A Qualitative Study of Referral Practices of the Public Healthcare System in Bhopal District of Madhya Pradesh

A Qualitative Study of Referral Practices of the Public Healthcare System in Bhopal District of Madhya Pradesh | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Qualitative Study of Referral Practices of the Public Healthcare System in Bhopal District of Madhya Pradesh Dr SUSHMA YADAV M, Sanjeev Kumar, Deepti Dabar, Pankaj Prasad This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4686495/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background - Referral system is backbone of any healthcare delivery system. Referral defined as the handover of patients from doctor to doctor or from one team to another has been identified as a high-risk area as patient valuable information can be lost or not quantified or recorded properly during the transit. Many referrals are regarded as unnecessary, meaning that the problem could be handled by the General Practitioner (GP). Improving the quality of the referral process is important to facilitate timely access to speciality care. Objectives - To understand the perceptions, attitude, behaviour, challenges and facilitators of referral policy, practices and pattern from all the stake holders involved in the referral process, i.e., the health policy makers, healthcare providers and users from primary care to higher levels of health care facilities in the public health system of Bhopal district in Madhya Pradesh. Materials and Methods - 24 in-depth interviews of the health policy or decision makers of the state, doctors, and administrators/ in-charges of the public health system in Bhopal by purposive sampling and exit interviews of a quota sampling of 63 patients were conducted. Thematic framework analysis was done manually and a conceptual framework for the referral system was generated. Results - Five major themes conceptualised for the continuous process of the referral system were referral policy, roles and responsibilities, implementation, barriers and facilitators, monitoring, feedback and evaluation. Conclusion - The implementation of the referral policy regarding the maintenance of the referral registers, issuing of referral slips, etc were not up to the required standards. There is a need for a uniform state referral policy and the establishment of a GP system to ensure continuity of care. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 INTRODUCTION India has one of the most extensive health infrastructures- a three-tier hierarchical referral system for the provision of effective and efficient health services to the majority of its population viz the primary, secondary and tertiary levels (1). People in India have the right to choose from the various government, private and informal healthcare provisions available to them as there is no uniform referral policy guiding the people for seeking healthcare. The referral system in the healthcare system is the backbone of the health system in any country. A referral is the handover of patients from one doctor to another doctor or from one team health care system to another. This has been identified as a high-risk area as patient valuable information can be lost or not quantified or recorded properly during this transit. Inappropriate referral has a good share of bringing poor clinical outcomes of the patient and poor patient satisfaction. Many times referrals are regarded as unnecessary, meaning that the problem could been easily handled by the General Practitioner (GP). Improving the quality of the referral process is important to facilitate timely access to the specialty care (2). Thus, timely and appropriate referral becomes a highly essential and significant process in health care delivery and health outcomes of a patient. The decision to refer should be based on the patient’s medical condition, needs, and an assessment of the optimal level of health care. The patient should be referred at the right time after adequate pre-referral management, and after an appropriate process that also takes the patient’s wishes into account. (3) Increased continuity of care decreases referrals to specialist care thereby reducing the wastage of resources and the burden on the system and also reduce the overall health care costs. (4) Therefore, the need to have a sound referral system is important, to fulfil the existing gaps in Health Infrastructure. The present study aims to understand the perceptions, attitude, behaviour, challenges and facilitators of referral policy, practices and pattern from all the stakeholders involved in the referral process, i.e., the health policy-makers, healthcare providers and users from primary care to higher levels of health care facilities in the public health system of Bhopal district in Madhya Pradesh. METHODOLOGY This study was conducted in the public health facilities and the healthcare decision making department in Bhopal district of Madhya Pradesh. Bhopal is the capital city of Madhya Pradesh state in Central India, with a population of 2371061, geographically divided into 2 blocks with 81% Urban Population and 19% Rural Population. There are 7 Tertiary Healthcare Centres or THCs (2 government and 5 private medical colleges), 4 Secondary Healthcare Centres or SHCs (3 CHCs and 1 District hospital,) 86 Primary Healthcare Centres or PHCs (9 PHCs, 8 UPHCs and 69 sub centres) (5), (6) This is a qualitative study which was conducted using phenomenology to understand the perspective of healthcare providers and users, healthcare administrators and health policymakers of the public health system. For this, in depth interviews were conducted among healthcare providers and users, healthcare administrators and health policy makers. This study was carried between December 2020 to June 2022. For this study we included Officials who were involved in the health policy making like the Directorate of Health Services (DHS), the Directorate of Medical Education (DME) and officials from the National Health Mission (NHM), Bhopal, Government of Madhya Pradesh. We also included Health Care Provider and Patients/ relatives who sought care in the public health system. Medical officers from the PHCs and doctors working in major departments like General medicine, Surgery, Obstetrics and Gynecology and Pediatrics and Emergency departments, the administrators/ in-charges of the secondary and tertiary healthcare facilities, the officials holding posts and involved in health policy making in the DME, DHS and NHM selected through purposive and snowball technique were the participants for the in-depth interviews. For the exit interviews of the patients, only the primary (2 PHCs) and secondary health facilities (1 CHC and 1 District hospital) were considered. Exit interviews of the patients leaving the health facilities after consultation were taken using a predesigned questionnaire administered with the Kobo tool software. Here the final sample of patient exit interviews came out to be 63 (28 in district hospital, 16 in CHC, 10 in PHC A and 9 in PHC B based on the patient load and the level of care provided in the hospital was taken from the OPDs, IPDs and Emergencies where ever applicable) which is more than the previously arbitrarily assigned sample size of 50. This was because some of the patients leaving the hospitals after consultation wanted to be interviewed as well exceeding the number of interviews that were meant to be taken. The interviews were conducted after due appointments from the study participants. All the participants of the qualitative study were explained about the purpose of the study through a Patient information sheet and a written informed consent was taken for all. The interviews were audio recorded with prior permission from the participants for analysis purpose and transcript notes were taken during the interviews. They were assured that all the information will be kept confidential, and all data will be anonymized before analysis and reporting. We conducted key informant interviews of 16 doctors from different medical and surgical specialities by purposive sampling, 4 hospital administrators by purposive and convenient sampling, 4 policy makers by purposive and snowball sampling and exit interviews of a quota of 63 patients who got treatment from the healthcare facilities. The inclusion criteria were the healthcare providers or doctors working in public health facilities for at least the past 1 month. Patients/ relatives (in the case of the minor patients) were those who had visited the selected health facility to seek outpatient, emergency and in-patient care on the day of the interview and had been original inhabitants of Bhopal and in migrants who had been staying in Bhopal for at least the past 6 months. Healthcare administrators working in the selected health facility for at least 1 month. Officials who worked in either Directorate of Health Services or Directorate of Medical Education or National Health Mission and had been holding the current administrative post for a period of at least 1 month and were involved in the policy/decision-making of the health matters of the state of Madhya Pradesh. Participants with language barriers who couldn’t communicate in English or Hindi or with visual, auditory or speech impairment, migrants or patients who are in transit and not regular residents of Bhopal were excluded from the study. Data Collection After thorough literature review and considering the input provided by experts of the field, a interview guide with appropriate probes and questions was constructed by deductive approach. A participant information sheet was given informing them about the study and consent was obtained from the study participants. In-depth interviews of approximately 40 minutes to one hour each were conducted and audio recorded with due permission. Two PHCs were conveniently selected based on the distance from the central tertiary institute and ease of access. One out of the three CHCs in Bhopal was selected by conducting simple random sampling as one of the secondary health facility. There is only 1 district hospital in Bhopal which was taken up as one of the secondary health facility. There are two tertiary care institutes in Bhopal, out of which one was conveniently selected on account of ease of access. Analysis Audio records were transcribed in Microsoft Word and translated to English. The translated interviews were uploaded onto NVivo for coding. Framework analysis was performed. Deductive as well as inductive coding was done to identify themes and subthemes. As most approaches to qualitative analysis rely on identifying recurrent issues in the data or organisation of those responses that emerge as general headings under which most of the data can be explained, thematic approach was applied. We conducted framework analysis manually. The codes generated from the patient exit interviews were also incorporated into the conceptual framework of referral. ETHICAL ISSUES This study has been approved by the Institutional Human Ethics Committee AIIMS Bhopal, with LOP no 2020/PG/Jan/05. The subjects were informed about the research and procedures through Participant Information Sheet (PIS). Data was collected only after getting written informed consent from the study participants. RESULTS After analyzing the determinants and perspectives of the stakeholders involved, five major themes were extracted from the qualitative data and a conceptual framework of the referral system was generated. The themes were “Referral Policy, Roles and Responsibilities, Implementation, Barriers and Facilitators, Monitoring, Evaluation and Feedback.” (as shown in figure 1) Referral policy Interviews mainly from the policy makers and administrators revealed that most of them weren’t aware of the referral guidelines released by the state of Madhya Pradesh in February 2021. All of them agreed on the fact that there is a need for a uniform national referral policy to ensure a holistic approach towards the delivery of healthcare services. The subthemes for the theme ‘Referral policy’ were categorized into existence of a referral policy, reasons for not having referral policy, views on referral, understanding referral and importance of universal referral policy (as shown in figure 2). Some of the verbatims of the participants were: “So, there is no written order as such for practicing referral, how each patient is supposed to go to another hospital. There is no order” …. (Doctor of Medicine from SHC) “Universal referral policy advantage is that any patient won’t have any problem, any delay, reach right centre at the right time” …… (Administrator of SHC) Roles and responsibilities Many of the administrators had said that there was no written order on referral policy and hence their hospital staff hadn’t been trained for it. The doctors also expressed that they were neither assigned any specific roles and responsibilities nor trained to ensure smooth referral mechanisms. The subthemes for the second theme ‘Roles and responsibilities’ were categorized into role in referral policy making, duties/ responsibilities and mechanisms to ensure smooth referral (as shown in figure 3). Some of the verbatims were: “……I give my technical inputs to the department based on the ground realities, based on the new innovations, or best practices as adopted by the other states in the country…” (policymaker in DHS) “Pre communicated/ pre informed so staff is prepared to receive, ensuring patient stability during transport in ambulance and prevent patient deterioration” ….(doctor in THC) Implementation Most of the doctors mentioned that they referred patients based on their necessity with a referral slip, in the format that is available in the hospital and would document the same in the referral registers in the ward or OPDs after counselling or clear communication as to seriousness of the condition of the patient. They sometimes give in to the demands of the patients as well. The subthemes for the third theme ‘Implementation’ were categorized into training, maintenance of referral record, designated referral point, patient beliefs and choices, factors influencing successful referral and types of referrals (as shown in figure 4). The verbatims were: ” the patient goes there and does it all in own… So there should be some person for help. Some referral officer… referral handling officer. Something like some destination should be met there, and that person should be there” …. (Administrator or in-charge of SHC) “Timely and appropriate referral will increase treatment outcomes, patient satisfaction, improve quality of work for doctors and generate robust epidemiological data”…… (doctor in THC) “Patient referred to government hospital but sometimes patient go to private hospital” ... (doctor in PHC) Barriers & Facilitators Policymakers, administrators, and doctors briefed that patients are referred only when certain necessary services were not available in the designated hospitals like, required investigations, OT services, lack of super specialty doctors or any staff, medicines, etc. Patients had elaborated on the cumbersome procedures in certain hospitals and their preference with respect to distance from their residence, waiting time, comfort and trust levels with the doctors and hospital services, cost of treatment, etc. as determinants in seeking healthcare in a particular hospital. The subthemes for the fourth theme ‘Barriers & Facilitators’ were categorized into factors affecting referral, reasons for referral, facility factors, patient factors, illness characteristics and doctor factors (as shown in figure 5). The verbatims were: "It's nearby.... free medicines….old hospital… more crowds... government hospital.... Fast service"…. (patients from PHC and SHC) “BPL patients for cost of treatment…where beneficiary schemes like Ayushman Bharat (AB PM-JAY) and other grants are available” …. (administrator or in-charge of THC) “They may not be having proper infrastructure, proper staff for that…. equipment may not be available…. no expert or no specialist” …. (Policymaker in DME) Monitoring, feedback and evaluation Many stakeholders had agreed that a uniform referral policy if implemented, would decrease duplication of resources, increase patient satisfaction, compliance, treatment adherence, and thus improve patient health outcomes. They also emphasized that there needs to be a monitoring and feedback mechanism to evaluate and ensure the appropriateness of referral and prevent unnecessary referrals. The subthemes for the fifth theme ‘Monitoring, feedback and evaluation’ were categorized into appropriateness of referral, effects / outcomes of referral, prevent unnecessary referrals and average referral percentage (as shown in figure 6). The verbatims were: “Backward and forward chain to be coordinated by outside/ third party level” …. (administrator or in-charge of THC) “…of course, increase patient satisfaction, compliance, treatment adherence, improve outcomes…. comfort near home….no disturbance to livelihood…..”(doctor in THC) DISCUSSION Referrals are performed by a healthcare facility or provider when they are unable to offer the level of care or type of intervention best suited to the patient's needs. A strong connection between all levels of the healthcare system is ensured through an efficient referral policy, which also makes sure patients get the finest care near to where they live. Additionally, it aids in the efficient use of primary healthcare providers and hospitals. Most patients treated in secondary outpatient clinics can be adequately cared for in the primary care center while reducing the overall cost to the patient and the healthcare system. (7) Targeted systems-based interventions are urgently required to improve information provision and exchange. Similarly, Humpries et al findings also indicate that well-designed patient-held booklets are likely to be an acceptable, affordable and effective part of the solution. (8). As per the available evidence in the literature search, there aren’t any comprehensive referral frameworks that could be adopted by our government to be implemented into the healthcare system. Although according to one study in Nigeria, more than two-thirds of participants felt that it’s unreasonable for any hospital to reject patients, being unreferred to their facility.(9) From our qualitative study, we conceptualised a working framework for the referral system. It consists of the following 5 steps in a continuous process. Firstly, the formulation of a uniform national referral policy detailing the roles and responsibilities of all the health staff involved in patient care, followed by the implementation of this policy as per the guidelines in all the health facilities across the state and so the nation. Finally, a continuous scrutiny on the monitoring, feedback and evaluation system to erase the barriers in meeting standards of healthcare provision and to ensure facilitation of continuum of care to the people of the nation. Referral system if implemented will ensure continuity of care, reduce loss to follow up of patients, prevent duplication of services, lessen cost of health care, increase patient satisfaction and treatment adherence, provide timely provision of care, meet patient expectations, reduce burden on the doctors/ health staff, prevent misuse of resources, provide integrated healthcare services delivery with proper communication between the health facilities/ doctors and other health staff thus improving the quality of life of both the healthcare providers and the healthcare receivers. The major strength of this study is that it studied the overall referral practices, unlike other studies, which restricted to only certain specific disease conditions referral. It also provides for a larger vision and perspective change for the betterment of health policy. We have included all stakeholders pertaining to ensure smooth referral flow of patient in this study. This study has some limitations as it comprised of only urban health facilities, the dynamics of healthcare seeking behavior and service delivery of rural areas is not captured in this study. CONCLUSIONS This study gave us an insight that the Referral system if implemented in its true sense will ensure continuity of care, reduce loss to follow-up of patients, prevent duplication of services, lessen cost of health care, increase patient satisfaction and treatment adherence, provide timely provision of care, meet patient expectations, reduce the burden on the doctors/ health staff, prevent misuse of resources, provide integrated healthcare services delivery with proper communication between the health facilities/ doctors and other health staff thus improving the quality of life of both the healthcare providers and the healthcare receivers. Although health is a state matter, provision of healthcare is not uniformly practiced or distributed in all the health facilities and hence healthcare services are not delivered equivocally to all the people in the nation. We hereby also recommend that a Uniform state referral policy needs to be drafted and implemented in each state for better health outcomes of the patients and that the referring healthcare facility should facilitate the referral of patients in every stage. Declarations Ethics approval and consent to participate This study has been approved by the Institutional Human Ethics Committee, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India, with LOP no 2020/PG/Jan/05. The subjects were informed about the research and procedures through Participant Information Sheet (PIS). Data was collected only after getting written informed consent from the study participants. Consent for publication Written consent was taken from participants through Participant Information Sheet (PIS) before data collection, These following lines were mentioned in the PIS, where the consent for publication is implied: ‘The present study results will be shared to health care provider and policy makers which will further be utilized to develop a good referral system to ensure safe ongoing care of the patients. You will not be identified in any manner in the study data-base or your identity disclosed in any reports or publications. Your interview records may be reviewed by authorized government & regulatory agencies and the sponsor as required.’ In this manuscript, appropriate precautions have been taken to ensure that identifying images or other personal or clinical details of participants are not presented that compromise anonymity. Availability of data and materials The datasets during and/or analysed during the current study available from the corresponding author on reasonable request. Competing interests The authors declare that they have no financial and non-financial competing interests. Funding No funding was obtained for this study. Authors' contributions SY, PP, SK and DD conceived the presented idea. SY, PP and SK contributed in concept and design of study. PP, SK and DD verified the analytical methods. SY planned and carried out the data collection, analysed the data and devised the results of the study. PP guided SY to conduct the study and supervised the findings of this work. All authors discussed the results and read, contributed, and approved the manuscript. Acknowledgements Not applicable. As this study was a part of a dissertation or thesis for the degree of MD Community and Family Medicine at All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India, there was no funding available for this study. Hence, I request for full waiver of publication charges for this study. References Bhola N, Kumari R, Nidha T. Utilization of the health care delivery system in a district of North India. East Afr J Public Health. 2008 Dec;5(3):147–53. Thorsen O, Hartveit M, Johannessen JO, Fosse L, Eide GE, Schulz J, et al. Typologies in GPs’ referral practice. BMC Fam Pract. 2016 18;17:76. Ringberg U, Fleten N, Førde OH. Examining the variation in GPs’ referral practice: a cross-sectional study of GPs’ reasons for referral. Br J Gen Pract. 2014 Jul;64(624):e426-433. Olthof M, Groenhof F, Berger MY. Continuity of care and referral rate: challenges for the future of health care. Fam Pract. 2019 20;36(2):162–5. 2327_PART_A_ DCHB_BHOPAL.pdf. health-institutions.pdf [Internet]. [cited 2020 Aug 24]. Available from: http://www.mponline.gov.in/Quick%20Links/Pdfdocs/health-institutions.pdf Kumar S. referral Guidelines for health facilities in UTTAR PRADESH. :55. Humphries C, Jaganathan S, Panniyammakal J, Singh S, Goenka S, Dorairaj P, et al. Investigating clinical handover and healthcare communication for outpatients with chronic disease in India: A mixed-methods study. PLoS ONE. 2018;13(12):e0207511. Farrag NS, El‑Gilany A, Ibrahim AM, Abdelsalam S. Does Implementation of the Universal Health Insurance Affect the Quality of Referral in the Healthcare System? A Cross‑sectional Comparative Study in Egypt. Indian Journal of Public Health. 2021;65(3):7. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4686495","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":324144917,"identity":"9615cccb-7e92-4838-95cd-4ef49fdbb44f","order_by":0,"name":"Dr SUSHMA YADAV M","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYJACZgiVwMDwAUixsZOihXEGSAszKVqYeZC4OIFu/xnjz4U5don97cnPpG1+bZPnY2Zg/PAxB7cWsxs5ZtIztyUnzjjzzEw6t++2YRszA7PkzG34tPCYMfNuY05suJFgbJzbc5sRqIUNKIJHy3mgw3i31SfOv5H+2diy57Y9YS0HcgykebcdTtxwI8fwMcOP24mEtdxIKwNqOW688cybwoe9DbeT25gZm/H75fzhzUCHVcvOO56+4cCPP7dt57c3H/zwEY8WGHBsAJGMbWCygbB6ILCHUH+IUjwKRsEoGAUjDAAAISFUaSexVP4AAAAASUVORK5CYII=","orcid":"","institution":"All India Institute of Medical Sciences Bhopal","correspondingAuthor":true,"prefix":"Dr","firstName":"SUSHMA","middleName":"YADAV","lastName":"M","suffix":""},{"id":324144918,"identity":"fc0ffa02-f0e0-418c-becf-c1eb1ee80b2e","order_by":1,"name":"Sanjeev Kumar","email":"","orcid":"","institution":"All India Institute of Medical Sciences Bhopal","correspondingAuthor":false,"prefix":"","firstName":"Sanjeev","middleName":"","lastName":"Kumar","suffix":""},{"id":324144919,"identity":"51c77672-7469-4634-a119-f451497928f5","order_by":2,"name":"Deepti Dabar","email":"","orcid":"","institution":"All India Institute of Medical Sciences Bhopal","correspondingAuthor":false,"prefix":"","firstName":"Deepti","middleName":"","lastName":"Dabar","suffix":""},{"id":324144920,"identity":"12445670-b50f-421f-8d5c-c4dd9870b6ee","order_by":3,"name":"Pankaj Prasad","email":"","orcid":"","institution":"All India Institute of Medical Sciences Bhopal","correspondingAuthor":false,"prefix":"","firstName":"Pankaj","middleName":"","lastName":"Prasad","suffix":""}],"badges":[],"createdAt":"2024-07-04 12:13:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4686495/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4686495/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62126979,"identity":"a433549e-11bc-4ff3-9576-635cdf9e4b8b","added_by":"auto","created_at":"2024-08-09 14:54:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":607287,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eThemes and categories/ Sub themes\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eKey- Themes are depicted in the darker shades of their categories/ Sub themes\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4686495/v1/9aa45ceb39ceecf01433bd6e.png"},{"id":62126242,"identity":"836611f4-3e2b-49f9-80cc-084a68e45757","added_by":"auto","created_at":"2024-08-09 14:46:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":741765,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eTheme 1- Referral policy, categories, and their codes\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4686495/v1/d777fa29eb5f8aee5eb4f03b.png"},{"id":62126244,"identity":"f6e3e609-99aa-440a-abe9-87a4f9998206","added_by":"auto","created_at":"2024-08-09 14:46:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":559645,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eTheme 2 - 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People in India have the right to choose from the various government, private and informal healthcare provisions available to them as there is no uniform referral policy guiding the people for seeking healthcare.\u003c/p\u003e\n\u003cp\u003eThe referral system in the healthcare system is the backbone of the health system in any country. A referral is the handover of patients from one doctor to another doctor or from one team health care system to another. This has been identified as a high-risk area as patient valuable information can be lost or not quantified or recorded properly during this transit. Inappropriate referral has a good share of bringing poor clinical outcomes of the patient and poor patient satisfaction. Many times referrals are regarded as unnecessary, meaning that the problem could been easily handled by the General Practitioner (GP). Improving the quality of the referral process is important to facilitate timely access to the specialty care\u0026nbsp;(2). Thus, timely and appropriate referral becomes a highly essential and significant process in health care delivery and health outcomes of a patient.\u003c/p\u003e\n\u003cp\u003eThe decision to refer should be based on the patient\u0026rsquo;s medical condition, needs, and an assessment of the optimal level of health care. The patient should be referred at the right time after adequate pre-referral management, and after an appropriate process that also takes the patient\u0026rsquo;s wishes into account.\u0026nbsp;(3)\u003c/p\u003e\n\u003cp\u003eIncreased continuity of care decreases referrals to specialist care thereby reducing the wastage of resources and the burden on the system and also reduce the overall health care costs.\u0026nbsp;(4)\u0026nbsp;Therefore, the need to have a sound referral system is important, to fulfil the existing gaps in Health Infrastructure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe present study aims to understand the perceptions, attitude, behaviour, challenges and facilitators of referral policy, practices and pattern from all the stakeholders involved in the referral process, i.e., the health policy-makers, healthcare providers and users from primary care to higher levels of health care facilities in the public health system of Bhopal district in Madhya Pradesh.\u0026nbsp;\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003eThis\u0026nbsp;study\u0026nbsp;was conducted in the public health facilities and the healthcare decision making department in Bhopal district of Madhya Pradesh. Bhopal is the capital city of Madhya Pradesh state in Central India, with a population of 2371061, geographically divided into 2 blocks with 81% Urban Population and 19% Rural Population. There are 7 Tertiary Healthcare Centres or THCs (2 government and 5 private medical colleges), 4 Secondary Healthcare Centres or SHCs (3 CHCs and 1 District hospital,) 86 Primary Healthcare Centres or PHCs (9 PHCs, 8 UPHCs and 69 sub centres)\u0026nbsp;(5),\u0026nbsp;(6)\u003c/p\u003e\n\u003cp\u003eThis is a qualitative study which\u0026nbsp;was conducted using phenomenology to understand the perspective of\u0026nbsp;healthcare providers and users, healthcare administrators and health policymakers of the public health system. For this, in depth interviews were conducted among healthcare providers and users, healthcare administrators and health policy makers. This study was carried between December 2020 to June 2022.\u003c/p\u003e\n\u003cp\u003eFor this study we included Officials who were involved in the health policy making like the Directorate of Health Services (DHS), the Directorate of Medical Education (DME) and officials from the National Health Mission (NHM), Bhopal, Government of Madhya Pradesh. We also included Health Care Provider and Patients/ relatives who sought care in the public health system.\u003c/p\u003e\n\u003cp\u003eMedical officers from the PHCs and doctors working in major departments like General medicine, Surgery, Obstetrics and Gynecology and Pediatrics and Emergency departments,\u0026nbsp;the administrators/ in-charges\u0026nbsp;of the secondary and tertiary healthcare facilities,\u0026nbsp;the officials holding posts and involved in health policy making in the DME, DHS and NHM selected through purposive and snowball technique were the participants for the in-depth interviews.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the exit interviews of the patients, only the primary (2 PHCs) and secondary health facilities (1 CHC and 1 District hospital) were considered. Exit interviews of the patients leaving the health facilities after consultation were taken using a predesigned questionnaire administered with the Kobo tool software. Here the final sample of patient exit interviews came out to be 63 (28 in district hospital, 16 in CHC, 10 in PHC A and 9 in PHC B based on the patient load and the level of care provided in the hospital was taken from the OPDs, IPDs and Emergencies where ever applicable) which is more than the previously arbitrarily assigned sample size of 50. This was because some of the patients leaving the hospitals after consultation wanted to be interviewed as well exceeding the number of interviews that were meant to be taken.\u003c/p\u003e\n\u003cp\u003eThe interviews were conducted after due appointments from the study participants. All the participants of the qualitative study were explained about the purpose of the study through a Patient information sheet and a written informed consent was taken for all. The interviews were audio recorded with prior permission from the participants for analysis purpose and transcript notes were taken during the interviews. They were assured that all the information will be kept confidential, and all data will be anonymized before analysis and reporting.\u003c/p\u003e\n\u003cp\u003eWe conducted key informant interviews of 16 doctors from different medical and surgical specialities by purposive sampling, 4 hospital administrators by purposive and convenient sampling, 4 policy makers by purposive and snowball sampling and exit interviews of a quota of 63 patients who got treatment from the healthcare facilities.\u0026nbsp;The inclusion criteria were the healthcare providers or doctors working in public health facilities for at least the past 1 month. Patients/ relatives (in the case of the minor patients) were those who had visited the selected health facility to seek outpatient, emergency and in-patient care on the day of the interview and had been original inhabitants of Bhopal and in migrants who had been staying in Bhopal for at least the past 6 months. Healthcare administrators working in the selected health facility for at least 1 month. Officials who worked in either Directorate of Health Services or Directorate of Medical Education or National Health Mission and had been holding the current administrative post for a period of at least 1 month and were involved in the policy/decision-making of the health matters of the state of Madhya Pradesh.\u0026nbsp;Participants with language barriers who couldn’t communicate in English or Hindi or with visual, auditory or speech impairment, migrants or patients who are in transit and not regular residents of Bhopal were excluded from the study. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter thorough literature review and considering the input provided by experts of the field, a interview guide with appropriate probes and questions was constructed by deductive approach.\u003c/p\u003e\n\u003cp\u003eA participant information sheet was given informing them about the study and consent was obtained from the study participants. \u0026nbsp;In-depth interviews of approximately 40 minutes to one hour each were conducted and audio recorded with due permission.\u003c/p\u003e\n\u003cp\u003eTwo PHCs were conveniently selected based on the distance from the central tertiary institute and ease of access. One out of the three CHCs in Bhopal was selected by conducting simple random sampling as one of the secondary health facility. There is only 1 district hospital in Bhopal which was taken up as one of the secondary health facility. There are two tertiary care institutes in Bhopal, out of which one was conveniently selected on account of ease of access.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAudio records were transcribed in Microsoft Word and translated to English. The translated interviews were uploaded onto NVivo for coding. Framework analysis was performed. Deductive as well as inductive coding was done to identify themes and subthemes.\u003c/p\u003e\n\u003cp\u003eAs most approaches to qualitative analysis rely on identifying recurrent issues in the data or organisation of those responses that emerge as general headings under which most of the data can be explained, thematic approach was applied.\u0026nbsp;We conducted framework analysis manually.\u0026nbsp;The codes generated from the patient exit interviews were also incorporated into the conceptual framework of referral.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICAL ISSUES\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has been approved by the Institutional Human Ethics Committee AIIMS Bhopal, with LOP no 2020/PG/Jan/05. The subjects were informed about the research and procedures through Participant Information Sheet (PIS). Data was collected only after getting written informed consent from the study participants.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAfter analyzing the determinants and perspectives of the stakeholders involved, five major themes were extracted from the qualitative data and a conceptual framework of the referral system was generated. The themes were “Referral Policy, Roles and Responsibilities, Implementation, Barriers and Facilitators, Monitoring, Evaluation and Feedback.” (as shown in figure 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReferral policy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterviews mainly from the policy makers and administrators revealed that most of them weren’t aware of the referral guidelines released by the state of Madhya Pradesh in February 2021. All of them agreed on the fact that there is a need for a uniform national referral policy to ensure a holistic approach towards the delivery of healthcare services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe subthemes for the theme ‘Referral policy’ were categorized into existence of a referral policy, reasons for not having referral policy, views on referral, understanding referral and importance of universal referral policy (as shown in figure 2).\u003c/p\u003e\n\u003cp\u003eSome of the verbatims of the participants were:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“So, there is no written order as such for practicing referral, how each patient is supposed to go to another hospital. There is no order” …. (Doctor of Medicine from SHC)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Universal referral policy advantage is that any patient won’t have any problem, any delay, reach right centre at the right time” …… (Administrator of SHC)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRoles and responsibilities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany of the administrators had said that there was no written order on referral policy and hence their hospital staff hadn’t been trained for it. The doctors also expressed that they were neither assigned any specific roles and responsibilities nor trained to ensure smooth referral mechanisms.\u003c/p\u003e\n\u003cp\u003eThe subthemes for the second theme ‘Roles and responsibilities’ were categorized into role in referral policy making, duties/ responsibilities and mechanisms to ensure smooth referral (as shown in figure 3). Some of the verbatims were:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“……I give my technical inputs to the department based on the ground realities, based on the new innovations, or best practices as adopted by the other states in the country…” (policymaker in DHS)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Pre communicated/ pre informed so staff is prepared to receive, ensuring patient stability\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eduring transport in ambulance and prevent patient deterioration” ….(doctor in THC)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost of the doctors mentioned that they referred patients based on their necessity with a referral slip, in the format that is available in the hospital and would document the same in the referral registers in the ward or OPDs after counselling or clear communication as to seriousness of the condition of the patient. They sometimes give in to the demands of the patients as well.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe subthemes for the third theme ‘Implementation’ were categorized into training, maintenance of referral record, designated referral point, patient beliefs and choices, factors influencing successful referral and types of referrals (as shown in figure 4).\u003c/p\u003e\n\u003cp\u003eThe verbatims were:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e” the patient goes there and does it all in own… So there should be some person for help. Some referral officer… referral handling officer. Something like some destination should be met there, and that person should be there” …. (Administrator or in-charge of SHC)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Timely and appropriate referral will increase treatment outcomes, patient satisfaction, improve quality of work for doctors and generate robust epidemiological data”…… (doctor in THC)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Patient referred to government hospital but sometimes patient go to private hospital” ... (doctor in \u0026nbsp;PHC)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers \u0026amp; Facilitators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePolicymakers, administrators, and doctors briefed that patients are referred only when certain necessary services were not available in the designated hospitals like, required investigations, OT services, lack of super specialty doctors or any staff, medicines, etc. \u0026nbsp;Patients had elaborated on the cumbersome procedures in certain hospitals and their preference with respect to distance from their residence, waiting time, comfort and trust levels with the doctors and hospital services, cost of treatment, etc. as determinants in seeking healthcare in a particular hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe subthemes for the fourth theme ‘Barriers \u0026amp; Facilitators’ were categorized into factors affecting referral, reasons for referral, facility factors, patient factors, illness characteristics and doctor factors (as shown in figure 5).\u003c/p\u003e\n\u003cp\u003eThe verbatims were:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"It's nearby.... free medicines….old hospital… more crowds... government hospital.... Fast service\"…. (patients from PHC and SHC)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“BPL patients for cost of treatment…where beneficiary schemes like Ayushman Bharat (AB PM-JAY) and other grants are available” …. (administrator or in-charge of THC)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“They may not be having proper infrastructure, proper staff for that…. equipment may not be available…. no expert or no specialist” …. (Policymaker in DME)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMonitoring, feedback and evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany stakeholders had agreed that a uniform referral policy if implemented, would decrease duplication of resources, increase patient satisfaction, compliance, treatment adherence, and thus improve patient health outcomes. They also emphasized that there needs to be a monitoring and feedback mechanism to evaluate and ensure the appropriateness of referral and prevent unnecessary referrals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe subthemes for the fifth theme ‘Monitoring, feedback and evaluation’ were categorized into appropriateness of referral, effects / outcomes of referral, prevent unnecessary referrals and average referral percentage (as shown in figure 6).\u003c/p\u003e\n\u003cp\u003eThe verbatims were:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Backward and forward chain to be coordinated by outside/ third party level” …. (administrator or in-charge of THC)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“…of course, increase patient satisfaction, compliance, treatment adherence, improve outcomes…. comfort near home….no disturbance to livelihood…..”(doctor in THC)\u003c/em\u003e\u003c/p\u003e"},{"header":"DISCUSSION ","content":"\u003cp\u003eReferrals are performed by a healthcare facility or provider when they are unable to offer the level of care or type of intervention best suited to the patient\u0026apos;s needs. A strong connection between all levels of the healthcare system is ensured through an efficient referral policy, which also makes sure patients get the finest care near to where they live. Additionally, it aids in the efficient use of primary healthcare providers and hospitals. Most patients treated in secondary outpatient clinics can be adequately cared for in the primary care center while reducing the overall cost to the patient and the healthcare system.\u0026nbsp;(7)\u003c/p\u003e\n\u003cp\u003eTargeted systems-based interventions are urgently required to improve information provision and exchange. Similarly, Humpries et al findings also indicate that well-designed patient-held booklets are likely to be an acceptable, affordable and effective part of the solution.\u0026nbsp;(8). As per the available evidence in the literature search, there aren\u0026rsquo;t any comprehensive referral frameworks that could be adopted by our government to be implemented into the healthcare system. Although according to one study in Nigeria, more than two-thirds of participants felt that it\u0026rsquo;s unreasonable for any hospital to reject patients, being unreferred to their facility.(9)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFrom our qualitative study, we conceptualised a working framework for the referral system. It consists of the following 5 steps in a continuous process. Firstly, the formulation of a uniform national referral policy detailing the roles and responsibilities of all the health staff involved in patient care, followed by the implementation of this policy as per the guidelines in all the health facilities across the state and so the nation. Finally, a continuous scrutiny on the monitoring, feedback and evaluation system to erase the barriers in meeting standards of healthcare provision and to ensure facilitation of continuum of care to the people of the nation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eReferral system if implemented will ensure continuity of care, reduce loss to follow up of patients, prevent\u0026nbsp;duplication of services, lessen cost of health care, increase patient satisfaction and treatment adherence, provide timely provision of care, meet patient expectations, reduce burden on the doctors/ health staff, prevent misuse of resources, provide\u0026nbsp;integrated healthcare services delivery with proper communication between the health facilities/ doctors and other health staff thus improving the quality of life of both the healthcare providers and the healthcare receivers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe major strength of this study is that it studied the overall referral practices, unlike other studies, which restricted to only certain specific disease conditions referral. It also provides for a larger vision and perspective change for the betterment of health policy. We have included all stakeholders pertaining to ensure smooth referral flow of patient in this study. This study has some limitations as it comprised of only urban health facilities, the dynamics of healthcare seeking behavior and service delivery of rural areas is not captured in this study.\u0026nbsp;\u003c/p\u003e"},{"header":"CONCLUSIONS ","content":"\u003cp\u003eThis study gave us an insight that the Referral system if implemented in its true sense will ensure continuity of care, reduce loss to follow-up of patients, prevent duplication of services, lessen cost of health care, increase patient satisfaction and treatment adherence, provide timely provision of care, meet patient expectations, reduce the burden on the doctors/ health staff, prevent misuse of resources, provide integrated healthcare services delivery with proper communication between the health facilities/ doctors and other health staff thus improving the quality of life of both the healthcare providers and the healthcare receivers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough health is a state matter, provision of healthcare is not uniformly practiced or distributed in all the health facilities and hence healthcare services are not delivered equivocally to all the people in the nation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe hereby also recommend that a Uniform state referral policy needs to be drafted and implemented in each state for better health outcomes of the patients and that the referring healthcare facility should facilitate the referral of patients in every stage.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has been approved by the Institutional Human Ethics Committee, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India, with LOP no 2020/PG/Jan/05. The subjects were informed about the research and procedures through Participant Information Sheet (PIS). Data was collected only after getting written informed consent from the study participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten consent was taken from participants through Participant Information Sheet (PIS) before data collection, These following lines were mentioned in the PIS, where the consent for publication is implied:\u003c/p\u003e\n\u003cp\u003e‘The present study results will be shared to health care provider and policy makers which will further be utilized to develop a good referral system to ensure safe ongoing care of the patients. You will not be identified in any manner in the study data-base or your identity disclosed in any reports or publications. Your interview records may be reviewed by authorized government \u0026amp; regulatory agencies and the sponsor as required.’\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this manuscript, appropriate precautions have been taken to ensure that identifying images or other personal or clinical details of participants are not presented that compromise anonymity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets during and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no\u0026nbsp;financial and non-financial competing\u0026nbsp;interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was obtained for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSY, PP, SK and DD conceived the presented idea. \u003cstrong\u003eSY,\u0026nbsp;\u003c/strong\u003ePP and SK contributed in concept and design of study. PP, SK and DD verified the analytical methods. SY planned and carried out the data collection, analysed the data and devised the results of the study. PP guided SY to conduct the study and supervised the findings of this work. All authors discussed the results and read, contributed, and approved the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNot applicable.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs this study was a part of a dissertation or thesis for the degree of MD Community and Family Medicine at All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India, there was no funding available for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHence, I request for full waiver of publication charges for this study.\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBhola N, Kumari R, Nidha T. Utilization of the health care delivery system in a district of North India. East Afr J Public Health. 2008 Dec;5(3):147\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eThorsen O, Hartveit M, Johannessen JO, Fosse L, Eide GE, Schulz J, et al. Typologies in GPs\u0026rsquo; referral practice. BMC Fam Pract. 2016 18;17:76. \u003c/li\u003e\n\u003cli\u003eRingberg U, Fleten N, F\u0026oslash;rde OH. Examining the variation in GPs\u0026rsquo; referral practice: a cross-sectional study of GPs\u0026rsquo; reasons for referral. Br J Gen Pract. 2014 Jul;64(624):e426-433. \u003c/li\u003e\n\u003cli\u003eOlthof M, Groenhof F, Berger MY. Continuity of care and referral rate: challenges for the future of health care. Fam Pract. 2019 20;36(2):162\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003e2327_PART_A_ DCHB_BHOPAL.pdf. \u003c/li\u003e\n\u003cli\u003ehealth-institutions.pdf [Internet]. [cited 2020 Aug 24]. Available from: http://www.mponline.gov.in/Quick%20Links/Pdfdocs/health-institutions.pdf\u003c/li\u003e\n\u003cli\u003eKumar S. referral Guidelines for health facilities in UTTAR PRADESH. :55. \u003c/li\u003e\n\u003cli\u003eHumphries C, Jaganathan S, Panniyammakal J, Singh S, Goenka S, Dorairaj P, et al. Investigating clinical handover and healthcare communication for outpatients with chronic disease in India: A mixed-methods study. PLoS ONE. 2018;13(12):e0207511. \u003c/li\u003e\n\u003cli\u003eFarrag NS, El‑Gilany A, Ibrahim AM, Abdelsalam S. Does Implementation of the Universal Health Insurance Affect the Quality of Referral in the Healthcare System? A Cross‑sectional Comparative Study in Egypt. Indian Journal of Public Health. 2021;65(3):7. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4686495/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4686495/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e- Referral system is backbone of any healthcare delivery system. Referral defined as the handover of patients from doctor to doctor or from one team to another has been identified as a high-risk area as patient valuable information can be lost or not quantified or recorded properly during the transit. Many referrals are regarded as unnecessary, meaning that the problem could be handled by the General Practitioner (GP). Improving the quality of the referral process is important to facilitate timely access to speciality care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e- To understand the perceptions, attitude, behaviour, challenges and facilitators of referral policy, practices and pattern from all the stake holders involved in the referral process, i.e., the health policy makers, healthcare providers and users from primary care to higher levels of health care facilities in the public health system of Bhopal district in Madhya Pradesh.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods\u003c/strong\u003e- 24 in-depth interviews of the health policy or decision makers of the state, doctors, and administrators/ in-charges of the public health system in Bhopal by purposive sampling and exit interviews of a quota sampling of 63 patients were conducted. Thematic framework analysis was done manually and a conceptual framework for the referral system was generated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e- Five major themes conceptualised for the continuous process of the referral system were referral policy, roles and responsibilities, implementation, barriers and facilitators, monitoring, feedback and evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e- The implementation of the referral policy regarding the maintenance of the referral registers, issuing of referral slips, etc were not up to the required standards. There is a need for a uniform state referral policy and the establishment of a GP system to ensure continuity of care.\u003c/p\u003e","manuscriptTitle":"A Qualitative Study of Referral Practices of the Public Healthcare System in Bhopal District of Madhya Pradesh","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-09 14:46:00","doi":"10.21203/rs.3.rs-4686495/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d1fbc1f8-1bdd-4a10-b4b6-a999dc3a593d","owner":[],"postedDate":"August 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-18T19:02:27+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-09 14:46:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4686495","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4686495","identity":"rs-4686495","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}