Hospital-based spiritual care: what matters to patients?

Demographic changes in Australia have led to an increase in both religious diversity and the number of people who do not nominate a faith affiliation at hospital admission. Models of chaplaincy have shifted from clerical and largely male to an increasingly skilled and diverse spiritual care workforce appointed directly by health services. This study uses survey and in-depth interview methods at an inner-city Australian hospital to examine patient preferences for hospital chaplaincy provided by faith communities, and the importance of faith affiliation compared to other spiritual care provider characteristics. Survey results indicate that of 110 respondents, a high proportion (74%) prefer spiritual care to be provided by a person of the same faith. However, when considered relative to other characteristics, faith affiliation was not as important as kindness, listening skills and a non-judgmental attitude. Our findings have implications for workforce planning and educating. Further research in different settings and with different populations will make the findings more generalizable.

OPTIMISE: a pragmatic stepped wedge cluster randomised trial of an intervention to improve primary care for refugees in Australia.

OBJECTIVES: To examine whether primary care outreach facilitation improves the quality of care for general practice patients from refugee backgrounds. DESIGN: Pragmatic, cluster randomised controlled trial, with stepped wedge allocation to early or late intervention groups. SETTING, PARTICIPANTS: 31 general practices in three metropolitan areas of Sydney and Melbourne with high levels of refugee resettlement, November 2017 - August 2019. INTERVENTION: Trained facilitators made three visits to practices over six months, using structured action plans to help practice teams optimise routines of refugee care. MAJOR OUTCOME MEASURE: Change in proportion of patients from refugee backgrounds with documented health assessments (Medicare billing). Secondary outcomes were refugee status recording, interpreter use, and clinician-perceived difficulty in referring patients to appropriate dental, social, settlement, and mental health services. RESULTS: Our sample comprised 14 633 patients. The intervention was associated with an increase in the proportion of patients with Medicare-billed health assessments during the preceding six months, from 19.1% (95% CI, 18.6-19.5%) to 27.3% (95% CI, 26.7-27.9%; odds ratio, 1.88; 95% CI, 1.42-2.50). The impact of the intervention was greater in smaller practices, practices with larger proportions of patients from refugee backgrounds, recent training in refugee health care, or higher baseline provision of health assessments for such patients. There was no impact on refugee status recording, interpreter use increased modestly, and reported difficulties in refugee-specific referrals to social, settlement and dental services were reduced. CONCLUSIONS: Low intensity practice facilitation may improve some aspects of primary care for people from refugee backgrounds. Facilitators employed by local health services could support integrated approaches to enhancing the quality of primary care for this vulnerable population. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12618001970235 (retrospective).

Improving access to refugee-focused health services for people from refugee-like backgrounds in south-eastern Melbourne through the education sector.

People from refugee-like backgrounds living in Australia face substantial health challenges that benefit from access to health and social services. Many people from refugee-like backgrounds have frequent contact with education sector staff, who have the potential to act as conduits to health and social services. The aim of this project was to improve access to refugee-focused health services for people from refugee-like backgrounds in south-eastern Melbourne by codesigning and delivering a 1-day education forum to education sector staff. Evaluation of the forum used mixed-methods analysis of data from pre-post and follow-up surveys (n=11; administered before, immediately after and 1 month after the forum respectively), post-forum interviews (n=4) and one school's referral records. The forum improved attendees' refugee-focused health service referral knowledge, confidence and behaviour. This was supported by the qualitative findings of high staff motivation, high forum satisfaction and evidence of outcome sustainability. Education staff are an important complement to an integrated model of health care for recently resettled people from refugee-like backgrounds. These results show that a straightforward local intervention can improve the ability of education staff to act as conduits to health services, increasing access to health services for people from refugee-like backgrounds.

Building quality chronic illness care: implementation of a web-based care plan.

Structured, multidisciplinary approaches to chronic disease management (CDM) in primary care, supported by eHealth tools, show improved clinical outcomes, yet the uptake of eHealth tools remains low. The adoption of cdmNet, an eHealth tool for chronic disease management, in general practice settings, was explored. This was a qualitative case study in three general practice clinics in Melbourne, Australia. Methods included non-participant observation, reflexive note taking and semi-structured interviews with GPs, non-GP clinical staff, administrative staff and patients with chronic conditions. Data were analysed iteratively and results were reviewed at regular team meetings. Findings highlighted the significance of clinical and organisational routines in determining practice readiness for embedding innovations. In particular, clinical routines that supported a structured approach to CDM involving team-based care, allocation of resources, training and leadership were fundamental to facilitating the adoption of the eHealth tool. Non-GP roles were found to be key in developing routines that facilitated the adoption of cdmNet within a structured approach to CDM. Practice managers, administrators and clinicians should first focus on routinising processes in primary care practices that support structured and team-based processes for CDM because without these processes, new technologies will not be embedded.

The OPTIMISE project: protocol for a mixed methods, pragmatic, quasi-experimental trial to improve primary care delivery to refugees in Australia.

BACKGROUND: Australia is one of many nations struggling with the challenges of delivering quality primary health care (PHC) to increasing numbers of refugees. The OPTIMISE project represents a collaboration between 12 organisations to generate a model of integrated refugee PHC suitable for uptake throughout Australia. This paper describes the methodology of one component; an outreach practice facilitation intervention, directed towards improving the quality of PHC received by refugees in Australian general practices. METHODS: Our mixed methods study will use a cluster stepped wedge randomised controlled trial design set in 3 urban regions of high refugee resettlement in Australia. The intervention was build upon regional partnerships of policy advisors, clinicians, academics and health service managers. Following a regional needs assessment, the partnerships reached consensus on four core areas for intervention in general practice (GP): recording of refugee status; using interpreters; conducting comprehensive health assessments; and referring to refugee specialised services. Refugee health staff trained in outreach practice facilitation techniques will work with GP clinics to modify practice routines relating to the four core areas. 36 general practice clinics with no prior involvement in a refugee health focused practice facilitation will be randomly allocated into early and late intervention groups. The primary outcome will be changes in number of claims for Medical Benefit Service reimbursed comprehensive health assessments among patients identified as being from a refugee background. Changes in practice performance for this and 3 secondary outcomes will be evaluated using multilevel mixed effects models. Baseline data collection will comprise (i) pre-intervention provider survey; (ii) two surveys documenting each practices' structure and approaches to delivery of care to refugees. De-identified medical record data will be collected at baseline, at the end of the intervention and 6 and 12 months following completion. DISCUSSION: OPTIMISE will test whether a regionally oriented practice facilitation initiative can improve the quality of PHC delivered to refugees. Findings have the potential to influence policy and practice in broader primary care settings. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12618001970235 , 05/12/2018, Retrospectively registered. Protocol Version 1, 21/08/2017.

A systematic review of studies with a representative sample of refugees and asylum seekers living in the community for participation in mental health research.

BACKGROUND: The aim was to review the literature to identify the most effective methods for creating a representative sample of refugee and asylum seeker groups living in the community to participate in health and mental health survey research. METHODS: A systematic search of academic and grey literature was conducted for relevant literature with 'hidden' groups published between January 1995 and January 2016. The main search used Medline, PsycINFO, EMBASE, CINAHL and SCOPUS electronic databases. Hidden groups were defined as refugees, asylum seekers, stateless persons or hard/difficult to reach populations. A supplementary grey literature search was conducted. Identified articles were rated according to a created graded system of 'level of evidence for a community representative sample' based on key study factors that indicated possible sources of selection bias. Articles were included if they were assessed as having medium or higher evidence for a representative sample. All full-text papers that met the eligibility criteria were examined in detail and relevant data extracted. RESULTS: The searches identified a total of 20 publications for inclusion: 16 peer-reviewed publications and four highly relevant reports. Seventeen studies had sampled refugee and asylum seekers and three other hidden groups. The main search identified 12 (60.0%) and the grey search identified another eight (40.0%) articles. All 20 described sampling techniques for accessing hidden groups for participation in health-related research. Key design considerations were: an a priori aim to recruit a representative sample; a reliable sampling frame; recording of response rates; implementation of long recruitment periods; using multiple non-probability sampling methods; and, if possible, including a probability sampling component. Online social networking sites were used by one study. Engagement with the refugee and asylum seeker group was universally endorsed in the literature as necessary and a variety of additional efforts to do this were reported. CONCLUSIONS: The strategies for increasing the likelihood of a representative sample of this hidden group were identified and will assist researchers when doing future research with refugee groups. These findings encourage more rigorous reporting of future studies so that the representativeness of samples of these groups in research can be more readily assessed.

The PULSAR primary care protocol: a stepped-wedge cluster randomized controlled trial to test a training intervention for general practitioners in recovery-oriented practice to optimize personal recovery in adult patients.

BACKGROUND: General practitioners (GPs) in Australia play a central role in the delivery of mental health care. This article describes the PULSAR (Principles Unite Local Services Assisting Recovery) Primary Care protocol, a novel mixed methods evaluation of a training intervention for GPs in recovery-oriented practice. The aim of the intervention is to optimize personal recovery in patients consulting study GPs for mental health issues. METHODS: The intervention mixed methods design involves a stepped-wedge cluster randomized controlled trial testing the outcomes of training in recovery-oriented practice, together with an embedded qualitative study to identify the contextual enablers and challenges to implementing recovery-oriented practice. The project is conducted in Victoria, Australia between 2013 and 2017. Eighteen general practices and community health centers are randomly allocated to one of two steps (nine months apart) to start an intervention comprising GP training in the delivery of recovery-oriented practice. Data collection consists of cross-sectional surveys collected from patients of participating GPs at baseline, and again at the end of Steps 1 and 2. The primary outcome is improvement in personal recovery using responses to the Questionnaire about the Process of Recovery. Secondary outcomes are improvements in patient-rated measures of personal recovery and wellbeing, and of the recovery-oriented practice they have received, using the INSPIRE questionnaire, the Warwick-Edinburgh Mental Well-being Scale, and the Kessler Psychological Distress Scale. Participant data will be analyzed in the group that the cluster was assigned to at each study time point. Another per-protocol dataset will contain all data time-stamped according to the date of intervention received at each cluster site. Qualitative interviews with GPs and patients at three and nine months post-training will investigate experiences and challenges related to implementing recovery-oriented practice in primary care. DISCUSSION: Recovery-oriented practice is gaining increasing prominence in mental health service delivery and the outcomes of such an approach within the primary care sector for the first time will be evaluated in this project. If findings are positive, the intervention has the potential to extend recovery-oriented practice to GPs throughout the community. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry ( ACTRN12614001312639 ). Registered: 8 August 2014.

Rites of passage: improving refugee access to general practice services.

BACKGROUND: Refugees in Australia experience barriers in accessing healthcare services. The aim of this study was to analyse the factors influencing Afghan refugees' access to general practice. METHODS: A qualitative study on a single general practice in south-east Melbourne in 2013 was conducted. Data were collected using individual, semi-structured interviews and field observations. Data were analysed thematically and informed by the Penchansky and Thomas concept of access. RESULTS: The general practice utilised multiple strategies to improve access for refugees. Nevertheless, persistent barriers included language and cultural differences at reception, difficulties with transport to the practice, long wait times and the cost of care. DISCUSSION: This case study highlights the benefits of providing affordable, co-located, culturally responsive services with integrated interpreter and settlement agency support. Increasing the use of interpreters and translated materials at reception, and improving the coordination of patient transport assistance could enhance refugees' access to general practice.

Importance of community engagement in primary health care: the case of Afghan refugees.

Refugees can experience problems accessing and utilising Australian primary health care services, resulting in suboptimal health outcomes. Little is known about the impact of their pre-migration health care experiences. This paper demonstrates how the Afghan pre-migration experiences of primary health care can affect engagement with Australian primary care services. It considers the implications for Australian primary health care policy, planning and delivery. This paper is based on the international experiences, insights and expert opinions of the authors, and is underpinned by literature on Afghan health-seeking behaviour. Importantly, Afghanistan and Australia have different primary health care strategies. In Afghanistan, health care is predominantly provided through a community-based outreach approach, namely through community health workers residing in the local community. In contrast, the Australian health care system requires client attendance at formal health service facilities. This difference contributes to service access and utilisation problems. Community engagement is essential to bridge the gap between the Afghan community and Australian primary health care services. This can be achieved through the health sector working to strengthen partnerships between Afghan individuals, communities and health services. Enhanced community engagement has the potential to improve the delivery of primary health care to the Afghan community in Australia.

A narrative synthesis of the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination.

INTRODUCTION: Refugees have many complex health care needs which should be addressed by the primary health care services, both on their arrival in resettlement countries and in their transition to long-term care. The aim of this narrative synthesis is to identify the components of primary health care service delivery models for such populations which have been effective in improving access, quality and coordination of care. METHODS: A systematic review of the literature, including published systematic reviews, was undertaken. Studies between 1990 and 2011 were identified by searching Medline, CINAHL, EMBASE, Cochrane Library, Scopus, Australian Public Affairs Information Service - Health, Health and Society Database, Multicultural Australian and Immigration Studies and Google Scholar. A limited snowballing search of the reference lists of all included studies was also undertaken. A stakeholder advisory committee and international advisers provided papers from grey literature. Only English language studies of evaluated primary health care models of care for refugees in developed countries of resettlement were included. RESULTS: Twenty-five studies met the inclusion criteria for this review of which 15 were Australian and 10 overseas models. These could be categorised into six themes: service context, clinical model, workforce capacity, cost to clients, health and non-health services. Access was improved by multidisciplinary staff, use of interpreters and bilingual staff, no-cost or low-cost services, outreach services, free transport to and from appointments, longer clinic opening hours, patient advocacy, and use of gender-concordant providers. These services were affordable, appropriate and acceptable to the target groups. Coordination between the different health care services and services responding to the social needs of clients was improved through case management by specialist workers. Quality of care was improved by training in cultural sensitivity and appropriate use of interpreters. CONCLUSION: The elements of models most frequently associated with improved access, coordination and quality of care were case management, use of specialist refugee health workers, interpreters and bilingual staff. These findings have implications for workforce planning and training.