PRAIDA – Montreal Programme régional d’acceuil et d’intégration des demandeurs d’asile
Lavanya Narasiah MD/MSc PRAIDA medical health services CSSS de la Montagne site Côtes-des-Neiges Montreal 2011
Disclosure No conflict of interest
Asylum seeker
Ü Person who requests refugee status after arrival in Canada Ü Refugee status claim based on fear of returning to their
country of origin
Ü Must defend their file in front of Immigration and Refugee
Board of Canada (IRBC) to obtain recognition of their status
Ü Length of process: several months to years
DEMANDEURS D’ASILE ASYLUM SEEKERS CANADA Jan. – Déc. 2010
15 263
TOTAL: 23 157
4 890 1891
QUÉBEC
ONTARIO
CB/Yukon
1113
AUTRES
Source: SSOBL/FOSS DIVISION DU RENSEIGNEMENT - RÉGION DU QUÉBEC INTELLIGENCE DIVISION – QUEBEC REGION
A.S. Quebec vs Canada Year
Quebec
Canada
%
2006
6880
22 887
30%
2007
9939
28 179
36%
2008
12874
36 783
35%
2009
9096
33 251
28%
2010
4890
23 157
22%
Bulletin statistiques du CISR
Canada 2010 Top 10 countries for A.S. 1. 2. 3. 4. 5.
Hungary China Colombia Mexico Sri Lanka
6. Haiti 7. Nigeria 8. USA 9. St-Vincent 10. El Salvador
10 PAYS EN TÊTE DE LISTE TOP 10 COUNTRIES Québec
Jan. Déc. 2010
754
Haiti Colombie
375
Inde
265
Mexique St-Vincent
234
USA
229
Hongrie
SOURCE: SSOBL/FOSS
245
195
RD Congo
142
Djibouti
140
El Salvador
136 DIVISION DU RENSEIGNEMENT - RÉGION DU QUÉBEC INTELLIGENCE DIVISION – QUEBEC REGION
Health care for A.S. Ü Federal Ü Dispensed by Provincial services Ü Coverage by the Interim Federal Health Program (IFHP) Ü Administered by private company : previously FAS (Funds
Administrative Service) but since Jan. 2011 : Medavie Blue cross
Interim Federal Health (IFH) Ü Since 1957 Ü Created for humanitarian reasons Ü Temporary coverage for A.S. and refugees during period of
inadmissibility to provincial programs
Ü To insure health care that cannot wait regularisation of status
Ü In theory: essential and urgent health care services Ü In practice: broader array of health care services
IMM1442 - document
Problems accessing health care Ü From the system: -
No knowledge of the IFH program
-
Laborious administrative tasks (procedure, billing...)
-
Communication issues
-
Time constraints
-
Reluctance to accomodate unusual requests
-
Difficulties in providing culturally sensitive and adapted care
-
Prejudice towards patients: non-compliant, somatisation, manipulators…
Problems accessing health care Ü From A.S.: -
Often multiple complex problems
-
Little or no knowledge about rights to services
-
Little or no knowledge on existence or availability of resources (walk-in clinics, 911, info-santé,…)
-
Navigating the system (moving about, booking appointments , F/U…)
-
Understanding and to be understood (language, culture, customs, Rx)
-
Expectations and knowledge regarding the healthcare system (differences in methods of consultation, confidentiality issues, …)
-
Fear of repurcussions (immigration, hearing, community, family…)
-
Identifying issues as medical problems (psychiatry, substance abuse…)
-
Different priorities (legal procedures, work, housing over health)
PRAIDA
Programme régional d’accueil et d’intégration des DA 2 services of PRAIDA ü Social services ( formerly - SARIMM x 50 years) ü Health services ( formerly - Clinique Santé Accueil x > 25 years) CSSS de la Montagne – Côte-des-Neiges • Regional mandate to offer services to asylum seekers Affiliated to our main housing shelter – YMCA Provide expert services and support to public and community organisations Informal network with other services and clinics « IFH Friendly » Role in research, training and awareness
PRAIDA’s clientele Ü Asylum seekers Ü Populations having difficulties in access or status
regularisation:
Ü Information/ orientation Ü Rejected claims; ERAR; humanitarian claim
Ü Consultation for: Ü Persons with defined migration status : Ü Vulnerability/complex needs/no medical coverage Ü Persons between 2 statuses (multiple scenarios, ex: family
help - » permanent resident, breach in sponsorship…) Ü Waiting period Ü Uninsured tourists Ü Persons who stay after visa/permit expired
PRAIDA’s health services – clientele Ü Asylum seekers Ü Our patients with rejected claims; ERAR; humanitarian
claim
Ü If/when possible…consultation for: Ü Populations having difficulties in acces or status regularisation Ü Persons with defined migration status (Vulnerable/complex
needs/no medical coverage)
Ü Persons between 2 status Ü Waiting period
Ü Very rarely: Ü Uninsured tourists Ü Persons who stay after their visa/permit has expired
PRAIDA medical – Model of care Multidisciplinary Team 6 MD part time = < 2 fulltime 1.6 nurses (8 days/10) 1 administrative agent – for referrals Since 2010 – 1 secretary Shared with the CSSS
ü Main Reception hall ü Central/Appointment booking ü Rooms ü 1 employee for billing (immigration/interpreters…) ü Interpreters from the Régie régionale ü PRAIDA Social services (on another floor–team of 18 SW)
Health services of PRAIDA ü Primary health care services and referral center ü Appointments (with F/U – ad regularisation of status) ü Walk-in clinic 2 afternoons/wk (nurses - MD on call) ü Health work-up tailored to the patient (not systematically
done anymore!)
ü Psychiatric consultation and F/U Ü Medical expertise with: survivors of organized crime, victims of
torture and abuse
Ü Partnered psychosocial support with: Ü Social services Ü RIVO (Réseau d'intervention auprès des personnes ayant
subi la violence organisée) Ü Cultural consultation service JGH Ü Transcultural pediatric psychiatry service MCH Ü CSSS Montagne transcultural pedopsychiatry Ü Local NGOs
Profile of services requested by A.S. Ü Acute : respiratory, digestive, dermato, musculo-squelletique Ü Chronic: HTA, DM… Ü Mental health: PTSD, depression, anxiety disorders (40% of
our population)
Ü Infectious: STD/HIV/AIDS, TB, hepatitis, intestinal parasites Ü Pregnancy, contraception Ü Other: medical certificates (hearing, torture report, FGM…)
Prevalence study § Retrospective study : 2000-2004 § Reference: Ouimet M., Munoz M., Narasiah L., Capron V., Correa J. Pathologies courantes chez les demandeurs d’asile : Prévalence et facteurs de risque associés. RCSP 2008 ; 99 (6) : 499-504.
Chief complaint
N
%
Body Pain
73
25,3
Mental Health
66
22,8
Reproductive health
27
9,3
Gastro Enterology
23
8,0
Cardiovascular
17
5,9
Dermatology
13
4,5
Other
13
4,5
Certificate
11
3,8
Endocrinology
11
3,8
Screening
10
3,5
Respirology
8
2,8
HEENT
5
1,7
MSK
4
1,4
Infectious diseases
3
1,0
Ophtalmology
2
0,7
Urology
2
0,7
Vaccination
1
0,3
289
100
Total
Dr. Lavanya Narasiah
Chief Complaints (Prevalence Study, PRAIDA, 2000-2004)
Psychiatric diagnosis
Psychiatric diagnosis 47,1 % : 1. 2. 3. 4. 5. 6.
Depression (22,1%) PTSD (14%) Adjustment disorder (12,5%) Anxiety disorder not PTSD (8,8%) Double diagnosis [mostly depression with PTSD] (37,5%) Other (5,1%)
Dr. Lavanya Narasiah
% positive on total screened Anemia
20,3
Anemie microcytic
9
Eosinophilia
9
Hepatitis B core+
28,4
Hepatitis B core +isolated
5,8
Hepatitis B
HBsAg+
5,1 (14/276)
HBeAg+
0,7 (2/276)
Hepatitis C
3,7 RNA +
1,5
HIV*
2,5
PPD
45,9
O&P
10,4 (Amibe, Giardia, Ankylostoma)
Serology Strongyloides st.
17,3
Serology schistosomiasis †
3,9
Lab work-up
Challenges in organizing care for A.S. Ü Ensuring that A.S. are aware and exercise their rights to
health care services
Ü Make others aware and understand the needs and rights of
A.S. in the health care system (in times of resource limitations + provincial restrictions!)
Ü Ensure knowledge and obligations that professionnals
and institutions have towards this population
Ü Ensure commitment in the concerned establishments
Barriers and challenges- Administrative 1.
Articulation between PRAIDA and CLSC/CSSS : v v v v
2.
Integrated care between medical and social services – done in theory…BUT in reality : v v v
3.
Regional program within an entity having a territorial vocation – different needs! Intrinsic need for autonomy and visibility Efficiency difficult to demonstrate with usual parameters because unique service of its kind Improvement of support clerical/logistics/locals
Virtual relationship … Progressive disassociation and since 2008…rapprochement to CLSC health services! Not under the same administrative direction !
2010: v Computerized records v Switch from FAS to Medavie Blue Cross (Rx; psychotherapy) v Bill C-11 + C-49
Barriers and challenges Loss of medical staff Survival mode functioning 2. Cut backs on: § Primary care (walk-in clinics, access...) § Clientele (irregular migrants...) § Teaching (affiliated to McGill university) § Support / information / education / outreach / flourish and shine § Information sessions and workshops in housing centers (on health care system; women’s health…) § Research 1.
Barriers and challenges 1.
Disproportion between desired mandate and capacity of team v Management of public health crisis - paralyzing!
(varicella – scabies - bed bugs – H1N1….)
2.
Links with surrounding ressources ü
Trying to keep most vulnerable and transfer/refer others v BUT at the mercy of constraints of the system • • • • • •
Provincial shortage of md creation FMP Patient - bonus RAMQ/orphan client list AMP/PREM waiting list SW need interpreters; cultural brokers)
v So function as stopgap and try to palliate these
shortcomings
Future…solutions? Ü Recruiting MD’s !...AND keeping them ! (AMP; PREM) Ü Tools to enable better organisation of care with
adapted clerical support tailored to clientele / logistics
Ü Improving knowledge + understanding of refugee
health care in community health clinics Ü Education/Workshops Ü Teaching students
Ü CCIRH (Canadian collaboration for Immigrant and
Refugee Health)
Ü Canadian guidelines
Ü Better partnerships and service corridors to enable
transferring our non-complex and accepted patients
Future … Ü Maintain our research component to better assert AS needs Ü Developping strategy to educate/sensitize other centers : Ü CSSS --- expand network (workshops-pilot project) Ü Other centers across Quebec (Comité bilan santé 2010) Ü Continue to play the role of experts and «advocacy (CCIRH;
Screening workup for newly arriving immigrants and refugees)
Ü Continue to strenghten partnership Ü Facilitate articulation between the different levels of the
system
Ü Regularly obtain feedback (re: big divide between theory
and pratice)
Ü Support and reinforce respect of rules (ie. access for persons
with IFH coverage)
MERCI !
