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Meet Gwenivere: An Integrated Care Model for Newly Resettled Refugee Families

Posted By Eboni Winford, Thursday, January 5, 2017



"Please don’t tell my parents.” These were the words spoken by 20-year-old "Gwenivere” upon learning that her routine pregnancy test to determine which post-resettlement vaccinations she could receive was positive. Gwenivere had just resettled to Knoxville, TN, after fleeing the war and violence of Burundi, an East African country that borders Rwanda, Tanzania, and the Democratic Republic of Congo. She and her family, including her parents and younger sister, lived in a Tanzanian refugee camp for 12 years after fleeing Burundi; eight of these years were spent undergoing the UN Refugee Agency’s formal resettlement process.


Two weeks after arriving to Knoxville, and after being oriented to their new home by the local resettlement agency, Gwenivere and her family made their first visit to Cherokee Health Systems (CHS) where they received routine vitals and had labs that were specific to their country of origin or country of refuge performed.


At their second visit, which occurs 10 days after these initial labs are drawn, Gwenivere and her family met with a medical provider who performed a medical screen designed by the CDC and Office of Refugee Resettlement. She and her family also met with a behavioral health consultant (BHC) who assessed Gwenivere and her family’s adjustment to resettlement and screened for psychological symptoms including posttraumatic stress disorder and depression. The results of Gwenivere’s labs 10 days prior revealed a positive pregnancy test.


"Please don’t tell my parents,” Gwenivere said via an in-person Kirundi interpreter. "If they find out that I’m pregnant and I’m not married, they will kick me out of their home.” Because CHS has a well-established model of integrated care and because continuity of care is key as refugees settle into their new lives in the US, the care team collaborated with Gwenivere to quickly implement a plan to accommodate her new healthcare needs.


The BHC provided an overview of the available services at CHS including but not limited to blended primary care and BH services; obstetrical and gynecological care; care coordination from community health coordinators; and specialty services including psychiatry, cardiology, and nephrology, and worked to develop a culturally appropriate and sensitive treatment plan that best suited Gwenivere’s needs. The care team honored Gwenivere’s wishes to not disclose her health status to her parents and utilized that opportunity to teach an important lesson regarding protected health information and privacy, something with which Gwenivere was not familiar.

The care team coordinated an initial prenatal care visit on a day when Gwenivere was already scheduled to return to the clinic to receive another vaccination. As such, this additional medical visit did not appear unusual to her parents. She met with the OB/GYN provider and a BHC who worked with Gwenivere to explore pros and cons of informing her parents of her pregnancy. The BHC coordinated with a community health coordinator who met with Gwenivere to discuss alternate housing arrangements in the event that her parents did ask her to leave their home after learning of her pregnancy.


The CHC also provided resources for obtaining necessary supplies for the baby upon its birth. With coaching and support from the care team, Gwenivere made a plan to tell her parents of her pregnancy, which went surprisingly well. Her parents expressed disappointment but did not ask her to leave the home. Gwenivere continues to receive behaviorally-enhanced prenatal care at CHS, which emphasizes wellness promotion during pregnancy as well as ongoing monitoring for the development of trauma-related symptoms secondary to her exposure to war in Burundi.

When CHS began the integrated refugee resettlement program in October 2015, members of the care team quickly learned that offering care via our health care home helped eliminate barriers such as access to care, language difficulties, and a sense of displacement that may linger after being uprooted from one’s home of origin. We also learned that routine BH monitoring was essential for prevention, early detection, and intervention of trauma-related symptoms, which may not appear until several months after refugees have resettled in their new home countries.


Not only are BH providers able to implement interventions at the point of care but they are also able to reduce stigma associated with receiving BH care by being present at every clinical encounter refugees have during their initial year following resettlement. Sharing an EHR allows for enhanced communication of previous traumatic experiences to various care team members, which improves the overall delivery of trauma-informed and culturally sensitive care. Accordingly, whether Gwenivere would have had a positive pregnancy test or not, she and her family would have been invited to make CHS their health care home where they would then gain access to the range of services presented to Gwenivere.


The integrated refugee resettlement program is still in its infancy, but since its inception one year ago, we have provided services to individuals from Iraq, Burundi, Ukraine, Sudan, Colombia, Tanzania, Cuba, South Africa, and Burma. As we continue to evaluate and improve the care we provide, we seek to do so in a manner that is culturally sensitive and responsive to the needs of this unique population while also remaining true to the spirit of integrated care. We are honored to serve these families and to work as a bridge as they start their new lives here.

Eboni Winford, Ph.D. is a Behavioral Health Consultant and licensed psychologist at Cherokee Health Systems in Knoxville, TN. Dr. Winford is involved in workforce development and is a member of the training committee of CHS’s APA-accredited clinical psychology internship and the APPIC-approved postdoctoral fellowship program. She supervises trainees at multiple levels including postdoctoral fellows, clinical psychology interns, and graduate-level psychology practicum students. Additionally, she consults with other primary care organizations as they seek to integrate their practices. She is currently involved in multiple integrated care initiatives including the refugee medical screening process and the National Institute of Medicine’s All of Us: Precision Medicine Initiative. She is the incoming Co-Chair and previous co-secretary to the Primary Care Behavioral Health Special Interest Group, a member of the Early Career Professionals Task Force, and the recipient of CFHA’s 2016 Founders’ Early Career Professionals Award. Dr. Winford earned her degree in Clinical Health Psychology from the University of North Carolina at Charlotte.

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