REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF HEALTH
METRO MANILA CENTER FOR HEALTH DEVELOPMENT

Metro Manila Center for Health Development

RO No. 2023-009:
Guidelines on the Establishment of Referral System in Metro Manila
Towards UHC Implementation

Health Facility Development and Enhancement Unit (HFDEU)

Department of Health - Metro Manila Center for Health Development doh.gov.ph
Rationale
The evolution of health service delivery and acceleration of the implementation of the
Universal Health Care (UHC) Act, or Republic Act No. 11223, with quality care as the
central theme, seeks to ensure that every Filipino is healthy, protected from health
hazards and risks, and has access to affordable, quality, and readily available health
services suitable to their needs.
A critical component of UHC is to ensure that patients are navigated properly to access
the appropriate care at the appropriate time and appropriate health facility. Republic Act
11463, also known as the Malasakit Centers Act has likewise emphasized the crucial role
of patient navigation as a component of an integrated people-centered health service
delivery by ensuring that health services are responsive to the needs of all Filipinos.

The need for a mechanism to navigate patients across the spectrum of care became
prominent and paved the way for the establishment of a referral system.
Republic of the Philippines
Department of Health
/doh.gov.ph
Objectives
This Order shall establish the Referral System in Metro Manila pursuant to the provisions
of the Universal Health Care Act (RA 11223) and its related policies. It shall also set the
guidelines for the organization and operationalization of the Health Care Provider
Networks (HCPN) in accordance with the Service Delivery Design provided in AO No.
2020-0019.

Republic of the Philippines

Department of Health
/doh.gov.ph
 This Referral System Guidelines shall apply to all

Scope of public and private hospitals and other health

facilities such as: primary care facilities,

Application
infirmaries, birthing homes, outpatient clinics
(medical/dental), custodial care facilities,
diagnostic/therapeutic facilities, specialized
outpatient facilities, and pharmaceutical
establishments within the Local Government
Units (LGU) of Metro Manila.

Republic of the Philippines

Department of Health
/doh.gov.ph
 General Guidelines
1. All hospitals and other health facilities in the Local Government Units (LGU)
of Metro Manila shall establish a Referral System for the delivery of health
services.
Department of Health
Republic of the Philippines

2. The referral system shall be organized within the framework of the Universal
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Health Care Act with the Primary Care Provider Network (PCPN) as its
foundation.

3. All Health Care Provider Networks (HCPN) shall adopt Administrative Order
2020-0019 “Guidelines on the Service Delivery Design of Health Care
Provider Networks”
 Specific Guidelines
1. HCPNs shall be established by virtue of a Sanggunian Panlungsod Resolution,
Executive Order, or City Ordinance.

2. A local health board shall be established in every LGU with compositions,

Department of Health
Republic of the Philippines

roles, and functions consistent with the existing rules and regulations as stated
in R.A. 7160 (Section 102.a), R.A. 11223 (Section 19), their respective IRRs
/doh.gov.ph

and other related laws.

3. The Local Health Board shall be composed of the Local Chief Executive as
chairman, the local health officer as the vice chairman, the chairman on the
committee on health in their respective Sanggunians, private sector
representative, and a DOH Representative (as defined in DOH A.O. 2020-
0029). Any additional members to the Board are within the prerogative of
their respective LGUs.
Organization of HCPN
 Specific Guidelines
4. The Local Health Board, assisted by the City Health Office as the Technical
Secretariat and Management Support Unit as its Administrative Secretariat, shall
facilitate and sustain the organization and operations of the HCPN.
Department of Health
Republic of the Philippines

5. Public, private, or mixed HCPNs shall be established to provide all population

groups with continuous health care from primary to tertiary, which shall be
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delivered in a safe, efficient, and coordinated mechanism.

6. Public HCPNs may complete their service capability through contractual

arrangements with the private sector or vice versa.

7. HCPNs shall enter into a memorandum of agreement (MOA) with at least one
apex hospital. In addition, an apex hospital may actively seek to enter into a MOA
with a HCPN.
Organization of HCPN
 Specific Guidelines
8. All DOH hospitals shall endeavor to become apex hospitals. Provided that, in
the interim, DOH Hospitals that currently do not qualify as apex hospitals may be
contracted by PhilHealth as stand-alone facilities.
Department of Health

9. HCPNs shall ensure the availability of ambulances and patient transport

Republic of the Philippines

vehicles as necessary for its catchment population.

/doh.gov.ph

10. All hospitals shall have a Public Health Unit (PHU) to facilitate the
implementation of population-based health services and seamless patient
navigation within the HCPN. The PHU shall be established under the Office of
the Medical Center Chief or Chief of Hospital with the following minimum
dedicated or designated staff (see Annex E):
• Health education and promotion office
• Care navigator/educator
• Administrative staff Organization of HCPN
 Organization of HCPN

Public Health Unit (PHU)

● AO No. 2020-0019: Guidelines on the Service Delivery Design of Health Care
Provider Networks
● All hospitals shall have a Public Health Unit (PHU) to facilitate the provision of
population-based health services and patient navigation.
● The PHU shall ensure that hospital policies are aligned with national public health
programs.
● The PHU shall assist the hospital management in ensuring surveillance and reporting
of notifiable diseases through the disease surveillance officer or disease surveillance
coordinator.
● The PHU shall ensure proper referral and navigation of patients within the hospital
and from the hospital to primary care facilities and other necessary facilities in the
network.
Republic of the Philippines
Department of Health
/doh.gov.ph
 Organization of HCPN

Public Health Unit (PHU)

● DM No. 2024-0020: Delineation of Functions of the Health Facility Development Unit,
Health Emergency Management Staff - Operation Center, and the Regional Patient
Navigation and Referral Unit in the Centers for Health Development _and the Public
Health Unit and Health Emergency and Disaster Management Unit in DOH Hospitals
Relative to their Roles in the Referral System

Delineation of Referral Functions of PHU and HEDMU in DOH Hospitals

The PHU is responsible for establishing and institutionalizing the patient navigation and referral
system of the hospital. However, it is crucial to emphasize that the PHU will not be solely
responsible for executing the actual patient navigation and referral tasks. The delegation of
these responsibilities to other units (i.e. ED, HEDMU) may occur based on the hospital
management's discretion and as deemed appropriate.

Republic of the Philippines

Department of Health
/doh.gov.ph
 Organization of HCPN

Public Health Unit (PHU)

Delineation of Referral Functions of PHU and HEDMU in DOH Hospitals

In accordance with the Revised Standards on Organizational Structure and Staffing Pattern
(RSOSSP) for Level III Government Hospitals, the PHU shall operate under the Office of the
Medical Center Chief.

The unit is expected to comprise of 5-6 staff members, with the exact number contingent upon the
authorized bed capacity of the hospital. Furthermore, functions of the Hospital Epidemiology and
Surveillance Unit and HPU are subsumed under the PHU.

Republic of the Philippines

Department of Health
/doh.gov.ph
 Specific Guidelines
11. All public and private health facilities that are part of the HCPN shall be
licensed by DOH and accredited by PhilHealth. (PCF licensing and Konsulta
Provider)
Department of Health

12. All HCPNs shall determine and continuously monitor the services, human
Republic of the Philippines

resource complement, equipment, and infrastructure of all its health facilities.

/doh.gov.ph

(Local Health Facility Development Plan and Health Facility Profiling)

13. All participating health facilities shall annually comply with the Health
Facility Profiling of DOH and PhilHealth.

14. All HCPNs and their apex hospitals shall endeavor to meet access standards
for health facilities in alignment with the Philippine Health Facility Development
Plan, wherein people shall have access to a primary care facility within thirty (30)
minutes travel time and to a hospital within one (1) hour. Organization of HCPN
 Specific Guidelines
15. Public HCPNs shall follow current legal frameworks and policies for partnership with the
private sector including, but not limited to, the following:

• Government Procurement Reform Act and its IRR for infrastructure, equipment and
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Republic of the Philippines

services;
/doh.gov.ph

• Public Private Partnership for Health through: NEDA Joint Venture Guidelines,
provided that the necessary ordinances are in place; and, Build Operate and Transfer
Laws; and, Guidelines for Local Government Units such as Public-Private
Partnerships for the People (LGU P4) as issued by the DILG.

• Administrative Order 2023-003 “Policy Framework for Private Sector Engagement

for the Province-Wide and City-Wide Health Systems in Support of Universal
Health Care”

Organization of HCPN
 Specific Guidelines
1.Service Delivery

The HCPN shall be composed of PCPN providing primary care service, and
hospitals delivering secondary and tertiary general health care.
Department of Health
Republic of the Philippines

The PCPN shall be composed of the following health facilities that provide
/doh.gov.ph

population and/or individual-based primary care services:

• Primary Care Facilities, such as Rural Health Units, Health Centers,
and Medical Outpatient Clinics, which shall ensure proper
coordination and service delivery across the PCPN; and, other health
facilities necessary for the delivery of primary care, such as but not
limited to, health stations, stand-alone birthing homes, stand-alone
laboratories, pharmaceutical outlets, and dental clinics.

Operationalization of the HCPN

 Specific Guidelines
1.Service Delivery

All Local Government Units shall ensure that all Filipinos living and residing within
their territorial jurisdiction are registered to DOH-licensed/certified and/or
Department of Health
Republic of the Philippines

PhilHealth-accredited/contracted Primary Care Provider, whether public or private.

The following health facilities, whether public or private, shall provide general
/doh.gov.ph

in-patient care services for the HCPN:

• Infirmaries, if present in the existing geographic or political boundary, and,
hospitals, as classified by the DOH, which shall include:
• At least one Level 1 providing secondary care; and,
• At least one Level 2 or 3 hospital providing tertiary care.

The linked Apex hospital shall deliver specialty healthcare services not expected to
be provided in HCPNs.
Operationalization of the HCPN
 Operationalization of the HCPN

Specific Guidelines
2. Information System

HCPNs shall have a patient record management system with an interoperable

electronic medical record in all member health facilities capable of real-time
Department of Health

information-sharing. The system shall include patient records, diagnostics, treatment

Republic of the Philippines

history, and other pertinent medical information that enables medical care, subject to
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guidelines to be developed by DOH and PhilHealth, and in compliance with the

Data Privacy Act or RA 10173.

All Primary Care Providers shall have validated electronic health records (EHR) for
efficient and effective monitoring of health status and availment of services.

The Electronic Health Record (EHR) shall be utilized for patient navigation and
coordination mechanism to higher levels of care within the HCPN and to support
continuity of care and the provision of comprehensive primary care.
 Operationalization of the HCPN

Specific Guidelines
3. Supply Chain Management

HCPNs shall standardize health facility operations in its catchment to include the
following:
Department of Health
Republic of the Philippines

• Integrated financial management including pooled fund management, provider

/doh.gov.ph

payment mechanism, unified price structures of services, and accounting processes

across component facilities, among others;

• Maintenance team in charge of local capital asset management especially for

equipment and infrastructure depreciation and obsolescence;

• Unified supply and/or cold inventory management systems for essential medicines,
supplies, and equipment;
 Operationalization of the HCPN

Specific Guidelines
3. Supply Chain Management

HCPNs shall standardize health facility operations in its catchment to include the
following:
Department of Health
Republic of the Philippines

• Systematic healthcare waste management for the network conferring to the standards
/doh.gov.ph

indicated in the Health Care Waste Management Manual for the different types of
health care wastes and a sewage treatment plant for hazardous solid waste through in-
house treatment or third party hauler

• Adherence to A.O. No. 2014 — 0034 of the Food and Drug Administration (FDA)
Rules and Regulations which includes, but is not limited to:
o Compliance with licensing requirements in the procurement of drugs
o Compliance with Good Distribution Practice (GDP), Good Storage Practice
(GSP) and Good Clinical Practice (GCP)
 Operationalization of the HCPN

Specific Guidelines
3. Supply Chain Management

HCPNs shall standardize health facility operations in its catchment to include the
following:
Department of Health
Republic of the Philippines

• Systematic healthcare waste management for the network conferring to the standards
/doh.gov.ph

indicated in the Health Care Waste Management Manual for the different types of
health care wastes and a sewage treatment plant for hazardous solid waste through in-
house treatment or third party hauler

• Adherence to A.O. No. 2014 — 0034 of the Food and Drug Administration (FDA)
Rules and Regulations which includes, but is not limited to:
o Compliance with licensing requirements in the procurement of drugs
o Compliance with Good Distribution Practice (GDP), Good Storage Practice
(GSP) and Good Clinical Practice (GCP)
 Operationalization of the HCPN

Specific Guidelines
4. Human Resource for Health

All LGUs in Metro Manila shall have an available Human Resources for Health (HRH)
Plan integrated in the Local Investment Plan for Health (LIPH), for the whole City- Wide
Department of Health
Republic of the Philippines

Health System reflecting the following minimum contents:

/doh.gov.ph

a. Filling-up of vacant plantilla positions

b. Mechanism on HRH sharing within the HCPN
c. Incremental creation of plantilla positions for HRH
d. Learning and development plan/intervention
 Operationalization of the HCPN

Specific Guidelines
5. Patient Navigation and Referral System

The PCPN shall serve as the foundation of the HCPN and act as the initial contact and
navigator to guide patients to appropriate levels of care, facilitate two-way referrals, and
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Republic of the Philippines

enable patient records to be accessible throughout the health system.

/doh.gov.ph

HCPNs shall observe presence and full implementation of the following:

• LHB-approved technical guidelines/manual on the implementation of the referral
system that contains the following minimum contents:

a. Clear and standardized criteria for the transfer of patients and an algorithm for
emergency and non-emergency referrals and patient flow in the network as shown in
Annex A and B.
 Specific Guidelines
Operationalization of the HCPN

5. Patient Navigation and Referral System

Department of Health
Republic of the Philippines

/doh.gov.ph
 Operationalization of the HCPN

Specific Guidelines
5. Patient Navigation and Referral System

• LHB-approved technical guidelines/manual on the implementation of the referral

system that contains the following minimum contents:
Department of Health
Republic of the Philippines

b. Standard referral form to be used (Annex C)

/doh.gov.ph

c. Directory of health facilities within the HCPN indicating service capabilities,

pricing catalog, operating hours, and contact details.

d. Roles and responsibilities of all actors in the referral system

e. Adoption and implementation of prevailing clinical pathways, health program

protocols, and updated case management protocols as circulated and endorsed by the
DOH
 Specific Guidelines

5. Patient Navigation and

Referral System
Department of Health
Republic of the Philippines

/doh.gov.ph
 Operationalization of the HCPN

Specific Guidelines
5. Patient Navigation and Referral System

• LHB-approved technical guidelines/manual on the implementation of the referral

system that contains the following minimum contents:
Department of Health
Republic of the Philippines

f. Medical transportation and inter-facility communication guidelines

/doh.gov.ph

g. Directory of the ambulance and medical transport reflecting the contact

information of the provider, operating hours, list of services and prices

h. Guidelines on feedback mechanisms that include data collection from both

clients/patients and healthcare providers in the HCPN

i. Data recording, storage, and utilization protocols

 Operationalization of the HCPN

Specific Guidelines
5. Patient Navigation and Referral System

• LHB-approved health facility development plan

Department of Health
Republic of the Philippines

• HCPNs shall standardize the process of communication with the following

components:
/doh.gov.ph

• Appropriate communication facilities available for contact during operations (e.g.

telephone number, cellular phone, two-way radio).

• Standardized communication tools for endorsements such as the Situation

Background Assessment Recommendation (SBAR) communication tool
(Annex C).
Republic of the Philippines
Department of Health
/doh.gov.ph
 Operationalization of the HCPN

Specific Guidelines
5. Patient Navigation and Referral System
• HCPNs shall standardize the process of communication with the following
components:
Department of Health

• Uniform referral form with minimum data components indicated in Annex D

Republic of the Philippines

and a back-referral form with follow-up and home instructions, which may be
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transformed into an electronic report.

• Local call center/chat hotline for health ideally with a geographic information
system (GIS) that shall coordinate patient emergency referral, in compliance
with Executive Order 56, s. 2018, entitled: “Institutionalizing the Emergency
911 Hotline as the Nationwide Emergency Answering Point, Replacing Patrol
117, and for Other Purposes.
 Evaluation and Monitoring
• The HCPN shall conduct regular general assemblies to provide an opportunity for
all stakeholders to be informed on the activities and plans of the local health system.
Department of Health

It shall also ensure that other means are employed to facilitate consultation of
Republic of the Philippines

proposed policies, and to discuss development and concerns on health services.

/doh.gov.ph

• A Committee on Referral System shall be organized to facilitate the regular

monitoring/evaluation of its implementation, all HCPNs shall strictly observe a
reporting system to record
 Evaluation and Monitoring
Evaluate and/or address the following:

a. Rate (%) of coordinated referrals:

Department of Health

i. PCPN to referral facilities (secondary/ tertiary)

Republic of the Philippines

ii. Referral facilities (secondary/tertiary) to other referral facilities

/doh.gov.ph

(secondary/ tertiary) or Apex Hospital/s

iii. Referral facilities or Apex hospital/s to PCPN
b. Leading causes of referrals
c. Top reasons for declined referrals
d. Patient satisfaction rating on service delivery
e. Registration of all constituents to a primary care provider within their jurisdiction
 Evaluation and Monitoring
Evaluate and/or address the following:

a. Rate (%) of coordinated referrals:

Department of Health

i. PCPN to referral facilities (secondary/ tertiary)

Republic of the Philippines

ii. Referral facilities (secondary/tertiary) to other referral facilities

/doh.gov.ph

(secondary/ tertiary) or Apex Hospital/s

iii. Referral facilities or Apex hospital/s to PCPN
b. Leading causes of referrals
c. Top reasons for declined referrals
d. Patient satisfaction rating on service delivery
e. Registration of all constituents to a primary care provider within their jurisdiction
Republic of the Philippines
Department of Health
/doh.gov.ph

Monitoring
Evaluation and
 Evaluation and Monitoring
Submit on a quarterly basis the Referral System Report, on
or before the 5th day of the succeeding month of the quarter
Department of Health
Republic of the Philippines

using the prescribed reporting form (

/doh.gov.ph

https://tinyurl.com/HCPNFORMS).

Note that the report submitted by the coordinator is the

consolidation of the referrals within HCPN. Reports per
facility shall be kept for validation purposes.
 Funding
The city-wide health systems shall pool and manage all resources intended for health
services through a Special Health Fund. Sources for the SHF shall include:
• financial grants and subsidies from national government agencies such as the
DOH in accordance with Section 22 of the IRR of the R.A. 11223
Department of Health
Republic of the Philippines

/doh.gov.ph

• income from PhilHealth payments in accordance with Section 21 of the IRR of

the R.A. 11223

• other sources such as, but not limited to, financial grants and donations from
Non-Government Organizations, Faith-Based Organizations, and Official
Development Assistance; provided that the concerned LGUs may opt to transfer
their local budget intended for health to the SHF through a mechanism of
cooperative undertakings as provided under Section 33 of RA 7160 (Local
Government Code of 1991)
 Frequently Asked Questions:
DISCUSSIONS RECOMMENDATIONS / AGREEMENT

DC No. 2023-0213: The Department of Health emphasizes the right of

LGUs and healthcare facilities to select their preferred IHIS/EMR/EHR
Department of Health

provider or develop their own based on their specific needs and

Republic of the Philippines

requirements.
/doh.gov.ph

However, for providers who wish to efficiently reimburse from PhilHealth,

Different EMRs being
utilized by health facilities compliance with rules on processing and submission of health and health-
note that PhilHealth requires use of EHR/IHIS that have certification
conforming to the national health data standards for interoperability, and
related data and reports at the local and national level as stipulated in the
Joint DOH-Philhealth-DICT AO No. 2021-0001 entitled "Guidelines on the
Implementation of the Standards Conformance and Interoperability
Validation (SCIV)" and Joint DOH-Philhealth-DOST-DICT AO No. 2017-
0001 entitled "Implementation of the National eHealth Electronic Health
Record System Validation (NEHEHRSV).
https://tinyurl.com/m6k7eutp
https://www.philhealth.gov.ph/partners/csp/
 Frequently Asked Questions:
DISCUSSIONS RECOMMENDATIONS / AGREEMENT

AO No. 2020-0019:Apex hospitals shall have the ability and commitment to

Department of Health

provide performance mentoring and technical assistance to the HCPNs in the

Republic of the Philippines

following areas:
i. Quality, efficient, and patient-centered clinical services;
/doh.gov.ph

What services are ii. Teaching and training of human resources;

anticipated from private iii. Functionality of the referral system; and,
hospitals if they are deemed iv. Clinical, public health, and operations research.
Apex hospitals?
DC 2023-0524:Apex hospitals may be owned and managed by DOH, other
National Government Agencies, State Universities and Colleges, or private
entities. In keeping with Section 19.10 of the UHC Act Implementing Rules
and Regulations, hospitals owned and managed by Local Government
Units shall not be considered in the selection of eligible apex hospitals to
ensure that an adequate number of hospitals remain within the HCPN.
List of 2023 Eligible Apex Hospitals and sample MOA: https://rb.gy/q1p7f9
 Frequently Asked Questions:
DISCUSSIONS RECOMMENDATIONS / AGREEMENT

Direct referral can be done if the case is for special concerns that the HCPN
(including L3 hospital) can not manage. Apex hospitals shall deliver
Direct referral to
specialty health care services not expected to be provided by HCPN.
Department of Health

Apex hospitals
Republic of the Philippines

Agreement for this shall be stipulated in the MOA and the in the technical
Guidelines on the Referral Mechanism of the HCPN.
/doh.gov.ph

Refer to : Joint Memorandum Circular No. 2019-01 (JMC) aims to provide

Public-Private LGUs further guidance on the modalities listed under Section 5.3 of said
Partnership DILG MC. It also aims to provide a template LGU Code for Joint Ventures
(JVs) that LGUs may adopt. https://rb.gy/sf0gk1
 Maraming Salamat
Sa Healthy Pilipinas, Bawat Buhay Mahalaga!

Republic of the Philippines

Department of Health
/doh.gov.ph