Yale Refugee Health Program Provides Medical Home for Refugees

Yale School of Medicine (YSM) students and faculty play a key role ensuring that the approximately 250 refugees who arrive annually to Greater New Haven receive high quality health care and guidance as they transition to a new health care system. The Yale Refugee Health Program (YRHP), which seeks to provide a medical home for refugees, coordinates these efforts.

The YRHP collaborates with Integrated Refugee and Immigrant Services (IRIS), a nonprofit refugee resettlement agency that has welcomed more than 5,000 refugees to Connecticut since 1982. The Adult Refugee Clinic, a central part of YRHP, was created in 2009, when a third-year Traditional Internal Medicine resident at YSM, Teeb Al-Samarai, volunteered at IRIS and saw that the health care pathway for refugees was not well-defined.

With YRHP, there now is a clear and supportive path. The Adult Refugee Clinic, which operates on Wednesday nights, and the Pediatric Refugee Clinic, which operates Friday afternoons, service all refugees and other immigrants who IRIS resettles in the New Haven area, and establishes longitudinal care for them at a Yale New Haven Hospital primary care site.

Leslie Koons, IRIS’s health promoter, says “IRIS is fortunate to have the relationship we do with an established clinic,” explaining that many refugee agencies cobble together appointments to ensure the strongly-recommended medical appointments, within 30 days of arrival, occur. Moreover, she believes IRIS benefits from Yale’s expertise addressing the particular health challenges of refugees, and its status as an academic medical center allows doctors to spend more time with patients. Koons shares IRIS health care responsibilities with IRIS healthcare coordinator Fereshteh Ganjavi, who brings cultural expertise to IRIS, as a refugee who has lived in several countries in the Middle East and Asia, as well as five months in refugee camps in Slovakia.

Internal medicine residents conduct the screening health exams in the Adult Refugee Clinic. While this is a required part of the program, many residents volunteer additional hours in the clinic, as well as providing longitudinal refugee primary care.

Prior to the Trump administration’s immigration policies taking effect, IRIS typically brought about four new patients a week to the clinic. That has dropped to around two a week. The clinic has responded by shifting resources and offering additional follow-up services. Koons says it is advantageous when the doctor the patient saw in clinic ends up being the primary care physician, removing the need to start over with a new provider. “We are so fortunate to have the team at Yale,” she says. “Our clients are getting the best care.”

The health care needs of refugees vary depending on numerous factors, including their home country, previous access to health care, and possible physical and psychological effects of forced migration. For example, Aniyizhai Annamalai, MBBS, MD, associate professor of psychiatry, and director of the Adult Refugee Clinic, notes that while they still see infectious diseases in refugees, especially from parts of Africa, they frequently encounter chronic medical conditions. She adds that the overall rate of infectious diseases is low, in part because the International Office of Migration requires rigorous health screening before someone can enter the country.

Over time there are shifts in refugee patterns; for example, there was a spike in refugees from Syria during the refugee crisis in 2016, followed by few Syrian refugees after Trump administration policies prevented them from entering the country. This can cause shifts in medical issues. However, as Bryan Brown, MD, instructor of medicine, medical education fellow, long-time YRHP volunteer, and interim director for the Adult Refugee Clinic, points out, many chronic health issues consistent across countries, such as high blood pressure and diabetes, are sometimes triggered by refugee camp experiences.

Annamalai estimated that about one-quarter of the patients need mental health care. Some are suffering from post-traumatic stress disorder from the issue that led them to leave their country. Others feel isolated from their dislocation and language barrier, with related mental health issues. Maya Prabhu, MD, LLB, associate professor of psychiatry, volunteers in the clinic and supervises psychiatry trainees.

There is significant interest in volunteering for YRHP, for a variety of reasons. For example,

MD-PhD student Christina Lin’s grandparents fled China as war refugees; their stories motivate her to pay it forward. She also believes the experience will be valuable given her plan to go into internal medicine.

Volunteer roles are dependent on experience. During their first 18 months at YSM, MD students, as well as YSM Physician Associate and Yale School of Nursing students, can be Student Health Navigators; they also can create and teach the Health Literacy Curricula. Once YSM students have completed a year of clinical rotations, they may see patients, with a faculty preceptor, as part of the Wednesday clinic. The areas of greatest medical need for refugees are navigating the health system, care coordination, and longitudinal primary care.

Student navigators help patients and/or their families needing follow-up care, who have challenges navigating the health care system because of a language or cultural barrier. AsBrown describes it, the problems with our nation’s health care system are often more pronounced when refugee challenges are layered on, creating a “primary care stress test.” Koons says because IRIS has a small staff and cannot access the EPIC records system, navigators are valuable.

Koons also views the health literacy classes, on such recurring topics as nutrition and health care navigation, as well as specialty courses, as critical. Koons explains that some refugees’ home countries do not focus on preventative care, so they have not been socialized on why, for example, colonoscopy screening is important. “Until refugees understand why such appointments matter, it is hard to encourage them to attend,” she says.

YRHP, including director of the Pediatric Refugee clinic, Camille Brown, and Yale collaborators, mainly the Department of Internal Medicine Office of Global Health, annually organize a one-day Yale Health Conference which approximately 100-150 Connecticut clinicians and clinicians-in-training attend to learn about the mental and physical health needs of refugees. Yale also is a leader in the refugee health field nationally. Annamalai serves on the board of the Society of Refugee Healthcare Providers, formed in 2015 to educate, coordinate, and provide a forum for best practices in refugee health care. Annamalai, with contributions from others in YRHP, is editing the second edition of a textbook on refugee health, to be published this fall, which she describes as “probably the only one of its kind.” It will serve as a clinical reference book.