Background

The offshore health alert process and the pre-departure health check (DHC) were strengthened in response to the death of a child from sickle cell disease in New South Wales immediately after arrival in 2005.

The Department of Home Affairs (DHA) holds responsibility for offshore assessments (including health assessments) and visas. Health assessments are completed by International Organization for Migration (IOM) - contracted by DHA. The DHA also contracts post-arrival settlement services - the Humanitarian Settlement Program (HSP). The HSP includes on-arrival reception, accommodation and linking people with healthcare in Australia. In Victoria these services are provided by AMES Australia. There are settlement health coordinators (SHC, who are refugee nurses) based in AMES, who help coordinate health alerts. 

• All permanent arrivals to Australia have an Immigration Medical Examination (IME) 3-6 months prior to travel (details on Initial assessment)
• Humanitarian entrants may also have a voluntary Departure Health Check (DHC) in the week prior to travel 
• Both the IME and DHC are recorded in the DHA HAPlite system (an electronic health record)
• The IME or DHC can generate health alerts - previously called ‘red alerts’ and ‘general alerts’; over 2018-19 the terms ‘potential alerts’ and ‘critical alerts’ were used. The IME can generate ‘potential health alerts’, which can then generate a ‘critical health alert’. The process to confirm a critical alert is not clear, and the DHC is voluntary 
  • Critical alerts may have a health escort, which may be either medical or nursing. In this situation, a doctor has decided the patient is sick enough to need a health escort during travel 
    • DHA provide the health escort through the offshore health assessment process for refugee visas (200, 201, 203, 204), but not for (sponsored) Special Humanitarian Program visas (202), where the onus is on the sponsor to support travel costs for the humanitarian entrant 
    • The health escort will have English proficiency as well as the same language as the patient. In our experience, the most health escorts have been nurses 
  • Critical alerts without health escorts need medical follow-up within 24-72 hrs after arrival in Australia. If a child has a critical alert, they will require specialist care (essentially their health condition is not a primary care issue alone, although they will still need a primary care provider).

Issues arising

• Clinical need and health alerts do not always correlate. We have seen:
  • Cases where individuals needed health alerts, but these were not in place
  • Cases where health alerts have been in place, but children have been stable and had chronic/complex issues (which did not need immediate healthcare on arrival) - this has been the more common scenario
  • Contradictory information on the HAPlite record (where the record is internally inconsistent, or where health issues have not been identified)
  • A number of ‘near miss’ events in late 2016/early 2017
• The system of potential alerts and critical alerts and access to offshore health information is confusing for providers and makes it difficult to plan ahead. Settlement providers cannot access the HAPlite system, but health providers onshore need to get the HSP number from settlement providers in order to get the HAP number (to access the HAPlite system), and there are multiple points where information transfer is challenging. Flight times often change, which is also difficult for planning
• Medical handover can be challenging. There is a DHA contract requirement for medical-to-medical handover, and that the health escort should stay with client until this has occurred. 
  • Clinical experience has been that most health alerts arrive out of hours. The most common scenario has been that the child is not unstable, the escort is not concerned, and the child and family want to go to their accommodation to sleep. It is not clear how the contract handover provisions are interpreted when the health escort is a nurse
  • Under the DHA contract, the medical escort cannot provide intervention in Australia (also they are not Australian registered)
  • There is complexity to escort staying with the patient in accommodation
  • It is not straightforward/appropriate for children/families to stay awake for hours for a daytime appointment after travel to Australia
•  If the health escort thinks the child is stable on arrival, it is not appropriate for the child to be seen in ED.  Emergency Departments (ED) are not placed to sort out chronic/complex conditions - their role is emergency care. 

Planning for critical health alerts

The following applies to RCH, but could also be adapted by other health services. 

1. Immigrant health and the SHC in AMES will coordinate health alerts pre-arrival - to ensure i) there is a plan in place, ii) that clinical information from HAPlite is in the health record, and iii) ED are notified when information is received, and the patient is on the ED ‘expects list’  
   
2. If someone is unwell enough to need an escort, and medical handover is required, then it is not easy to justify handover to primary care, and neither primary care nor outpatient specialist care are available outside hours. On balance, acknowledging low numbers (~5/year), and complexity of previous critical transfers (regardless of the availability of a health alert) - linking with ED is the safest option. Acknowledging ED workflow and preferences we suggest: 
   • After arrival in Australia, the medical escort phones ED admitting officer and provides a full set of observations (including oxygen saturation), and discusses travel. 
   • If the health escort is happy with the patient’s clinical state, then they can be transported to their accommodation. The receiving settlement provider will ensure the patient knows how to call an ambulance if needed.
   • If the health escort has any clinical concerns, they will being the patient to ED triage, and will provide observations, written records of conditions during travel, past health records and a medical handover. The health escort will speak the patient's language and also English, so communication is achievable. 
3. All refugees have permanent residency on arrival to Australia, with full access to the health and welfare system -they will obtain Medicare within the next days, and should not be billed as international patients.
4. All paediatric health alerts should be linked with a specialist paediatrician - North, West, East - RCH, South Monash. Patients in the North, West and East may be linked with local immigrant health services
5. If there are any concerns about the health alert process, please provide feedback to the DHA on health@homeaffairs.gov.au.

^{Immigrant health resource. Author Georgia Paxton, Daniel Mason and Marianne Safe, January 2020. Contact georgia.paxton@rch.org.au}