1. 5th edition NTP MANUAL OF PROCEDURES TB-DOTS Referral System

2. 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.

3. 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

4. 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.

5. 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

6. 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

7. 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.

8. 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.

9. Form 7. NTP Referral Form

10. Form 7. NTP Referral Form

11. Form 8. Hospital TB Referral Logbook

12. Form 8. Hospital TB Referral Logbook

13. 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.

14. 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.

15. 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.

16. 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.

17. 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)

18. 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.

19. 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.

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