5th edition NTP MANUAL OF PROCEDURES TB-DOTS Referral System

I. TB-DOTS referral system List of Health Facilities or Practitioners Providing TB Care Services Public health facilities Health centers Rural health units MDR-TB treatment centers Satellite treatment centers Treatment hubs Other public health facilities Public hospitals and laboratories Jails and prisons School clinics Military barracks There are different kinds of health facilities providing TB services. They are grouped into (1) public health facilities, (2) other public health facilities, (3) private health facilities and (4) community groups.

I. TB-DOTS referral system Private health facilities Private clinics/hospitals Diagnostic centers Pharmacies NGOs Community groups Barangay workers Community health teams TB task forces and others

Major reasons for referral For diagnosis For registration and initiation of treatment For treatment continuation For management of serious side effects and complications For MDR-TB screening For TB screening among PLHIV These are the major reasons for referrals under the National TB Control Program. There are examples cited in the MOP. For example, a hospital referring a TB case to health center for registration and initiation of treatment or a health center referring presumptive MDR-TB to a treatment center.

II. Objective To ensure that various diagnostic,treatment and information needs of presumptive TB/confirmed TB cases are promptly and adequately addressed through an effective two-way referral system between health facilities to: reduce delay in diagnosis and treatment of a TB case ensure continuity of and compliance with treatment reduce out-of-pocket cost to patients ensure that TB patient is registered and notified to NTP

III. Definition of terms Referral process  set of processes of systematically referring a patient from health care provider to another health facility to address his/her needs and know the outcome of referral Internal referral system  a system of referral within a hospital External referral  process of referral from one health facility to another health facility or institution Referral feedback  process by which a receiving facility informs the referring health facility of the referral outcome

III. Policies Patients shall have the right to know the reason/s for referral, and participate in the choice of facilities where he/she is referred. Health care providers have the responsibility to ensure prompt and appropriate response to patients’ health needs by immediate referral of services. A two-way functional referral must be observed by ensuring that receiving facility provides feedback to referring facility.

III. Policies It is a shared responsibility of referring and receiving facilities to exert all efforts to ensure that referred patients are not lost during the referral process. All referring facilities/providers must use a standard referral form (Form 7. NTP Referral Form). All hospitals shall maintain a referral logbook. Patients who are not referred in accordance with policies and procedures shall be accommodated and evaluated accordingly.

Form 7. NTP Referral Form

Form 7. NTP Referral Form

Form 8. Hospital TB Referral Logbook

Form 8. Hospital TB Referral Logbook

IV. Procedures Hospital internal referral system Referring staff fills up intra-hospital referral form with documents attached and sends to hospital TB team or point person. Hospital TB team evaluates the patient,fills up the reply form and records the patient in the hospital TB logbook. Patients may be provided NTP drugs while at the hospital. Drugs may come from: health centers near patient’s residence, or hospital TB team. These are the procedures for the internal referral system in the hospital. Emphasize this when training hospital staff. But coordinators must be able to discuss this for monitoring and supervision purposes.

B. External referral system Explain to the patient why he/she will be referred. Mutually agree with the patient where he/she will be referred. Fill up the Form 7. NTP Referral Form; attach the documents depending on the purpose of referral. Discuss with patient the referral process. In a patient-centered TB care, patient participate in deciding where s/he will receive treatment.

B. External referral system 5. For hospitals Write remarks on the TB registry or Presumptive TB Masterlist. If patient is given TB drugs in the ward, fill up the ID card. List all referred patients to referral logbook. Upon discharge, refer to DOTS facility. Give at least one or two weeks supply of anti-TB drugs. It is important to give feedback to the referring facility to ensure that patient is not lost during the referral process. The referring and receiving facilities should help each other in tracing the lost patient.

B. External referral system Inform the receiving facility. Receiving facility gives feedback to the referring facility. Referring unit updates record upon receipt of feedback. Retrieve patient if he/she has not gone to health facility within five days.

C. Referring presumptive DRTB patients The following are considered DRTB patients: All retreatment cases, including non-converters of Category II New TB cases Contacts of new DRTB cases Non-converters of Category I Persons living with HIV (PLHIV) who are presumptive TB Fill up Form 7 (NTP Referral Form) with the attached documents Old treatment card/s DSSM results Chest X-ray (plate and result)

C. Referring presumptive DRTB patients Record the details of the referral. Form 1  Presumptive TB Masterlist Form 8  Hospital TB Referral Logbook Refer patient to DOTS facility with PMDT services. Receiving facility acknowledges the referral.

D. Handling TB patients previously managed outside a DOTS facility and not referred according to NTP policies and procedures Get a detailed clinical history. Secure copy of supporting documents. Assess patient’s willingness to continue treatment. Do DSSM if not yet done or was done by a non-NTP laboratory facility. Physician decides whether to continue, modify, re-start or discontinue treatment. Provide treatment. Provide feedback to previous attending physician. This is common specially in areas where there are many private health care providers who refer cases using prescription pad or any piece of paper. Through patient interview, review of documents or even talking with the previous physician, the physician of the receiving facility will be in the best position to evaluate patient and decide on the next action.

Modes of knowing the outcome of referral Sending back NTP referral reply slip  hand-carried, faxed, mailed or emailed Through phone call SMS or texting Reviewing TB case registry