Referral System Guide for Better Healthcare

Referral System as a Tool for
Health Care Delivery
Dr. Abubakr .Y. Ibrahim
Associate Professor - Community medicine
Community medicine Department
Elrazi University

Referral System &Health Care Delivery
Introduction:
Take place in clinical medicine in Europe during
19th century when lines were started to be
drawn between primordial clinical specialists.
It can not take place without looking at the
context in which health service delivered at its
all levels.
 Ultimately affects how various aspects of the
health system function.

Introduction:
 Does not depend on a structured system only,
but on a potential interaction between facilities
of different technical capacity.
High proportion of consumer seen at outpatient
clinics at 2nd facilities could be appropriately
looked after at primary health care centres at
lower overall cost, if referral system is adapted.

Introduction:
In order to have efficient referral system the
national health system should be provided for
three tiers of health care; primary, secondary
and tertiary.
The three levels should adopt referral system
as main linkage between them.

Introduction:
For the P.H.C.C are the1st point of contact
though it is supposed to be referred from here
to other levels of health care.
 Referral should be a process by which a
health worker transfers the responsibility of care
temporarily or permanently to another health
professional or social worker or to community.

What is Referral System?
It is a two-way system advocated from lowest
level of health care to the highest (Village
health worker to Basic Health Units, to Primary
Health Care, to Comprehensive Health Centre
and to State General Hospital, Specialized /
Teaching Hospitals ), by sending customers to
another health facility through a referral paper
authorizing his visit, with exception of the
emergency cases when patients can attend to
any of the facilities for immediate treatment.

Referral System
Definition :
It is a process, in which the treating physician
at the primary level has inadequate skills by
virtue of his qualification or has a lesser facilities
at his level to mange a clinical condition and
seeks assistance of a better equipped and
specifically trained person with better resources
at the higher level in the hospital.

Reasons for Referral
Reasons either emergency or routine can be :
To seek expert opinion.
To seek additional or different services .
To seek admission and management .
To seek use of diagnostic & therapeutic tools.
For co-management or further management
of the illness e.g. complications in pregnancy.
For continuity of care.

Rationale of Referral System
Most common ,most complicated and life
threatening diseases requires different levels.
Maximize limited resources & avoid duplication
of services.
 Ensures a close relationship between all levels
of the health system.
Helps people receive the best possible care
closest to home.
Assists in making cost-effective use of hospitals
& primary health care services.

Support primary health centers & outreach
services by experienced staff from the
hospital or district health office.
 Helps to build capacity & enhance access to
better quality care.
 Reduce the high proportion of customers
seen at the outpatient clinics at 2nd facilities

A good referral system can help to ensure:
customers receive optimal care at the
appropriate level& not unnecessarily costly.
Hospital facilities are used optimally and
cost-effectively.
customers who most need specialist services
can access them in a timely way.
Primary health services are well utilized and
their reputation is enhanced
Promotes continuity of treatment.

Levels of Referral System
It was developed as a product of widely
heeded concept which classifies health care
need according to illness severity into:
primary, secondary, and tertiary care levels,
which in turn presents the need of referral
system to interlink or interconnect one to
another.

Levels for Referral System
Primary level of care
Developed to urban and rural areas
Referral site for the to Village health worker
& Basic Health Units
Usually is the 1st contact level between
community & other levels of health facility.
Provide management for common &minor
alignments requiring simple uncomplicated
interventions

Secondary level of care
Referral site for the primary care facilities
Given by physicians with basic health training.
Usually given in health facilities either private
owned or government operated.
 Rural hospitals, State General Hospital, out-
patient departments are main sites of care.
Rendered by specialists in health facilities.
Provide care for serious conditions that needs
technical interventions & inpatient care which are
not expected to available at P.H.C level

Tertiary level of care
Referral site for the secondary care facilities.
Can be Medical centers, Regional , Provincial
Hospitals and Specialized Hospitals.
Provide care for complicated, uncommon and
serious diseases requiring highly specialized
or high technology interventions

Referral System Design
The most important inputs are resource,
management and technology and most of
its problems related to them.
Design & functioning can be influenced by:
Health systems determinants:
Capabilities of lower levels.
Availability of specialized personnel.
Training capacity.
Organizational arrangements.
Cultural & political issues, and traditions

Design & functioning can be influenced by:
General determinants:
Population size and density.
Terrain and distances between urban
centers.
Pattern and burden of disease.
Demand for and ability to pay for referral
care.

Framework of the two way system should:
Encourage an environment in which referral
hospital is viewed as a community resource.
Be responsive to local situations, while being
part of over all province-wide referral system
 Be inclusive of private medical sector & NGOs
involved in the provision of community based
health care.
 Include a properly functioning communication
and transport system (telephone, radiophone,
ambulance, email …etc).

Basic health unit
1st level Primary
Health Care
2nd care level
Rural Hospital
Tertiary Care level
Tertiary
Care level
Tertiary
Care level
FLOW CHART OF REFERRAL SYSTEM

Components of a Referral System
Can be adjusted relevant to the local situation.
Components can include :
1. Health System.
2. Referral process at the 1st level of care
3. Referral activities
4. Referral process at 2nd or tertiary level
5. Supervision and capacity building

Components of Referral System Flow chart

Perspectives & Issues of Establishing
1- Health System Issues
Service providers & quality of care:
For its best; relationships are formalized and
the procedures agreed upon.

To be functioning appropriately each facility:
Have clear idea about their role, responsibilities
and limitations.
Have readily available protocols of care for that
level of service.
Have suitable means of communication and
transport.

To be functioning appropriately each facility:
The communication route can be by :
• The referral forms.
• Additional means ( radio, phone or fax).
Community-based system of organizing
transport can be the alternative where there is
shortage to provide an ambulance for health
centres.

 Customers bypassing lower level services to
higher level facilities and this be overcome by:
Improvement in resource availability.
Quality of care at the lower levels should be
the 1st priority by strengthening P.H.C services
to make them attractive and credible .

In overcrowded hospital:
The [outpatient, queuing systems] :
• Designed to separate & fast-track referred
customers.
• Explain to who bypass primary services why
they have to wait longer .
• Penalty fees charged to those who arrive at
higher level facilities without a referral letter.

In urban areas, having primary & secondary
services in separate (but proximate) locations
enables rigorous enforcement of the referral
only policy at the secondary facilities.

Intensive public communication &education is
essential to:
 Inform how, where and when they should
seek health care at different levels.
 Build their confidence that lower level facilities
really can offer acceptable quality care when
they need it.

Performance expectations &involvement of
organizations
 The system will function effectively if :
All service providers are expected to :
Adhere to the referral discipline.
Refer appropriately.
 Follow the agreed protocols of care (where
system applied).

organizations
 It is the role of supervising organization &
facility supervisors to monitor referral statistics
& to provide feedback as appropriate.
The national health authorities (e.g. MoH) must
expect the supervisors to regularly take action
to ensure that the referral system progressively
improves.

organizations
To achieve the level of consistent professional
performance :
Appropriate education at medical & nursing
schools.
 Involvement of medical & nursing professional
associations in setting standards for the
referral processes.

2-Referral process at 1st level (initiating facility )
During visits of H.C, it is important that the
health worker:
 Attends to them promptly.
 Treats with respect, privacy & confidentiality.
 Acknowledge the cultural beliefs.
 Identify their needs.

For proper performance the health workers :
Need to have ready access to used protocols.
 Familiar with, the agreed upon regional or
national protocols for that level of facility.
 assess the consumer, gather relevant
information & provide any necessary care
possible at that facility.
In an emergency situation, maintain all vital
functions to minimize any further damage.

Protocols need to include :
Likely circumstances for referral .
Details of the information and documents that
should be sent with the consumer.
Making decision to refer comes after the
gathering and analyzing relevant information
using protocols as a guide.
Deciding to refer does not mean that the health
worker is inadequate or bad.

3- Referral activities
 Adoption of standardized referral form to
ensure equality whenever a referral is initiated
 The referral form:
Be designed to facilitate communication in both
directions
Initiating facility completes the top part or the
outward referral.

Pts referred out should be accompanied by :
A written record of the clinical findings.
 Any treatment given before referral.
Specific reasons for making the referral.
The referred customer :
 Referral form should accompanied (often
carried by them)
Should given a clear designation of to which
facility is being sent.

 Carefully filled referral card cab helps to get
timely attention at the receiving facility.
In some situations it will be necessary to
communicate with the receiving facility:
To make appointment or other arrangements
 Let them know of the pending arrival of an
emergency case.
Emergency cases should be accompanied with
a health worker.

When taking decision to refer give relevant
information to reduce frightening or distressing
such as:
Reasons and importance of the referral.
 Risks associated with not going.
How to get receiving facility, location &transport
Who to see and what is likely to happen.
The process of follow-up on their return.

Show empathy in understanding implications of
referral for consumer &their family that may be:
Frightened of the unknown.
frightened of becoming more ill or even dying
concerned about meeting costs of transport,
treatment and family accommodation.
Concerned about leaving work that needs to be
done.

Each facility:
 Should have a referral register to keep track of
all the referrals made & received.
 Should use the information from the register to
monitor referral patterns and trends.
 Use the standardized referral register
throughout the network of service providers

4- Referral process at 2nd or 3rd level (receiving facility )
 The receiving facility :
If forewarned:
Can anticipate the arrival .
Receive the customer with their referral form.
Use the information sent to begin a thorough
assessment and management .
Use its particular resources to provide high
quality care.

Maintain documentation according to agreed
standards.
As the progresses a plan for rehabilitation or
follow-up programme or support network should
be initiated.

When care has finished at the higher level
facility, back referral to the original facility is
important after completing the lower part of form .
The back referral:
 Should contain Information on investigations,
findings, diagnosis and treatment given
Follow up expected from the lower level facility.

The back referral:
 Can be delivered by consumer to the initiating
facility, or sent by fax or post, which is better to
ensure receiving feed back.
 It assures proper patient care and provides
continuing education to initiating facility & their
staff.

The supervisor :
Should check that back referral is received .
 In its absence, pursue relevant staff at the
higher level to provide proper back referral
information.
Receiving facility can give feedback to the
initiating facility on appropriateness of referral.

4-Referral process at 2nd or 3rd level (receiving facility )
If there are any issues regarding the need for
referral, timing, speed or information sent, then it
is important that the higher level facility provides
specific feedback to the initiating facility to assist
the lower level facility to be more sure of referral
process in the future.
The receiving facility completes its own register
of referrals in and out, from their perspective

5- Supervision and capacity building
Facility managers & supervisors at all levels
should monitor all referrals to & from facilities .
Usually between 5% and 10% of customers
seen in a P.H.C will be referred for diagnostic
services or more specialized care.

Supervisors should discuss referred cases to:
Identify cases which should have been treated
at the facility without referral.
Identify cases which should have been referred
but were handled locally.
Check back referrals received to determine
whether the information is adequate and being
acted upon by the facility.

Supervisors should discuss referred cases:
Follow up cases that have been referred but no
feedback yet received to assure that the
consumer has arrived at the higher level
Identify issues regarding timing, promptness &
completeness of information sent

Results of analysis can be covered at meetings
with hospital &clinic staff or together.
 After issues are discussed, identify what is
needed to be improve that might include :
Clinical training.
 Strengthening of particular parts of the referral
system or its procedures.
Facility managers &supervisors need to ensure
that items discussed are followed-up & acted on.

In-service education &capacity strengthening
can be reinforced by good supervision.
Long-term treatment of chronic illnesses such
as DM, HPT, &psychiatric managed at suitably
resourced P.H.C.C:
 Assures high quality of care for customers.
 Greater convenience to utilize service provided
Maintain fewer burdens on consumer and
higher levels of health system.

6- Continuous quality improvement
 It must be open to revision in the light of
practical experience, in order to meet the overall
goals of health system.
Periodically, there may be need to analyze the
functioning of the referral system, beyond
looking at the statistical patterns and trends.
 The methodology used to assess the status of
and constraints to referral vary according to the
standard adopted for an entire region or country.

6- Continuous quality improvement
The methodology can be adapted to varying
circumstances is to examine referral system by
using indicators regarding:
Structure and resource indicators.
Procedures indicators.
Outcome indicators.

Conclusion
It is essential for cohesiveness &integration of
health care delivery .
It is conceived as a technical process that
enhance the transfer of pts. through care
delivery levels according to guidelines &
protocols agreed upon.
The subsequent developments & increase
demands for specialist care, made the system
as an important tool to evaluate, assess &
monitor the adequacy & equity of the health
delivery system as a whole.

Conclusion
It needs to be two-way system, while there can
be horizontal referral at the different levels.
 Cooperation between health professionals is
crucial ,in how to operate a referral system and
to ensure that referral works.
 The cooperation should be backed up by
written protocols and service guidelines.

Conclusion
In order for the system to function properly
there should be a number of supporting
activities at the community, health centre and
hospital levels.
 Monitoring & evaluation is essential to ensure
that the proper functioning of referral system
and this can be done, either through periodic
audits, random review and field visits for
validation or review meetings at the different
levels.

References
• Marshal Mariker, David Wilkin & David H.Metcalfe; Referral to hospital: Can we do better? BMJ, Vol.297, pp 461-466.
• Federal Ministry of Health (FMOH). National health policy in Nigeria 1988; 11-14.
• Federal Ministry of Health (FMOH). Guidelines and training manual for the development of primary health care
system in Nigeria. National Primary Health Care Development Agency, Lagos, 1990; 7-92.
• Ransome-Kuti O, Sorungbe AOO, Oyegbite KS et al. Strengthening primary health care at the local Government
level. The Nigerian experience. Academy Press, Lagos, 1998; 44-47.
• Bitran R. and Giedion U. (2002) Waivers and exemptions for health services in developing countries, Bitran and
Associates for The World Bank.
• Sweeny B (1994) ‘The Referral System’, British Medical Journal, Vol. 309 pp. 1180-1181.
• World Health Organization (1992) The Hospital in Rural and Urban Districts, Report of a WHO Study Group on the
Functions of Hospitals at the First Referral Level, WHO Technical Report Series, 819.
• Marin Ronald and Brian Bewley;Boneline:evaluation of an initiative to improve communication between specialists
and general practitioners ,Journal of Public Health Medicine ,Vol.14,No. 3 , pp.307-309.
• Al-Mazrou, Y., S. Al-Shehri, and M. Rao. 1990. Principles and Practice of Primary Health Care. Riyadh: Al-Helal
Press.
• Holdsworth, G., P. Garner, and T. Harpham. 1993. “Crowded Outpatient Departments in City Hospitals of Developing
Countries: A Case Study from Lesotho.” International Journal of Health Planning and Management 8 (4): 315–24.
• Kloos, H. 1990. “Utilization of Selected Hospital, Health Centers, and Health Stations in Central, Southern, and
Western Ethiopia.” Social Science and Medicine 31 (2): 101–14.
• Sanders, D., J. Kravitz, S. Lewin, and M. McKee. 2001 “Zimbabwe’s Hospital Referral System: Does It Work?” Health
Policy and Planning 13 (4): 359–70
• Stefanini, A. 1994. “District Hospitals and Strengthening Referral Systems in Developing Countries.”World Hospitals
30 (2): 14–19.
• Cervantes K, Salgado R, Choi M and Kalter H. 2003 Rapid Assessment of Referral Care Systems: A Guide for
Program Managers, published by the Basic Support for Institutionalizing Child Survival Project (BASICS II) for the
United States Agency for International Development, Arlington, Virginia, available on line at:
http://www.jsi.com/Managed/Docs/Publications/WomensHealth/PNACW615.pdf

Referral System Guide for Better Healthcare

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