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• W2895896844 abstract "In recent years, immigration policy has taken center stage in the political arena. Regulations have been passed; processes have changed, and bans have been placed and lifted. It is not always clear the long-term impact this changing political landscape will have on US citizens or the hundreds of thousands of people trying to immigrate to the United States each year. In times of uncertainty, one thing remains true: people need health care. Medical providers receive training in a myriad of topics related to culturally competent care, but not much of this is traditionally focused specifically on refugee populations. Although many of the same principles apply to this group as other vulnerable populations, there are also distinct differences that need to be considered. This article seeks to highlight these additional considerations that must be made for refugee patients. How and why an individual comes to the United States helps determine their legal status and impacts their ability to receive various health benefits. Understanding the differences between these terms is key to navigating the US health care system with a patient (Table 1).1Immigration terms and definitions involving aliens. Internal Revenue Service. Available at: https://2009-2017.state.gov/j/prm/releases/factsheets/2016/264449.htm. Accessed May 30, 2018.Google Scholar This article focuses on discussion to the refugee population (Box 1).2U.S. Refugee Admissions Program FAQs. US Department of State. Available at: https://www.state.gov/j/prm/releases/factsheets/2018/277838.htm. Accessed May 30, 2018.Google ScholarTable 1Legal status in the United StatesData from Immigration terms and definitions involving aliens. Internal Revenue Service. Available at: https://www.irs.gov/individuals/international-taxpayers/immigration-terms-and-definitions-involving-aliens. Accessed May 30, 2018.TermDefinitionUS nationalAn individual who has ties to outlying possessions of the United States. As of 2018, this only includes American Samoa and the Commonwealth of the Northern Mariana IslandsUS citizenIndividual born in the United States, Puerto Rico, Guam, the US Virgin Islands, or individual whose parent is a US citizenAlienAn individual who is not a US citizen or US nationalImmigrant (lawful permanent resident)An individual granted the right to reside permanently in the United States by the USCISNonimmigrantAn individual who legally resides temporarily in the United StatesUndocumented alienAn alien who has entered the United States illegally, did not obtain the proper documentation or authorization, or has overstayed set time limitationsRefugee statusStatus granted to an individual who left their country seeking refuge or asylum, typically for persecution or fear of persecution. Status if granted before entering the United StatesAsylum statusProtection granted to people who meet the definition of refugee but are already living within the United States or seeking admission at a US port of entryAbbreviation: USCIS, US Citizenship and Immigration Services, a component of the US Department of Homeland Security. Open table in a new tab Box 1Department of Homeland Security's 5 protected groundsTo be considered for refugee status in the US, a well-founded fear of persecution must be met for one of the Department of Homeland Security's (DHS) five protected grounds:•Religion•Political opinion•Race•Nationality•Membership in a particular social group Abbreviation: USCIS, US Citizenship and Immigration Services, a component of the US Department of Homeland Security. To be considered for refugee status in the US, a well-founded fear of persecution must be met for one of the Department of Homeland Security's (DHS) five protected grounds:•Religion•Political opinion•Race•Nationality•Membership in a particular social group A patient who was a refugee once explained to me that it was difficult to assimilate to life in the US because living here was not a dream she had growing up. Moving to the US became a necessity, a choice to live, when it was no longer safe to stay in her home city.—Stephanie L. Neary, PA-C Between 2001 and 2016, almost 900,000 refugees resettled in the United States. Although this number seems large, refugee numbers are very small in comparison to the close to 1 million legal immigrants who come to the United States annually.3Megan Alpert. By the numbers: the United States of refugees. Smithsonian.com; 2017. Available at: https://www.smithsonianmag.com/history/by-numbers-united-states-refugees-180962487/. Accessed May 23, 2018.Google Scholar The process of gaining refugee status by the US Refugee Admissions Program takes an average of 18 to 24 months and includes biographical data collection, a medical screen, an in-person interview, and a joint security screen by the Department of State, the Department of Homeland Security, the National Counterterrorism Center, and the Department of Defense.4Philbrick A.M. Wicks C.M. Harris I.M. Make refugee health care great again.Am J Public Health. 2017; 107: 656-658Crossref PubMed Scopus (15) Google Scholar The United States resettles more refugees than all other nations combined (Box 2).5Annamalai A. Refugee health care: an essential medical guide. Springer, New York2014Crossref Google Scholar The United States does not discriminate or rank individuals during this resettlement process; all individuals, regardless of age, health, or work experience, are considered equally (see Box 2).Box 2Top 5 countries sending refugees to the United States (2001-2016)•Burma•Iraq•Somalia•Bhuatan•Iran •Burma•Iraq•Somalia•Bhuatan•Iran The Cash and Medical Assistance Program is a 100% federally funded program that reimburses states for services, including administrative costs, provided to refugee patients. Individuals must first be determined ineligible for Temporary Assistance for Needy Families and Medicaid before gaining eligibility for Refugee Cash Assistance or Refugee Medical Assistance programs. Patients must apply to their individual state within 8 months of the date of final granting of asylee status or of arrival in the United States as a refugee.6About cash & medical assistance. Office of Child Care | ACF, 2018https://www.acf.hhs.gov/orr/programs/cma/aboutGoogle Scholar After 8 months, individuals must navigate the complexities of the US health care system without the assistance of the Office of Refugee Resettlement (ORR) (Fig. 1). There are many volunteer organizations available to continue assisting refugee patients through this resettlement process, but given the time and intricacy of most cases, there are often lapses in coverage and care. The Health Insurance Marketplace was created under the Patient Protection and Affordable Care Act (PPACA) to provide private health insurance options for individuals who make between 100% and 400% of the federal poverty level (FPL). For a family of 4 in 2018, this range is $24,600 to $98,400.7Federal Poverty Level (FPL)—HealthCare.gov Glossary. HealthCare.gov. Available at: https://www.healthcare.gov/glossary/federal-poverty-level-FPL/. Accessed May 30, 2018.Google Scholar Individuals who qualify are eligible for federally funded tax credits to reduce the cost burden of health insurance premiums. Individuals making below 138% of the FPL in states that expanded Medicaid coverage under PPACA are eligible for Medicaid, while individuals making below 100% of the FPL in states that did not expand Medicaid may be left without coverage.7Federal Poverty Level (FPL)—HealthCare.gov Glossary. HealthCare.gov. Available at: https://www.healthcare.gov/glossary/federal-poverty-level-FPL/. Accessed May 30, 2018.Google Scholar Eligibility also varies based on legal satus in the United States (Table 2).8Find out what immigration statuses qualify for coverage in the Health Insurance Marketplace. HealthCare.gov. Available at: https://www.healthcare.gov/immigrants/immigration-status/. Accessed May 30, 2018.Google ScholarTable 2Health care marketplace eligibilityData from Healthcare.gov. Immigration status and the Marketplace. Available at: https://www.healthcare.gov/immigrants/immigration-status/. Accessed May 30, 2018.Marketplace Eligible?US nationalsYesUS citizensYesImmigrants (lawful permanent residents)YesNonimmigrantsYesUndocumented aliensNoRefugeesYesAsyleesYes Open table in a new tab As mentioned, individuals must undergo a medical examination before being accepted to resettle in the United States. Those who are found to have class A conditions are not permitted to resettle, but certain class A infectious conditions, like tuberculosis, are able to be treated and reclassified to class B, allowing a travel waiver to be granted that outlines any necessary follow-up.5Annamalai A. Refugee health care: an essential medical guide. Springer, New York2014Crossref Google Scholar Examples of class A conditions include tuberculosis, syphilis, gonorrhea, Hansen disease (leprosy), mental disorders with harmful behaviors, and substance abuse.9Volume 8—Admissibility, Part B—Health-related grounds of inadmissibility. USCIS, 2018https://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter2.htmlGoogle Scholar In general, class A conditions are communicable diseases or conditions that are of specific public health significance. Class B typical conditions are those that interfere with an person’s ability to work or care for themselves.5Annamalai A. Refugee health care: an essential medical guide. Springer, New York2014Crossref Google Scholar Individuals traveling from certain regions must also undergo presumptive treatments for common, treatable endemic conditions. Within 30 days of arriving in the United States, it is recommended that every refugee patient receive a comprehensive health screening by a primary care provider. Most refugee patients who did not receive childhood vaccinations started this process as part of their international health screen but require additional vaccinations at specific intervals after arriving in the United States to be considered fully immunized. For children, it is important to be aware of state vaccination requirements; this may delay their ability to enroll in public school. A comprehensive history and physical examination should be performed, with special consideration given to conditions that are not common in the United States but very common in other regions (Boxes 3 and 4).Box 3Recommended screening for all patients•Mental health•Prior abuse or mutilation•CBC•CMP•HIV 1 and 2 antibodies•Vaccine titers•STD•HbA1c•Fasting lipid profileBox 4Specific conditions to consider•Tuberculosis•Thalessemia•Hepatitis B•Strongyloidiasis•Schistosomiasis•B12 deficiency•Lead poisoning •Mental health•Prior abuse or mutilation•CBC•CMP•HIV 1 and 2 antibodies•Vaccine titers•STD•HbA1c•Fasting lipid profile •Tuberculosis•Thalessemia•Hepatitis B•Strongyloidiasis•Schistosomiasis•B12 deficiency•Lead poisoning About 3 pm, I looked at the board and saw my next room, grabbed the superbill and walked in to find a family of 8 sitting across from me. After 6 months of working at a non-English, non-Spanish family medicine clinic serving solely refugee patients, I was used to seeing entire families together. My translator handed me the father’s lab report he had brought from the county hospital and I began reviewing the details. I explained that his cholesterol and blood glucose were elevated and he would need to begin exercising and change his diet and we would continue to monitor. I explained the importance of lifestyle changes and the basis of a healthy, balanced diet. After a few minutes of discussion, the translator interrupted and stated, “He would like to let you know that he and his family came to the US 3 days ago. They are living with his sister and her family of 5, 13 in one apartment. Their family was separated for the past year and just reunited last week in Turkey. He has no job, he does not speak English and brought nothing with him when he and his family came to the US.” In that moment, I realized that I had become numb to my surroundings. I worked with this vulnerable population every day and I had let their struggles become routine because this was the norm in my clinic. I failed to recognize the unique struggles of each patient, of each family, and let this impact the quality and attention given to the patient in front of me. I had been through this difficult transition many times with my patients, I knew we had services and support available, but this was the first time my patient was going through it and I lost sight of that reality. It is easy to get lost in the daily shuffle of life in a clinic, but this encounter changed my persepctive as a provider and remains in the forefront of my mind each time I meet a new patient.—Stephanie Neary, PA-C There are challenges to treating any patient population, and refugee patients are no exception (Fig. 2). From language barriers and lack of transportation to overcrowded housing and untreated chronic medical conditions, there are many factors that confound the traditional patient encounter. Being aware of these factors, discussing them openly with the patient, and knowing the resources available to aid in care are very useful in the resettlement process. Small changes like having female translators available for sensitive gynecologic examinations can help make a patient feel more comfortable and ease anxiety to these often very foreign screenings. Nonemergency medical transportation services are available for most Medicaid beneficiaries and can help patients keep appointments without having to navigate a confusing or nonexistent public transportation system. Most large cities have volunteer refugee assistance organizations to help connect individuals with employers, with English classes, and for securing stable housing. Understanding this network of resources in your own community will help ease the transition for a refugee patient when they present to your clinic (Box 5).10Admissions & arrivals. Refugee Processing Center, 2018http://www.wrapsnet.org/admissions-and-arrivals/Google ScholarBox 5Top 10 refugee native languages (fiscal years 2008-2018)•Arabic•Nepali•Somali•Sqaw Karen•Spanish•Kiswahili•Chaldean•Burmese•Armenian•Farsi •Arabic•Nepali•Somali•Sqaw Karen•Spanish•Kiswahili•Chaldean•Burmese•Armenian•Farsi The ORR offers an online state resource locating service to connect individuals with local volunteer affiliates to aid in the resettlement process.11ORR Network Resources. Office of Child Care | ACF. 2018. Available at: https://www.acf.hhs.gov/orr/resource/orr-network-resources. Accessed May 30, 2018.Google Scholar Nationwide, there are approximately 350 volunteer affiliate organizations working with a group of national nongovernmental agencies all contracted with the Department of State and the Department of Health and Human Services. Together, these groups adhere to a Cooperative Agreement, signed each year, to aid in the initial resettlement process by helping to provide access to basic needs and assist processes such as securing health insurance, food stamps, and social security cards.5Annamalai A. Refugee health care: an essential medical guide. Springer, New York2014Crossref Google Scholar, 11ORR Network Resources. Office of Child Care | ACF. 2018. Available at: https://www.acf.hhs.gov/orr/resource/orr-network-resources. Accessed May 30, 2018.Google Scholar Having a foundational knowledge of refugee populations in your community, common cultural practices, and the local organizations available to help can provide a more smooth transition into the US health care system while still respecting the cultural values of the individual patient." @default.
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• W2895896844 date "2019-01-01" @default.
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• W2895896844 title "Medical Care for Refugee Patients" @default.
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