Monitoring referrals to
strengthen service integration
Cristina de la Torre, MPH, DSc.
MEASURE Evaluation/ICF Internationa...
Health services integration
Objectives
 Improve efficiency, reduce costs
 Increase access to and coverage of services
 ...
Models of integration
1. Single provider – multiple services
2. Multiple services on site – different providers
3. Linking...
Range of services for HIV/AIDS clients
1. Adherence
counseling
2. Antiretroviral
therapy
3. Childcare
4. Clinical care
5. ...
Components of an effective referral system
 Group of organizations providing comprehensive range
of services within a def...
Methods for assessing and monitoring
referral systems
Depend on why you are studying the system:
Clinical appropriateness...
Clinical appropriateness
Are clients receiving the care they need?
Are the right persons being referred?
Examines decisio...
Service utilization patterns
Surveys with target population
0
10
20
30
40
50
60
70
80
90
PercentofMSM
ProgramBeneficiaries...
Referral Assessment and Monitoring
(RSAM) Toolkit
Guidelines for
Establishing a routine monitoring system of
referrals
A...
RSAM TOOLKIT
Referral System Assessment
Focus on processes and systems
Consists of interviews and document review to deter...
RSAM TOOLKIT
Referral System Monitoring
Consists of routine data collection at facility
How often referrals are made to d...
Routine monitoring of referral systems
Key indicators:
 Referral initiation
% clients referred from service A to service ...
Referral systems
  COLUM
N Y
TOTAL
NUMBER
CLIENTS
SEEN AT
REFERRING
SERVICE
CLIENTS REFERRED
TO
RECEIVING SERVICES
 
Service 1
(FP)
Service...
Referring
Service
Receiving
Service
Indicator 1:
Proportion of 
clients 
referred from 
initiating service
Indicator 2:
Pr...
Illustrative monitoring data
Illustrative data
Benefits of monitoring and assessing referrals
Aid in Identifying:
under or over-utilized services
providers who are not...
References
 Referral System Assessment and Monitoring (RSAM) Toolkit
(MEASURE Evaluation)
http://www.cpc.unc.edu/measure/...
The research presented here has been supported by the
President’s Emergency Plan for AIDS Relief (PEPFAR)
through the Unit...
www.measureevaluation.org
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Monitoring Referrals to Strengthen Service Integration

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Monitoring Referrals to Strengthen Service Integration

  1. 1. Monitoring referrals to strengthen service integration Cristina de la Torre, MPH, DSc. MEASURE Evaluation/ICF International Cristina.delatorre@icfi.com
  2. 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. 3. Models of integration 1. Single provider – multiple services 2. Multiple services on site – different providers 3. Linking services across sites
  4. 4. Range of services for HIV/AIDS clients 1. Adherence counseling 2. Antiretroviral therapy 3. Childcare 4. Clinical care 5. Education/ schooling 6. Family planning 7. Financial support 8. Foodsupport 9. HIV counseling and testing 10. Home-based care 11. Legal support 12. Material support 13. Mental health services 14. Microfinance 15. Nutrition counseling 16. OB/GYNservices 17. Peercounseling 18. PEP services 19. Pharmacy 20. PLHA support 21. PMTCT services 22. Post-test clubs 23. Prevention services 24. Psychosocial support 25. Social services 26. Spiritual support 27.STI services 28. Substanceabuse management 29. Support for domestic violence victims 30. Treatment support 31. TB services 32. Youthsupport groups 33. Other________ Source: FHI, 2005
  5. 5. 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  Coordinating unit  Information exchange across providers, including feedback loop  Tracking of referrals (standardized registers, referral forms) Adapted from: FHI 2005
  6. 6. Methods for assessing and monitoring referral systems Depend on why you are studying the system: Clinical appropriateness of referrals Is the system set up effectively (processes and systems are in place) Flow of clients across services Use of a package of services
  7. 7. Clinical appropriateness Are clients receiving the care they need? Are the right persons being referred? Examines decisions of providers (and client compliance) Review of medical records Requires clear guidelines and referral protocols E.g. Rapid assessment tools developed by Basics II project for childhood illnesses
  8. 8. Service utilization patterns Surveys with target population 0 10 20 30 40 50 60 70 80 90 PercentofMSM ProgramBeneficiaries 2005 2007 Peer Outreach and Education above plus Condoms above plus Targeted Media above plus VCT above plus STI Source: Coverage Plus Data from Thailand (MEASURE Evaluation) Are persons accessing the full range of services available to them?
  9. 9. Referral Assessment and Monitoring (RSAM) Toolkit Guidelines for Establishing a routine monitoring system of referrals Assessing overall functioning of the referral system Can be adapted to any type of referral system
  10. 10. RSAM TOOLKIT Referral System Assessment Focus on processes and systems Consists of interviews and document review to determine: 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. 11. RSAM TOOLKIT Referral System Monitoring Consists of routine data collection at facility How often referrals are made to different services (initiation) What types of services are clients most often referred to Are clients able to take advantage of the referrals (completion) Is adequate follow-up provided after the fact (counter- referral)
  12. 12. Routine monitoring of referral systems 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
  13. 13. Referral systems
  14. 14.   COLUM N Y 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 REFERRING SERVICE Service 1 (FP)           Service 2 (VCT)               Service 3 (STI)               Service 4 (ART)           Service 5               Service 6               (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: ______________ 
  15. 15. Referring Service Receiving Service Indicator 1: Proportion of  clients  referred from  initiating service Indicator 2: Proportion of  referred clients  that completed  referral at  receiving  facility Indicator 3: Proportion of  referred clients  seen at receiving  service that is seen  back at referring  service for counter- referral Service 1 Service 2       Service 1 Service 3       Service 1 Service 4       Service 2 Service 1       Service 2 Service 3       Service 2 Service 4       Service 3 Service 1       Service 3 Service 2       Etc. Etc.         Geographic unit: _____________________Region: _____________________________________  Reporting period—Month: _______ Year: _________Prepared by: _________________________     Group for which data are reported—Age range: _______________ Sex: ______________  Indicator Reporting Form
  16. 16. Illustrative monitoring data
  17. 17. Illustrative data
  18. 18. 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
  19. 19. References  Referral System Assessment and Monitoring (RSAM) Toolkit (MEASURE Evaluation) http://www.cpc.unc.edu/measure/publications/MS-13-60  Rapid Assessment of Referral Care Systems: A Guide for Program Managers (BASICS II) http://www.who.int/management/facility/RapidAssessmentofReferralCareSystems.pdf  Establishing Referral Networks for Comprehensive HIV Care in Low-resource settings (FHI) http://pdf.usaid.gov/pdf_docs/PNADF677.pdf  Tools for Establishing Referral Networks for Comprehensive HIV Care in Low-resource settings (FHI) http://pdf.usaid.gov/pdf_docs/PNADI858.pdf
  20. 20. 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-00-08-00003- 00. 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.
  21. 21. www.measureevaluation.org

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