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Toolkit for Primary Care Providers Treating Refugees

Update January 2015:   CDC Guidelines have changed since this Toolkit was created and some of the information in the Toolkit is out of date.  The entire Toolkit is still available as an example of collaboration and best practice, with the caveat that it is no longer up-to-date.

Health screening for refugees entering their new communities differs across the United States.  The Toolkit for Primary Care was created in King County, WA and reflects conditions solely in this community site. It may not be appropriate or accurate for your locale.  See below for guidelines on adapting the toolkit.

The Toolkit was created by the Pathways to Wellness Program in conjunction with medical staff from Harborview Medical Center. Content was generously contributed and reviewed by: Mary Stasio, R.N., Dr. Genji Terasaki, Dr. Suzinne Pak-Gorstein, Dr. David Roesel and Dr. Joseph P. Sherman.

Toolkit for Primary Care is designed to provide your clinic with:

  • Information about medical assessments and interventions that occur as part of the refugee resettlement process.
  • Tips on accessing your patient’s previous medical information.
  • Suggestions on health screening priorities in the primary care setting.
  • Links, referrals and other relevant information to provide health care to refugee patients.

Toolkit: Background and Need

There are approximately 40-42 million displaced people in the world. Of this total number, approximately 16 million are refugees and asylum seekers (others are internally displaced populations). Each year an average of 120,000 individuals are proposed for resettlement to a 3rd country for permanent asylum. In 2010, the United States accepted 73,293 refugees. Washington State accepted 3,004 newly arrived refugees. During 2010 and 2011, Washington State consistently ranked 8th in arrivals and 6th in affirmative asylees. (US Department of Homeland Security, Office of Immigration Statistics, Annual Flow Report, 2011). Over half of the new refugee arrivals in Washington resettle throughout King County, predominately in South King County.

Many community health clinics are unfamiliar with refugee resettlement processes (including the limited duration of refugee benefits), the overseas health screening, and the health screenings that occur once a refugee is in the United States. While the domestic health screening focuses on detection of communicable diseases, some public health clinics also provide basic health literacy information and information about ethnic-specific resources available in the community. The screening tests performed differ by each local health district across Washington State, however, all refugees have up to 8 months to receive their benefits, upon which time their primary medical home should be established.

Primary care providers in South King County are serving an influx of refugee patients who are seeking care in the U.S. health care system for the first time. Many refugees experience marked disparities in infectious and various chronic diseases. Many new arrivals have serious health conditions needing immediate attention and follow-up.  In addition to contagious diseases, many refugees have experienced trauma, may be suffering from mental health conditions, hypertension, diabetes, skin, vision and dental problems, and/or malnourishment.  In particular, refugees resettled in the U.S., the U.K., and Australia have been shown to have an increased risk of suffering from malnutrition, anemia, lead poisoning, tuberculosis, malaria, HIV, hepatitis, and intestinal parasites (Ackerman, 1997), (Lifson et al. 2002),  (Miller et al. 2000), (Varkey et al. 2007).

Although resources exist to increase health care providers’ knowledge and understanding of the unique cultural and medical contexts in which refugees experience health and health care, there is often a lack of coordination among the various health and social systems that provide initial orientation to newly arrived refugees. Ineffective coordination across critical systems can be detrimental, putting providers who are less-resourced at a disadvantage in their efforts to provide high quality health services, and having a negative impact on the health and well-being of refugee patients seeking care. Primary care providers, resettlement agencies and Public Health refugee screening clinics could benefit from greater coordination of care and information sharing. Primary care providers in private or small community clinics typically do not have extra training or resources to effectively serve the refugee population.  

Method for Intervention

The “Toolkit for Primary Care Providers” grew as a cross-sector community response to the increasingly adverse effects refugees were having as they were encountering healthcare in South King County in Seattle, Washington. The toolkit consists of health screening and treatment information, referrals, links & resources, as well as the patient’s individual health records and language identification card. The “Toolkit for Primary Care Providers” packet was developed by an interdisciplinary team of health professionals including social workers at Lutheran Community Services Northwest (LCSNW), a graduate student at the University of Washington and a group of physicians at the International Medicine Clinic at Harborview Medical Center.  Input was also provided by public health nurses from Public Health Seattle & King County (PHSKC) who have been distributing the toolkits to recently arrived refugees at the Public Health Refugee Screening Clinic in their downtown office. The packet is distributed to refugees upon their initial visit. Refugee families or individuals are then encouraged to bring the packet with them when they visit their primary care provider.

The primary audience for the toolkit is primary care providers.  The toolkit is intended to:

  1. Explain overseas PRE-departure assessment and POST-departure screening needs
  2. Facilitate exchange of information between Public Health Refugee Screening & primary care providers
  3. Share links, referrals & other information, including contacts to interpretation services
  4. Advocate and empower refugee patients

The intervention also aims to reduce barriers to health services that add to health disparities among the refugee population including under-utilization of health care. It is hoped that the toolkit will decrease health-screening duplications and facilitate deeper communication among the providers that provide initial cultural and medical orientation to newcomers throughout King County.

The information contained in the Toolkit may be updated periodically based on recommendations set forth by CDC.

The Toolkit

The Toolkit can be viewed and printed in its entirety (12 pages PDF). Also, the Toolkit can be viewed and printed in sections:

Health Assessments for Refugees

(1 page PDF) This page includes information about: Oversees pre-departure medical examination; Class A and Class B conditions (medical conditions that deem a refugee inadmissible, or require immediate follow-up); An overview of domestic refugee health screening in King County; and Provider tips for obtaining patient records in King County.

Checklist for Primary Care Providers: Refugee Health Assessment

UPDATE Jan 2015: Some of the CDC Guidelines have changed since this was checklist was developed and it has been removed here.  The entire Toolkit is still available as an example of collaboration and best practice, with the caveat that the checklist is no longer up-to-date. 

See also: 

  • New Arrival Refugees - Guidelines for Primary Care Providers in King County, WA
    These guidelines reflect current screening practice in King County, WA as of 10/1/2015. Please note that refugees screened prior to this date or outside of King County may have received a different screening.
  • Domestic Medical Screening Guidelines Checklist for Newly Arriving Refugees in WA State:
    Washington State Department of Health's Domestic Medical Screening Guidelines Checklist for Newly Arriving Refugees. Based upon the CDC Guidelines for the US Domestic Medical Examination for Newly Arriving Refugees and the Office of Refugee Resettlement (ORR) Domestic Medical Screening Guidelines Checklist.  The purpose of this document is to provide guidance around screening asymptomatic refugees.
    Local Health Jurisdiction Based Screening | Primary Care Based Screening

Community Resources and Cultural Information

(1 page PDF) Includes information and resources about:

  • Federal Guidelines for Language Access
  • Metro-Seattle Interpreter Services
  • Epidemiological, Cultural Information and Multi-Language Resources
  • Refugee Resettlement Agencies (King County)
  • Community Support & Mental Health Services for Refugees (King County)

Refugee Health Screening: Seattle & King County Public Health

(1 page PDF) Flow chart describing health screening and other services provided to new refugee arrivals in King County.

Language ID Card

(1-page PDF) Two-sided ID card.  One side has blanks for writing in refugee's name, language(s) spoken, and contacts for emergency and primary care. The flip side has phone numbers for Metro-Seattle Interpreter Services, with explanation of the rights provided to persons with limited English under Title VI of the Civil Rights Act.

Guidelines on Adapting the Toolkit

(2 page PDF) Counties and states differ on how they implement refugee health screening. Therefore, this toolkit may not be appropriate or accurate for your locale.  The Toolkit for Primary Care is being used at Public Health Seattle & King County, in Washington State. These guidelines can help you to develop a similar toolkit in your community.

Cover Page for Toolkit Packet

(1 page PDF) Describes what the toolkit is designed to provide, and defines who is a refugee.

Folder Label for Toolkit Packet

(1 page PDF)

Toolkit Folder Label Image

















The folder label lists the contents of the toolkit packet: information about medical assessments and interventions; tips on accessing patient's medical information; suggestions for health screening; links, referrals and resources; forms from Public Health: "Intake" and "What to do next"; and, overseas pre-departure exam information.  The directions BRING THIS FOLDER TO YOUR DOCTOR are printed on the label in 7 languages (Arabic, Bhutanese, Burmese, Farsi, Nepali, Russian and Somali).  The label is designed to be affixed to the front of a folder that becomes the toolkit packet a refugee can share with their primary care provider. 


Pathways to Wellness

Pathways to Wellness Program

Pathways to Wellness supports the emotional well-being of refugees by enhancing adjustment, increasing capacity for self-sufficiency, and coordinating care through the primary health care system. Pathways is a pioneering effort linking mental and primary healthcare systems, and creating opportunities for better coordination and collaboration, resource sharing, and the emergence of more holistic best practices. Pathways to Wellness is a program of Lutheran Community Services Northwest, Asian Counseling and Referral Service, and Public Health Seattle & King County. Pathways is supported by the Robert Wood Johnson Foundation, the Bill & Melinda Gates Foundation, United Way of King County, the Seattle Foundation, the Medina Family Foundation and the Boeing Employees Community Fund.