Linkage to Care

Community Based Services (CBS) are a critical tool in assuring the health of communities in resource poor settings. They 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. There are 850 Community Health Workers and 62 registered nurses who provide CBS to the 1.1 million residents in the Klipfontein Mitchells Plain Substructure. The challenge is that these services are under-utilised due to administrative failures and inefficiencies in referring these patients. Less than 500 CBS referrals were completed in 2021. An informal audit revealed that contributory factors to low referrals included lack of staff awareness of available services, how to access these services, limited access to paper-based referral forms, limited administrative support to ensure paper forms were scanned/e-mailed and frequent scanner/computer failure. This meant that the limited referrals that were actually completed, often never reached the destination, to the detriment of the patient. It is for this reason that a Doctor at Mitchells Plain Hospital came up with a solution.