THE REPUBLIC OF SOUTH SUDAN

L A K ES S T A T E

MINISTRY OF HEALTH

EFFECTIVE CLOSED LOOP REFERRAL SYSTEM

GUIDELINE AND PROTOCOLS

July /2015

LAKES STATE

Table of ContentsACRONYMS.................................................................................................................................................2

Acknowledgments..........................................................................................................................................3

BACKGROUND...........................................................................................................................................4

INTRODUCTION.........................................................................................................................................5

DEFINITIONS...........................................................................................................................................................5RATIONAL FOR FUNCTIONAL REFERRAL SYSTEM GUIDE............................................................6

PURPOSE OF EFFECTIVE REFERRAL SYSTEM....................................................................................7

THE REQUIREMENTS FOR AN EFFECTIVE REFERRAL SYSTEM....................................................7

ESSENTIAL ELEMENTS OF REFERRAL SYSTEM................................................................................8

REASONS FOR REFERRAL.......................................................................................................................8

LAKE ESTATE REFERRAL MECHANISM:.............................................................................................9

PATIENT TRANSFER...............................................................................................................................................9A framework for the referral from PHCC/U, County Hospitals to Rumbek State Hospital Hospital..9

1. Community level..............................................................................................................................10

2. Health facility level..........................................................................................................................10

3. 24-HOUR EMERGENCY CALL CENTER..................................................................................11

FUNCTIONAL CLOSED LOOP REFERRAL SYSTEM MODEL...........................................................11

REFERRAL FEEDBACK MECHANISM..................................................................................................13

ROLE AND RESPONSIBILITY OF ORGANIZATIONS AND SERVICES PROVIDERS IN THE

REFERRAL SYSTEM................................................................................................................................14

ROLES AND RESPONSIBILITIES OF THE REFERRING HEALTH PROFESSIONAL.............................................................14ROLES AND RESPONSIBILITIES OF THE REFERRAL COORDINATOR............................................................................14ROLES AND RESPONSIBILITIES OF THE REFERRING FACILITY....................................................................................14ROLES AND RESPONSIBILITIES OF RECEIVING HEALTH PROFESSIONAL.....................................................................15RESPONSIBILITIES OF THE RECEIVING FACILITY.......................................................................................................15

Referral tool kits..........................................................................................................................................15

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ACRONYMS

CHD: Community Health Department

HF: Health Facility

IMC: International medical corps

PHCU Primary health care unit

PHCCs: Primary health care center

TBA: Traditional Birth attendants

IMC: International medical corps

SOPs: Standard Operating Procedures

TBA: Traditional Birth Attendants

VHC: Voluntary Health committees

MoH: The Ministry of Health

RSS: Republic of South Sudan

WHO: World Health Organization

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Acknowledgments

This document was made possible through the support of South Sudan Health pooled Fund

This guide consumed huge amount of work and dedication. Still, implementation would not have

been possible if we did not have a support of many individuals and organizations. Therefore we

would like to extend our sincere gratitude to all of them.

First of all we are thankful to the Director General of the Lakes State Ministry of Health, Dr.

Michael Mading and the Acting Director of Administration and Finance in the Lakes State

Ministry of Health, Dr. Hakim for their support and for providing necessary guidance concerning

the implementation of the guide.

We are also grateful to the different stakeholders and implementing partners in Lakes State for

provision of expertise, and technical support during discussions towards the implementation of

the guide. Without their superior knowledge and experience, the guide would may lacking in

quality, and thus their support has been essential.

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BACKGROUND

The Ministry of Health (MoH) of the Republic of South Sudan (RSS) operates a decentralized

structure of health services delivery in line with its interim Constitution and the current 11

National Health Policy. The provision of health care services is based on the principle of a

‘Continuum of Care’ as recommended by the World Health Organization (WHO).

In South Sudan this continuum of care is provided through a pyramidal structure with primary

health care services provided through a network of Primary Health Care Units and Primary

Health Care Centers being the lowest level of contact between the community and the health

system.

Primary Health Care Units (PHCUs) provide basic preventive, promotive and curative care while

Primary Health Care Centers (PHCCs) in addition to services offered by PHCUs provide basic

diagnostic laboratory services and maternity care.

The South Sudan health system therefore envisages a three-tier structure of primary, secondary

and tertiary health-care facilities to bring health-care services within the reach of the population.

Primary health care services are provided by the PHCC/PHCUs while the secondary tier services

are provided by the county hospitals. The county hospitals are the first level referral point from

the PHCC/PHCUs and community. Secondary health care is provided by state Hospitals

providing comprehensive specialist services.

Administratively, the Ministry of Health (MoH) oversees the delivery of health services in the

country through the respective State Ministries of Health (SMoH). Each state ministry of health

provides leadership of the health Sector through coordination, personnel management,

monitoring of primary facilities and infrastructure

The State Ministry of health is able to execute its functions through the administration of the

County Health department that is in charge of managing service delivery at county level. The

CHD oversees and coordinates the activities of the PHCC/PHCU, village health committees at

Payam and Boma levels.

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INTRODUCTION

A referral may be for temporary, permanent or partial transfer of responsibility for the care of a

patient. A referral system entails the interrelationships and coordination of patient care services

from one health care facility to another. The referral process begins by the referring health

professional communicating to the receiving health professional or specialist relevant patient

information. The receiving health professional communicates back to the referring health

professional with information and plan for continuum of care thereby completing the referral

process.

Referral can be vertical as in the hierarchical arrangement of the health services from the lower

end of the health tier system to the higher ones. It also can be horizontal between similar levels

of facilities in the interest of patients for cost, location and other reasons. Referrals can also be

diagonal when a lower level health facility directly refers patients to a state hospital facility

without necessarily passing through the hierarchical system.

In an effort to ensure effective deliver of referral health care services and strengthen the referral

chain with primary health care facilities and county hospitals, Health Pooled Fund (HPF), in

collaboration with the MOH, has proposed a strategy to support the State Ministries of Health

(SMOH) and state-level hospitals. This includes the following: supporting delivery of services

including comprehensive emergency obstetric and neonatal care, trauma care, general surgery,

gynecology, pediatrics, and internal medicine; ensuring an effective referral system; and

strengthen the management and administration of the State Hospitals

DEFINITIONS

A referral: can be defined as a process in which a health worker at a one level of the health

system, having insufficient resources (drugs, equipment, skills) to manage a clinical condition,

seeks the assistance of a better or differently resourced facility at the same or higher level to

assist in, or take over the management of, the client’s case.

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Referring unit is a health facility that initiates the referral process. A facility can be both a

referring and receiving unit depending on circumstances.

Receiving unit is a health facility that receives patients or clients from referring units and

ensures that required care is given to the client and returns the patient with feedback.

Community to facility referral: traditional birth attendants or community health workers refer

clients to PHCU health facilities.

Facility to facility referral: Clients can be referred between health facilities through standard

referral slip for services not rendered in their facility and for further care and support.

Successful referral: can be defined as a process in which if the referred client received the

service for which he/she referred and confirmed through referral feedback loop system

A referral loop: is the complete cycle/link between the initiating and receivng faciltiy.

Servcie directory is: a lists of all organizations providing specialist care. Such a directory can

facilitate the search for the most appropriate service provider for a particular referral. In such

setting, it is important to keep the contact information up-to-date.

Counter-Referral or Return-Referral: Is the process of re-directing the referred patient back to

the originating unit once the reason for referral has been resolved.

Level 1 Hospital (County hospital): A Level 1 Hospital also known as a County Hospital or

general hospital is a registered health care facility, public or private, for profit or not for profit,

which provides curative, preventive, promotive and rehabilitative care, through outpatient,

inpatient, and community health services.

Level 2 Hospital (State hospital): A State hospital is the referral hospital for the state health

system and renders services at a general specialist level. It receives referrals from county

hospitals as well as PHCC and provides specialist services. State hospitals also serve as a

platform for training of health workers and research.

Level 3 Hospital (Teaching hospital): Level 3 hospitals also known as teaching or National

Referral hospitals provide comprehensive specialist services as tertiary care. These hospitals

should have highly specialized staff and technical equipment—for example, cardiology,

intensive care unit, and specialized imaging units.

RATIONAL FOR FUNCTIONAL REFERRAL SYSTEM GUIDE

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One of the objectives of the Health Pooled Fund project is strengthening the State Hospitals referral and linkage system through implementing bi-directional successful effective referral from community to PHCU/PHCCs and county hospital and then to Rumbek State Hospital and beyond.

The Health Pooled Found have an interest on effective functional referral system to enhance the accessibility and utilization of health service for the general population specifically for mothers suffering with pregnancies and birth related complications . The presence or absence of effective functional referral system can determine the uptake of the health services and ensure continuum of care, if an appropriate level of care is made available when it is needed (taking geographical factors, time, affordability and emergency services into consideration); The referral guide helps to:

Increases the efficiency and effectiveness of the referral system

Ensure continuum of health and Social service

Promotes cooperation between the partners who are working in the referral network

PURPOSE OF EFFECTIVE REFERRAL SYSTEM For continuity of treatment and care

To save life in emergency situation

For a specific treatment, procedure and care

For further medical management

For quality service.

 Maximize limited resources.

THE REQUIREMENTS FOR AN EFFECTIVE REFERRAL SYSTEM• There should be referral guideline and referral protocol.

• Service providers should be skilled in knowing what, when, where and how to refer.

• There should be standard treatment protocols and SOPs at each health facility level,

according to their competencies.

• Accessibility of services should be facilitated in terms of logistic, through the availability

of adequate transport and communication means, whose use should be regulated.

• Receiving facilities should be equipped to receive referrals and to provide the expected

care

• The system should be able to monitor, supervise and evaluate the quality of care, referral

practices

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• There should be enough permanently available resources to ensure the referral system

being free of charge for patients

ESSENTIAL ELEMENTS OF REFERRAL SYSTEM 1. A structured health system, constituted by different service providers organized along

a hierarchical line according to the kind of assistance they can offer and which all

together ensure compressive health care service in defined geographical area

2. Clients

3. Standard Referral Guidelines

4. Standard harmonized referral forms

5. Referral directory

Contents of Referral directory

Name of Organization

Organization Address/Location and phone number

Services Provided

Hours of service

Contact person

6. Focal person/liaison officer at service provider facility

7. Feedback loop

8. Documentation

9. Logistic and related material/financial resources (transport means, communication means)

REASONS FOR REFERRAL

The criteria 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

When the patient/client needs social support

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LAKE ESTATE REFERRAL MECHANISM:The recommended referral plan for South Sudan is such that: the Level 1 (county) hospitals

provide general in-patient services and accept referrals from the Primary Health Care Units and

Centres (primary level). Level 2 (State) hospitals receive patients referred from county hospitals

and provide general specialist services. Teaching hospitals (tertiary level) in the major urban

centres serve as national referral facilities and provide specialist and sub-specialist services.

In lake state, Rumbek state hospital receives all referrals from county hospitals and dirctly from

PHCC/Us when required, and state hospital referr upward to Juba Teaching hospital.

PATIENT TRANSFER

A framework for the referral from PHCC/U, County Hospitals to Rumbek State Hospital HospitalThis referral model is designed to adress the referral challenges as proposed by the SMoH. This

framework emphasises the referral coordination mechanism for maternal and child referral-this is

in response to high maternal mortality rates recorded in South Sudan. That said, this model can

always be adapted to suit the coordination of referral of any other cases not necessarily maternal

and child health related. This should be done in consideration of the criteria describe earlier.

South Sudan has one of the world’s highest MMR in the world with most of the maternal deaths

occuring due to pregnancy and childbirth related complications. These deaths are largely

preventable through timely identification, early referral and access of quality/adequate medical

interventions. Like in most developing countries, maternal deaths are majorly due to delays at

three levels i.e. Level 1 delay- The delay in decision to seek care, Level 2 delay-Delay in

reaching care and Level 3 delay- Delay in receiving adequate health care.

In order to save the lives of pregnant women and the unborn/new-borns, it is important to

develop an effective referral mechanism that adequately addresses the 3 delays identified above.

The referral system should be efficient, sustainable and customized to the community contexts.

The success of the referral system is soley anchored on commitment from all levels-MoH/SMoH,

CHD, NGOs and the community.

This referral system will be implemented jointly by the SMoH, CHD , County hospital, PHHC

and PHCUs with the collaboration of the community as described here below.

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1. Community levela) Identification, registration and linking :each pregnant woman to a focal TBAs member in the

community. Each TBAs shall follow-up and monitor estimated 15-20 pregnant women in their

respective villages. During the ANC process, the pregnant women will be linked to TBAs in

their area for emergencies. This is a process that is cheap to implement by the CHD and their

respective supporting partners.

b) The TBA shall be the focal point for the pregnant women : the pregnant can report to the

TBAs for assistance in emergency so that the referral process can be initiated as early as

possible. Where there are no networks avalable,a VHF radio is to be installed at the facility to

aid timely communication. Where possible, the TBAs should be supported/provided with

alternative means of transport such as a bicycle which can be used to initiate the referral process

from the community to the nearby PHCU/PHCC or BEmONC centre. Whenever faced with an

emergency, the TBAs will call the nearest health facility and immediately start the patient

transfer process to meet the health facility team along the way. This kiss-movement approach

will directly reduce the referral time by about 30%.

2. Health facility levela) Service delivery :The health facilities should be staffed and equipped to provide BEmONC

and stabilization services in emergencies. This will reduce the risk of death and morbidity during

transportation over long distances to CEmONC centre when required. The health workers will

also accompany the patient during transit/referral

b) Training:The health workers and TBAs should be extensively trained on the referral

protocol, early identification of risk factors and danger signs and referral

c) Communication. The county hospital, PHCCs should be have a cell phone or VHF radio to

communicate with the Rumbek sate hospital call center. The telephone numbers of the call center

and services directory shuld be provided to refering health facilities .

The transport will be free of charge and available 24/7 the Ambulance use will be regulated and exclusively dedicated to referral

d) Documentation and feedback. The receiving health facilities will document the case details

including outcome and share this feedback with the referring centre. At county level and facility

level, it is recommended that a monthly review meeting be conducted to evaluate the referral

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system. At State level, there will be a quarterly referral coordination meeting to assess progress

of implemenation of the referral system and continue improving the quality of service.

3. 24-HOUR EMERGENCY CALL CENTER A core component of the referral system will be a 24-hour call center located at Rumbek State

Hospital, which will serve as a referral service for patients who are in need of a higher level of

care. The number for the call center will be available to the PHCC/PHCUs and county hospitals.

The call center will be staffed by a health worker who is trained in basic obstetric and newborn

care and can advise the caller on whether or not to refer the patient to the next level of care. The

call center will also be a mechanism to support tracking the number of referrals taking place and

will report these numbers to the CHD and the SMOH. An additional responsibility of the call

center will be to track the operating status of the county hospitals in the state. For example, the

call center operator can contact the hospitals on daily basis to determine their bed availability,

whether they have a working ambulance, etc. This way, when a PHCC/PHCU or county hospital

contacts the call center, they will be provided accurate information on the availability of higher-

level health services in the area. The call center will also be equipped with a high frequency (HF)

radio so that it can communicate with key primary health facilities, county hospitals and

ambulances across the state, which will also be equipped with base and mobile HF radios.

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PHCC -qualified staff-BEmONC, stabilization-onsite VHF radio, cell phone, motorcycle

County Hospital B-qualified staff-BEmONC, stabilization-onsite VHF radio, cell phone, motorcycle

County Hospital B-qualified staff-BEmONC, stabilization-onsite VHF radio, cell phone, motorcycle

PHCU B-qualified staff-BEmONC, stabilization-onsite VHF radio, cell phone, motorcycle

Rumbek State Hospital• All general services• Radio call center

7/24 hours• Ambulance 7/24

PHCU A-Safe and clean delivery -onsite VHF radio, cell phone, motorcycle

Village A –TBA Village B -TBA

FUNCTIONAL CLOSED LOOP REFERRAL SYSTEM MODEL

REFERRAL FEEDBACK MECHANISM

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PHCC

County hospitalCounty hospital

PHCU-B

Village-BCVD b

PHCU-A

Rumbek State Hospital

Village-A CVD a

ROLE AND RESPONSIBILITY OF ORGANIZATIONS AND SERVICES PROVIDERS IN THE REFERRAL SYSTEM

Roles and responsibilities of the referring health professional

Should know what, whom, when and where to refer

Should fill the referral form with all the necessary information and attach relevant

documents

Should explain to the patient the rationale or reasons for referral, the means of

transportation, the preparation, the expected indirect costs he/she might have to afford

during his/her stay in the other facility, and possible outcome of referral

Should be available to answer queries from the referral coordinator or receiving facility

about the referral if necessary

Should properly document stamped referral for monitoring

Roles and responsibilities of the referral coordinator

Responsible to properly record and document for both in and out referrals

Facilitates scheduling based on the level of priority for consultation, i.e. emergency,

urgent and routine cases

Utilizes the following communication methods: VHF radio, telephone and email if

available

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

referral

Facilitates transportation for emergency cases

Roles and responsibilities of the referring facility

Performs a situation analysis regarding the process of referral in the facility

Ensures that staff are well aware of the referral system

Ensures 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

Provides transportation in emergency conditions

Assigns referral coordinator with clear roles and responsibilities

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Roles and responsibilities of receiving health professional

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 family

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

Responsibilities of the receiving facility

Conducts situation analysis of the current referral process to identify gaps and strengths

Assigns referral coordinator with clear roles and responsibilities

Devises follow up plans and ensures the plans are communicated to the referring

facility /professional

Ensures staff at points of entry clearly understand the referral process

Provides continuing education about the referral process to staff and the community

Ensures referred patients are seen by appropriate professionals

Ensures that all prescheduled referrals are attended without undue delay

Referral tool kits 1. Referral slip2. Referral feedback collection box3. Referral service directory4. Referral registration book

Referred to____________________________________________________________________15

Name:_______________________________________________________________________Age_____________________Sex_____________________Addressess (Resident)_____________C/C:______________________________________________________________________________________________________________________________________________________Physical Examination –findings:_____________________________________

Labresults__________________________________________________________________________________________________________________________________________________Diagnosis:__________________________________________________________________________________________________________________________________________________TreatmentGiven:_____________________________________________________________________________________________________________________________________________Reason for referral____________________________________________________________________________________________________________________________________________Referred by:________________________________DD/MM/YY___________________________Signature___________________________________________

REFERRAL FEEDBACK (section B)

Name: _______________________________________________________________________Age_____________________Sex_______________Addressess (Resident) __________________

Name of Facility: ________________________________________________________________

Type of health service/care/support provided: ___________________________________________

____________________________________________________________________________

Feedback______________________________________________________________________

_____________________________________________________________________________

Name of service provider____________________________Signature:______________________Date /Month/Year _________________________

LAKE ESTATE MINISTRY OF HEALTH REFERRAL DIRECTORY

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………………………………………………………………………………………………………………………………………………

Name of the health facility_______________________________________________________

Physical address: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________Telephone: _______________________________________

Contact person:__________________________________________________________________________Mobile phone:__________________________________________________________________________Available services: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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REFERRAL IN REGISTRATION BOOK

Name of the facility: ____________________________________________________________________________________________________

State : ______________________________________________________County ___________________________________________________

Date Name of the patient

 Card No

Age Sex Referred from (name of facility)

Referred for Diagnosis Service provided (Write Yes or No)

Feedback provided (Write Yes or No)

Remark

REFERENCES

1. An Electronic Patient Referral Application: A Case Study from Zambia Niamh Darcy,

Chris Kelley, Eileen Reynolds, Gordon Cressman, and Perry Killam, March 2010

Research Report

2. Rapid Assessment of Referral Care Systems A Guide for Program Managers:JSI/USAID

3. The Health Referral System In Indonesia

4. Tools for Establishing Referral Network for Comprehensive HIV care in low –Resource

Setting