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 health assessments and visas for migrants to Australia. Health assessments were previously completed by International Organization for Migration (IOM) - contracted by DHA. The Toll Group is now responsible for assisted passage and medical services for Australian humanitarian entrants, although some health assessments are still completed by IOM. The DHA also contracts post-arrival settlement services for humanitari 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. 

• Immigration medical examination (IME) - all permanent arrivals to Australia have an IME 3-12 months prior to travel (see Initial assessment).
• Departure health check (DHC) - humanitarian entrants may also have a voluntary DHC in the week prior to travel. 
• Two separate databases - both the IME and DHC are recorded in the DHA HAPlite system (an electronic health record) and individuals have a HAP number. The HSP program uses a separate HSP database, and applicants (i.e. the family unit) have an HSP number.
  • HSP providers hold the HAP numbers, but cannot look up the HAP database. 
  • Health providers can access the HAPlite system if they are registered, but need the HAP number from HSP providers.
• The IME or DHC can generate health alerts. Two types of alert are used in the HSP system: potential medical issue (PMI, triggered at the IME) and critical medical issue (CMI, triggered at the DHC only if the visa holder is travelling with a medical escort or requires follow-up in 24-72 hours).
  • CMI with medical escort (red alert cases) - in this situation, a doctor has decided the patient is sick enough to need medical care during travel to Australia. Medical escorts may be either medical or nursing providers.
    • DHA provide medical escorts if needed 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 medical escort will have English proficiency as well as the same language as the patient. In our experience, the most health escorts have been nurses. 
  • CMI without medical escorts need follow-up within 24-72 hrs after arrival in Australia. If a child has a CMI, 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).
• In Victoria, AMES notify the Refugee Health Program (RHP) nurses of any incoming PMI or CMI cases. 
  

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 (including cases where humanitarian entrants have not had a DHC so there was no CMI generated). 
  • 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)
  • Some ‘near miss’ events.
  • Concerns can be notified to DHA by health providers using the audit function on HAPlite or email to health@homeaffairs.gov.au
• Access to offshore health information is complex. Settlement providers cannot access the HAPlite system, but hold the HSP and HAP numbers. Onshore health providers need to have access to the HAPlite system, and they need to get the HAP number from settlement providers to access  IME and DHC information. Flight times often change, which can difficult for planning, and there are often long delays between PMI and arrival.
• Medical handover can be challenging. There is a DHA contract requirement for handover, and that the medical 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. 
  • 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 an emergency departments (ED).  EDs 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, the RHP and AMES will coordinate health alerts pre-arrival - to ensure i) there is a plan in place, ii) that the plan and clinical information from HAPlite is in the EMR, and iii) ED are notified when the patient is arriving 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, 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 medical escort is happy with the patient’s clinical state, then the patient can be transported to their accommodation. The receiving settlement provider will ensure the patient knows how to call an ambulance if needed.
   • If the medical 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 paediatrician - patients settling in the north, west and east may be linked with RCH or a local immigrant health service depending on acuity and care needs, patients settling the south east are linked with Monash Health.
5. If there are concerns about the health alert process, please provide feedback to the DHA on health@homeaffairs.gov.au and/or use the audit function in HAPlite.
6. For health alerts coming to RCH, please contact the immigrant health team with any queries.

^{Immigrant health resource. Author Georgie Paxton, Daniel Mason and Marianne Safe, January 2020, last updated Oct 2025. Contact georgia.paxton@rch.org.au}