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4.5 Linkages, Referral Systemand NetworkingThe primary intention of HCBC isto provide a continuum ofholistic care that is supportedby strengthening referral linkages,follow up, monitoring and casemanagement. The following actionsprovide a guide for maintaining thecontinuum of care.4.5.1 Integrating ServicesThis refers to the mix of care,treatment, psycho-social support andpreventive services in proportions thatmaintain a continuum of care. Thecontinuum involves an integratednetwork of resources and services toprovide holistic, comprehensivesupport for the sick person, the familyand caregivers from home,community, hospitals and vice versa.4.5.2 Strengthening Linkages andNetworkingLinkage is networking with importantservice contributors to the HCBCprogramme. It can be with businesspeople, NGOs, FBOs and otherresource people at the local level.Such relationships should bestrengthened through sharedactivities of staff, service provision,training, monitoring and supervision,and a two-way referral and follow upsystem.Community network meetingsamong the different practitioners,organizations and agencies involvedin caring for the sick and families athome are important. NetworkingHCBC Implementation Strategiesfacilitates discussions on differentissues and possible solutions toproblems such as transport andaccess to certain services.Coordinating committees andlocal leaders, especially the chief whois responsible for resolving localconflicts and problems at communitylevel, should be involved instrengthening community levelnetworking.4.5.3 Establishing Referral SystemsNot all programmes are able to meetall care needs of the patient, familymembers and caregivers. Establishingreferral systems is important foraccess to care services such ashospice care, or caregivers’ access tocounselling and rehabilitationservices. In addition, access tosupport groups, voluntary counsellingand testing, ART and laboratoryservices, spiritual support andguidance services, and other forms ofcommunity-based care may also beneeded. Effective referrals should bemade from health facilities to thehome and back again, highlightingtreatment and care plans to beimplemented. A well organizeddischarge plan ensures a strongreferral system and maintenance ofthe continuum of care.Orphans will need access to childsupport services through theChildren’s Department of the Ministryof Home Affairs, education facilities,child protection programmes andlegal services. Accessing these formsof support require strengtheninglinkages and referral systems.17