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Home Care - 5.6 Referrals
5.6 Referrals
A key component of the continuum of care is a functional referral system between hospitals, district-level health facilities, VCT and community support structures, including the home care teams themselves. This is necessary to enable PLHA to access the appropriate level of care, according to the stage of their illness, thus avoiding overburdening hospitals with minor ailments and ensuring more serious conditions are treated promptly.
Acknowledging the importance of referrals for PLHA, significant efforts were made during, and subsequent to, the pilot phase to establish a viable referral system within Phnom Penh. Referral forms were developed, and the key staff at the main hospitals were consulted and briefed about the referral system.
The strategy was that patients would only be referred by HCTs to hospital when their condition required an intervention which could not be provided at home. It was anticipated that the hospitals would accept the judgement of the HCTs on the need for admission and would facilitate easy referral.
On discharge, patients would be referred by the hospitals back to the appropriate HCT, with continuity of care being maintained through the use of “yellow cards” containing patient data.
Despite concerted efforts by the HCTs and the HCNG, it appears that this component of the referral system is not working effectively. The Home Care programme has had limited success in institutionalising referrals to and from hospitals. The evaluation found that only 11% of patients were referred by hospitals, compared with 15% the previous year.
Furthermore, the HCTs frequently report problems encountered when taking patients to the main referral hospitals, and the patients themselves often refuse to go to hospital because of the long waiting times and perceived unwelcome reception from hospital staff.
Recently, the HCTs reported some difficulties encountered at Centre of Hope, when patients waited all day without being attended to. It appears that these difficulties arose because neither the HCTs nor the patients fully understand the “lottery system” employed by Hope for dealing with outpatients. This issue should easily be resolved through a meeting of HCT Co-ordinators and Hope medical staff.
At Calmette Hospital, on more than one occasion, staff have refused to accept HIV test results from VCT centres, even when the patient was accompanied by the HCT, and have insisted on the patients being re-tested.
It is perhaps unfair to highlight these two issues, as there have been problems with referrals to other institutions. It is believed that institutionalising the Home Care programme more firmly within MoH will help to resolve these problems.
During the pilot phase, each of the HCTs was attached to one of the four main referral hospitals (Calmette, Norodom Sihanouk, Municipal Hospital and Centre of Hope), according to geographical location. Each hospital designated contact staff, who were supposed to know, and be known by each member of the HCTs. It is strongly recommended that this system, which has long lapsed, is reinstated.
Each of the referral hospitals should work closely with their “partner” HCTs to provide medical supervision, and to agree a set of criteria for admission of a patient, or for the provision of outpatient treatment. This should help to improve the diagnostic skills of the HCTs and avoid unnecessary referrals.
It is believed that these strategies will help to improve the referral process and thus fill one major gap in the continuum of care.
It is recommended that the HCNG strengthens the hospital referral system by reinstating the system of attaching each of the HCTs to one of the main referral hospitals in Phnom Penh. The designated hospital would then assume responsibility for medical supervision and facilitate referrals for their partner HCTs.
On a positive note, the evaluation found that the vast majority of referrals of patients to the HCTs arise from within the community, with an increasing number coming from neighbours (27%), other patients (9%) and community leaders (5%). Many patients (28%) are found by the HCTs themselves, generally through their volunteers, but also through the weekly meetings where referrals are exchanged between the teams. Health Centres referred a further 18% of patients.
SOURCES OF REFERRAL
HCTs/ Volunteers 28%; Neighbours 27%; Health Centres 18%; Hospitals 11%; Other patients 9%; Community leaders 5%; NGOs 2%.
It is felt that the increasingly high levels of community-based referrals provides significant indicators of success of the programme. These process indicators are outlined below:
A key component of the continuum of care is a functional referral system between hospitals, district-level health facilities, VCT and community support structures, including the home care teams themselves. This is necessary to enable PLHA to access the appropriate level of care, according to the stage of their illness, thus avoiding overburdening hospitals with minor ailments and ensuring more serious conditions are treated promptly.
Acknowledging the importance of referrals for PLHA, significant efforts were made during, and subsequent to, the pilot phase to establish a viable referral system within Phnom Penh. Referral forms were developed, and the key staff at the main hospitals were consulted and briefed about the referral system.
The strategy was that patients would only be referred by HCTs to hospital when their condition required an intervention which could not be provided at home. It was anticipated that the hospitals would accept the judgement of the HCTs on the need for admission and would facilitate easy referral.
On discharge, patients would be referred by the hospitals back to the appropriate HCT, with continuity of care being maintained through the use of “yellow cards” containing patient data.
Despite concerted efforts by the HCTs and the HCNG, it appears that this component of the referral system is not working effectively. The Home Care programme has had limited success in institutionalising referrals to and from hospitals. The evaluation found that only 11% of patients were referred by hospitals, compared with 15% the previous year.
Furthermore, the HCTs frequently report problems encountered when taking patients to the main referral hospitals, and the patients themselves often refuse to go to hospital because of the long waiting times and perceived unwelcome reception from hospital staff.
Recently, the HCTs reported some difficulties encountered at Centre of Hope, when patients waited all day without being attended to. It appears that these difficulties arose because neither the HCTs nor the patients fully understand the “lottery system” employed by Hope for dealing with outpatients. This issue should easily be resolved through a meeting of HCT Co-ordinators and Hope medical staff.
At Calmette Hospital, on more than one occasion, staff have refused to accept HIV test results from VCT centres, even when the patient was accompanied by the HCT, and have insisted on the patients being re-tested.
It is perhaps unfair to highlight these two issues, as there have been problems with referrals to other institutions. It is believed that institutionalising the Home Care programme more firmly within MoH will help to resolve these problems.
During the pilot phase, each of the HCTs was attached to one of the four main referral hospitals (Calmette, Norodom Sihanouk, Municipal Hospital and Centre of Hope), according to geographical location. Each hospital designated contact staff, who were supposed to know, and be known by each member of the HCTs. It is strongly recommended that this system, which has long lapsed, is reinstated.
Each of the referral hospitals should work closely with their “partner” HCTs to provide medical supervision, and to agree a set of criteria for admission of a patient, or for the provision of outpatient treatment. This should help to improve the diagnostic skills of the HCTs and avoid unnecessary referrals.
It is believed that these strategies will help to improve the referral process and thus fill one major gap in the continuum of care.
It is recommended that the HCNG strengthens the hospital referral system by reinstating the system of attaching each of the HCTs to one of the main referral hospitals in Phnom Penh. The designated hospital would then assume responsibility for medical supervision and facilitate referrals for their partner HCTs.
On a positive note, the evaluation found that the vast majority of referrals of patients to the HCTs arise from within the community, with an increasing number coming from neighbours (27%), other patients (9%) and community leaders (5%). Many patients (28%) are found by the HCTs themselves, generally through their volunteers, but also through the weekly meetings where referrals are exchanged between the teams. Health Centres referred a further 18% of patients.
SOURCES OF REFERRAL
HCTs/ Volunteers 28%; Neighbours 27%; Health Centres 18%; Hospitals 11%; Other patients 9%; Community leaders 5%; NGOs 2%.
It is felt that the increasingly high levels of community-based referrals provides significant indicators of success of the programme. These process indicators are outlined below:
- increased referrals from neighbours and other patients indicates reduced discrimination against PLHA and increased trust in the HCTs
- increased referrals from volunteers indicates acceptance of the volunteers within the community and their successful involvement in the programme
- increased referrals from community leaders indicates support of the programme and confidence in the HCTs by local authorities