Health Referral Systemfor Care of People with

Disability

Nguyen Hoang Nam, MD, MPHWelcome To Life Project Coordinator, Khanh Hoa,

Viet Nam

Health referral is the process:Health care providers at lower levels to seek the

assistance of providers who are better equipped or specially trained to guide them in managing or to take over responsibility for a particular episode of a clinical condition in a client

Key reasons for deciding to refer toseek expert opinion regarding the client seek additional or different services for the clientseek admission and management of the clientseek use of diagnostic and therapeutic tools

What is a Health Referral?

Goal of the health referral:

To ensure that patients can receive appropriate, high-quality care for their condition in the lowest cost and closest facility possible

Goal of the Health Referral

1. External Vertical – patient/client referral from lower to higher-

level facility and vice-versa Horizontal –patient/client referral from one facility to

another facility with a higher capability and vice versa

2. Internal This is usually within the health facility and from one

health personnel to another

Types of the Referral

Health referrals system is organized as four level referral system: First level: Commune Health Centers (CHC) Second level: District Health Centers (DHC) Third level: Provincial Hospitals/Centers Fourth level: National Hospitals/Centers

CHCs are the first contact of the community/individual with the formal health system

CHCs serve as the gatekeepers for higher levels of health care

Framework of Referral System

Referral System Model

Family/Community

Commune Health Centers/CBR workers

District Health Centers

Provincial Hospitals/Centers

National Hospitals/Centers

Individual

Referral

Return referral

1. Health system Network of service providers Adherence to referrals protocols Transport, communications and other resources

2. Initiating facility The client and their condition Protocol of care for that condition at that level of service Treat and stabilize client – document treatment provided Decision to refer

Components of Referral System

3. Referral practicalities Outward referral forms Communicate with receiving facility Information to the client Referral register

4. Receiving Facility Receive client with referral form Treat client and document Plan rehabilitation

5. Supervision and capacity building Monitor referral Ensure back referral Feedback and training for facility staff

Components of Referral System

- In Viet Nam, CBR program are managed by Ministry of Health and implemented through primary health structure.- The role of CBR is to work in collaboration with people with disabilities, their families and medical services toFacilitate referrals for people with disabilities and their families for general or specialized medical care needsMake sure referrals have been made for people with disabilities who require access to secondary and tertiary levels of health careFacilitate referrals to access more specialized rehabilitation services

CBR and Health Referral System

Identify rehabilitation referral services available at all levels of the health system

Provide information regarding referral services to people with disabilities and their families, including location, possible benefits and potential costs

Encourage people with disabilities and their families to express concerns and ask questions about referral services

Once a referral is made, maintain regular contact with the services and individuals involved to ensure that appointments have been made and attended

Facilitating Referral by CBR workers

Identify what support is required to facilitate access to services (e.g. financial, transport, advocacy) and how this can be provided

CBR personnel can accompany people to their appointments

Provide follow-up after appointments to determine whether ongoing support is needed, e.g. rehabilitation activities may need to be continued at home (Community-Based Rehabilitation Guidelines, WHO,

2010)

Facilitating Referral by CBR workers

Under utilization of commune health centers and district health centers (referral discipline)

Delayed referral Poor referral communications

Major Issues in Referral System

Improving design by assessing which services should be provided at what level of care, including home and community-based care; primary health care; and district, secondary, tertiary, and other specialized hospitals;

Transferring information better between levels of care (whether referring patients up or down in the system) and from a geographic perspective, ensuring patients have transportation arrangements from remote areas when needed;

Instilling “referral discipline” by fast-tracking patients who are referred and explaining to non referred patients that they need to wait or go to another facility for care

(DCP2 Project – World Bank, 2008)

Proposed Solutions

WHO. 2010. Community-based Rehabilitation: CBR Guidelines

World Bank. 2008. Referral Hospital in In Disease Control Priorities in Developing Countries, 2nd ed

WHO. 2011. Management of Health Facility. (http://www.who.int/management/facility/referral/en/index.html)

Viet Nam Ministry of Health. 2008. CBR Training Manual for Health Staff

References