Health Referral System
for Care of People with Disability
Nguyen Hoang Nam, MD, MPH
Welcome To Life Project Coordinator, Khanh Hoa, Viet Nam
What is a Health Referral?
 Health referral is the process:
Health care providers at lower levels to seek the assistance of
providers who are better equipped or specially trained to guide
them in managing or to take over responsibility for a particular
episode of a clinical condition in a client
 Key reasons for deciding to refer to
seek expert opinion regarding the client
seek additional or different services for the client
seek admission and management of the client
seek use of diagnostic and therapeutic tools
Goal of the Health Referral
Goal of the health referral:
 To ensure that patients can receive appropriate,
high-quality care for their condition in the lowest
cost and closest facility possible
Types of the Referral
1. External
 Vertical – patient/client referral from lower to higher-level facility
and vice-versa
 Horizontal –patient/client referral from one facility to another
facility with a higher capability and vice versa
2. Internal
 This is usually within the health facility and from one health
personnel to another
Framework of Referral System
 Health referrals system is organized as four level referral
First level: Commune Health Centers (CHC)
Second level: District Health Centers (DHC)
Third level: Provincial Hospitals/Centers
Fourth level: National Hospitals/Centers
 CHCs are the first contact of the community/individual with the
formal health system
 CHCs serve as the gatekeepers for higher levels of health care
Referral System Model
District Health
Return referral
Commune Health
Centers/CBR workers
Components of Referral System
1. Health system
 Network of service providers
 Adherence to referrals protocols
 Transport, communications and other resources
2. Initiating facility
The client and their condition
Protocol of care for that condition at that level of service
Treat and stabilize client – document treatment provided
Decision to refer
Components of Referral System
3. Referral practicalities
Outward referral forms
Communicate with receiving facility
Information to the client
Referral register
4. Receiving Facility
 Receive client with referral form
 Treat client and document
 Plan rehabilitation
5. Supervision and capacity building
 Monitor referral
 Ensure back referral
 Feedback and training for facility staff
CBR and Health Referral System
- In Viet Nam, CBR program are managed by Ministry of Health and
implemented through primary health structure.
- The role of CBR is to work in collaboration with people with
disabilities, their families and medical services to
 Facilitate referrals for people with disabilities and their families for
general or specialized medical care needs
 Make sure referrals have been made for people with disabilities
who require access to secondary and tertiary levels of health care
 Facilitate referrals to access more specialized rehabilitation
Facilitating Referral by
CBR workers
 Identify rehabilitation referral services available at all levels of
the health system
 Provide information regarding referral services to people with
disabilities and their families, including location, possible
benefits and potential costs
 Encourage people with disabilities and their families to express
concerns and ask questions about referral services
 Once a referral is made, maintain regular contact with the
services and individuals involved to ensure that appointments
have been made and attended
Facilitating Referral by
CBR workers
 Identify what support is required to facilitate access to services
(e.g. financial, transport, advocacy) and how this can be
 CBR personnel can accompany people to their appointments
 Provide follow-up after appointments to determine whether
ongoing support is needed, e.g. rehabilitation activities may
need to be continued at home
(Community-Based Rehabilitation Guidelines, WHO, 2010)
Major Issues in Referral System
 Under utilization of commune health centers and
district health centers (referral discipline)
 Delayed referral
 Poor referral communications
Proposed Solutions
 Improving design by assessing which services should be
provided at what level of care, including home and communitybased care; primary health care; and district, secondary,
tertiary, and other specialized hospitals;
 Transferring information better between levels of care
(whether referring patients up or down in the system) and
from a geographic perspective, ensuring patients have
transportation arrangements from remote areas when needed;
 Instilling “referral discipline” by fast-tracking patients who are
referred and explaining to non referred patients that they need
to wait or go to another facility for care
(DCP2 Project – World Bank, 2008)
 WHO. 2010. Community-based Rehabilitation: CBR
 World Bank. 2008. Referral Hospital in In Disease
Control Priorities in Developing Countries, 2nd ed
 WHO. 2011. Management of Health Facility.
 Viet Nam Ministry of Health. 2008. CBR Training
Manual for Health Staff

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