What is a referral?
In medicine, referral is the transfer of care for a patient from one clinician or clinic to another by request. Generally speaking, it is an act of referring someone or something for consultation, review, or further action.
What are the steps involved in performing a referral? How should a referral be done appropriately? How should a referral be supported? How should expectations be managed in the referral process?
At the very least, any referral should be prefaced with a thorough client-centred assessment of what the help seeker needs. The next step is to determine if those needs can be met within the agency initially contacted for help. If this is not the case, the person at the first help desk should have access to a list of agencies and the relevant personnel (a regularly updated list) that could potentially be service options i.e., with resources and programs that could meet the needs being reported. Referral should involve making phone calls on behalf of the help-seeker, contacting the next agency and initiating the chain of communication, and then empowering the help seeker to speak with the person at the other end. It involves offering language assistance where needed, and perhaps offering staff help to accompany the help seeker on to the next agency to support the change of guard and to make sure that the help seeker does not feel shunted out and passed on. Ideally, there should be a referral protocol that guides and formalizes the handover, along with all the information collected at outset. This protocol should also contain guidance for follow-up amongst the agencies so that outcomes can be tracked down the line. During the handover, the person at the initial agency should make it amply clear to the help seeker that they are always welcome later on as well. It is crucial to retain trust and manage expectations during the handover. Help seekers should be engaged and should receive gently phrased clarifications about the reasons for the handover so that they do not feel abandoned.
What are the challenges with referral?
Simply put, they are too often mismanaged or not done at all. For example, when the initial agency does not perform a proper needs assessment, lacks any understanding of referral protocols or process, does not have a clue who else can help, does not have an up-to-date directory of sister agencies, lacks the willingness to make the calls and to persist in finding supports. Worst of all, an agency may promote the illusion that they are the first and last answer for all needs, even if they don’t have a clue what they can and cannot offer the help seeker. These challenges are compounded when other agencies down the line have similar inadequacies, when help seekers have language problems and there is no language support, and when handovers are done without regard for retaining trust and without attending to the help seeker’s feelings and needs during the handover.
And these are just a few examples.
Non-profits work in a notoriously siloed service landscape where agencies do not communicate well enough to perform referrals in a seamless manner. There is some recognition (which is growing, albeit slowly) that this situation needs to change so as to curb the client shunting and duplication of processes and services, and wastage of resources that is now ongoing across the board.
What happens when a survivor of violence is referred onwards?
In brief, a survivor of violence should have the service brought to her, rather than the other way around.
The initial agency should provide survivors with immediate help and comfort and bridge them to relevant mainstream agencies. It is futile to merely refer women with language barriers and trauma onwards alone. When immigrant survivors approach grassroots agencies for help, it is insufficient to merely dispense information and refer them on to a mainstream agency. If not closely supported and accompanied, the women return to abusive situations without going on to the next link in the service chain. Intake, support and information sharing done on-site in relevant languages will help us better serve vulnerable women than the current trend in which survivors are shunted around to obtain help.
A new model of supported referrals: Bringing the service to the survivor
For survivors, supported referral should involve bringing the provider to the survivor. Here is a scenario of what could be done in this model of reversed referral.
Stage one: When the survivor contacts Agency A
When a survivor walks into Agency A for help, a staff member would perform intake and provide immediate help. This will include basic risk assessment, crisis counselling, and information sharing with prioritization of physical safety. The staffer would provide service in a relevant language where this is required. She would interpret for the survivor where required. Interpretation would follow standards of neutrality, objectivity, accuracy, and confidentiality (See the relevant do’s and don’ts of culturally competent and safe interpretation in this post). In the situation that the language required is outside agency A competencies, the staffer could seek to access telephone interpretation services (e.g. United Cultures of Canada (UCCA) which offers free telephone and in-person interpretation services). This should be done only if the survivor consents. Safety planning would be done in the survivor’s language. Thus translation of safety planning tools from English into other languages is essential. The traumatized women who come looking for help can hardly be expected to process a lengthy document in a language that poses a daily challenge for them.
In an emergency situation, when the survivor reports that she is at immediate physical risk, Agency A should advise and support her in calling 911 and will make themselves available to support her during the conversation with police and to provide interpretation if permitted. Where children are in the situation of violence, Agency A will consult with the client and share with her an obligation to inform Child and Family Services. Agency A staff and volunteer should also help the survivor to create a safety and escape plan. This also involves supporting the client and interpreting for her to access emergency shelter, and if that option does not work, to contact out-of-shelter outreach staff.
Stage 2: Agency A calls in partner Agency B for offsite intake and supported handover
With consent from the survivor, Agency A calls in a partner’s outreach staff (Agency B) to meet the survivor at the initial Agency A’s location to perform offsite intake and support.
This sort of reversed referral could better help the survivor to enter the support network by shortening the distance between the survivor and the service by bringing Agency B staff out to the survivor rather than someone sending the survivor off to a mainstream agency in an unfamiliar and discouragingly remote (for the survivor) location. In other words, it reverses the conventional referral movement by bringing the mainstream service provider to the survivor at a safe space at the grassroots point of contact, where some tools and platforms should be in place to provide a supported referral.
In the event that the survivor is willing and able to access emergency shelter Agencies A and B should support her in the process, by accompanying her and interpreting for her, as the situation requires. If the survivor is not able to go into shelter (for any reason), the agencies A and B should connect with out-of-shelter outreach staff at shelters eg WINHouse and LaSalle in Edmonton. Out-of-shelter outreach efforts involve the use of risk assessment tools, engagement of the sufferer in the safety planning process, and support without end dates on the process of engagement. Crucially, these newer approaches have an understanding that shelter is not a universal solution and that exit, even where possible, can trigger a cascade of other problems, notably, loss of housing.
This model of reversed referral and survivor-centred support work is currently being piloted (May 2017-end 2018) at ICWA in a ‘Bridge to Safety (B2S)’ pilot service, that involves ICWA and the Today Centre as primary partners (agencies A and B) in the supported referral process. See the figure below.