Health Referral System for Care of People with Disability Nguyen Hoang Nam, MD, MPH Welcome 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 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 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 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 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 Community-based Rehabilitation: CBR Guidelines  World Bank Referral Hospital in In Disease Control Priorities in Developing Countries, 2nd ed  WHO Management of Health Facility. (  Viet Nam Ministry of Health CBR Training Manual for Health Staff References