Bekenisa health center

Bekenisa health center

Liaison and referral protocol

Prepared By Emergency Department

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Ginbot 2018
 Bekenisa health center

Liaison and referral protocol

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Table of Contents
Introduction ................................................................................................................................................... 4

Definition of terms ........................................................................................................................................ 5

Objective ....................................................................................................................................................... 5

Rationale for establishing referral system and liaison service ...................................................................... 5

The essential element of a referral system .............................................................................................. 6

Reasons for referrals ................................................................................................................................. 6

Rationale for establishing a liaison service ............................................................................................... 7

Benefit of good referral system .................................................................................................................... 7

Roles and responsibilities with regards to liaison service in health center .................................................. 8

Referral service ........................................................................................................................................... 11

Receiving in patient referrals .................................................................................................................. 11

Receiving outpatient referrals ................................................................................................................ 11

Receiving Outpatient Referrals ............................................................................................................... 12

A feedback loop to track referrals .......................................................................................................... 13

Bed management ........................................................................................................................................ 13

Processes on admission .......................................................................................................................... 14

Discharge plan......................................................................................................................................... 15

Documentation and reporting .................................................................................................................... 16

Reporting ................................................................................................................................................ 17

Monitoring and Evaluation. ........................................................................................................................ 17

References. ................................................................................................................................................. 19
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Introduction

An effective referral system requires a close relationship between all levels of the system and helps to
ensure people receive the best possible care closest to home time. It also assists in making cost-effective
use of hospitals and primary health care services. Support to health centers and outreach services by
experienced staff from the hospital or district health office helps build capacity and enhance access to
better quality care.

A good referral system can help to ensure:

 Clients receive optimal care at the appropriate level and not unnecessarily costly

 Health facilities are used optimally and cost-effectively

 Clients who most need specialist services can accessing them in a timely way

 Primary health services are well utilized and their reputation is enhanced.

Referral can be vertical in the hierarchical arrangement of the health service from the lower end of the
health tier system to the higher one. It also can be horizontal between similar level of facility because of
bed unavailability, location and other reason. Referral can also be diagonal when a lower level health
facility directly refers patient to a specialized facility without necessarily passing through the hierarchical
arrangement.

The referral system centers on the transfer of responsibility of a patient's care, temporarily or
permanently, from one physician or health institution to another. An effective referral system, particularly
in developing countries, is an extremely important public health issue. Not only is a successful referral
system important in maximizing limited resources, it also avoids duplicating services. It promotes
cooperation and complementation of primary, secondary and tertiary health facilities. In addition, it
encourages the continuity of treatment, as well as ensures the sustainability of services. XX health center
as one of the health centers in the region, zone is part of the referral system. It has developed the
following referral protocol from MOH guidelines for implementation of a patient referral system. The
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Health center and all the staff should abide by the referral protocol
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Definition of terms

Referral is a process by which a health worker transfers the responsibility of care to or permanently to
another health professional or social worker or to the community response to its inability or limitation to
provide the necessary care.

The facility that starts the referral process is called the Initiating facility, and they prepare an outward
referral to communicate the patient's condition and status The facility that accepts the referred case is
called the receiving facility and, at the end of their involvement, they prepare a back referral/feedback,
on the lower part of the, to let the initiating facility know what has been done. This completes the referral
loop between the 2 facilities. Referral network is a patient flow system among geographically localized
health service and health related service providing facilities upon referral of a patient. Referral in are
those cases that are accepted by the receiving facility Referral outs are cases referred to other facilities
by the initiating facilities

Objective
I. Objective of the protocol

Objective of the protocol For improving liaison services and that of the referral network so that
effective utilization of health care services resources to ensure provision of better quality of care.

Rationale for establishing referral system and liaison service

Rationale for establishing referral System and liaison service an effective referral system ensures a close
relationship between all levels of the health system and helps to ensure people receive the best possible
care closest to home in timely manner. It also assists in making cost-effective use of hospitals and primary
health care services.
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Support to health centers and outreach services by experienced staff from the hospital or district health
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office helps build capacity and enhance access to better quality of care. Moreover, it reduces patient
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overcrowding at secondary and tertiary level facilities. Studies have shown that in many developing
countries, a high proportion of clients seen at the outpatient clinics at secondary facilities could have been
appropriately looked after at primary health care centers at lower overall cost to the client and the health
system.

The essential element of a referral system

A good referral system can help to ensure: Clients receive optimal care at the appropriate level
and not unnecessarily costly Hospital facilities are used optimally and cost-effectively. Clients
who most need specialized services can access them in a timely way Primary health services are
well utilized and their reputation is enhanced 4.1 The essential elements of a referral system are
further outlined in the Guideline as: A group of organizations that in aggregate provide
comprehensive health care services in a defined geographic area A unit that coordinates and
oversees referral activities Designated referral focal persons at each health facility Directory of
services and organizations within a defined territory Standardized referral format Feedback loop
to track referral Documentation of referral

Reasons for referrals

Referral Reasons for referral should be medical, objective and in the best interest of the patient or
client. The following are considered good reasons for referrals:

 When a patient needs an expert advice as determined by the attending health professional

 When technical examination is required that is not available at the referring facility

 When a technical intervention that is beyond the capabilities of the facility is required .

 When patients require inpatient care that cannot be given at the referring facility

 When the referring facility cannot no more accept patients due to shortage of beds and
unavailability of professionals Referrals are also made to the lower level health facilities
and community based organizations in the best interest of the patient depending on:
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The condition of the patient.

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The capacity of the lower level health facility/community based organization.

Rationale for establishing a liaison service

 Liaison service is need for effective communication and sustainable and smooth flow of
patient that need to be operated by liaison officers with special training for the position. a
liaison service aims at:

 Establishing and maintaining an effective liaison network with pertinent institutions and
the public to achieve the best utilizations of resources

 Disseminating information and monitoring feedback to ensure continuous improvement

 Organizing awareness creation programs- to ensure proper use of the service or the
system Perform emergency liaison duties during mass casualties such as, flooding, fire,
industrial accidents, etc.

 A Liaison Officer is thus a person that runs the liaison services and liaises between two or
more organizations and the public to communicate and coordinate their activities.

Benefit of good referral system

A good referral system increases the efficiency of the health system by maximizing the appear use of
health care facilities. It strengthens the peripheral health facilities and improves the de making capacity of
professionals at the lower level of the referral network. It also opportunities for balanced distribution of
funds, services and professionals while at the san improving the effectiveness of the health system. In
addition, a good referral system helps to promote cooperation among primary, secondary and tertiary
levels of care.
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Roles and responsibilities with regards to liaison service in

health center
Health center each health center should have a liaison officer or referral focal person with specified roles
and responsibilities as the health center receives patients from health posts and refer patients to hospitals
for better management

Responsibilities of Liaison officers

Health center should establish a liaison officer that is responsible to:

1. Facilitate emergency admission for 24 hours.

2. Facilitate social support to the emergency and outpatient case teams.

3. Manage the referral service, specifically: Coordinate the overall referral activities within the health
facility. Record and report the referral activities to facility management.

4. Compile, analyze and interpret data to improve the referral service. Take part in the quality assurance
programs of the referral system by participating

5. Have information about services provided by the health center such as emergency. outpatient, delivery,
laboratory and pharmacy etc. Facilitate to establish their own A & D protocol. Ensure that referred patient
has received service from a receiving health facility.

Roles and responsibilities Roles and responsibilities of the referring health professional Should know

 what, whom, when and where to refer

 Should fill the referral form with the necessary information and attach relevant document

 Explains to the patient the rationale, reasons choice of doctor or facility, preparation, cost, and
possible outcome of referral
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 Should be available to answer quires from the referral coordinator or receiving facility about the
referral if necessary Secures result of the referral Roles and responsibilities of the referral
coordinator/ liaison officer

 Responsible for both referrals out and received referrals Facilitates scheduling based on the level
of priority for consultation i. e emergency, urgent, and routine cases.

Utilizes the following communication methods:

Letter, telephone, email, photocopied reports sending, personal contacts, etc.

 Ensures the availability of service or professionals at the receiving health facility before referral

 Facilitates transportation for emergency cases

 Maintain good communication with emergency case team, inpatient case teams and the wards

 Ensures regular bed census is carried out, reported and used to update and manage the bed
utilization

 Roles and responsibilities of the referring facility performs a situational analysis regarding the
process of referral in the facility

 Ensure that the staffs are well aware of the referral system

 Ensure continuous supply of standardized referral forms are available

 Keeps directory of health services and facilities in the defined geographic area

 Ensures proper recording of all referral activities Devices mechanisms to track referrals Provides
transportation in emergency conditions

 Assigns referral coordinator with clear roles and responsibilities.

Roles and responsibilities of the receiving health professional

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 Responds promptly to consultation requests Reports in detail all pertinent findings and
recommendations to the referring health worker and may outline opinion to the patient
(feedback with all required information and recommendation)

 Communicate with the patient or the family

 Does not attempt by word or deed to undermine the role of the referring health worker

 Roles and responsibilities of the receiving facility Conducts situational analysis of the current
referral process to identify gaps and strengths

 Assigns referral coordinator with clear roles and responsibilities.

Liaison service in each health facility should establish a liaison and referral service that is responsible to:
1. Manage health center bed occupancy (bed management).

2. Facilitate emergency and non-emergency (elective) admission.

3. Facilitate social support to the emergency, inpatient and outpatient case teams.

4. Manage the referral service, specifically:

 Coordinate the overall referral activities.

 Record and report the referral activities to facility management.

 Compile, analyze and interpret data to improve the referral service.

 Take part in the quality assurance programs of the referral system by participating in regular
review meeting within and outside the health facility.

 Performance monitoring and evaluation.

 Ensure feedback is sent back to the referring health facility. 8.1 Referral service
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Referral service
Receiving in patient referrals
Emergency Referral in Each day, (every 8 hours) the liaison officer should asses the number of
unoccupied beds, number of patients in the emergency unit/department waiting to be transferred to
inpatient wards, If dispatch/command center is available, the liaison officer has to give report on vacant
beds three times a day to the center and update information of the particular day.

If the service is not available direct communication will be made between health institutions. Ensure the
ambulance service is in place for 24 hour and is equipped with the necessary medical supplies for critical
emergency patients.

When a facility calls to refer emergency cases a liaison officer should check the following things before
accepting the referral

1. The availability of beds in the case team where the patient requires service

2. The availability of the service and professional (some service can be given by a trained individual
professional; in such case the liaison should check the presence professional and the service).

3. Appropriateness of the referral, that is, the referral should be based on the referral network and any
referrals should not be out of the referral network agreement, or the importance has to be justified with a
discussion with the accepting physician.

4. Information on the patient's clinical condition, to insure safe transportation and to consider patient is
accompanied by a professional who has lifesaving skills.

5. Inform the accepting unit about the incoming patient's status, and the estimated time of arrival to the
unit so that the accepting unit will make the necessary arrangements accordingly.

Receiving outpatient referrals

Cold Cases Referral in when a facility calls to refer a non-emergency case that needs admission, the
liaison should check the appropriateness of the referral (the same procedure listed above) and the nature
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of the disease in case the waiting time is becoming prolonged.

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This information helps to identify the disease progress such as if cancer is diagnosed at its early stage and
prolonged appointment may lead for worsening of the diseases, therefore this information will help to
prioritize admissions.

There could be arrangement of elective admission date and inform the patient through the referring liaison
officer. A liaison should present the elective admission.

List to inpatient case team on regular base preferably on daily bases.

Receiving Outpatient Referrals

When a facility calls to refer outpatient referrals a liaison should confirm the appropriateness of the
referral, nature of the illness and arranges appointment date and passes the information through the
referring liaison officer. The liaison should present the outpatient attendances to outpatient department on
regular bases

Coordinating referral out cases

 Emergency Referral Out Once the Clinician has decided to refer out a patient the case should be
immediately linked to liaison office. Before referring out a patient a liaison officer should:

 Check referral format is completely filed and signed by the physician.

 If there is a command center in the region the liaison should contact the command center to get
appropriate receiving facility.

 Use the service directory and the regional referral network to find appropriate facility.

 Send one copy with the patient and attaching one to the patient medical record.

 Before sending any referral out the liaison officer should ensure bed and service availability at
receiving facility.

 The liaison office should insure that the patient has a necessary transport to reach the receiving
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unit. Making use of the facility vehicles ambulance and professional attendance if it is essential.
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 Register the patient on referral register (sample on annex).

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 If the liaison officer can't find the service or the bed to refer the patient, the patient should stay in
the facility with available care until the liaison gets the needed service.

 If the patient is very sick and there are no beds in the receiving institutions the liaison officer has
to facilitate online consultation service or has to facilitate communication between referring and
receiving doctors/professionals for better management and facilitation, If there is any critical or
unstable patient that needs admission/stay referral should be made after communication with the
referring and receiving physicians/health workers/so that patient transfer is made safely and
proper arrangement for the patient management is done.

 Both the referring and receiving health institution liaison officers should make sure critical
patients are transported safely and accompanied by professionals who have lifesaving skills.

 Cold Cases Referral out after checking all necessary steps listed above and identifying
appropriate facility the liaison officer should communicate with receiving facility liaison officer
to pass the appointment information to the patient.

A feedback loop to track referrals

Feedback and communication in the referral system is a critical step in addressing capacity issues. In
addition effective communication facilitates learning and, can inform professionals about the outcomes of
the patients that they refer. Written feedback provides evidence that the referral process was completed
and the service was delivered, and should indicate whether there were problems. Using the original
referral request, documenting the status of service delivery and other pertinent information and returning
the form to the site of referral initiation is one method of feedback communication.

Bed management

The aim of bed management is to make maximum use of health centers beds, ensuring high bed
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occupancy, high patient turnover and minimum waiting times for elective admission.
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Methods for ensuring appropriate utilization of bed follow health centers A & D protocol Reduce
inappropriate length of stay Regular ward rounds make maximum use of Administrative service Bed
management information system

Bed survey should be done at least 3x a day/3 times/24hrs/ at any time the liaison should and have the
following information:

 Free beds in the health facility

 Number of bed that are due to be evacuated Likely discharges planned during admission

 Number of beds Occupied in the facility

 Number of patients transfer in and outs

 Number of 'reserved beds for elective admissions that day

 Admission and discharge process

 Admission and Discharge Process Effective and coherent admissions and discharge policy for
emergency

 Based on admitting physician's recommendation liaison officer should coordinate beds for
admission

Processes on admission

Emergency admissions processes ideally the length of stay should not be greater than 24 hours. Then
transfer to ward has to be facilitated for proper inpatient admission if necessary. If the patient is to be
admitted as an inpatient, a clinical member of emergency case team should. Contact the liaison officers.
As a minimum the following information has to be delivered:


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Patient name and medical record number

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 Summary of the clinical history and reason for emergency admission C

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 as team to which patient should be admitted like surgical case team, internal medicine case team
etc.

 Expected date of discharge

When request for admission is made the liaison officer should follow the steps below:

 Is a bed immediately available in the relevant inpatient case team/ward?

 If yes admit patient

 The liaison officer should inform the case team leader of the receiving ward that the patient
should be transferred to that ward and any necessary administrative tasks carried out with the
assistance of runner.

 Is there any patient in the relevant case team/ward due to be discharge that day?

 If yes confirm that patient will be discharged.

 Identify and address any factors that are delaying discharge.

 Consider moving patient to transit lounge (if available) or another waiting area.

 In this way the bed can be freed and the new patient can be admitted

 Is a bed available within another case team/ward?

 If yes discuss with director of inpatient service and the responsible physician for the patient
where the patient is located, ensure the patient will be properly followed and managed by
appropriate case team, and ensure that the patient is transferred to correct case team bed/ward as
soon as a bed is available.

Discharge plan
During admission A physician who should complete a discharge summary for the patient should
make the decision for discharge. A copy of the discharge summary containing medical history should
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be given to the patient and a second copy filed in the Medical Record.
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If a patient was referred from another facility the discharging physician should also complete the
feedback section of the Referral Form. The processes required for effective discharge planning
provide that:

There should be an organization led commitment to manage all health centers beds.

Resources such as a discharge coordinator should be available to ensure delays are minimized and
extensive patient and family involvement in decision-making processes.

Discharge documentation should be audited to ensure compliance with health centers protocols.
Analysis of trends and data should be undertaken by the Liaison Officer and communicated to
hospital senior management. Multidisciplinary teamwork is the key to success with discharge
planning. A nominated member of the multidisciplinary case team should coordinate a patient's
discharge plan.

Discharging patients in the morning on the day of discharge, and Discharging patients over the weekend
and holidays. Key Steps in Timely Discharge

Expected date of discharge is identified early as part of patient's assessment within 24 hours of
admission/stay (or in pre-assessment for elective patients). It is based on the anticipated time needed for
tests and interventions to be carried out and for the patient to be clinically stable and fit for discharge.

In parallel, all the necessary arrangements are put in place to optimize the (simple) discharge including
Discharge Summary, outpatient appointment, hospital sick leave completed, any medicines to be taken
away, and patient transport arrangements

Documentation and reporting

 The liaison has a responsibility to document its activities including referrals and A&D process in
order to monitor referral volume so that, it allows the facility to better plan

 Identify the Initiating facility so that it can eases the reimbursement of service fee for fee waiver
patients based on health care financing procedure.
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 To appropriately manage the hospital bed Manage appointments for elective patients Follow
timely discharge Monitor and evaluate the performance of referral system at hospital and health
center level to continuously improve the quality of referral service.

 Strengthen accountability of referral care be able to conduct researches.

 To use on national, regional and catchment level review meeting with view to improvement.

Liaisons should document referral in and out register.

 The liaison officer has the responsibility to follow the documentation and aggregates all received
referrals and report on a monthly bases.

 Every admitted patient with their ward and EDD (expected date of discharge)

 Bed management details of bed information should be documented

 For all appointed patients there appointment date, the appointed department, appointed physician
and details of the patient address should be documented reporting

 The liaison officer should analyze and report referral and A&D reports on regular bases (monthly,
quarterly, biannually and annually to the hospital SMT)

Reporting
The liaison officer should analyze and report referral and A&D reports on regular bases (m quarterly,
biannually and annually to the hospital SMT)

Monitoring and Evaluation.

Monitoring and evaluation of the implementation of the liaison service in facilities such A&D, bed
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management and referral services should be carried out by FMOH, the RHBs and Hospitals senior
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management. Sources of data for the M&E can be HMIS, Supportive Supervision and Rapid Assessment
findings, surveillance records, etc

iv. Health center. Conduct internal supervision on liaison service Data based monitoring and evaluation
on referral system. Monitor the referral system performance with catchment Health post and catchment
leading hospital.
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References.

1. Health Referral Protocol Guide

2, Ethiopian national referral guideline

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