Linkage to care – Removing communication barriers between Health care Facilities and Community Based services.

Community Health Workers are a essential component of the health workforce who provide personalised directed health care in the comfort and safety of a patients home.

This innovation addressed the administrative injustice and barriers experienced y health care workers which result in gross under utilization of the resource.

The innovation automates arduous paper referral to a instant digital referral using Quick Response codes and existing tools in Office 365, all without leaving the bedside

Innovation Summary

Innovation Overview

Background: Community based services (CBS) are a critical tool in assuring the health of communities in resource poor settings, CBS have the tools to provide a comprehensive set of services which include nutrition; wound care; home based rehabilitation; adherence to therapy, palliative care and psychosocial support. They have been shown to reduce re-admission rates to hospital. As care is provided directly in the patients home, they are placed to identify and modify social determinants of disease with a mandate to care for all members of the household. Though there are 850 community health workers to provide these services the previous paper based system only resulted in 500 referrals annually, and administartive injustice with gross under utilisation of the health workforce

This project addressed inefficiencies in the paper-based system of referral of patients between health care facilities and community-based services: an automated digital system was created to streamline the referral of any patient.
The key principle of the project is that paper-based systems are slow, prone to error and demand significant physical resources and especially time. The intervention aims to remove these barriers by allowing health care workers to readily complete these referrals from their own devices or a PC without leaving the patients bedside. The key features are summarised as below:
1. Quick Response (QR) codes providing access to a digital form were placed in clinical areas, the link (https://forms.office.com/r/DD5GVuf3jT) was distributed through routine digital communication channels.
2. Clinicians are able to enter relevant referral data at the bedside via cell phone or on computer.
3. On submission ,the data automatically generates, and emails, a copy of the referral form to the CBS coordinator at Substructure/District office this can then immediately be sent on to the relevant CHW (Community Health Worker)
4. The CHW on completion of the home visit, could elect to provide feedback through means of a short online form; this is automatically provided real-time feedback to the referring clinician who can appreciate the continuum of care
5. A real-time record of referrals and associated data is automatically immediately captured and populates onto a PowerBI Dashboard for purposes of monitoring; evaluation and planning further service developments according to utilisation trends. This data is instrumental for managers as well as saving clerical time manually capturing referral data as was previously done.
Raw Data is also saved in a Sharepoint database for analysis in referral trends
7. Copies of referrals (for audit purposes eg Ideal Clinic) kept in a POPIA compliant Sharepoint Folder.

Innovation Description

What Makes Your Project Innovative?

The innovative aspect of the project is that it harnesses existing resources to automate seemingly meaningless administrative tasks. No additional resources, besides the motivation to bring about change, were required in the implementation and development of this project.
However, it resulted in a tenfold increase in the number of patients accessing the services.

The people who implemnted the project had no technical experience in coding or automation, but all skills required for the implementation of the project were learnt on Youtube.

The innovation creates real-time information as to referral pattern9s) and the nature of services required, this results in a responsive healthcare management that allocate staff and perform targeted training

What is the current status of your innovation?

The innovation was piloted in April of 2022 and by October of that year it had become established - on the basis of its success in linking patiets to community health workers in the clients area of residence it was rolled out to a second second sub-district in the Cape Metropolitan area, by April of 2023 the intervention had organically grown and was in use across health facilities in the entire Cape Metropole.
Use of the tool has remained consistent with increasing numbers of referrals from a growing group of clinicians.

Innovation Development

Collaborations & Partnerships

The clinicians key contribution was addressing the administrative barriers experienced by their staff.
CBS coordinators were critical in acknowledging and supporting a move from paper based referrals would increase legibility but also accuracy of applications,
The NPO were key as the primary stakeholder who would apply the service, they were key in assuring the community health workers had the adequate training and support to disseminate the service, to assist the CHW in providing the feedback

Users, Stakeholders & Beneficiaries

Clinicians in healthcare facilities across the cape metropole were primary users - they experienced ease of access to the form and could readily complete from the patient bedside
The key stakeholders were the CBS coordinators who would disseminate the forms to NPOs, benefitted from legible forms and thus patients could readily be connected to NPOs and CHWs.The key beneficiaries were the patients, who would be able to receive health care in their own home. The referral assured continuity of care

Innovation Reflections

Results, Outcomes & Impacts

In the 22 months following commencement of the intervention there have been 8800 digital referrals in the immediate drainage area of the facility which represents a tenfold increase from the baseline number of paper-based referrals. A total of 23 thousand referrals have been sent from health care facilities in the Cape Metropole, this equates to 1 referral for every 200 residents of the city. 1 fifth of referrals are for patients suffering with tuberculosis who have failed to access or are requiring support in continuing their treatment. Health care managers can access a real-time dashboard of utilisation and how they can further support their staff, whilst NPOs can see services requested and develop targeted training for their CHWs

Challenges and Failures

In essence, this system reduces administrative load by task shifting to an automated process. The strength is that it leverages a single Office 365 account is also a potential Achilles heel in the sense that any disruptions to the account poses significant threats to the entire process and redundancy must be inbuilt into the system to avoid this.
Though developed by an individual needs to be well documented; communicated and other individuals must have a firm grasp of the system in order to make changes.
The system is dependent on accurate email routing, any inaccuracies in recipient addresses or lapsing of email access occur the system would be rendered non-functional, the use of generic shared inboxes avoids this challenge.

Conditions for Success

The key condition to the success of this intervention was the ability to harness already existing resources in the form of tools available through a Office 365 License, this would reduce administrative challenges and create the capacity to directly the significant human resource that existed within the organization.
Though seemingly overwhelming, the technical skills to create the initial automation is readily gained from readily accessible resources, most notably youtube.com which has real-time step-by-step tutorials to assist in gaining the skills.
The motivation to bring about change and assure that health care is equitably accessed are key drivers to address the challenges faces

Replication

As the tool leverages existing products in the office 365 suite and that it only requires a single user license, the innovation which focusses on moving organisations from paper-based to digital processes is readily scalable. A single Office 365 license was used to scale this innovation to provide the service to approximately 5 million people with referrals from 80 health facilities in the Cape Metropole – in the coming months it will be implemented to all health facilities in the Western Cape.
The code running the process in non-proprietary and templated so might readily be implemented in other provinces – there are only 2 dependencies 1) an Office 365 license
2) a email address of a willing recipient to act

Lessons Learned

The key learning from this experience was that not only patients experience barriers in accessing health care, but there are significant administrative barriers that prevent clinicians from its provision. If one can identify the barriers, readily available tools can address these.
The success of the innovation was the conversion of an opaque process (where and how and to whom does one complete a referral) to simply scanning a quick response code.
Clinician’s vis a vie any civil servant have to derive meaning from the work that they do. If task outcomes are not immediately evident they are suboptimally performed – in this case there was a fourfold increase in the number of referrals when clinicians started to receive feedback of the visits

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