They report challenges obtaining timely access to sick visits with primary care doctors and urgent visits with specialists and dentists. Additional barriers that make obtaining unscheduled care challenging include identifying clinics that offer comprehensive interpretation services, accept Refugee Medical Assistance, and are geographically convenient. Scheduling appointments over the phone, specifically automated services, is particularly challenging for refugees with limited English proficiency. On arrival to the ED, the same language barriers create challenges to understanding care received. In addition, the lack of trauma informed care can hinder the appropriate workup and treatment of symptoms. Finally, after obtaining care in any acute care setting, refugees face significant financial risk due to limited understanding of the health insurance system. It is important to highlight that some of the aforementioned barriers to acute outpatient care reported exist among U.S.-born individuals, including geographical and insurance barriers, and difficulty accessing mental and dental services. However, these challenges are exacerbated for refugees due to language and cultural barriers. The U.S. healthcare system is new and often quite different from health systems refugees have used in the past, adding an extra layer of complexity to understand. The lack of interpretation services limits already limited resources such as appointments with specialists, dentists, and mental health providers. Additionally, refugees have unique mental healthcare needs given their history of trauma that adds an additional challenge when identifying appropriate mental health services. There is limited existing data on the utilization of acute care services by refugees in the U. S.
In Australia a study evaluating the use of emergency services by refugees suggested that some refugees know how to call for emergency help,weed drying room yet have significant fear of calling for help because of security implications faced previously in their home countries.10 In our study, refugees identified knowing how to call 911 if they were ill but did not express fear as a barrier to using this service. It is possible that the study population perceived less fear because the resettlement employees recommended the use of 911. A qualitative study in the U.S. evaluating healthcare barriers of refugees one year post resettlement also identified individual and structural barriers to accessing health services. Barriers included challenges with language, acculturation processes, and cultural beliefs.Similarly, our study found that language and acculturation were significant barriers when accessing health services. Our study differed in that we were specifically focusing on barriers to acute care access and that we identified additional barriers related to health insurance and perceived poor access to prompt outpatient clinic options. Additionally, our results identified the important role of resettlement agencies in addressing these barriers. Notably, our study occurred early in the resettlement process, a time when resettlement agencies are typically more involved, as opposed to one year after resettlement. Respondents identified several areas for improvement to reduce barriers to accessing care for newly arrived refugees . Areas for improvement within the acute care system include establishing partnerships with resettlement/post resettlement agencies to assist with triage of refugees with acute conditions, and developing specific protocols that may help resettlement employees direct patients to appropriate levels of care. Finally, respondents recommended incorporating cultural competency and trauma-informed care training for providers. Trauma-informed care is based on the premise that past exposure to trauma can have long-lasting effects on the physical and mental health of patients. Thus, providers and organizations can respond by adopting trauma-informed models of care.
A trauma-informed organization acknowledges that trauma is pervasive, recognizes the signs and symptoms of trauma, and integrates knowledge about trauma into policies, procedures and practices with the goal of avoiding retraumatization.While it is challenging to accurately estimate the number of refugees who have experienced trauma prior to resettlement, estimates suggest that the prevalence rate may be as high as 35%.This does not account for trauma associated with the resettlement process. ED specific approaches of trauma-informed care have been suggested for violently injured patients who have been injured due to violence and are treated in the ED; and some components may be applicable to refugee populations.While more research is needed to establish trauma-informed models of care for refugees in the ED, providers should acknowledge a patient’s history of trauma, ongoing signs and symptoms, and avoid practices that may result in retraumatization. A major theme in our interviews was the importance of interpretation services. Refugees and resettlement employees describe challenges at all points of acute care access due to language barriers and a lack of appropriate interpretation services. Revisions to the Affordable Care Act in 2016 mandated that healthcare facilities must offer qualified interpreters to limited English proficient patients and the 2010 Joint Commission standards also require qualified interpreter services in hospital settings.However, patients with LEP have worse clinical outcomes and receive a lower quality of care.18 In the ED formal interpretation should be offered to all patients who do not identify English as their primary language, and operation teams should ensure interpretation services are embedded throughout a refugee’s ED course, and that all members of the ED team are routinely trained on how to use in-person and phone interpreters. Similarly, clinic teams can ensure that interpretation services are available during clinic visits, but also when refugees call to schedule appointments or ask questions. Another common barrier reported by resettlement employees and refugees is that refugees struggle to understand health insurance, which is also supported in prior studies.More education for refugees was suggested as a potential intervention to address this concern, and may be useful.
However, additional policy changes may be required to avoid insurance-related barriers to accessing care. For example, refugees who live in states without Medicaid expansion have a much smaller chance of enrolling in health insurance once Refugee Medical Assistance ceases.Additionally, it has been reported that in states where Medicaid requires reapplication annually, refugees often have a gap in insurance coverage.A study evaluating health coverage for immigrants suggests that expanding universal coverage may actually reduce net costs for LEP patients by increasing access to primary prevention and reducing emergency care for preventable conditions.For refugees, the cessation of Refugee Medical Assistance after eight months occurs at a difficult time of transition. At six to eight months, cash assistance from the government typically ends as does support from the resettlement agency based on the expectation that refugees are self-sufficient after six to eight months of support.A study evaluating unmet needs of refugees demonstrated that refugees in the U.S. for a longer period of time are more likely to report a lack of health insurance coverage and a delay in seeing a healthcare provider.Policymakers should consider extending Refugee Medical Assistance beyond the first eight months as an additional strategy to improve access to health insurance and ensure stable access to care. Finally, additional research is needed to understand networks of care for refugees. In order to understand ED utilization by refugees and barriers to acute care,drying rack for weed future studies should focus on prospectively following refugees after arrival to identify patterns of use and integration long term. This would then help guide types of interventions at locations where refugees most frequently seek acute care. Systematic identification of refugees in national datasets would assist with understanding variations in patterns of utilization between different regions and identifying areas of particular importance. We obtained the data from this study from one city. This limits the generalizability as results may be specific to the refugee experience in this location and healthcare system. However, our sample engaged refugees from a variety of countries, representing the current distribution of refugees resettled to locations throughout the country. This study did not specifically evaluate differences in access to acute care barriers for refugees based on country of origin, gender, educational, cultural, or economic background; however, all of these factors may influence experiences and are important to consider in future studies. Interviews with refugees occurred at a refugee clinic affiliated with a local resettlement agency and did not include refugees without acces to care and services.
Similarly, resettlement agency employees were recruited by the study team, largely consisting of physicians. Interviews with refugees were conducted mostly within three months of their arrival, thus only targeting newly arrived refugees. Barriers to access may differ at different stages of the resettlement process. However, this early period is likely to be the most vulnerable time with significant language, acculturation, and financial challenges. In addition, refugees typically see a physician within 30 days of arrival in the U.S. Many resettlement agencies work with specific clinics to meet this goal, making this the optimal time to capture a diverse population receiving care at one location. Some members of the study team had significant experience working at the refugee clinic and may have been influenced by potential biases from previous work with refugees, specifically when identifying themes. To counter these potential biases, members of the study team included individuals who did not work at the refugee clinic. Transcripts were double coded by both a clinic and non-clinic investigator and reviewed by a non-clinic investigator. Additionally, the use of interpreters may have altered responses from refugee patients. In some languages, a direct translation for specific words or meanings may not exist and as a result may be translated in a meaning that is different than what was intended. Finally, as with all qualitative studies, results generate hypotheses from the experience of the participants rather than testing or measuring a hypothesis. The Joint Commission, other medical governing agencies, and various hospital policies mandate that certain screening questions be asked of all patients who come through the emergency department for evaluation. Before a patient has even seen a physician, they have likely been asked dozens of screening questions as part of the triage or nursing assessment. Screening questions are often implemented with good intentions and some questions serve as public health screening where the ED acts as a safety net.The downstream consequences of adding on numerous questions to the ED stay are often not considered. There is the potential for a significant amount of nursing time to be used administering assessments. Additionally, the purpose of triage is to identify and prioritize patients who require immediate treatment over those who do not. The required screening questions often have an unclear benefit on determining triage acuity and on the care that the patient receives in the ED. In many instances the addition of screening questions is based on rudimentary studies that do not examine clinical outcomes or costs.4 Screening questions can add time to the triage process and ED wait time, and take nurses away from performing more direct patient care. While any individual question may not take long to ask, when you multiply it by the tens of thousands of patients who pass through the ED and the expanding number of screening questions, it quickly adds up to a significant amount of time. Our objective was to analyze the time nursing spent conducting standardized nursing screens and calculate the corresponding time cost.This is a cursory look at the potential monetary and time costs of standardized screening questions in the ED. The calculated values directly affect time and cost efficiency in the ED process and could potentially be redirected to more direct patient care. For just the five observed triage questions alone, we estimated the nursing time cost to our institution to be $20,675.50. This time cost would be significantly increased if we examined additional triage and nurse screening questions. Furthermore, this is just the time spent in a single ED. If all 136.9 million adult ED visits in the U.S. included the five studied questions the screening would take 964,354 hours to complete.5 This equates to $33.8 million in nursing costs annually. The required screening questions are often unrelated to the patient’s chief complaint and have a debatable impact on the medical management in the ED. Questions that may impact care, such as medication allergies, are typically asked by multiple medical providers during the ED visit, and redundancy leads to additional wasted time and cost. It is unclear whether the standardized questions are suitable for triage where the goal is to identify and prioritize patients who require immediate treatment over those who do not.