Pioneering enhanced hospital referral coordination in Sierra Leone

Our Hospital Performance Monitor volunteer, Lucy Hartshorn, describes her experience working as part of the referral coordination team, funded by USAID through JSI Research & Training Institute’s Advancing Partners & Communities project.



At the beginning of October last year, the Sierra Leone Ministry of Health launched a new national referral system, building on successful elements of previous Ebola survivor-targeted efforts, to support broader access to health services for the population of Sierra Leone. Critical to this system are the 17 KSLP-supported referral coordinators. A new cadre of specialist health workers, the referral coordinators are based in each district’s government secondary hospital and in the specialist, tertiary hospitals in Freetown. They use their clinical backgrounds to support incoming and outgoing patient referrals at the facility and make sure patients are at the right place at the right time.

Patients in Sierra Leone face a myriad of obstacles when they get sick, from knowing who to visit for a diagnosis or navigating where they need to get to receive treatment, to the availability of health care workers who are trained and able to provide the specific care a patient may need. In Sierra Leone, this is complicated by significant resource constraints – on both individuals and the health system. For the hospitals, doctors, nurses, midwives and laboratory staff that work in the government hospitals across Sierra Leone, getting each patient the care they need is often accomplished through a clever mix of compassion, teamwork and communication. As the Hospital Performance Monitor Volunteer, I lead the referral coordination team in training and supporting our Referral Coordinators (RCs) and working with the Ministry of Health.

Lucy and the KSLP Referral Coordinator mentors, Sorie Samura and Hassan Shaw, recently supported district level leadership meetings in Makeni.

It is exciting, if not initially intimidating, to be able to work with King’s Sierra Leone Partnership! I am not clinical and instead have a background in ‘global health’, spanning biomedical sciences, public health and health partnerships. While much of KSLP focuses on overcoming challenges in clinical care, which you can read more about here, the referral coordination work is pioneering a new model of enhanced hospital coordination to overcome wider Sierra Leone health system challenges. The two KSLP RC Mentors, Sorie Samura and Hassan Shaw, and myself make up the Referral Coordination support team. They both bring clinical experience and a near-unlimited understanding of the Sierra Leone health system to our project, while I bring the baked goods (sometimes) and Americanisms. Together, we support the RCs spread across the country – mainly from the KSLP ‘Clinical Office’ tucked the end of the hall after Ward 10 in Connaught Hospital.

By referral coordination, we mean the networks, information and communication that helps clinicians direct patients to the right places, where they can get the right services, at the right time. This is different than the ambulance networks patients use, although the RCs link closely with emergency alert systems in each district to help notify hospitals of patient details prior to arrival, helping them prepare. For incoming referrals, this means receiving calls from Peripheral Health Units (PHUs), District Emergency Alert Systems or NGO and private facilities wanting to send patients to the government hospital; notifying clinical and laboratory staff of incoming patient diagnosis, needs and estimated time of arrival; and advocating for access to facility services for Free Health Care Initiative (FHCI) patients. For outgoing referrals, the RCs play a critical role in helping patients navigate the complex landscape of service delivery in Sierra Leone – a patchwork of government, private and NGO offerings. The RCs work with clinicians, patients and patient caretakers to determine which other facilities have the services the patient needs and their availability, and then contacts the next facility’s referral coordinator, who supports patients from the receiving end.

RCs are also hugely beneficial to the facilities that they work within, supporting hospital preparedness and improving patient flow. What is innovative about the RC-based referral coordination system is it’s ability to make huge impact and improvement within the space and resources available. Success has so far been build on small-small changes- the use of standardized referral forms, a designated hospital employee to take over a role often ad-hoc filled by clinicians, sharing of phone numbers with information on different hospital service offerings, a system of reporting these referrals on a weekly basis – to name a few. The referral system has given the MoH its most comprehensive understanding of patient referral numbers, needs and flow – fed back in KSLP-produced weekly and monthly reports. This is used by the Referral Coordinator’s hospitals, District Health Management Teams and the Ministry of Health and Sanitation for prioritising resources, visualizing system gaps and demand and advocacy for more accessible, high-quality health service provision across the country.

The referral coordination team is made up of 17 KSLP-supported referral coordinators, working at facilities across the country.

It is exciting to impact on this innovative creation – a national network providing individual patient, facility and system benefits. My role focuses on studying the referral system in real-time. I use the information produced by our RCs and RC Mentors for not only improved referral project implementation, but also through newly created feedback loops to help hospitals and the Ministry of Health plan, to advocate for services and resources for patients and facilities, and to enhance the global health sector’s understanding of patient access to care. It’s a process of constantly learning. New and updated patient referral information is compiled every week – a truly incredible feat and something which exists in few countries! From this, I get to think about interesting questions like: what challenges hospitals are facing, how to share the information to best visualizes these challenges, how the referral coordinators are impacting patient outcomes, and what the different benefits of referral coordinators in each unique facility and district are. What I think makes KSLP different from many other organisations is that we focus beyond just enhancing the understanding of the patients, hospitals and health system. For me, it’s about turning that knowledge of patient referrals and system access into action – informing policy, projects and research for better patient care.

Just as patients in Sierra Leone benefit from the teamwork and compassion of their health workers, I depend on the skill, expertise, collegiality and unrelenting commitment of the two KSLP RC Mentors, seventeen referral coordinators and the team at the MoH program implementation unit. They are responsible for the success of the referral system so far. As we approach the end of February, they can boast of having trained almost twenty specialist referral coordinators, supported over 4,200 referrals and helped patients navigate over 500 facilities!