1. Monitoring referrals to
strengthen service integration
Cristina de la Torre, MPH, DSc.
MEASURE Evaluation/ICF International
Cristina.delatorre@icfi.com

2. Health services integration
Objectives

Improve efficiency, reduce costs

Increase access to and coverage of services

Increase use of wider range of services
 (e.g. minimum package of services)

Meet diverse health needs of clients

Improve health outcomes

3. Models of integration
1. Single provider – multiple services
2. Multiple services on site – different providers
3. Linking services across sites

4. Components of an effective referral system
 Group of organizations providing comprehensive range
of services within a defined geographic region
 Directory of services & providers
 Referral protocols
 Processes to facilitate referral completion
 Information exchange across providers, including
feedback loop
 Tracking of referrals (standardized registers, client
referral forms)
 Coordinating unit
Adapted from: FHI 2005

5. Referral systems

6. Specify the referral system of interest
 Nature of system to be studied
 Program(s) included
 Geographic coverage
 Organizations
 Range of services offered
 Referral systems vs referral networks

7. Referral Assessment and Monitoring
(RSAM) Toolkit
Provide tools and guidance for studying the
performance of referral system
 Assess overall functioning of the referral system
 Establish a routine monitoring system of referrals
 Adapt tools, gather, analyze and interpret data
on referral system performance

8. Considerations
 Flexibility: Adaptable to
 Different programs & types of services
 Structure of referral systems
 Limit burden of data collection
 Use data commonly collected by service providers
 User-friendly

9. RSAM Toolkit Components
 Referral system assessment (RSA)
 In-depth examination of processes and
mechanisms at given point in time
 Referral system monitoring (RSM)
 Routine data to track levels of referral initiation
and completion across services

10. RSAM TOOLKIT
Referral System Assessment
Focus on processes and systems
 How the referral system is structured
 How networks are formed
 Whether written referral protocols and guidelines exist
 The processes providers follow to refer and counter-refer
clients
 How well referrals are tracked and followed up
 Barriers to referral initiation and referral completion

11. Referral System Assessment
 Provides a snapshot of the referral system at a
given point in time
 Can be used to evaluate changes in performance
if applied repeatedly
 Evaluate effectiveness of interventions

12. Referral System Assessment
Tools:
 RSA Questionnaire
 Document Checklist
 RSA Analysis Guide
 Decision Calendar

14. Referral System Assessment
Other information provided in toolkit:
 Who should implement an RSA
 Resources needed
 Selecting facilities
 Adapting instruments
 Guidelines for analysis
 How and why to involve stakeholders

15. RSAM TOOLKIT
Referral System Monitoring
Routine data from facilities
 How often referrals are made to different services?
 What types of services are clients most often referred to?
 Are clients able to take advantage of the referrals?
 Is adequate follow-up provided after the fact?
 Are referrals equitable across gender or age groups?

16. Referral system monitoring
Key indicators:
 Referral initiation
% clients referred from service A to service B
 Referral completion
% of referred clients who complete referral
 Counter-referral
% of clients who complete referral who are seen
again by initiating provider

17. Monitoring
Adapting tools
 What level of disaggregation do you need:
 Specificity of services
 Sub-populations

18. Referral systems

19. (TO BE COMPLETED BY REFERRING SERVICE)
PAGE 1 of 3
Name of organization and facility: _____________________________________
Geographic unit: _______________________________
Reporting period—Month: ______ Year: __________ Prepared by: ________________________
1. Number of clients referred by type of service
Group for which data are reported—Age range: _______________ Sex: ______________
COLUM
NY
REFERRING
SERVICE
Service 1
(FP)
Service 2
(VCT)
Service 3
(STI)
Service 4
(ART)
Service 5
Service 6
TOTAL
NUMBER
CLIENTS
SEEN AT
REFERRING
SERVICE
CLIENTS REFERRED
TO
RECEIVING SERVICES
Service 1
(FP)
Service 2
(VCT)
Service 3
(STI)
Service 4
(ART)
Service 5
Service 6

20. Indicator Reporting Form
Geographic unit: _____________________Region: _____________________________________
Reporting period—Month: _______ Year: _________Prepared by: _________________________
Group for which data are reported—Age range: _______________ Sex: ______________
Referring
Service
Receiving
Service
Service 1
Service 1
Service 1
Service 2
Service 2
Service 2
Service 3
Service 3
Etc.
Service 2
Service 3
Service 4
Service 1
Service 3
Service 4
Service 1
Service 2
Etc.
Indicator 1:
Proportion of
clients
referred from
initiating service
Indicator 2:
Indicator 3:
Proportion of
Proportion of
referred clients
referred clients
that completed seen at receiving
referral at
service that is seen
receiving facility back at referring
service for counterreferral

21. Illustrative monitoring data

22. Illustrative data

23. Benefits of monitoring and assessing referrals
Aid in Identifying:
 under or over-utilized services
 providers who are not referring patients
 access or quality issues that impede service
utilization
 linkages between services that are not
sufficiently established
Aid in planning, resource allocation

24. Referral System Assessment and Monitoring (RSAM) Toolkit
(MEASURE Evaluation)
http://www.cpc.unc.edu/measure/publications/MS-13-60

25. The research presented here has been supported by the
President’s Emergency Plan for AIDS Relief (PEPFAR)
through the United States Agency for International
Development (USAID) under the terms of MEASURE
Evaluation cooperative agreement GHA-A-00-08-0000300. Views expressed are not necessarily those of
PEPFAR, USAID or the United States government.
MEASURE Evaluation is implemented by the Carolina
Population Center at the University of North Carolina at
Chapel Hill in partnership with Futures Group, ICF
International, John Snow, Inc., Management Sciences for
Health, and Tulane University.