Health Referral System for Care of People with Disability

1. Health Referral Systemfor Care of People with Disability Nguyen Hoang Nam, MD, MPH Welcome To Life Project Coordinator, Khanh Hoa, Viet Nam

2. What is a Health Referral? • 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 to • seek expert opinion regarding the client • seek additional or different services for the client • seek admission and management of the client • seek use of diagnostic and therapeutic tools

3. Goal of the 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

4. Types of the 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

5. Framework of Referral System • 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

6. Referral System Model National Hospitals/Centers Provincial Hospitals/Centers Referral District Health Centers Return referral Commune Health Centers/CBR workers Family/Community Individual

7. Components of Referral System 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

8. 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

9. CBR and Health 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 to • Facilitate referrals for people with disabilities and their families for general or specialized medical care needs • Make sure referrals have been made for people with disabilities who require access to secondary and tertiary levels of health care • Facilitate referrals to access more specialized rehabilitation services

10. Facilitating Referral by CBR workers 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

11. 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)

12. Major Issues in Referral System • Under utilization of commune health centers and district health centers (referral discipline) • Delayed referral • Poor referral communications

13. Proposed Solutions Improving design by assessing which services should be provided at what level of care, including home andcommunity-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 referredpatients that they need to wait or go to another facility for care (DCP2 Project – World Bank, 2008)

14. References 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