York State are located upstate, particularly the greater Buffalo, Rochester, and Utica areas. Although refugees come from different parts of the world, many share similar health-related challenges-including previous inadequate medical care, exposure to torture or terrorism, poverty, and language barriers-that make it difficult to access health care.

Over the past decade, this influx of newly resettled people in upstate New York has forced several nonprofit health care clinics to either shut their doors to new refugees or close down altogether because of the financial burden of treating these patients. In most cases, provider reimbursement comes from Medicaid, for which most incoming refugees are temporarily eligible upon arrival, but standard reimbursement rates are often too low given the complex health needs of refugees. Additionally, most refugees require interpreters during their visits. Medicaid does reimburse for interpretation services. However, the rate is low and not enough to cover the costs.

For many providers, the provision of care to refugees has proven to be a financial stress or unsustainable. Metropolitan areas in upstate counties have cobbled together informal networks of clinics, health departments, and for-profit agencies in an effort to keep up with the health care needs of the increasing flow of refugees entering their geographic areas.

However, these efforts can contain inefficiencies. For example, each clinic or agency either has its own interpreters or uses outside interpretation services at a substantial cost. The capacity for clinics to treat refugees also varies widely, and no coordinated system for equally distributing newly arrived refugees exists.

Furthermore, all refugees must receive a federally mandated health assessment, to be completed within ninety days of arrival, by a health care provider or agency. However, the federal funds distributed by the state to entities that complete the health assessments often do not flow to the primary care practices that manage the medical conditions of refugees during the post-resettlement period. Instead, many outside agencies perform these assessments and collect the fees but don't provide ongoing care to the refugees thereafter. Consequently, funds that could be used to support some of the expenses associated with the ongoing provision of primary care to refugees are bypassing primary care providers.

In Rochester, New York, two health centers began to see new refugees in an organized fashion starting in 2000. After a few years, both of these health centers closed their doors to refugees because of the financial burden of providing primary care to this complex group of patients. By 2008, Rochester faced a crisis-no primary care practices were accepting refugees as new patients into care, despite the arrival of 800 refugees in the Rochester area, on average, each year. Thus, newly arrived refugees had no access to the health care system other than through hospital emergency departments or urgent care clinics.

In response to this burgeoning problem, Rochester General Hospital (RGH) approached the New York State Health Foundation (NYSHealth) in 2009 for help. NYSHealth encouraged RGH to first determine the major factors contributing to the refugee health care crisis so as to better understand how to create a sustainable model of care for this vulnerable population.

Through research and extensive on-the-ground work, RGH identified the two largest barriers to a financially sustainable model of care:

1. The agencies performing the refugee health assessments were not primary care providers and therefore were not connecting refugees to follow-up primary care after assessments were completed. These organizations (some of which were for-profit) were receiving reimbursement simply to screen refugees, rather than the primary care providers getting reimbursed and being able to benefit from the additional revenue and establish ongoing patient relationships.


2. Medicaid coverage for eligible refugees automatically expires after six months of living in the United States. Even though almost all remain eligible for ongoing coverage and may reapply, many refugees are either unaware that they must renew, or they face a variety of obstacles to recertifying, including language barriers, mental health problems related to trauma, and general misunderstanding and misinformation.

Once apprised of the fundamental obstacles, NYSHealth saw this as an opportunity to help develop and test a new, innovative refugee health care model. With guidance from NYSHealth, Rochester General Hospital subsequently proposed a primary care model for refugees that addressed both barriers by:

• Shifting the refugee health assessments to agencies that already delivered primary care or that partnered with primary care providers to link refugee patients to preventive care; and


• Adding a document to the immigration paperwork that refugees are required to fill out that gives consent to the state of New York to send a Medicaid recertification application to the nearest hospital (to be filled out by hospital staff on behalf of the refugee and sent to RGH so it can proactively intercede for the patient). This allows for continuous Medicaid coverage of all eligible refugees, in turn allowing primary care clinics full reimbursement for all primary care services provided.

In 2009, with NYSHealth funding, RGH began to pilot the model using specific strategies that included developing strong partnerships with refugee resettlement agencies; providing the initial refugee health assessments and capturing the associated reimbursement funds; helping refugees retain Medicaid coverage after their initial six-month coverage period expired; recruiting new primary care practices to treat refugees; and coordinating patient services (for example, transportation, interpretation, and patient navigation).

Staffed by the director of refugee health care at RGH, three refugee patient navigators, one patient services coordinator, and rotating college student volunteers, RGH's refugee health care program proved to be the first financially sustainable model of care that allowed primary care practices in Rochester to see new refugees without becoming financially overwhelmed.

The model's unique features included

Coordination of Services

A hospital director acts on behalf of primary care practices within the hospital's medical groups to evenly distribute incoming refugees to those practices willing to accept them. Also, the director works with resettlement agencies and primary care practice leaders to coordinate important services such as transportation, interpretation, and patient navigation, which helps refugees overcome barriers to care and helps them to understand the US health system.

Consolidation of Resources

A centralized approach is employed that uses human resources such as social workers and interpreters who are shared among sites as needed, thereby avoiding duplication, or underuse, of services.

Increased Primary Care Capacity

A robust educational curriculum is used to instruct physicians and other staff members who want to accept refugees into their practices, as well as to provide the educational tools necessary to develop culturally competent medical providers. Educational tools include in-service presentations, one-on-one discussions with physicians in the same practice or health system, workshops, websites, and medical conferences.

Financial Stability

Fifty percent of the federal reimbursement that the state distributes to primary care practices for performing refugee health assessments is used for continued operating costs of the program, with the other half going to the physicians caring for the refugees (for assessments and ongoing care). Thus, primary care practices receive operational support for refugee care but still receive supplemental reimbursement (in addition to Medicaid billing) for providing primary care to refugees.

Two years after the pilot was launched in Rochester in 2009, its outcomes demonstrated the model's transformative potential to increase refugees' access to high-quality and continuous primary care services. Among the model's outcomes:

• Scheduling processes and procedures were created;


• Strong collaborations were formed among multiple agencies;


• Patient access to interpretation services increased;


• Eligible refugees retained their Medicaid coverage beyond their initial six-month coverage period;


• A refugee health care website was created by RGH in 2010;


• A curriculum for cultural competency training was developed to better prepare providers to meet the challenges of treating refugee patients;


• An annual, national refugee health care conference was instituted for physicians to learn best health care practices for refugee patients;


• Twenty primary care physicians in New York State were engaged to accept refugees into their practices;


• Eighty percent of refugees entered into a primary care practice within thirty days of arrival in the United States; and


• The RGH refugee health care program gained financial self-sustainability, as did the participating practices.

By 2012, approximately 1,953 refugees had been served by this program, which resulted in $240,000 per year in additional health assessment reimbursement to the primary care practices doing the health assessments-of which half was used toward operational costs and half was distributed to physicians as an incentive to provide services to refugees. Since the development of this model, 96 percent of refugees who relocated to Monroe County (of which Rochester is the county seat) have been accepted into primary care practices-and these practices have not experienced financial strain as a result. To date, nearly 6,000 refugee patients in that county have received care and services.

What began as an initial idea and pilot project with some early NYSHealth funding in 2009 has since expanded into a global model for refugee health care with Rochester as its epicenter. For example, RGH helped develop the annual North American Refugee Health Conference, which has become one of the largest clinical conferences on refugee health, globally. It is the only conference on the continent completely dedicated to educating physicians about the primary care needs of refugees.

Additionally, RGH has created the North American Society of Refugee Healthcare Providers with more than 1,800 subscribers to its listserve-a tool used by medical providers worldwide who are focused on refugee health care issues.

RGH's successful model has filled a void by making primary care services available to refugees and allowing health centers to provide that care in a sustainable, cost-efficient manner.