Presentation by Cristina de la Torre

1. Monitoring referrals to
strengthen service integration
Cristina de la Torre, MPH, DSc.
MEASURE Evaluation/ICF International
Cristina.delatorre@icfi.com

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. Models of integration
1. Single provider – multiple services
2. Multiple services on site – different providers
3. Linking services across sites

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. 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. 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. 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. 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. 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. 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. 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. 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. Referral systems

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. 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. Illustrative monitoring data

17. Illustrative data

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. 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. 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. www.measureevaluation.org