13.4 Available Resources & Referrals for Other Services
Key Takeaways
- Task V.3 covers multidisciplinary collaboration and referral and is worth 6 scored items, with statements spanning available resources, service referrals, consultations, and handoff communication.
- The United Ostomy Associations of America is the principal national peer-support and advocacy organisation for people with ostomies in the United States, and peer support is an evidence-supported adjunct rather than an optional extra.
- The blueprint names rehabilitation, nutrition, social services, mental health, and ostomy clinic as referral targets, and each has a defined trigger that a certified nurse should be able to state.
- Supply access is a referral problem as often as a clinical one: distinguishing a coverage failure, a supplier failure, and an affordability failure determines whether the answer is documentation, a supplier change, or a social work referral.
- Post-acute transition — home health, skilled nursing, or outpatient ostomy clinic — is planned before discharge, because the highest-risk window for dehydration and skin breakdown is the first two weeks after leaving hospital.
Available Resources & Referrals for Other Services
Quick Summary: Blueprint Task V.3 — "multidisciplinary care collaboration and referrals to support patient-centered care" — carries 6 scored items across four statements: available resources, referrals for other services, facilitating consultations, and handoff communication. This section covers the first two; the next covers consultations and handoff.
Available Resources (Statement 050301)
The blueprint groups resources into three categories: support and advocacy, supply access, and post-acute care.
Support and advocacy
- The United Ostomy Associations of America (UOAA) is the principal national organisation for people with ostomies and continent diversions in the United States, providing affiliated support groups, patient education material, an ostomy patient bill of rights, and advocacy on access issues.
- Local affiliated support groups and hospital-based groups provide the peer contact that changes adjustment trajectories most reliably.
- Disease-specific organisations matter where the underlying diagnosis drives the experience — inflammatory bowel disease foundations and cancer support organisations, for example.
- Peer visitor programmes pair a new patient with a trained volunteer who has a similar diversion. For many patients, meeting one person living well with a stoma does more than any amount of professional teaching.
Supply access
Distinguish three different failures, because they have three different answers:
| Failure | Presentation | Answer |
|---|---|---|
| Coverage | Insurer denies or limits quantity | Clinical documentation justifying medical necessity |
| Supplier | Order lost, wrong product, late delivery | Change supplier; escalate; provide interim supplies |
| Affordability | Uninsured, high deductible, fixed income | Social work referral, manufacturer assistance programmes, charitable supply programmes |
Ostomy supplies are covered by Medicare Part B as prosthetic devices, with published monthly quantity guidance that can be exceeded when the medical record documents the need. Uninsured patients need a different route entirely, which is why identifying which failure is occurring comes first.
Post-acute care
- Home health with a nurse competent in ostomy care for patients not independent at discharge.
- Skilled nursing facilities, where the ostomy nurse's handoff quality determines whether the plan survives the transfer.
- Outpatient ostomy or WOC clinic for the six-to-eight-week re-measurement and for complication management.
- Telehealth follow-up, useful for technique review and early leak troubleshooting.
Referrals for Other Services (Statement 050302)
The blueprint names the targets. Each has a trigger a certified nurse should be able to state without hesitation.
| Referral | Trigger |
|---|---|
| Dietitian / nutrition | High output, weight loss, food blockage recurrence, short bowel, complex fistula, neonatal or paediatric growth concern |
| Social work | Supply affordability, insurance navigation, housing or transport barriers, caregiver strain, discharge placement |
| Mental health | Depression, anxiety, persistent body image disturbance, avoidance of self-care, social withdrawal, suicidal ideation |
| Rehabilitation (PT/OT) | Dexterity or reach limitation affecting self-care, adaptive equipment need, deconditioning, return-to-work assessment |
| Ostomy / WOC clinic | Recurrent leakage, peristomal skin damage, complex contour, complication management, scheduled re-measurement |
| Sexual health | Persistent sexual dysfunction, particularly after abdominoperineal resection or cystectomy |
| Palliative care | Symptom burden in advanced disease; complex fistula or malignant obstruction |
| Pharmacy | Medication formulation review after ileostomy; absorption concerns |
Important: A referral without a reason is a delay. State what has been observed, what has already been tried, and what specific question you want answered. "Please see for stoma issues" wastes the consultation; "recurrent leaks despite mouldable barrier and ring, wear time one day, query dexterity limitation affecting application" gets an answer.
Peer Support Is a Clinical Intervention
It is easy to file peer support under "nice to offer." The ostomy literature treats it as more than that: connection with others living with a diversion is associated with better adjustment, better self-care engagement, and reduced isolation. The practical implication is that the offer should be specific and timed, not generic:
- Offer the peer contact when the patient is ready to look at the stoma, not on the day of surgery.
- Name the organisation and, where possible, the local group and the meeting format.
- Match on diversion type and life stage where the programme allows — a 24-year-old with an ileostomy for Crohn disease and a 70-year-old with a colostomy for rectal cancer have limited overlap.
- Follow up on whether the connection happened, exactly as you would for any other referral.
Planning the Transition Before Discharge
The first two weeks after discharge carry the highest risk of dehydration readmission and peristomal skin breakdown. The resource plan should therefore be complete before the patient leaves:
BEFORE DISCHARGE - resource checklist
[ ] 30-day supply in hand + reorder source confirmed + funding route identified
[ ] Home health or outpatient follow-up arranged, with a date
[ ] Ostomy clinic appointment for 6-8 week re-measurement booked
[ ] Red-flag sheet given, teach-back completed, phone number provided
[ ] Referrals made with reasons: dietitian / social work / mental health / rehab
[ ] Peer support offered, organisation named
[ ] Written handoff to the receiving clinician or agency
An item on that list that is "arranged verbally" and not documented has a habit of not existing by the time the patient gets home.
A patient on a fixed income with a new colostomy tells the ostomy nurse they have been reusing pouches because they cannot afford the co-payments on their supplies. What is the most appropriate referral?
Which referral note is most likely to produce a useful response from the outpatient ostomy clinic?
When is the most appropriate time to offer a peer visitor connection to a patient with a new ostomy?
Why is the resource and referral plan completed before discharge rather than at the first outpatient visit?