referral notes

8/2/2019 Referral Notes

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Referral Systems - a summary of key processes to guidehealth services managers

An effective referral system ensures a close relationship between all levels of the health system and helps toensure people receive the best possible care closest to home. It also assists in making cost-effective use ofhospitals and primary health care services. Support to health centres and outreach services by experiencedstaff from the hospital or district health office helps build capacity and enhance access to better quality care.In many developing countries, a high proportion of clients seen at the outpatient clinics at secondary facilitiescould be appropriately looked after at primary health care centres at lower overall cost to the client and thehealth system. A good referral system can help to ensure:

Clients receive optimal care at the appropriate level and not unnecessarily costly

Hospital facilities are used optimally and cost-effectively Clients who most need specialist services can accessing them in a timely way

Primary health services are well utilized and their reputation is enhanced

Being a system, examination of a referral system requires consideration of all its parts. Importantcomponents of a referral system are listed in Box 1 and referral flows are depicted in Figure 1. These can beadjusted as relevant to the local situation. The design and functioning of a referral system in any individualcountry will be influenced by:

health systems determinants: capabilities of lower levels; availability of specialized personnel;training capacity; organizational arrangements; cultural issues, political issues, and traditions

general determinants, such as: population size and density; terrain and distances between urbancentres; pattern and burden of disease;demand for and ability to pay for referral care

Figure 1. Referral system flows


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1. Health Systema. Service providers (public and private sector) and quality of care

i. Strengthened primary health care servicesii. Clarity of level and role of each facilityiii. Availability of protocols of care for conditions for each level of facilityiv. Availability of communication and transport

b. Performance expectationsi. Expectation to refer appropriately and follow protocols of careii. Expectations that health workers and clients adhere to the referral disciplineiii. Regular supervision and capacity building

c. Involvement of organizations

i. Ministry of Healthii. Medical and nursing schoolsiii. Medical and nursing professional associations

2. Initiating facilitya. The client and their conditionb. Protocol of care for that condition at that level of servicec. Treat and stabilize client document treatment providedd. Decision to refer

3. Referral practicalitiesa. Outward referral formb. Communication with receiving facility (make arrangements as appropriate)c. Information to the client and their family/support network

i. Reasons and importance of referral, risks of non-referralii. How to get to the receiving facility location and transportiii. Who to see and what is likely to happeniv. Follow-up on return

d. Empathy - understanding of implications for client and family/support network

i Overall fear


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to seek use of diagnostic and therapeutic tools

In this paper, the facility that starts the referral process is called the initiating facility, and they prepare anoutward referral to communicate the client condition and status (see sample tool 1).

The facility that accepts the referred case is called the receiving facility and at the end of their involvement,they prepare a back referral on the lower part of the forms to let the initiating facility know what has beendone (see sample tool 1). This completes the referral loop between the 2 facilities.

A referral registeris a means of maintaining a list of all outward and inward referrals for one facility orservice provider (see sample tool 2). Information registered includes client referred, to where, when and why,whether the case is closed or continuing (the retuning referral form has been received with any necessaryrehabilitation or follow-up), and whether it was an appropriate referral or if there were any issues.

Some areas maintain a directory of services that lists all organizations providing specialist care. Such adirectory can facilitate the search for the most appropriate service provider for a particular referral. Wheresuch a directory is used, it is important that the contact information is kept up-to-date.

These terms are not hard and fast, but are used here to assist clarity of description. The referral system inyour country might use different terms.

Description of components of the referral system

1. Health system issues

a. Service providers (public and private) and quality of care

For a referral system to work at its best, relationships between service providers are formalized andreferral procedures agreed. All levels of the health system, including primary health care services,need to be functioning appropriately. This includes each facility:

being clear about their role, responsibilities and limitations

having readily available protocols of care for conditions for that level of service

having suitable means of communication and transport Communication is generally by the


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2. Initiating facility

a. When a client visits the health centre, it is important that the health worker attends to thempromptly, treats them with respect, privacy and confidentiality, acknowledging their cultural beliefs,and identify their needs.

b. If protocols of care are used in this country, the health workers need to have ready access to, andbe very familiar with, the agreed regional or national protocols for that level of facility. Protocolsneed to include likely circumstances for referral and details of the information and documents thatshould be sent with the client.

c. The health workers assess the client, gather relevant information and provide any necessary carepossible at that facility. In an emergency situation, the health worker must maintain all vital

functions and minimize any further damage.

d. Making the decision to refer the client comes after the health worker has gathered and analyzedthe relevant information using the protocol of care as a guide. Deciding to refer does not mean thatthe health worker is inadequate or bad.

3. Referral practicalities

a. A referral form that is standardized throughout the network of service providers ensures that thesame essential information is provided whenever a referral is initiated (see sample tool 1). Thereferral form is designed to facilitate communication in both directions - the initiating facility

completes the top part or the outward referral. Every patient referred out should be accompaniedby a written record of the clinical findings, any treatment given before referral and specific reasonsfor making the referral. The referral form should accompany the client (often carried by them) andgive a clear designation of to which facility the patient is being sent. A carefully filled referral cardcab help the client get timely attention at the receiving facility.

b. In some situations it will be possible and necessary to communicate with the receiving facility tomake an appointment or other arrangements for the referral, or to let them know of the pendingarrival of an emergency case. If the client is very ill, it might be necessary for a health worker toaccompany them to the receiving facility.


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continuing education to the initiating facility and their staff. The supervisor should check that backreferral is received and, in its absence, pursue the relevant staff at the higher level facility toprovide proper back referral information.

e. The receiving facility can also give feedback to the initiating facility on the appropriateness ofreferral. If there are any issues regarding the need for referral, timing, speed or information sent,then it is important that the higher level facility provides specific feedback to the initiating facility.This will assist the lower level facility to be more sure of referral processes in the future.

f. The receiving facility completes its own register of referrals in and out, from their perspective (seesample tool 2)

5. Supervision and capacity building

Facility managers and supervisors at all levels should monitor all referrals made to and from facilities in

their area each month. Usually between 5% and 10% of clients seen in a primary health care facility willbe referred to a higher level for diagnostic services or more specialized care. Supervisors should discussreferred cases:

Identify those which should have been properly treated at the facility itself without referral

Identify cases which should have been referred but were handled locally

Check the back referrals received to determine whether the information is adequate andbeing acted upon by the facility

Follow up cases that have been referred but no feedback yet received to assure that theclient has arrived at the higher level

Identify any issues regarding timing, promptness and completeness of information sent

Results of this analysis can be covered at meetings with hospital and clinic staff together. As the issuesare discussed, staff will identify what is needed to improve things - this might include clinical training orstrengthening of particular parts of the referral system or its procedures. Facility managers andsupervisors need to ensure that such items are followed-up and acted on. In-service education andcapacity strengthening can be reinforced by good supervision.

Long-term treatment of chronic illnesses such as diabetes, hypertension, epilepsy and psychiatric illness

can be managed at suitably resourced health centres this assures not only high quality of care for the


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References

Bossyns P and Van Lerberghe W, 2004, The weakest link: competence and prestige as constraints toreferral by isolated nurses in rural Niger, in Human Resources for Health 2004, 2-1, available on line at:

http://www.human-resources-health.com/content/pdf/1478-4491-2-1.pdf

Cervantes K, Salgado R, Choi M and Kalter H. 2003 Rapid Assessment of Referral Care Systems: A Guidefor Program Managers, published by the Basic Support for Institutionalizing Child Survival Project (BASICSII) for the United States Agency for International Development, Arlington, Virginia, available on line at:http://www.jsi.com/Managed/Docs/Publications/WomensHealth/PNACW615.pdf

Department of Health, Republic of South Africa, 2003, The Clinic Supervisors Manual, Version 3, seeSection 6: Referral System Guidelines, available on line at:

http://www.doh.gov.za/docs/factsheets/guidelines/clinical/index.html

Department of Reproductive Health and Research (RHR), World Health Organization, Care of mother andbay at the health centre: A practical guide, see Section 3 Developing and maintaining a functioning referralsystem, available on line at:http://www.who.int/reproductive-health/publications/msm_94_2/care_mother_baby_health_centre.pdf

Jamison D T, Breman J G, Measham A R, Alleyne G, Claeson M, Evans D B, Jha P, Mills A and MusgroveP, 2006, Disease Control priorities in Developing Countries, A co publication of Oxford University Press andThe World Bank, see Chapter 66: Referral Hospitals, available on line at::

http://files.dcp2.org/pdf/DCP/DCP.pdf

Saunders D, Kravitz J, Lewin S and McKee M, 1998, Zimbabwes hospital referral system: does it work? InHealth Policy and Planning: 13(4): 359-370, available on line at:http://heapol.oxfordjournals.org/cgi/reprint/13/4/359.pdf

Stuart L, Harkins J, and Wigley M, 2005, Establishing Referral Networks for Comprehensive HIV Care inLow-Resource Settings, Family Health International, Impact and USAID, available on line at:http://www.fhi.org/NR/rdonlyres/ewym4k3dirreee3fwj43u2wt47o5gctbnrvichtethbx5uwl3tglsewndqxvwfhoqvb

5agzccsce6k/RefNetsGuide pdf
http://www.human-resources-health.com/content/pdf/1478-4491-2-1.pdfhttp://www.jsi.com/Managed/Docs/Publications/WomensHealth/PNACW615.pdfhttp://www.doh.gov.za/docs/factsheets/guidelines/clinical/index.htmlhttp://www.who.int/reproductive-health/publications/msm_94_2/care_mother_baby_health_centre.pdfhttps://outlook.who.int/exchweb/bin/redir.asp?URL=http://files.dcp2.org/pdf/DCP/DCP.pdfhttp://heapol.oxfordjournals.org/cgi/reprint/13/4/359.pdfhttp://www.fhi.org/NR/rdonlyres/ewym4k3dirreee3fwj43u2wt47o5gctbnrvichtethbx5uwl3tglsewndqxvwfhoqvb5agzccsce6k/RefNetsGuide.pdfhttp://www.fhi.org/NR/rdonlyres/ewym4k3dirreee3fwj43u2wt47o5gctbnrvichtethbx5uwl3tglsewndqxvwfhoqvb5agzccsce6k/RefNetsGuide.pdfhttp://www.human-resources-health.com/content/pdf/1478-4491-2-1.pdfhttp://www.jsi.com/Managed/Docs/Publications/WomensHealth/PNACW615.pdfhttp://www.doh.gov.za/docs/factsheets/guidelines/clinical/index.htmlhttp://www.who.int/reproductive-health/publications/msm_94_2/care_mother_baby_health_centre.pdfhttps://outlook.who.int/exchweb/bin/redir.asp?URL=http://files.dcp2.org/pdf/DCP/DCP.pdfhttp://heapol.oxfordjournals.org/cgi/reprint/13/4/359.pdfhttp://www.fhi.org/NR/rdonlyres/ewym4k3dirreee3fwj43u2wt47o5gctbnrvichtethbx5uwl3tglsewndqxvwfhoqvb5agzccsce6k/RefNetsGuide.pdfhttp://www.fhi.org/NR/rdonlyres/ewym4k3dirreee3fwj43u2wt47o5gctbnrvichtethbx5uwl3tglsewndqxvwfhoqvb5agzccsce6k/RefNetsGuide.pdf


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These tools are in Microsoft Word, so that you can adjust them to your particular country situation.


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Name of facility: Referral Form original / copyReferred by: Name: Position:

Initiating Facility Nameand Address:

Date of referral:

Telephonearrangements made:

YES NO Facility Tel No. Fax No.

Referred to FacilityName and Address:

Client Name

Identity Number Age: Sex: M F

Client address

Clinical history

Findings

Treatment given

Reason for referral

Documentsaccompanying referral

Print name, sign & date Name: Signature: Date:

Note to receiving facility: On completion of client management please fill in and detach the referral back slip belowand send with patient or send by fax or mail.

--------------------------------------------------receiving facility - tear off when making back referral------------------------------------

Back referral from


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Print name, sign & date Name: Signature: Date:


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Name of facility: _______________________________________

Register of Referrals OUT

Datereferralmade

Client Name (M or F) Identity No. Referred to

(name of facility /specialty)

Referred forDateBackreferralreceived

Follow-uprequiredYES / NO

Follow-upcompletedYES / NO

AppropriatereferralYES / NO


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Name of facility: _______________________________________

Register of Referrals IN

Datereferralreceived

Client Name (M or F) Identity No. Referred from

(name of facility /specialty)

Referred forAppropriate

referralYES / NO

Summary of treatmentprovided

DateBack

referralsent


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Name of facility: _______________________________________