Overview

Who: District Principal Nursing Officer, Medical Assistant and Public health nurse

When: At least once a year or as often as needed

Supporting Tools: Community mapping, Annex 1

Not all Community Engagement services are able to meet all care needs of the patient, family members and caregivers. The primary intention of Community Engagement Services is to provide a continuum of holistic care that is supported by strengthening referral linkages, follow up, monitoring and case management of chronic diseases. The purpose of strengthening linkage, coordination and referral is to ensure this continuity of care.

Effective referrals therefore where needed should be made from the home to services and vice versa including health facilities.

Establishing referral systems is important for access to care services such as professional counselling, legal services and rehabilitation services. In addition, it allows for easier access to support groups, spiritual counselling and laboratory services, and other forms of community-based care that may also be needed. A well-organized community engagement plan ensures a strong referral system that provides maintenance of the continuum of care.