Implementation and Evaluation of an Integrated Care Team for Refugee Health: A Case Study in Ontario, Canada

Background: Refugees face significant barriers in accessing primary care, often resulting in poorer health outcomes. This case study evaluates the implementation of a multidisciplinary Integrated Care Team (ICT) for refugees, in Ontario, Canada. The aim of the ICT was to transition refugees into primary care practices.

Methods: A mixed-methods process evaluation was conducted to assess the implementation and outcomes of the ICT program. Data sources included ethnographic observations, in-depth interviews with ICT staff, clinicians, and refugee patients. Thematic analysis was applied to qualitative data, and program database metrics were analyzed to evaluate patient transitions and service use.

Findings: In its first year, the ICT transitioned 664 refugees to primary care, surpassing its goal of 300. Key successes included improved collaboration, enhanced system navigation, and reduced pressure on refugee clinics. Refugee participants reported feeling supported through the ICT program, emphasizing the importance of personalized care and assistance in navigating the healthcare system. The program improved access to primary care, facilitated timely referrals, and addressed social determinants of health.

Discussion: The ICT program demonstrates the potential of integrated care to enhance refugee health outcomes. Flexibility, collaboration, and proactive support were essential to its success. Future research should explore long-term impacts and scalability.