Community Worker Refugee Transition to General Practice – Coffs Harbour

Refugee communities experience significant barriers to accessing ongoing primary healthcare, including language and cultural barriers, unfamiliarity with the Australian health system, trauma-related needs, and difficulty finding general practices with the capacity and confidence to provide culturally responsive care. As a result, many refugee patients experience fragmented care and poorer health outcomes. This project addresses these needs by building the capability of mainstream general practices to provide high-quality care for refugee patients, supporting safe and supported transitions from the Refugee Health Service into ongoing general practice care, strengthening collaboration between services, and improving access to sustainable, equitable primary healthcare across the region.

The project uses a collaborative, capacity-building approach to support the transition of refugee patients from the Refugee Health Service into mainstream general practice. A dedicated Social Worker works with participating practices to coordinate patient transitions, strengthen referral pathways, address barriers to care, and provide ongoing support. General practices receive education, mentoring and practice support funding to build their capability to deliver culturally responsive care, while community outreach helps improve awareness of available health services and how to access them.

The project has been designed and delivered in partnership with the Refugee Health Service (RHS), which has extensive experience supporting refugee communities and understanding their health needs. The model has been informed by the RHS’s experience of the challenges refugee patients face when transitioning to mainstream general practice and by ongoing collaboration with participating general practices to identify barriers and practical solutions. Community outreach and education activities with refugee and multicultural communities also provide opportunities to hear directly from community members and adapt the project to better meet their needs. Regular engagement between HNC, the RHS and participating practices supports continuous refinement of the program throughout implementation.

– establishing referral pathways to and from RHS to ensure a seamless and efficient process for clients

– coordinating community outreach and education sessions with refugee communities to raise awareness of health care services and how to access them

– connecting refugee patients and their families to necessary healthcare services

– assisting refugees to navigate the health system

– advocating for the needs of refugee patients

– providing culturally sensitive support and generally bridging communication gaps between refugee and providers.

– working with HNC in the collection of data to evaluate the program and make improvements where identified.

– Improve access to ongoing, culturally responsive primary healthcare for refugee patients.

– Build the capability and confidence of mainstream general practices to care for refugee patients.

– Support safe and coordinated transitions from the Refugee Health Service to general practice.

– Develop and evaluate a sustainable model for refugee transition to primary care.

Outcomes

– Refugee clients can access quality healthcare from community GPs with support from the social worker

– Social worker and community GPs address barriers refugee clients may face when receiving healthcare

– Community staff improve their knowledge, behaviours, and practices to better support community members in understanding and accessing health service

– Capability of general practices is enhanced to deliver quality, culturally appropriate healthcare to refugee clients