5.8 Referrals, Care Coordination, and Transitions of Care
Key Takeaways
- Referrals and Coordination of Care is sub-topic 3E on the CDR CSO outline, worth 5 scored items, and is tested as recognising the referral trigger rather than as team-structure trivia.
- ASCO recommends that patients with advanced cancer receive dedicated palliative care concurrent with active treatment early in the disease course, within about eight weeks of diagnosis.
- Dental evaluation and clearance before head and neck radiation is a coordination step that reduces later osteoradionecrosis risk, and it must happen before radiation starts.
- Suspected aspiration or new dysphagia warrants speech-language pathology referral for instrumental swallow evaluation rather than an empiric texture downgrade by the dietitian alone.
- Medicare covers home enteral and parenteral nutrition under the prosthetic device benefit only when impairment is expected to be long-term, so home nutrition support discharge requires early coordination with the supplier and documentation of permanence.
5.8 Referrals, Care Coordination, and Transitions of Care
Quick Summary: CDR assigns 5 scored items to Referrals and Coordination of Care (3E). These items typically present a patient with a problem that is adjacent to nutrition and ask what the specialist does next. The tested competency is knowing the boundary of your own intervention — when acting alone is unsafe or insufficient, and who owns the next step.
The Referral Decision
A specialist-level dietitian is expected to escalate rather than improvise. Three questions define the boundary:
- Does the problem require a diagnostic procedure I cannot order or perform? (Swallow study, endoscopy, imaging.)
- Does it require treatment outside dietetics scope? (Antidepressant prescribing, stent placement, wound débridement.)
- Will the plan fail without a resource I do not control? (Transport, supply, funding, home nursing.)
Any yes is a referral.
Referral Triggers and Team Roles
| Team member | Refer when | Why it matters nutritionally |
|---|---|---|
| Speech-language pathologist | New or worsening dysphagia, coughing with meals, suspected aspiration, post-laryngectomy or post-neck-dissection swallow change | Instrumental evaluation (videofluoroscopic swallow study or fibreoptic endoscopic evaluation) defines a safe texture and the need for alternative access; empiric texture downgrades without evaluation both under- and over-restrict |
| Palliative care | Advanced or metastatic disease, high symptom burden, goals-of-care uncertainty | ASCO recommends dedicated palliative care alongside active treatment early in the course of advanced disease, within about eight weeks of diagnosis; earlier involvement improves quality of life and symptom control |
| Oncology social work | Positive food-insecurity screen, financial toxicity, transport or housing problems, caregiver strain | Converts an unaffordable plan into an executable one |
| Psychosocial oncology / psychiatry | Distress Thermometer score of 4 or higher, suspected depression, eating-related family conflict, disordered eating | Depression is a treatable cause of anorexia and weight loss |
| Physical and occupational therapy | Functional decline, deconditioning, falls, lymphoedema, prehabilitation before major resection | Resistance exercise is required for protein to translate into lean mass |
| Dentistry / oral medicine | Before any head and neck radiation; ongoing caries and trismus risk after | Pre-radiation dental evaluation and extraction of non-restorable teeth reduces later osteoradionecrosis risk |
| Clinical pharmacy | Complex polypharmacy, herb-drug interaction concern, enzyme or antiemetic optimisation | Owns interaction checking and formulary alternatives |
| Genetic counselling | Suspicious family history, young age at diagnosis, syndrome-associated tumours such as Lynch-related colorectal cancer | Changes surveillance and family risk, and sometimes the survivorship diet conversation |
| Interventional gastroenterology / IR | Need for gastrostomy or jejunostomy, oesophageal or biliary stent, malignant obstruction | Owns the access the nutrition plan depends on |
| Wound, ostomy and continence nurse | New ostomy, high-output stoma, peristomal skin breakdown, fistula | Output management is inseparable from fluid and sodium prescription |
| Home infusion / DME supplier | Any patient going home on enteral or parenteral nutrition | Supplies pump, formula, and nursing; must be engaged days before discharge |
Working Inside the Multidisciplinary Structure
Tumour boards and multidisciplinary clinics are where treatment plans are made, and the specialist dietitian's value there is anticipatory: flagging that a planned chemoradiation course to the oropharynx will produce Grade 3 mucositis by week 4, so the enteral access conversation should happen at week 0 rather than week 5. Coordination is most effective upstream of the toxicity, not in response to it.
Document referrals in the shared record with the reason, the expected outcome, and a date to close the loop. An uncompleted referral is functionally identical to no referral, and following up is part of the intervention.
Transitions of Care
Transitions are where nutrition plans break. Each handoff needs an explicit nutrition component.
Inpatient to Home on Enteral or Parenteral Nutrition
This transition has the longest lead time and the most failure points:
- Confirm access is appropriate for home use — a nasogastric tube is not a home-discharge device for long-term feeding; a gastrostomy or jejunostomy is.
- Engage the home infusion or DME supplier early, because insurance authorisation, delivery scheduling, and pump training take days.
- Coverage basics: Medicare covers home enteral and parenteral nutrition under the prosthetic device benefit, which requires that the impairment be expected to be long-term rather than transient and that nutrition be delivered by tube or intravenously — oral nutritional supplements are not covered under this benefit. Home parenteral nutrition additionally requires documentation that enteral feeding is not feasible. Documentation written at discharge determines whether the patient's formula arrives.
- Teach with teach-back before discharge: formula preparation and storage, pump programming, flush volumes and schedule, tube-site care, what to do for a blocked or dislodged tube, hypoglycaemia and hyperglycaemia signs on cyclic feeds, and a named number to call.
- Arrange the first follow-up before the patient leaves, and confirm home nursing where required.
Active Treatment to Survivorship
At completion of treatment, the patient should leave with a survivorship care plan — a treatment summary plus a follow-up plan — shared with the primary care clinician. The nutrition component names residual deficiency risks created by the treatment received (B12 after gastrectomy or ileal resection, enzyme therapy after pancreatic resection, bone health after androgen or oestrogen deprivation), the surveillance those require, and the shift from repletion to long-term risk-reduction eating.
Treatment to Hospice
Handoff includes explicit goals-of-care documentation about artificial nutrition and hydration, so that the hospice team does not have to re-litigate a decision the patient already made.
Telehealth and Access
Remote follow-up has become a mainstream tool in oncology nutrition, particularly for rural patients and those too fatigued to travel. Practical constraints belong in the plan: dietitians are licensed by state and must be authorised where the patient is located, patients need working connectivity and a home scale for weight monitoring, and some assessment elements — nutrition-focused physical examination, handgrip dynamometry — cannot be reproduced remotely and should be scheduled for in-person visits.
A patient with newly metastatic pancreatic cancer has a high symptom burden and is starting first-line chemotherapy. When does ASCO recommend involving dedicated palliative care?
A patient is scheduled to begin definitive radiation to the oropharynx in three weeks. Which coordination step must occur before radiation starts to reduce a specific late complication?
A patient recovering from a complicated oesophagectomy will be discharged home on jejunostomy tube feeding. Which statement about coverage and discharge coordination is correct?
A head and neck cancer patient four weeks into chemoradiation begins coughing during meals and has a wet vocal quality after swallowing liquids. What is the most appropriate next step?