Blog: Addressing the Health and Social Needs of Refugees and Migrants at a Social Safety Net Clinic in CT

Author: Zeba Kokan, Health Policy Research Fellow

Collaborators: Lilian Gutierrez, CHCI Deputy Regional Vice President; Kasey Harding-Wheeler, Director of the Center for Key Populations; Kimberly Willet, Family Nurse Practitioner, Center for Key Populations, Fellow at Community Health Center

I. Overview

Data from the United Nations indicates that approximately 100 million people internationally are displaced due to violence, war, and climate change. According to the UN High Commissioner of Refugee data, the international refugee population has grown twice as large in the past decade.¹ Countries around the world will be directly impacted by this migration of refugees and will need to implement efforts to address the social, economic, and health needs of those moving into their country, states, and communities.

Communities around the United States (U.S.) have been engaging in this work recently, as the U.S.’s departure from Afghanistan in August 2021 resulted in over 76,000 Afghan nationals coming into the country, including to Connecticut.² According to the CT Mirror, more than 700 refugees from Afghanistan have come to Connecticut since—an unprecedented number for Connecticut and double the original goal.³ In fact, Connecticut has one of the highest rates of refugee settlement.

Federally Qualified Health Centers (FQHCs) like the Community Health Center, Inc. (CHCI) have a longstanding history of working with underserved populations, and thus, are uniquely positioned to address the health and social needs of refugees. This blog post describes CHCI’s implementation of a Saturday health clinic that launched in November 2021 for refugees^* in New Britain, Connecticut. It will discuss the clinic’s formation and implementation, the clinical care provided to the refugees, and how staff provided cultural appropriate care, and also addressed the social needs of patients.

II. Background

Setting the Stage

Refugees represent a very diverse population, though a significant proportion of refugees face similar challenges when migrating into the U.S., such as lack access to quality healthcare and education, poverty, and trauma. Access to high-quality, affordable, and culturally appropriate healthcare is a major challenge due to various factors including language barriers, knowledge of the host country’s health system, and acculturation.⁴

Connecticut is one of the few states that immediately initiates Medicaid upon entry for refugees, evacuees, and asylees. This allows for this population to be insured and receive affordable services at health centers across the state, including CHCI. Community health centers and social safety net settings have historically played a vital role in providing healthcare to refugees and continue to do so today. ⁵

 The Formation of the Clinic and Defining the Key Players 

CHCI partnered with Integrated Refugee & Immigrant Services (IRIS), Connecticut Institute for Refugees and Immigrants (CIRI), and third-party organizations to provide integrated primary care and health services to hundreds of Afghan families arriving in Connecticut. The clinic also administered services to refugees from the Democratic Republic of the Congo, Syria, and Rwanda. CHCI provided these services during a Saturday clinic starting in November 2021.

IRIS is a non-profit agency that provides housing, health, case management, employment, education, and legal support for refugees and other displaced people who are resettling in Connecticut. IRIS led the Afghan resettlement program in the state and created a co-sponsor process, which encouraged other organizations (primarily community or faith-based groups) to lead resettlement tasks. These included raising a minimum of $10,000 for an incoming refugee family, identifying housing, job search, and advising on receiving public benefits (e.g., healthcare/Medicaid, SNAP, education).

Previous Clinic Infrastructure

CHCI previously held an ad-hoc health clinic providing health services to unaccompanied migrant youth. This experience was advantageous for several reasons. First, it allowed CHCI staff to rapidly respond to the influx of Afghan refugees into Connecticut and create a long-term clinic to provide refugee health assessments, screenings, and primary care services. Second, the ability to be agile and adapt quickly to changing circumstances aligns with the FQHC environment, where the needs of the community and patients can change quickly.

The decision to create the refugee clinic is well-aligned with CHCI’s mission of providing quality primary care to populations most in need. Lilian Gutierrez, CHCI Deputy Regional Vice President, developed internal and external partnerships to implement the clinic. External partners included the State of Connecticut, the Department of Public Health, IRIS and CIRI. There were also internal partnerships with Amy Taylor, Vice President of CHCI’s West Region, Kasey Harding-Wheeler, Director of the Center for Key Populations, Access to Care staff, and other critical clinical staff. These partnerships enabled the education of staff and ensured that various components of the clinic were developed, including refugee health assessments and how to provide ongoing care. Lilian explained this process:

We strategized before the refugees arrived. We did this with the notion that other healthcare facilities could not respond to the refugees’ immediate needs. Because education is critical to ensuring compliance with refugee health assessments and forming cultural awareness to assess and reassess the needs of our patients, staff received training from the State of Connecticut and participated in cultural awareness sessions.

Further preparation of the clinic included administrative staff working with clinical teams to strategize on the best way to deliver care to the incoming refugee population, including conducting background research. This resulted in the development and implementation of new operational processes that would be necessary to treat refugee populations, including a required refugee health assessment, and weekly operational meetings to ensure that adequate and appropriate personnel and resources were in place.

III. Meeting the Needs of the Patients

Clinical Needs

In the U.S., the Centers for Disease Control and Prevention aims to sustain and improve the health of refugees and migrants through mandating refugee health screenings within 30 days of entry. This also functions to prevent infectious diseases and other critical public health concerns from being introduced into the U.S.⁶

During initial visits, patients underwent a variety of screenings including refugee health screenings, behavioral health screenings, and medical and chronic list screenings. The comprehensive refugee health assessment includes the following assessments:

• immunization review & update;
• tuberculosis screening & diagnosis;
• Hepatitis B & C Screening;
• HIV & sexually transmitted infections/disease;
• parasite screening;
• lead screening;
• mental health screening; and,
• other screenings: dental, hearing, vision, nutrition/vitamin levels, pregnancy, lab testing.⁷

Other aspects of the visit centered on collecting stool samples, monitoring for bacteria, aggregating vaccine records and catching people up with vaccines. The comprehensive clinical and wellbeing services often took an average of six hours to finish.

There were several challenges that arose when addressing the clinical needs of refugees. First, there was a gap in provider knowledge of the differing international healthcare system, including which vaccines were required, and if they were widely available and received. Many refugees did not have medical records or documents, so staff did not know their patients’ medical history. Many refugee patients had never been seen by a medical provider in the past. This was a major barrier to not only providing care, but also for enrolling children in school, as those documents were required. Similarly, medical and dental care was generally not as accessible in their country of origin, and patients would arrive to the CHCI clinic with complex health concerns.  For example, patients would have chronic dental issues due to the lack of fluoride in the water. In order to gain a better understanding of the patient’s health, providers and the care team extended patient visits to 40 minutes. Third, there was a lack of understanding from the refugees of how to navigate American pharmacies. To eliminate that barrier, staff created workarounds by delivering medications directly to patients’ homes.

Cultural Needs

Ensuring that the healthcare workforce serving refugee populations understands the cultural differences and cultural practices is critical to providing high-quality care during their visits. To address this, CHCI held trainings with nurse practitioners and medical doctors who would be conducting the refugee health assessment, including reviewing compliance requirements. Providers also received cultural competence and humility training to gain a better understanding of the cultural differences of the Afghan population they were serving.

CHCI staff aimed to continuously improve the experience of patients by implementing multiple feedback tools, including daily morning huddles. During the huddles, staff highlighted key care components for providers to monitor and ensured a proper feedback loop between staff, clinicians, and patients.  They also provided a systematic approach to centering refugee voices—a key aspect of cultural humility.

There are several examples of CHCI clinic staff identifying and addressing cultural differences during the clinic. First, language barriers and communication differences were a barrier in conveying health-related information and building a strong patient-provider relationship.  Language Services Associates (LSA) were instrumental in providing interpreting services for refugees. The Access to Care (ATC) team at CHCI, particularly Llara Perez, coordinated the Refugee Health Assessment appointments where she reserved interpreting time with LSA. Second, staff learned that separating children from their parents during appointments induced anxiety for patients. In response, staff implemented an open-door policy that entailed having patients doors ajar during visits. Second, patients requested towels while at the clinic. Staff learned that towels were placed on the floor in order to perform daily prayers. This resulted in staff regularly disseminating prayer supplies to patients. Lastly, dietary habits and gender dynamics were two other areas where it was critical that staff had an understanding of these cultural nuances in order to best provide services and ensure a positive experience for the patients.

Social Determinants of Health Needs

During the first day of the clinic, staff noticed that patients had other social and non-medical needs, including food, and adequate supplies of clothing, jackets, and shoes. In response, CHCI staff began donation-based food and clothing drives for winter coats and foods that were culturally appropriate.

The availability of food, clothes, pots, and pans was also an incentive to get patients to primary care appointments. In fact, three patients shared with Kasey Harding-Wheeler that they would not have come without the donations as an incentive and led to more patients attending their visits. It was observed that patients, especially the Afghan population, emphasized reciprocity and they began providing staff with gifts as a form of giving back to the clinic.

Along with basic needs such as food and clothes, transportation was another identified need for clinic patients. To ensure that patients would attend appointment, staff from CHCI’s Center for Key Populations provided transportation through their departmental van for patients.

IV. Looking Ahead

CHCI’s health clinic is an example of how FQHCs are uniquely positioned to serve refugees impacted by humanitarian crises, climate change, and geo-political conflicts due to the accessibility of the integrated primary care process and commitment to health equity.⁸ Many refugees who were seen at the Saturday health clinic are starting to make the CHCI their permanent medical home, and an increased number are taking advantage of behavioral health, dental, or specialist referrals. CHCI’s clinic locations around the state of Connecticut has allowed patients to move, and seamlessly transfer their care to a different site. Although it is generally easy to track and transfer information due to the shared EHR system, differences in language and communication occasionally make this process challenging.

Other refugees groups will continue to arrive in the U.S. and in Connecticut as conflicts and climate change force people to flee their homes. The conflict in Ukraine is the most recent example of this. According to a UN Refugee report, around 3.5 million people have fled Ukraine. On March 24th, 2022, President Joe Biden declared that the U.S. would accept approximately 100,000 Ukrainian refugees after pressure from national and international domains.⁹ A senior administration official explained to reporters about the administration’s plan for resettlement: “To meet this commitment, we are considering the full range of legal pathways to the U.S. and that includes U.S. refugee admissions program, parole and immigrant and non-immigrant visas.”

The state of Connecticut is planning for Ukrainian refugees to resettle in various parts of Connecticut. Many local and grassroots community organizations are preparing to support the social and health-related needs of incoming refugees to Connecticut.¹⁰

As we continue this work, CHCI, as well as other FQHCs, should take some of the lessons learned mentioned above and apply them when serving the healthcare needs of refugee populations they currently, or will soon, serve. It is vital that community health centers are equipped to offer culturally competent and equitable services to vulnerable populations. CHCI’s experience providing culturally competent and equitable services to Afghan refugees is directly transferable to serving the needs of similar displaced groups of people like Ukrainian refugees arriving on American shores and settling in Connecticut.

Furthermore, it is vital that there are sustainable and long term solutions that enable FQHCs to continue providing this care. National, state, and local policy solutions, including increased funding, workforce development, and increase collaboration will help health centers build out their refugee health systems and increase workforce capacity to train clinicians and staff on best practices in refugee and migrant health. Lastly, policymakers must help address the social needs of refugees by increasing access to social services, creating pathways to long-term residency, and supporting the accessibility to healthcare services. ^{11, 12}

* It is important to note that the state of Connecticut refers to the “refugees” from Afghanistan as “evacuees” due to the expedited humanitarian parole status granted. However, local organizations and community members typically refer to this population as “refugees.” This designation does not provide a complete long-term path to permanent residence in the US and hinders the number of public benefits received.

Works Cited

1. United Nations High Commissioner for Refugees. (2022, May 23). Ukraine, other conflicts push forcibly displaced total over 100 million for first time. UNHCR. Retrieved May 24, 2022, from https://www.unhcr.org/en-us/news/press/2022/5/628a389e4/unhcr-ukraine-other-conflicts-push-forcibly-displaced-total-100-million.html
2. S. Department of Homeland Security. (2022, February 19). Operation allies welcome announces departure of all Afghan nationals from U.S. Military Bases. Operation Allies Welcome Announces Departure of All Afghan Nationals from U.S. Military Bases | Homeland Security. Retrieved June 1, 2022, from https://www.dhs.gov/news/2022/02/19/operation-allies-welcome-announces-departure-all-afghan-nationals-us-military-bases
3. Condon, T. (2022, April 1). CT welcomes Afghan evacuees with open arms – and driver’s licenses. CT Mirror. Retrieved April 19, 2022, from https://ctmirror.org/2022/03/27/ct-welcomes-afghan-evacuees-with-open-arms-and-drivers-licenses-refugees-ukraine-ukrainian/
4. Walden, J., Valdman, O., Mishori, R., & Carlough, M. (2017). Building capacity to care for refugees. Family Practice Management, 24(4), 21-27.
5. Ibid.
6. Centers for Disease Control and Prevention. (2021, March 12). About immigrant, refugee, and migrant health. Centers for Disease Control and Prevention. Retrieved May 24, 2022, from https://www.cdc.gov/immigrantrefugeehealth/about-irmh.html
7. All refugees should have a comprehensive … – portal.ct.gov. Connecticut Department of Public Health. (2013, January 25). Retrieved April 19, 2022, from https://portal.ct.gov/-/media/DPH/Tuberculosis/CTRHAPocketGuidepdf.pdf
8. REIHANI, A. R., ZIMMERMAN, H. G., FERNANDO, N., SAUNDERS, D. R., Edberg, M., & CARTER, E. (2021). Barriers and facilitators to improving access to healthcare for recently resettled Afghan refugees: A transformative qualitative study. Journal of Health and Social Sciences, 6(1), 59-72.
9. CNN, A. M., Kevin Liptak and Maegan Vazquez. (n.d.). US to welcome 100,000 Ukrainian refugees. CNN. https://www.cnn.com/2022/03/24/politics/us-to-accept-more-ukrainian-refugees/index.html
10. Condon, T. (2022, April 1). CT welcomes Afghan evacuees with open arms – and driver’s licenses. CT Mirror. Retrieved April 19, 2022, from https://ctmirror.org/2022/03/27/ct-welcomes-afghan-evacuees-with-open-arms-and-drivers-licenses-refugees-ukraine-ukrainian/
11. McNeely, C. A., & Morland, L. (2016). The health of the newest Americans: How US public health systems can support Syrian refugees. American journal of public health, 106(1), 13-15.
12. Ziersch, A., Freeman, T., Javanparast, S., Mackean, T., & Baum, F. (2020). Regional primary health care organisations and migrant and refugee health: the importance of prioritisation, funding, collaboration and engagement. Australian and New Zealand Journal of Public Health, 44(2), 152-159.