The background Anne a Refugee Community Health Nurse at a local CHS has been providing support to a recently arrived Hazari refugee couple Elaha and Ahmad

Elaha is 27 years old and is in the late stage of her pregnancy. She has no family connections in Australia. Elaha and Ahmad are living with a distant ‘family’ member from the Ahmad’s side.They have been staying in the lounge room. Ahmad is in his late 30’s and has a diagnosed mental illness. Elaha and Ahmad’s Story

Who is currently involved Ahmad is being treated at the Foundation House for Survivors of Torture for PTSD. Anne is coordinating referrals for the Elaha and Ahmad to a GP and providing general care. A community guide from AMES is trying to sought out long term housing. Local GP is providing general health care and support re pregnancy

The story continues.... The baby has just been born at the local public hospital following a long and difficult premature labour which resulted in caesarean section birth. The baby required neonatal intensive care and has been in IC for a week and is likely to be discharged in home in a few days. Elaha has preeclampsia and requires on going medical/nursing support although she has been discharged home.

Who is involved now? Paediatrician Hospital Social Work Interpreter Maternal and Child Health

What needs to happen? Get everyone together quickly to identify with Elaha and Ahmad their immediate and longer term priorities. Develop an Interagency care plan to reflect these priorities. Agree on who is going to do what and when and how to coordinate an ongoing interagency care response. Work together and keep communication channels open around how things are progressing. Work together to monitor and review the care plan at agreed times.

Some of the challenges Language Trust (both clients trust of providers and between providers – a key issue was around the sharing of information between providers) Getting providers together to develop a shared strategy and understanding Time consuming (Provider coordination and communication required) Sharing information (no shared record) Keeping track of information (some paper, some phone conversations)

Question to ponder How could e-technology have helped?