PCP Service Coordination - Case study template
Details of PCP contact
Name of PCP
South Coast Primary Care Partnership
Contact Person
Mandy Geary
Position/Title
Executive Officer
Phone No.
03 5674 0900
Email Address
eo@southcoastpcp.org.au
Identified Partners
Partner Organisation
Roles and responsibilities
with regard to the project
Contact person details
Gippsland Multicultural
Service (GMS)
Consultation phase; Planning
and Reporting
Simone Jamieson GMS
Settlement Worker – Bass Coast
Settlement Committee
Bass Coast Community
Health Service (BCCHS)
Consultation phase; Planning
and Reporting
Annie Bailey, Manager Nursing
Services
Bass Coast Adult
Education Centre
Consultation phase; Planning
and Reporting
Heather McGowan, Director
Bass Coast Regional
Health – Public Dental
Health (BCRH)
Consultation phase
Anne Ngaw, Dental Nurse
Bass Coast Regional
Health – Emergency
Department
Consultation phase
Debbie Garvey, Nurse Unit
Manager
Bass Coast Regional
Health – Family Resource
Centre
Consultation phase; Planning
and Reporting
Karen Chugg, Trauma
Assessment and Counselling
General Practice Alliance
– South Gippsland (GPA
SG)
Consultation phase; Planning
and Reporting
Jo Hillbrick, Practice Nurse
Initiative; Immunisation
Program; Judy Tiziani, Mental
Health Program Coordinator
Mitchell House
Community House
Consultation phase
Jan Bourne, Manager
South Gippsland Family
Medicine
Consultation phase
Wendy Notley, Practice Manager
Wonthaggi Medical Group
Consultation phase
Gayle Bloch, Practice Manager
Bass Coast Shire
Planning and Reporting
Antoinette Mitchell, Chair
SCPCP; BC Settlement
Committee (convenors)
Case Study Title
(name, position)
“Finding a way in - Mapping Health and Community Service
Pathways for Refugees in Bass Coast”.
South Coast PCP Service Coordination Case Study September 2010
Page 1 of 9
Summary/Abstract
This mapping project was developed to support planning for the provision of a coordinated
model for refugee health care in Bass Coast to improve accessibility and responsiveness of
health services to the needs of Karen Burmese refugees. The project, involving direct
consultation with eleven providers was conducted between October and December 2009 and
was based on the HealthWest Partnership service coordination model for refugees as an
example of good practice1 and the SEHCP Refugee Health Service Coordination Survey – April
/ May 2009.
Health and refugee services were well engaged in the project and the findings indicated the
services provided to the refugees of the Bass Coast are well coordinated given the current
level of funding support. In particular, the links between the services contracted under the
Integrated Humanitarian Settlement Strategy (IHSS) 2, which provides for intensive
settlement support for newly arrived humanitarian entrants, were reported as excellent.
There was a perceived need for connections between other services to be strengthened and
that cultural awareness in the healthcare workforce be enhanced by cultural training. Service
providers also need to commit to on-going collaboration in order to sustain accessible and
coordinated services beyond the initial six months funded by the IHSS.
Background
Name of
Project
“Mapping Health and Community Service Pathways for Refugees in Bass
Coast”.
Target client
group
The project targets newly arrived people from a refugee background or who are
asylum seekers. In the local context, the target group comprises Karen
(Burmese) refugees numbering approximately 15 located in the township of
Wonthaggi in Bass Coast Shire.
The term ‘refugee’ is generally used to refer to people who have arrived in
Australia under the Australian Government’s Humanitarian Program which
includes most refugees living in Victoria. A broader definition of ‘refugee’
includes all people who have escaped situations of displacement, conflict and
violence and includes people seeking asylum in Australia or who came on a
non-Humanitarian Program visa but from a refugee source country.
Refugees to the Bass Coast arrive under the Special Humanitarian Programs
(visa subclass 202) with individuals also identified under the Women at Risk
(visa subclass 204).
The Special Humanitarian Program (SHP) targets people outside their home
country and subject to persecution and /or discrimination in their home
country. Applications are supported by a proposer who is an Australian citizen,
permanent resident or a community organisation based in Australia. They are
entitled to a modified initial settlement package. The proposer is expected to
provide some assistance to the refugee to support them in their settlement.3
The Women at Risk visa is for vulnerable women and children such as female
headed households, single mothers, abandoned or single women .
DHS Service
Coordination
expectations
2009-12
Background
Develop and implement agreed service coordination practice for priorities hard
to reach and vulnerable groups including indigenous communities
Since 2005, more than 10,000 people granted permanent protection on
Humanitarian Program Visas have settled in Victoria - approximately 30 per
cent of the Australian total in this category (this is comparable to New South
Wales with other states and territories receiving much fewer). 4 In 2007-08,
fairly equal numbers of offshore arrivals came from Africa (mainly Sudan), Asia
http://www.health.vic.gov.au/pcps/downloads/careplanning/refugee_health.pdf
http://www.immi.gov.au/living-in-australia/delivering-assistance/government-programs/settlementprograms/ihss.htm
3
McDonald B, Gifford S, Webster K, Wiseman J, and Casey S (2008) Refugee Resettlement in Regional and Rural
Victoria: Impacts and Policy Issues, VicHealth
4
Settlement Database, Department of Immigration and Citizenship, August 2008.
South Coast PCP Service Coordination Case Study September 2010
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1
2
(mainly Afghanistan, Burma and ethnic minorities from Burma living in
Thailand) and the Middle East (mainly Iraq). Victoria also supports a number
of Medicare ineligible asylum seekers.
Most of Australia’s refugees and asylum seekers come from circumstances such
as refugee camps or marginalisation in urban settings where even the most
basic resources and services are scarce. This includes safe drinking water,
basic health care and education, shelter, safety and adequate food supplies. In
many places, diseases such as malaria are common. There is poorly developed
or disrupted health care infrastructure, which is unable to provide acute and
preventative health care. Most refugees would have experienced traumatic
evens such as prolonged periods of deprivation, loss of identify and culture,
human rights abuses and the loss of family members i.
As a result of these negative experiences, refugees are more likely to have
multiple and complex health problems on their arrival in Australia. Health
problems may be due to physical and psychological trauma, deprivation and
prolonged poverty, and poor access to health care prior to arrival. Refugees
are also less likely than other migrants to have family and community support
in Australia on arrival. Despite these challenges, over time, refugees settle
very successfully in Australia. Most health problems can be addressed through
health care and support in the early periods of settlement. Timely care is
critical, as successful settlement is more likely once health is restored.
Evidence supporting Refugee Health as an issue
Through it’s involvement in the Refugee Health Nurse Program (RHNP) and the
Bass Coast Settlement Committee, and in listening to the experiences of a
small group of Karen (Burmese) refugees recently settled in a small rural town,
SC PCP saw a need to examine more closely the status of our local service
system in regards to the key Primary Health Care Principles of accessibility and
appropriateness of care and the existing evidence base. ii
In May 2009 the Department of Human Service Southern Metropolitan Regions
published a summary of reports of refugee clients in the health system in
Australia which identified the following key issues:
Communication barriers and difficulties arranging interpreters: Refugees are
likely to arrive with poor English skills and are largely dependent on
interpreters, at least during the initial settlement period. This makes navigating
the health and other systems difficult and stressful. This is especially so when a
patient has difficulty communicating with a doctor, pharmacist or allied health
professional, during a consultation, a visit to hospital or during follow-ups.
Treating refugees usually requires extended consultations: Consultations
sometimes take up to double the time of a standard consultation. GPs have a
busy workload and are unlikely to be able to provide all the follow-up care and
case coordination necessary, and they are not adequately remunerated for
their time.
Lack of knowledge by refugees of the Australian health system: Refugees
lacked knowledge and experience navigating a health system in a developed
country. There are stark differences between the health systems in a developed
versus a developing country. Refugees need time and assistance to adjust to a
medical system which is based around appointments, referrals to specialists in
different locations and often multiple clinical tests. Refugees need greater
assistance during their orientation period, which may be achieved through
greater dissemination of translated information about the health system, the
services available and how to access them.
Logistical and settlement issues leading to missed appointments: Finally, until
refugees are familiar with their surroundings, some may require one-on-one
assistance to arrange appointments and organise transport arrangements.
These difficulties are further exacerbated if the refugee is illiterate. Refugees
may feel pressured to stay at work or at English language classes rather than
attend appointments (e.g. medical, Centrelink). In addition, they may avoid
using health care services because they cannot afford to pay, or because of
previous traumatic experiences in their country or birth or transit.
South Coast PCP Service Coordination Case Study September 2010
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Policy Context and Strategic Alignment
This project is consistent with the policy and program context underpinning
refugee health and the elements of the SC PCP Strategic Plan related to
Refugee Health. The RHNP aims for optimising the long-term health of refugee
community members through promoting accessible and culturally appropriate
health care services that are responsive to changing patterns of refugee
settlement are consistent with PCP strategic objectives in relation to the
Domain of Activity ‘Service Coordination’. The RHPN is part of a coordinated
response by the Victorian Government to the health and wellbeing of refugee
communities in Victoria and contributes to three outcomes of the Victorian
Government’s Growing Victoria Together 2iii:
 High quality, accessible health and community services.
 A fairer society that reduces disadvantage and respects diversity.
 Building friendlier, confident and safe communities.
The RHNP also contributes to the strategic goals of the Victorian Government’s
A Fairer Victoria 2008ivand is a part of the DHS’ Refugee Health and Wellbeing
Action Plan 2008-10v. The RHNP also operates within the frameworks provided
by:
 The Primary Care Partnerships (PCP) strategy
 The Community Health Services Policy
 The Primary Health Demand Management Framework vi which mandates
priority access for refugee clients
Philosophy underpinning the Project
This project recognises health and wellbeing as occurring within a social
context;
 Health outcomes are determined by a range of social, environmental
and economic factors.
 Disease prevention, early intervention and equity of access are
necessary components of high quality services that support the
immediate and long-term health care of refugees.
Health services for refugees in the Bass Coast areas should:

Be accessible, flexible and culturally sensitive.

Be affordable. Inability to pay should not be a barrier to access to health
services either provided or referred to by the RHNs.

Adopt a holistic approach to health care and ensure links are developed
and maintained with related services.

Recognise the rights (e.g. confidentiality, informed consent) of refugees as
health care clients.

Treat clients with dignity.

Acknowledge that informed decisions about health and health care require
accessible and appropriately targeted health information and access to
language services.

Be integrated with mainstream services.

Enable individuals, families and refugee communities to improve their
health and wellbeing.
Project Management and Governance
 Sponsor (s)
Refugee Health Nurse Initiative, Department of Human Services
 Project Management
Mandy Geary, Executive Officer reporting to Steering Group, SCPCP
 Project Worker
Vicki Bradley, IHP Officer reporting to stakeholder groups and Project Manager
via designated meeting networks and communication matrix policy for
dissemination of project findings
South Coast PCP Service Coordination Case Study September 2010
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Objectives
Service providers have access to information about the accessibility and
responsiveness of their services to refugees in Bass Coast as a catalyst for
improvement.
 Consumers and carers:
- Have timely access to the most culturally appropriate services
- Experience coordinated delivery of services and a continuum of
care
- Receive care and support that is appropriate to their cultural
background, circumstances, needs and preferences.

Project participants and key stakeholders
There are two sets of stakeholders for this project
1. The refugees
2. The service providers
The service providers will be engaged via a series of interviews and instructional sessions.
The refugees will be engaged via existing contacts that they can trust.This project involved
the following participants in one or more phases (planning, consultation, reporting);

Bass Coast Regional Health – Dental Health, Emergency Department, Family Resource
Centre

Bass Coast Community Health Service – Refugee Health Nurse

Gippsland Multicultural Service – Bass Coast Settlement Worker

GPA South Gippsland (Division of General Practice) – Immunisation, Mental Health and
Practice Nurse program workers

Mitchell House Community House – refugee support volunteers

South Gippsland Family Medicine – Practice Manager

Wonthaggi Medical Group – Practice Manager

Bass Coast Adult Education Centre – ‘English as Second Language’ Training Providers
South Coast PCP Service Coordination Case Study September 2010
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Methodology and approach
The project methodology involved the following steps:
1. Planning and preparation
a. Literature Review, Consultation with partners, completion of project brief and
plan and initial engagement of key stakeholders
Identification of organisations linked with refugees included:
Government agencies:
 Department of Immigration and Citizenship (DIAC)
Primary Settlement Services
 Gippsland Multicultural Service (GMS) – settlement worker
 Local Refugee Settlement Committee
 Victorian Foundation for the Survivors of Torture / Foundation House
Health Services

Bass Coast Community Health Service
- Refugee Health Nurse
- Maternal and Child Health Nurse
- Allied Health

Bass Coast Regional Health
- Family Resource Centre (trauma counselling)
- Accident and Emergency (first line and after hours emergency care)
- Inpatient services (medical/surgical, obstetric)
- Outpatient services (specialist AHP, nursing services)
- District Nursing services
- Public Dental Health Service
- Allied Health

GP Practices
- Wonthaggi Medical Group
- South Gippsland Family Medicine
Pharmacists in Wonthaggi
South Coast Primary Care Partnership
GPA South Gippsland (Division of General Practice)
Opticians
Tertiary Hospital Specialist Clinics (Latrobe Regional Hospital (amputee service),
infectious diseases, TB clinics, psychiatry, oncology)





English Language Centre

Bass Coast Adult Education Centre

Chisholm Institute of TAFE

Wonthaggi Secondary College

Wonthaggi North Primary School
Local Government

Bass Coast Shire Council
Housing Services

Friendly real-estate agents
Employment

Centrelink

Job network agencies
Social/ Community Support

Victoria Police driver education program

Mitchell House – Community House

Volunteer support and sponsors of refugees

Australian Red Cross, St Vincent De Paul, Salvation Army, local churches.
South Coast PCP Service Coordination Case Study September 2010
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Sport and Recreation – GippSport, Bass Coast YMCA.
b. Development of interview schedule and data collection tools
A set of questions were developed based on the Health West Refugee Health Service
Coordination guide and validated for local relevance with the manager of the BCRH Family
Resource Centre.
Interviews were undertaken with agencies to identify what services they provide for
refugees. Interview content included an
 introduction of the refugee service coordination project;
 assessment of current services provided by the stakeholder;
 their knowledge of other services available to refugees in the Bass Coast
 their perceptions/experiences related to gaps in health services for refugees
 their suggestions for improving the service coordination pathway for refugees and for
health services.
2. Consultation phase
a. Conduct individual interviews
Interviews were undertaken with 12 key stakeholders via face to face interview (10),
telephone interview (1) or written response (1). Results from interviews were collated in
this spreadsheet.

SCPCP Refugee
Health Mapping - Interview Data 2009
The stakeholders interviewed:
Bass Coast Adult Education Centre - English as a Second Language Teacher;
Bass Coast Community Health Service – Refugee Health Nurse Coordinator;
Bass Coast Regional Health
o Family Resource Centre Manager,
o Dental Health Service – Manager;
o Emergency Department - coordinator;
GPA South Gippsland (Division of General Practice)
o Mental Health Program Coordinator;
o Immunisation Program Coordinator;
Wonthaggi Medical Group – Practice Nurse Manager
South Gippsland Family Medicine – Practice Nurse Manager;
Mitchell House Neighbourhood House - Coordinator
3. Data analysis and reporting
a. Review of findings and preparation of report
b. Dissemination of findings and report
http://www.southcoastpcp.org.au/index.php/publications/265-refugee-healthmapping-in-bass-coast-case-study-2010
4. Project Evaluation
South Coast PCP Service Coordination Case Study September 2010
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Results
Service
improvement
and innovation
This project is essentially a scoping exercise to provide data and
feedback to service providers regarding the quality of their services,
specifically accessibility and cultural appropriateness, to the refugees. It
is therefore a preliminary, but necessary, step to providing baseline
evidence for change and service improvements.
Providing data regarding gaps in service coordination between providers,
and engaging those providers in more effective collaborations through
the existing Bass Coast Settlement network enables improvements in
health and social outcomes, refugees’ experiences of the local service
systems and supports improved commitment from the providers to
prioritising service coordination.
Opportunities for Service System and Practice Improvement
Strengthening connections between other services and for providers to
commit to on-going collaboration beyond the initial six months funded by
the IHSS is necessary to sustain accessible and coordinated services.
Cultural training is needed to improve levels of cultural awareness in
health care teams.
Outcomes
Project phases were completed according to defined time line and
budget.
12 of the 14 stakeholders identified as key sources of information were
effectively engaged.
Data in all fields of the interview framework was accurately and readily
provided by the service providers.
Project tasks were completed and results of the consultations were
disseminated consistent with the project plan.
Project objectives were achieved.
Status and
sustainability
SCPCP received a small amount of non-recurrent funding for Refugee
Health in 2009 that was insufficient to cover the costs of this project.
Whilst there is no further capacity for the PCP to take responsibility for
driving necessary changes in relation to refugee health, the project has
provided information and insights to the Bass Coast Settlement
committee which is composed of the health service providers and has a
specific mandate to support the refugee community in Bass Coast.
SCPCP will continue to support the on-going work of the settlement
committee, including further research, audit and/or evaluation activities
to build capacity and accountability in these agencies in relation to
monitoring and evaluating impacts and outcomes of any service system
and practice changes they plan to implement that will improve
coordination and quality of services to the Karen Burmese refugees.
Conclusions
Health and refugee services were well engaged in the project and the findings indicated the
services provided to the refugees in Bass Coast are well coordinated given the current level
of funding support. In particular, the links between the services contracted under the
Integrated Humanitarian Settlement Strategy (IHSS)5, which provides for intensive
settlement support for newly arrived humanitarian entrants, were reported as excellent.
http://www.immi.gov.au/living-in-australia/delivering-assistance/government-programs/settlementprograms/ihss.htm
South Coast PCP Service Coordination Case Study September 2010
5
Page 8 of 9
The key factors supporting the successful completion of this project were:






Effective project planning and management;
Utilisation of existing partnership networks for project support;
Effective communication with and engagement of stakeholders;
Comprehensive literature review;
Support from other PCPs in developing the project tools;
Funding from RHNS grant.
There were no key challenges affecting this project due to existing commitment of
stakeholders to support the health and wellbeing of the refugee group.
The key limitation of the project is the financial constraints affecting PCP capacity to act on
findings such as providing cultural training for healthcare workforce.
How activities and improvements will be sustained is dependent on the capacity of the Bass
Coast Settlement committee to implement recommendations arising from the project.
Project findings are relevant to service coordination and workforce development activities of
the South Coast PCP. Future directions will include investigating ways to integrate
strategies for improvement to meet the needs of this (relatively) small group in our
community including resourcing.
References
References have been provided as footnotes throughout this project report.
i
Victorian Foundation for Survivors of Torture 2007: Promoting refugee health. A guide for doctors and other health care providers caring for
people from refugee backgrounds: p24. www.foundationhouse.org.au
ii
‘Strategic Directions for a National Primary Health Care Policy’ 13 September 2007
iii
http://www.dpc.vic.gov.au/CA256D8000265E1A/page/Growing+Victoria+Together
iv
www.dpcd.vic.gov.au/afairervictoria
v
www.dhs.vic.gov.au › Multicultural Strategy
vi
www.health.vic.gov.au/communityhealth/downloads/demand/demand_management_framework_feb08.pdf
South Coast PCP Service Coordination Case Study September 2010
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