In conjunction with the federal government, Kingston has recently been named a Resettlement Assistance Program Centre. As a site where many new refugee families will begin to resettle, it is important that newcomers are provided with the quality health care they need. As a primary care provider, your role in providing health care to refugees is a vital one. In order to provide proper care to your newcomer patients, it is important to know about the people you will be treating. The Government of Canada and Citizen and Immigration Canada website provides a strong base of information about the refugee process as well as resettlement of refugees.
There are three main ways that refugees can be resettled in Canada:
Government-Assisted Refugees (GARs)
- These are Convention refugees whose initial settlement (for up to one year) is financially supported by the Government of Canada or by the province of Quebec.
- They are referred to Canada for resettlement by a referral organization like the United Nations High Commissioner for Refugees (UNHCR).
Privately Sponsored Refugees (PSRs)
- These are refugees who meet either the Convention refugee or the Country of Asylum
- They are referred for resettlement to a private sponsor in Canada who agrees to provide financial and other support for the refugee for up to one year.
Blended Visa Office-Referred Refugees (BVORs)
- These are Convention refugees referred by the UNHCR who are matched with a private sponsor in Canada.
- The Government of Canada provides up to six months of income support through the Resettlement Assistance Program (RAP), while private sponsors provide another six months of financial support and up to a year of social and emotional support.
All three resettlement types are covered by a form of health-care insurance during refugees' wait for OHIP. This coverage is known as the Interim Federal Health Plan. To learn more about the coverage of this plan and how to bill with it, click here.
Refugees and newcomers will be strangers to our Canadian culture, and care providers should endeavour to make patients' resettlement transition an easy and enjoyable experience. Here are some tips on how to provide culturally sensitive medical care to your patients, edited from compiled information found on www.refugeehealthta.org.
To avoid miscommunication and misunderstanding by patients and/or health-care providers, culturally and linguistically appropriate, gender-matched language interpretation should be made available at all times. Interpretation by family members, minors and the lay community should be avoided. Live, in-person interpretation by trained personnel allows direct, hands-on education and counselling, which can be enhanced by the use of audio-visual or pictorial aids and is preferred whenever feasible.
Access to Care
Avoid lapses in insurance coverage, particularly for patients with low literacy for whom letters in the mail may be difficult to comprehend; address transportation needs; promote awareness of available health and social services; be aware of prevailing social/cultural taboos and stigma that may limit a patient's self-efficacy in seeking help; and ensure continuity of care with the same provider whenever possible.
Issues of Gender
Whenever possible, health-care staff and interpreters should be gender-matched with the patient. However, circumstances may arise in which the only staff available or the most skilled personnel in performing a designated procedure is a different gender than the patient. In this case, counselling should take place in advance with the patient and his/her family to determine whether or not this would be acceptable, If not, an alternative strategy that ensures safety and quality of care while respecting the patient's wishes, as much as possible, should be secured.
Respect for Modesty
Touching private parts of the body may be deemed disrespectful or insulting for a patient, especially if by a health-care provider of a different gender. There should always be a "chaperone" in the examination room, regardless of the provider's gender. In the case of a female patient, if a male interpreter is present, interpretation should be provided from behind a curtain during the examination process. In this case, efforts should be made to keep the woman as fully clothed or draped as is feasible during examinations to minimize skin exposure and patient embarrassment. (The same may apply to male patients, depending on cultural preferences.)
Understanding Cultural/Traditional Practices and Religious Observances
Be cognizant of relevant religious and traditional cultural practices (e.g. female genital cutting, coining, Ramadan, etc.) that may influence a patient's health-care decision-making. Due to the sensitive nature of certain practices, patients may be reticent to readily discuss certain issues, but as trust is built and continuity of care occurs over time, there may be opportunities for more sensitive discussion and disclosure.
Fasting for Ramadan
While the holy month of Ramadan is a period of spiritual renewal and strength in the Islamic faith, it may pose a challenge for a patient's well-being, especially those with illnesses or in a fragile state of health (e.g. elderly patients, pregnant women, etc.). Patients who plan to fast should meet with their health-care provider before Ramadan to discuss any pertinent advantages and disadvantages of fasting. Medical and health-related conditions that may prevent safe fasting should be assessed and information provided on maintaining adequate nutrition and hydration during this time.
Co-ordination of Care and Case Management
Involving a multidisciplinary team to support refugee patients' health improves the consistency of follow-up and quality of care as patients' self-efficacy in navigating the health-care system increases. Given low health literacy and unfamiliarity with the Canadian health-care system, particularly among new refugee arrivals, efforts should be made to extend the traditional provider network to include social workers, case managers, interpreters and community health workers along with refugee resettlement agencies to facilitate seamless co-ordination of care.
As a primary care provider, especially physicians/family doctors, your first point of contact with a refugee or refugee family will be within the scope of a Post-Arrival Health Assessment (PAHA). The assessment is expected to take longer than a regular patient-doctor visit, as it will be the first time you will be meeting with your new patients, and it is likely you might be meeting with an entire refugee family. In addition, the PAHA can take place over several visits, as there are several items that should be covered.
For a more detailed look at recommendations for the PAHA, visit the CCIRH’s website: Evidence-Based Preventative Care Checklist For New Immigrants and Refugees.
(Please note that KFL&A Public Health will be involved with any newcomer to Canada with a history of active TB infection or an abnormal chest X-ray suggestive of TB as part of mandatory post-immigration surveillance within seven or 30 days of entering Canada. Completion of this medical surveillance is required by Citizenship and Immigration Canada for Canadian citizenship. Please contact KFL&A Public Health at 613-549-1232 or 1-800-267-7875 with any questions.)
Some important things that should be covered during the PAHA are the following:
- Making introductions between refugee patients and physicians; often translators/translation services might be required
- Explaining how the physician’s office and booking of appointments works
- Working through and addressing any cultural differences in health care about which the refugee patients might be concerned
- Advising newcomers briefly about the Canadian health-care system, expectations regarding appointments and patient-doctor confidentiality
- Addressing urgent health-care issues and a standard physical
- baseline blood tests (e.g.: complete blood count, serology for Hep B and C, etc.)
- age-based preventative screening
- vital signs, growth of children and targeted examination based on complaints
- identifying any allergies
- Walking through the patient’s complete medical and surgical history
- it can be difficult, as most refugees will likely NOT have past medical records
- interview patient(s) to discover any neglected diseases, injuries, disabilities, pregnancies, visual/hearing impairments, etc.
- Discussing restart of previously discontinued medications (finding appropriate substitutions if original medication is not available in Canada)
- Booking for more specific appointments (e.g., female-specific session for a PAP smear) and referrals to specialists, if needed
- Addressing need of immunization and setting up appointments to go through immunization records/begin vaccination schedule
Immunization is a key part of ensuring the complete health of newcomers, as well as Canadian citizens. Due to ongoing conflict in many refugees' country of origin, they might not have received effective immunizations. As a physician, it is important to ensure the safety of your current patients, and provide the best care possible to newcomers. As such, making sure immunizations are up to date for all newcomers is of the utmost importance.
Before or immediately after the arrival of any newcomer to Canada (immigrant or refugee), Citizenship and Immigration Canada proceeds with the Immigrant Medical Examination (IME). It is important to note that the IME does NOT include a review of immunization; therefore it is the duty of the primary care provider to perform a thorough health assessment of newcomer patients, including their need for certain vaccines.
If a newcomer does not have records, they can be considered unimmunized and should be started on an appropriate immunization schedule as soon as possible, considering their age and other health risk factors. On top of standard immunization in Canada, the following vaccines are especially recommended for newcomers:
- Hepatitis A
- Hepatitis B
- Rubella-containing vaccine
- Varicella-containing vaccine
- Inactivated polio-containing vaccine (IPV)
- Pertussis-containing vaccine
KFL&A Public Health is a resource to help determine which immunizations are required. A vaccination team is available to answer questions regarding publically funded vaccines and the immunization schedule. Additionally, there are drop-in and scheduled vaccination clinics available at 221 Portsmouth on Tuesday mornings and Wednesday afternoons/evenings where immunizations can be provided. Contact KFL&A Public Health at 613-549-1232 or 1-800-267-7875.
For more information about recommended vaccinations for newcomers, visit Part 3 of the Canadian Immunization Guide: Vaccination of Specific Populations
It's also important to note that immunization of newcomers might pose a challenge due to the following reasons listed on the Public Health Agency of Canada’s website:
- Immunization records do not exist
- Immunization schedules that differ from Canada
- Language barrier that makes it difficult to understand records (either complete or incomplete)
- Doubt concerning the authenticity of immunization records
For further guidelines on dealing with immunization schedules that differ from Canada, visit the World Health Organization’s site on global summaries for immunization schedules. For information regarding specific catch-up immunization schedules for children six and under, ages 7-17 and adults 18 and older, visit: Publicly Funded Immunization Schedules for Ontario (October 2015).
Catch-up schedules for immunizing refugees can also be difficult. However, the Ministry of Health and Long-Term Care has an Immunization Annex, which is a guideline for planning immunization activity for Syrian refugees that is applicable to refugees from all over the world.
For more information about vaccination schedules for a variety of populations, contraindications/adverse events following previous immunizations and even vaccination of persons with compromised immune systems, refer to the Canadian Immunization Guide found on the Public Health Agency of Canada’s website.
- All individuals with an IFHP certificate are entitled to the same coverage. This coverage includes resettled refugees (GARs and PSRs), refugee claimants, refused claimants until their deportation date and people detained under immigration laws.
- Government Assisted Refugees (GARs) and Privately Sponsored Refugees (PSRs) have IFHP coverage for the first 12 months after arrival. They are also entitled to provincial health insurance coverage for medical services (e.g., RAMQ, OHIP) upon arrival. For resettled refugees, IFHP coverage is primarily relevant for medications and "supplemental’ services."
- Refugee claimants: These clients do not have OHIP or other provincial health insurance on arrival. IFHP coverage continues until the refugee claim is accepted (+ 45 days) OR if the refugee claim is rejected, until the date set for deportation
- Medical, diagnostic and hospital services: same coverage as provincial health insurance
- Medications: similar to coverage for social assistance beneficiaries. More precisely, it is the same as the provincial medication insurance list along with some additional medications.
- Supplemental services: similar to coverage for social assistance beneficiaries, including emergency dental care, eye exams, glasses, psychotherapy, rehabilitation, prosthetics, orthotics, home care, etc.
IFHP certificates issued after April 10, 2016 will not have an expiry date
- For GARs and PSRs: coverage will expire 12 months after arrival. Of course, their provincial health insurance coverage will continue permanently and, after the first year, they will have access to the same programs and benefits as any other permanent resident (e.g., provincial prescription medication insurance programs)
- For refugee claimants: the IFHP certificate will continue to be valid, and they will continue to have IFHP coverage until their refugee claim is accepted (+ 45 days) OR if their refugee claim is rejected, until the date set for deportation. There is no longer any need to renew the IFHP certificate.
Information on the new IFHP is available on the Medavie Blue Cross website.
For a summary of the new IFHP: click on Bulletins
For detailed information: click on Guides
For health-care providers agreeing to see refugee claimants, please note that you need to register an account with Medavie Blue Cross to be reimbursed for providing care to patients who are covered by the Interim Federal Health Program (IFHP). If a patient has OHIP coverage, this may not be necessary.
This registration allows health-care providers to submit their billings for refugee health visits, request necessary bloodwork for refugees and ensure refugees are covered for the medications ordered. All physician billing is done through the Medavie Blue Cross Provider Portal, so it is important that physicians bookmark this website. Once a refugee qualifies for OHIP, you can normally bill under OHIP, though IFHP will continue to cover services such as medication, emergency dental care, etc.
The account registration process is straightforward.
- Go to the Medavie Blue Cross Provider Portal.
- In the top, right-hand corner, click on “Request Account.”
- Fill out the registration information and submit. This step should only take a few minutes.
- In most cases, Medavie Blue Cross will process your account request within 48 hours.
Once approved, Medavie Blue Cross will send your log-in information to the email you provided. This portal is used for all of your billing and provides resources for the different "types" of refugees and what is covered for each type. If you need assistance, you can call 1-888-614-1880 (select 1, then 1, then 5) during regular office hours.
For information on services covered by the IFHP through Blue Cross, please visit the Interim Federal Health Program: Summary of Benefits.
Patients or services not covered by the IFHP may be covered by the Ontario Temporary Health Program for Refugee Claimants.
The benefit grids below outline the kind of health services available and covered by IFHP for refugees without OHIP.
IFHP Benefit Grids:
Q: What is the billing process for patients covered under IFHP?
A: The IFHP provides several options for providers to determine whether the service or product is covered or not under the IFHP, depending on their type (hospital, doctor, pharmacists, etc.) or their specialty/profession (general practitioner, psychiatrist, optometrist, etc.). Claims can be mailed, faxed or submitted electronically to Medavie Blue Cross with the applicable information.
- Health-Care Professionals − Secure Provider Web Portal and Electronic Claims Submission: Medavie Blue Cross offers a secure provider web portal allowing hospitals, medical doctors, nurses, audiologists and other eligible health service providers to conveniently verify their patient’s eligibility, submit claims (7 a.m. to 12 a.m. seven days per week) or prior approval requests (24/7) online. This portal enables them to pre-determine client eligibility for specific treatment and, depending on their specialty, submit claims with real-time adjudication and confirmation of the amount to be paid by Medavie Blue Cross.
- Pharmacies − Pharmacy Claims for Point of Sale (POS) Claims Transmissions: Pharmacy providers can verify coverage for specific drugs and submit claims electronically to Medavie Blue Cross through Pharmacy Claims for Point of Sale (POS) Claims Transmissions. A beneficiary’s eligibility can be verified through the IFHP Secure Provider Web Portal.
- Dentists - can verify coverage for specific treatment and send claims electronically through CDAnet, DAcnet or Reseau ACDQ to Medavie Blue Cross. A beneficiary’s eligibility can be verified through the IFHP Secure Provider Web Portal.
Certain claims are not available for electronic submission, and providers must contact the Medavie Blue Cross Call Centre or submit claims/special authorization requests by mail or fax.
Paper claim forms can be downloaded from the secure provider web portal or by faxing a request to Medavie Blue Cross. Paper claims can be faxed to 506-867-3841 or mailed to:
Interim Federal Health Program
Medavie Blue Cross
644 Main St. PO Box 6000
Moncton, NB E1C 0P9
For more information on claim submission guidelines, please consult IFHP Information Handbook for Health Care Professionals or visit the Medavie Blue Cross site for health-care providers.
Q: I am a primary care physician working in a FHO, and I have recently taken on a large refugee family. Visits so far have been at least 45 minutes per person at a time, as everything goes through a translator and multiple family members with multiple medical concerns. Most of these issues would normally be billed as an A007 but each issue is taking upwards of 30 minutes to sort on its own. Any ideas for billing these visits?
A: One could bill the A911A, if it is a minimum of a 50-minute visit. This billing code is a "Special Family and General Practice Consultation" billed at $144.75 (out-of-basket). If there is counselling, for example: counselling patients on medical issues, one could bill the K013A code (in-basket) paid at $62.75 for 1.4 units, and then one could bill the K040A code $62.75 (out-of-basket) which is a "group counselling, per unit, where no group member received more than 1.4 units of K013A or K040A in 12 months. If the "Group" has had more than 1.4 units of K013A or K040A per 12 months, then one would bill the K041A code (out-of-basket) - $38.80.
There is also an A912A code that is billed for a "comprehensive family and general practice consultation" and needs to be a minimum of 75 minutes paid at $217.15 (out-of-basket).
For more information on the billing codes above, click on this resource: Billing & Payment Guide for Family Health Organization (FHO) Physicians – Opting for Solo Payment.
Communication between care providers and their patients is of the utmost importance. The language barrier between Canadian practitioners and their refugee patients can lead to frustrations, misdiagnoses and improper care. There are a variety of translation and interpretation services available in the KFL&A area that can help ease the communication between you and your newcomer patients.
Immigrant Women Services Ottawa: Language Interpretation and Translation Services
- Affordable translation services for the Eastern Ontario region (from Belleville to Cornwall and includes the following cities/counties/towns: Almonte, Arnprior, Carleton Place, Cornwall, Lanark County, L’ Originale, Ottawa, Pakenham, Pembroke, Perth, Smith Falls and Kingston)
- FREE translation services are available in situations involving victims of violence, including refugees (coming from refugee camps) proven to be survivors of war and trauma and who have been in Canada for less than one year
- Spoken language interpretation is available in over 60 languages on site, via telephone or written translations
- To book an appointment for translation (in person, telephone, etc.), click here.
Central Eastern Ontario Translation & Interpretation Services (CEOTIS)
- This organization, a division of the Quinte Immigration Services, has its headquarters in Belleville, Ontario
- Provides translation and interpretation services for a variety of fields, including the health sector
- All translators and interpreters working for CEOTIS are certified by the ATIO (Association of Translators and Interpreters of Ontario)
- There are also two drop-off locations in Kingston for documents that need to be translated, and one in Belleville
CognisantMD: Syrian Refugee Medical Assessment Translation Tool
- These free, secure online tools have been developed to allow patients to complete a full history and mental health screening in Arabic or Armenian
- Results are automatically translated to English for health-care providers to review and add to the patient record
- Collecting this information in the patient's first language can help ensure a more complete and accurate history is collected, including concerns around sensitive issues such as mental health
Health Information Translations in Arabic
- FREE on-line information for health-care providers translated from English to Arabic, click here.
- Google's free service instantly translates words, phrases, and web pages between English and over 100 other languages, click here.
For a list of all primary care providers (family physicians, dentists, pharmacists, etc.) registered with Medavie providing care under IFHP coverage, click here.
The Canadian Collaboration for Immigrant and Refugee Health (CCIRH) developed this Evidence-Based Preventive Care Checklist for New Immigrants and Refugees. This checklist is a practical clinical tool that can be used for the first few appointments a physician has with a new refugee patient. It can also be scanned and integrated into the patient's chart. It is an e-learning knowledge-translation tool designed to help primary care practitioners integrate the Canadian Immigrant Health Guidelines into their practice. CCIRH is an interdisciplinary collaboration involving primary care practitioners, specialists, researchers, immigrant community leaders and policy makers that shines an evidence-based lens on the emerging new discipline of migrant health.
These podcasts were developed in collaboration with the Evidence-Based Migrant Health Guidelines team within the Cochrane Community. The series of podcasts provides health-care practitioners with life-like scenarios and evidence-based solutions for a range of health-care topics, including post-traumatic stress disorder (PTSD), tuberculosis (TB), human immunodeficiency virus (HIV), domestic violence and parasites. Cochrane is a global network of health practitioners, researchers, patient advocates and others responding to the challenge of making the vast amounts of evidence generated through research useful for informing decisions about health.
This document contains information that will help support physicians in their early assessments and care of refugees. Ontario has excellent primary care providers that play an essential role in supporting and providing transitional care for refugees. The Ministry of Health and Long-Term Care is grateful to all health-care providers who will be caring for refugees in their practices.
This Canadian Paediatric Society guide was developed to assist health-care practitioners who provide care to immigrant and refugee children and youth. The society represents paediatricians, paediatric subspecialists, paediatric residents and other health professionals who work with and care for children and youth.
A peer review article from the Canadian Medical Association Journal (CMAJ). It outlines proposed guidelines, steps to be taken as well as specific considerations for physicians caring for immigrants and refugees. Recommended tests, vaccines and procedures as well as recommendations for preventative care are also outlined in this detailed resource.
DENTISTS & DENTAL CARE PROFESSIONALS
As Canada prepares to receive a large number of refugees from Syria, a greater need presents itself to help newly arriving refugees settle in their new home, and receive important care. Canadian Dentists for Refugees aims to make sure they get the care they need. If you are a dentist in Canada and are interested in providing low-cost or pro bono dental care to refugees in need, you are able to join a mailing and information list.
Community Dental Hygiene Clinics
KFL&A Public Health offers free dental assessments by registered dental hygienists for eligible children and youth aged 17 and younger to determine if the child may benefit from preventative dental services or oral hygiene instruction. It is available at multiple locations including Kingston, Napanee, Sharbot Lake and Cloyne.
Healthy Smiles Ontario Schedule of Dental Services and Fees for Dentist Providers
Refugees (ages 17 and under) are covered under IFHP and are eligible to be a part of the Healthy Smiles Ontario (HSO) program. This guide provides a basis for the billing schedule and services covered under this plan. This resource gives information regarding the low-cost and pro bono dental care services available to some refugees under IFHP as well as information regarding the HSO application process.
This resource allows health-care professionals such as pharmacists to communicate medication instructions to patients who do not share a common language with them. It can also be used for patients with difficulty seeing or those with cognitive impairments. The software is free for download and can be very useful for pharmacists who are taking on refugee patients that do not speak English.
MENTAL HEALTH PROFESSIONALS
The Refugee Mental Health Project (RMHP) aims to build settlement, social and health service providers' knowledge and skills regarding refugee mental health and promote inter-sector and inter-professional collaboration. Resources include information on refugee mental health, evidence-based suggestions for refugees and mental health support providers, award-winning online courses for health-care professionals and social service providers, and regular webinars on topics related to refugee mental health.
The RHTAC provides web-based information and resources related to refugee health, including webinars on such topics as refugee women’s health, refugee youth, mental health screening and care, and providing culturally and linguistically appropriate services to refugees.
The MMHRC seeks to improve the quality and availability of mental health services for people from diverse cultural and ethnic backgrounds, including immigrants, refugees and members of established ethno-cultural communities. This website presents resources designed for lay people; patients and their families; community organizations; and health professionals, policy makers, planners and administrators. Materials hosted and listed on this site include cultural competence training materials (print and online), training videos and podcasts from leading Canadian experts in the field of culturally competent care.
MENTAL HEALTH TRANSLATION/INTERPRETATION SERVICES
Several Kingston and surrounding area mental health facilities have translation/interpretation services that could prove useful to mental health professionals in treating refugees.
- AMHS-KFLA: Arabic Interpreters
- Hotel Dieu: multi/bilingual residents
- K3C: Arabic-speaking counsellors for women’s counselling
- Pathways for Children & Youth: Are willing to do in-person sessions with refugees when translator is required as opposed to over the telephone as per usual
Moreover, while the following specific services are not necessarily tailored to refugee clients, physicians are reminded of the following services that are available to all Kingston residents:
- SAC Kingston (Sexual Assault Centre Kingston)
- Interval House
- KGH’s SADV (Sexual Assault Domestic Violence) program