Refugee Domestic Screening Guidance: Key Considerations and Best Practices

Background

The domestic refugee health screening guidance outlines the recommended components of health screenings for new arrivals with humanitarian-based immigration status in the United States. This guidance is not meant to provide comprehensive clinical guidance for longitudinal care, but to highlight key screening considerations during the first 90 days of arrival. Humanitarian-based immigration status applies to refugees (including unaccompanied refugee minors), asylees, Amerasians, Afghan and Iraqi Special Immigrant Visa (SIV) holders, and Cuban and Haitian parolees (see the Frequently Asked Questions for definitions of immigration statuses). Certified victims of human trafficking are also eligible for refugee benefits, including the domestic medical screening (see Policy Letter 16-01 for additional information on benefits eligibility). Spouses and dependent children of adults with humanitarian-based immigration status are also eligible to receive a domestic medical screening. The Office of Refugee Resettlement (ORR) provides humanitarian-based newcomers with important resources, benefits, and services to help them become integrated members of American society. These benefits include a comprehensive domestic medical screening. For ease of use, the term refugee is used to refer to all humanitarian-based newcomers eligible for the screening program (historically, refugees account for the majority of screenings). Refugee populations have diverse health profiles, which may differ from the general US patient population. The CDC Domestic Screening Guidance for Newly Arrived Refugees highlights key differences in national recommendations due to global epidemiologic considerations, the impact of displacement and forced migration, and potential lack of access to routine or preventive healthcare prior to arrival in the United States.

In addition to the CDC Domestic Screening Guidance for Newly Arrived Refugees, providers and clinics may wish to consult the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS Standards) for a useful framework in care provision. It is vital that clinical care providers address language and cultural barriers that patients may experience.

Overseas Medical Examination and Pre-Departure Medical Screening

Under the authority of the Immigration and Nationality Act (INA) and the Public Health Service Act, the Secretary of Health and Human Services promulgates regulations outlining the requirements for the medical examination of persons seeking admission into the United States. CDC’s Division of Global Migration Health (DGMH) provides the Department of State (DOS) and the US Citizenship and Immigration Services (USCIS) with medical screening requirements for all examining physicians. The purpose of the pre-departure medical examination is to identify applicants with health-related grounds for inadmissibility (i.e., diseases of public health significance, substance use disorders, mental illness with harmful associated behaviors). For further examination details, length of exam validity, and health classifications of applicants (e.g., Class A, Class B), see the Technical Instructions for Panel Physicians.

To improve health during travel, reduce travel delays, and decrease associated health and cost burden on receiving communities, CDC, along with international partners, has implemented overseas health intervention programs, including the Vaccination Program for US-bound Refugees and presumptive treatment for select parasitic infections. Overseas medical examination findings and interventions are documented on the DS medical forms. The DS forms and digital chest x-ray are uploaded to the CDC Electronic Disease Notification (EDN) system. State and local health department officials, as well as clinic staff that treat refugees have access to information for their own arrivals. Additional information on the disease-specific aspects of the overseas medical examinations and health interventions, as it pertains to domestic screening, are also described in specific sections of the domestic guidance:

• Immunizations
• Intestinal Parasites
• Mental Health
• Sexual and Reproductive Health
• Tuberculosis (TB)
• Viral Hepatitis

CDC and its partners also monitor for acute infectious disease outbreaks among refugees and in host communities. In the event of an outbreak, refugees may be monitored for signs or symptoms of disease, prophylactic medication and immunizations may be administered, or their travel may be delayed. This helps ensure that refugees are healthy for travel to the United States. CDC routinely sends notification letters to state and local partners regarding outbreaks, disease surveillance, and interventions. Domestic providers can contact their state’s Refugee Health Coordinator (RHC) to be added to the mailing list for these communications alerts.

Domestic Medical Screening

The domestic medical screening program was established as part of the Refugee Act of 1980. All refugees should receive this comprehensive medical examination that screens for a wide range of infectious diseases and non-communicable conditions. The domestic medical screening provides clinicians with an opportunity to follow-up on or identify new health concerns that may hinder successful resettlement and self-sufficiency, to promote wellbeing, and to connect refugees with routine and specialty care. A patient-centered approach to refugee screening is critical in evaluating initial health needs and ensuring that each refugee is linked to appropriate ongoing care. Additionally, the domestic screening orients refugees to the US healthcare system.

The domestic medical screening can include up to three clinical visits, as lab results and other findings must be reviewed with the patient. Ideally, the domestic medical screening should be initiated and completed as soon as possible to ensure that ongoing and emergent health needs are addressed, and new arrivals are connected with appropriate follow-up care. For, additional details of timelines for initiation and completion of screening, which may vary by immigration status, refer to Policy | The Administration for Children and Families. CDC has developed clinical guidance for the domestic medical screening, highlighting the health conditions that should be evaluated and addressed soon after arrival. This guidance serves as recommendations, rather than mandates, and is based on established best practices and current epidemiological data. Furthermore, this guidance emphasizes special considerations for refugee patients due to unique geographic-based exposures, genetic predispositions, and known epidemiologic patterns among refugees.

Many screening clinics and local jurisdictions use the CDC screening guidance, while others adapt CDC guidance for their populations. Local jurisdictions may choose to develop their own screening protocols. The order of components within the screening examination, scheduling protocols (e.g., block scheduling, use of electronic health record smart sets), the number of clinical visits, and available logistical capacity (including transportation and patient reminders) may vary by clinic. Additionally, some clinics complete all aspects of the refugee screening on site, while other clinics partner with outside entities for some parts of the screening (e.g., TB clinic or social workers for mental health screening). Availability and accessibility of local resources, community partnerships, and the number of arrivals may also impact screening protocols. Lastly, screenings may need to be adapted for certain patients. For example, if an individual has a known history of trauma, it is recommended to establish a supportive rapport with the patient before proceeding with more invasive or distressing components of screening.

Best and Promising Practices in Domestic Screening

Addressing Social Determinants of Health

The World Health Organization (WHO) defines social determinants of health as the “conditions in which people are born, grow, live, work, and age [that] are shaped by the distribution of money, power, and resources at global, national, and local levels” [1]. Economic stability, education, health and healthcare, neighborhood and environment, and social and community contexts impact health and how people access care. Economic instability, lack of access to formal education, transportation challenges, language skills, and limited health literacy may be barriers to healthcare for many refugees, negatively affecting their long-term health, management of chronic health conditions, and self-sufficiency in the United States. When conducting the domestic medical screening and providing ongoing care, clinicians should consider social determinants of health and employ methods to address health equity and disparities. The National Culturally and Linguistically Appropriate Service (CLAS) Standards may be helpful for clinicians as they seek to improve individual and population health, but also advance health equity among refugees. Additionally, it is critical that clinicians work collaboratively across sectors to address the unique needs of refugee patients.

Logistics

Staffing and Scheduling

Depending on staffing, the number of anticipated arrivals, and general operations, some clinics may find it beneficial to identify staff to play a key role in facilitating, coordinating, and conducting the domestic medical screening. For example, some clinics have dedicated administrative staff who are responsible for scheduling appointments and coordinating transport for new refugee clients. Other clinics have specific providers to conduct screening exams. It is also important to foster diversity and inclusion among clinic staff, including hiring individuals from the refugee communities the clinic serves. Having dedicated staff who are familiar with the needs of refugee clients (e.g., logistical, language, cultural) and the components of the domestic medical screening helps ensure the screening is completed in a timely manner, appropriate referrals to specialized care are provided, and refugees with newly diagnosed conditions are connected to individual case support.

Transportation

Transportation is a major barrier to care for many newly arrived refugees. Transportation resources vary greatly among new arrivals, and in urban areas, many new arrivals rely on public transportation. The availability and reliability of public transportation may be highly dependent on where refugees are resettled. Upon arrival, refugees should receive an orientation to public transit (if applicable) from their resettlement agency. Refugees are often not prepared to use public transit independently by the time of the domestic medical screening. Other potential transportation resources may include ride-share or taxi services (may be covered by Medicaid), resettlement agencies, and community or family members who have been in the United States for a longer period of time. Medicaid coverage may include mileage reimbursement for community members who provide transportation. Clinics should also collaborate with local partners (including resettlement agencies) regarding transportation options, with special attention to arrivals without community support, large families with small children, and with persons requiring specialized transportation (e.g., those using wheelchairs or stretchers).

Funding

Clinics conducting the domestic medical screening are reimbursed through one of several mechanisms, including Refugee Medical Assistance (managed by ORR), as well as state Medicaid programs. Funding mechanisms are largely dependent on the state and an individual’s immigration status, and many states receive funding from both ORR and Medicaid. It is important to note that funding to cover the cost of screening may vary by state. Clinicians should contact their state’s RHC for information regarding funding and reimbursement. Additional information on benefits and funding is available from ORR.

Language Access

Clinicians administering written tools or providing educational materials should be aware that refugees have a wide range of educational backgrounds. Some refugees are literate in one or more languages, while others are pre-literate. Additionally, some refugees may not be familiar with Likert scale responses. Therefore, providers should use caution when using self-administered written tools, offering additional explanation and support as needed. It is not the role of an interpreter to explain written forms or materials.

Gender Concordance

Patients may prefer to work with a healthcare professional of their own gender. This may include interpreters, medical assistants, and nurses. If adequate staffing is available, such requests should be honored.

Consent and Confidentiality

Consent and confidentiality may be novel concepts for refugees, particularly in the context of healthcare associated with the resettlement process. It is important to review consent, confidentiality, and limits to confidentiality with refugee patients at the beginning of the first visit. It is critical that this conversation be in the refugee’s preferred language. This overview should include a discussion of who can access medical records and health information, and adult patients’ right to make their own healthcare decisions, although cultural awareness and sensitivity to the decision-making process in the family should be considered. Additionally, it is important to explain that confidentiality extends to ancillary staff (including interpreters and social workers). All providers and support staff are not permitted to share any health information with community members. For adults, it is important to emphasize that they can receive care without family members present, and that no one, including their spouse or parents, can access their medical records without their consent. The American Academy of Family Physicians (AAFP) has developed a number of materials on patient confidentiality that screening clinicians may find useful.

For adolescents (13-17 years of age), specific rules around confidentiality, including what can and cannot be shared with parents, should be reviewed. Emphasize that parents do not need to be present for sensitive components of care, which include discussion around substance use/abuse, sexual orientation, sexuality, and contraception method (e.g., instruction and prescriptions). It is essential to document protected adolescent health histories (i.e., sexual, substance abuse, and mental health concerns) and laboratory screening tests related to protected histories in a separate confidential section of the patient’s chart. Refer to the Confidential Health Care for Adolescents: Position Paper of the Society for Adolescent Medicine for additional information on consent and confidentiality.

Additional Considerations for the Domestic Medical Screening

Patient Education and Preventive Health: Healthcare Orientation, Wellness, and Safety

Patient education and preventive care should be integrated into the domestic screening appointment and revisited during routine primary care in the medical home. Cultural orientation is provided prior to travel to the United States and following resettlement. Overseas cultural orientation is provided by the International Organization for Migration (IOM), and resettlement agencies facilitate the domestic orientation developed by a technical assistance program supported by the DOS Bureau of Populations, Refugees, and Migration (PRM). Domestic cultural orientation programs vary among resettlement agencies. Some of the key concepts generally addressed during this orientation include healthcare access, wellness, and safety.

During the domestic medical screening, it is essential to provide patients with an orientation to the healthcare system. This orientation should include basic navigation of the local healthcare system, the importance of routine and preventive care (e.g., immunizations), the role of a primary care provider, and the concept of a medical home. Although some of these topics will have been introduced during orientations provided by IOM or resettlement agencies, it is critical that clinicians clearly and consistently reiterate these key concepts. Clinicians or clinic administrative staff should provide refugees with clear instructions on how to contact their healthcare provider, including direct access numbers for interpreters or telephone-based language interpreter services. Clinicians should also explain how to access care after hours and the appropriate reasons to visit urgent care or the emergency department. Although refugees may be introduced to 911 and emergency services during cultural orientation classes prior to US arrival, they may be hesitant to call 911 in a medical or other emergency, potentially resulting in adverse health outcomes [2]. Clinicians should reiterate that 911 should be used for police, fire, as well as medical emergencies. Refugees should be encouraged to call 911 even if they do not speak English, as most emergency services have interpreters, and even when interpreters are unavailable, operators will dispatch help to the location of the call. Some refugees may not know how to read numbers and may require a demonstration with detailed instructions on how to dial 911. Clinicians should consider printing a reference care card (Figure 1) for each refugee, which includes clinic and provider contact information and brief instructions for accessing care after hours.

Figure 1. Example Reference Care Card for Recently Arrived Refugees

Note: If possible, this card should be translated and have pictograms for refugees who are pre-literate.

Clinicians should also review preventive health, wellness, and safety information with each patient. Preventive health care and safety discussion topics may include:

• Healthy foods, food access, and food insecurity
• Obtaining, installing, and appropriate use of car seats for children
• Using seatbelts and helmets, and relevant laws
• Frostbite prevention
• Sunscreen use

While an in-depth discussion of preventive care during the initial domestic screening may not be possible due to time constraints, further discussion should be prioritized for follow-up and future primary care visits in the medical home (which, depending on the jurisdiction, may be separate from the screening clinic).

When providing health education, clinicians should employ a variety of teaching methods, including the use of video and pictorial materials, as well as teach-back methods. HealthReach, a national collaborative partnership within the US National Library of Medicine, has built a database of free multilingual and multicultural health information and patient education materials for those working with individuals with limited English proficiency. New materials are regularly made available. Providers should also consider connecting new arrivals with community-based organizations and other local partners who may offer additional wellness programs and support.

Incorrect Date of Birth (Chronological Age Discrepancy)

In many regions, dates of birth (DOB) are neither officially documented nor used for identification. Refugees may only have a general idea of when they were born, and parents or caregivers may only recall an estimated year, month, or season in which their child was born. Similarly, unaccompanied refugee minors may have no information available about their DOB. As of 2013, 230 million children under 5 years of age worldwide did not have a birth certificate [3].

When clear documentation is unavailable, DOB will be assigned overseas. Often, January 1 is assigned in these cases. However, incorrect recording on official documents may lead to a different DOB than the individual believes is accurate. Providers and refugees must understand that the DOB recorded on the DS forms is the legal date of birth.

An incorrect date of birth may affect or impede medical care and psychosocial wellbeing (Table 1). For appropriate age-based screening, clinicians should use the likely biological age of the patient. However, eligibility for some services and benefits is based on the documented legal age.

Table 1. Potential consequences of incorrect DOB documentation

If a refugee has a suspected incorrect DOB that negatively affects appropriate medical care, evaluation for suspected medical issues, and/or psychosocial wellbeing, further evaluation and discussion with the family should occur. Providers should:

1. Discuss findings with the patient (if age appropriate) and primary caregivers, explaining possible negative effects of incorrect DOB on medical evaluations and grade level placement in school.
2. Attempt to determine approximate biological age using season and approximate year of birth.
3. Document physical and behavioral findings in the medical chart that lead to an assessment of an incorrect DOB, including Tanner staging, growth percentiles, developmental milestones, and psychosocial development, as indicated.
   Note:  Radiographic bone and dental age are not recommended to estimate age in refugee populations, and there are no available growth standards for many ethnicities. Additionally, chronic malnutrition makes interpretation unreliable [4–11].
4. Offer preventive measures according to biological age, with supportive documentation (i.e. patient self-report, clinical findings that corroborate biological age).
5. Consider consulting a developmental-behavioral pediatrician and/or child psychologist who specializes in appropriate developmental milestone attainment and psychosocial developmental assessments.

If a child is determined to have an incorrect DOB that affects grade placement, the clinician should first discuss these concerns with the patient (if age appropriate) and the primary caregiver. The clinician must also contact school administrators and teachers at the child’s school to advocate for appropriate grade placement based on biological, psychosocial, and developmental age rather than reported legal age. Schools may require clinical documentation, and clinicians should be prepared to speak directly with the school representatives and provide a letter on behalf of their patient.