Measurement is the key to delivering culturally responsive care

Documenting patient diversity would support more tailored, culturally responsive care and better outcomes
 

Mainstream primary health care services play important roles in delivering high quality, affordable care to refugees, and general practitioners are the main providers of health assessments after their arrival. During 2019–20, Australia welcomed more than 11 000 of the 18 750 refugees foreseen for this period by our Offshore Humanitarian Program, before the COVID‐19 pandemic closed our international border.1 Refugees come from diverse backgrounds and have a wide range of acute, chronic and preventive health needs.2 Delivering care to people from refugee backgrounds can be challenging,2,3 and effectively measuring the impact of interventions to enhance care is fundamental.

In this issue of the MJA, Russell and colleagues describe the OPTIMISE trial,4 which assessed the value of practice facilitation for supporting delivery of quality health care to people from refugee backgrounds. The intervention was systems‐focused, recognising the team‐based nature of general practice care by practice administration staff, nurses, and medical practitioners. While the finding that practice facilitation can improve the quality of primary care for this vulnerable population may seem unsurprising, Russell and his colleagues offer invaluable insights for future primary care research. The OPTIMISE project establishes the importance of collecting data on cultural and linguistic diversity, as highlighted in the Federation of Ethnic Communities’ Councils of Australia report, “If we don’t count it… it doesn’t count!”5

The primary outcome in the OPTIMISE trial, Medicare‐billed refugee health assessments for eligible patients, illustrates the current difficulties with data collection. Health assessments are recommended for all patients with refugee‐like backgrounds.6 Beyond documenting their health needs, an assessment is an excellent opportunity for a refugee to establish a positive relationship with their general practice, and follow‐up visits for vaccinations and continuing care can strengthen this connection. The Australian Refugee Health Practice Guide can assist general practices with the health assessment process,7 while other resources can inform the delivery of care for people with specific health problems.6

Refugees are eligible for reimbursement by Medicare of the costs of a health assessment during their first year of settlement in Australia. Determining whether someone has been billed for a health assessment can be extracted from practice records; determining which patients are refugees is more problematic. While some medical software packages offer the possibility of entering “refugee” in diagnostic fields, this label can be perceived as stigmatising.8 Identifying who arrived in Australia during the preceding twelve months is also difficult. Surrogate markers for determining refugee status and date of arrival were described by Russell and colleagues,4 and also noted as limitations.

Capture of basic information regarding the need for language support was equally elusive. Again a surrogate marker was required: use of interpreting services by the practice.4 However, it remained unclear how many patients needed interpreters. Speaking a language other than English at home is not equivalent to needing an interpreter. Other studies have noted that linking health outcomes to the language spoken by a patient would be more meaningful if the need for, and use of, an interpreter were both recorded.9

The OPTIMISE trial opens an important conversation about enabling health services to deliver high quality culturally responsive care. More than one‐quarter of Australian residents were born overseas (26%), of whom 18% have arrived since 2012.10 Further, 11% of those who arrived during the past 25 years do not speak English well. More than one‐fifth of people in Australia speak a language other than English at home, as do more than 8% of those born in Australia.10 Delivering culturally responsive care is vital for our community.

Improving health outcomes requires better reporting of cultural and linguistic diversity.5 Five data fields — “country of birth”, “year of arrival”, “language spoken”, “need for interpreter”, and “cultural background” — could be included in patient registration forms to support the delivery of more tailored, culturally responsive care. The Royal Australian College of General Practitioners sample registration form shows how this information could be self‐reported by new patients.11 Including “year of arrival” for patients born overseas can assist in determining whether a person is from a refugee background.8 Specific data fields in medical software could enable these data to be entered and readily retrieved. Currently, no general practice software includes all five fields.

The OPTIMISE project will be of interest to primary health networks, which play important roles in health service planning for their local communities. Many primary health networks already provide health pathways to enable referrals, and build communities of practice that facilitate integrated care. Primary health networks can support quality improvement incentive programs, including “plan, do, study, act” interventions.12 Documenting cultural and linguistic diversity is critical to all these initiatives. Enabling better measurement by embedding the five cultural data fields in all healthcare databases will assist health services working with their communities to co‐design safe and culturally responsive care.