Addendum A
TRIGGERS FOR INTERDISCIPLINARY REFERRALS
Discipline Specific Referral Criteria for assessment of conditions and potential comorbidities post-stroke
Audiology
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Hearing evaluation needed – Inpatient or Outpatient
Lactation Consultant
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Breastfeeding mother who has been admitted to the hospital
Diabetic Education
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Newly diagnosed diabetic
Diabetic education
Wound care
Non-healing, infected, or necrotic wound
Leg ulcer (venous, arterial, diabetic)
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Pressure sore (decubitus ulcer)
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Skin problems related to incontinence
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Draining wounds/fistulas
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Pressure sore prevention and devices
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Product resource information
Nutrition Services
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Inpatient consuming < 50% of normal intake for > 2 days
 Loss of 10% usual body weight in 6 months
 Gain of 5% usual body weight in 1 month
 Cachexic appearance
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Stage II, III, IV, or unstageable pressure sore(s)
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Low Albumin <3.5g/dl and /or Pre-albumin < 16mg/dl (if testing done outside the hospital
within 1 month)
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Difficulty chewing, swallowing, or patient is aspirating
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Pregnant or lactating woman with an additional medical condition
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Newly diagnosed or uncontrolled diabetic
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Nutrition education
Occupational Therapy
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Recent decline in self-care abilities: decreased ability to feed, bathe, groom dress, and/or
toilet
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Visual perceptual deficits interfering with self-care or home management function, or low
vision
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Recent change in home management abilities: meal preparation, housework, home setting
transfers, decreased safety
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Recent change in upper extremity function: decreased strength, abnormal tone, decreased
sensation, fracture, joint pain/contractures, impaired fine motor coordination
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Requires training in areas of joint protection, energy conservation, work simplification in
relation to chronic condition (such as Rheumatoid Arthritis)
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Splinting or positioning needs
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Need for adaptive ADL equipment: such as reachers, dressing equipment, feeding utensils
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On bed rest more than 72 hours or need for coma stimulation

Assessment of driving skills needed

Need for patient and caregiver teaching for safe return home
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Addendum A
Pastoral Care
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Patient/Family Support: Serious injury, illness, major surgery, long term hospitalization or
treatment, cardiopulmonary arrest, or death
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Patient requests a Sacrament, prayer, or other spiritual support
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Ethical decisions
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Advance directives (at some facilities)
Pharmacy Services
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Patient or family requests more information about medications

Evaluation for possible adverse drug reactions, food-drug interactions, or drug-drug
interactions
Physical Therapy
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Recent change in mobility: Difficulty moving from/to bed, chair, tub, toilet; balance
problems; safety concerns

Recent change in ambulation: Difficulty walking (or with stairs) with or without a device;
recent history of falls

Positioning needs due to wounds, pressure ulcers, musculoskeletal issues

Uncontrolled back, neck, or extremity musculoskeletal pain
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Amputated limb: new amputation or improperly fitting prosthesis

Recent change in function related to decreased strength, fracture, altered muscle tone
range of motion, joint movement or sensation. Edema in trunk or extremities
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On bed rest more than 72 hours: excessive decrease in endurance
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Requires assistance to procure and training for the use of a wheelchair
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Requires patient and caregiver training for safe return home
Rehabilitation Psychology
 Anxiety management
 Assessment of competency
 Assessment of dementia
 Change in mental status/cognitive functioning
 Assessment of suicidal ideation, mood disturbances
 Emotional lability
 Depression
 Lack of motivation/participation
 Agitation/combativeness with need for behavior modification
Respiratory Care

Respiratory compromise

Patient requires artificial airway

Patient unable to perform Incentive Spirometry or deep breathing and coughing exercises
independently or with RN’s assistance

Patient on respiratory treatments at home
 CPAP/BIPAP
 Home ventilators
 Home nebulizer therapy
Social Services/Case Management

Abuse, neglect, or domestic violence
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Advance directives: assistance and problem solving
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Community resource needs (meals on wheels, transportation, adult day care, etc.)
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Potential need for: rehab, subacute, long term acute care, home care, nursing home, group
home, hospice, etc.

Resume prior services: nursing home, group home, home care meals, etc.

Diminishing capacity for self care, frail, or living alone with marginal or no support system

Homelessness/shelter needs

Altered mental status with potential for continuing care needs

Patient is caregiver to another person
Addendum A
Patient’s caregiver having difficulty coping
Psychosocial needs: adjustment to illness, grieving, patient/family conflict interfering with
care

ETOH abuse identified on the database (referral may also be made to Psych)
Speech Therapy

Recent change in swallowing ability: difficulty chewing, choking when eating/drinking,
residual food in mouth and/or aspiration suspected

Admitting diagnosis of aspiration pneumonia

Recent change in communication or cognitive skills:
 Difficulty with verbal or written expression
 Reduced understanding of spoken word or written word
 Slurred speech
 Decreased fluency with speech
 Inappropriate responses to questions
 Decreased attention, memory, problem solving or judgment
 Decreased safety awareness

Tracheotomy or is otherwise non-verbal and requires communication intervention

Change in voice quality (hoarseness, reduced intensity, etc.)
Therapeutic Recreation
 Major lifestyle changes as a result of illness or injury affecting leisure and community
interests, employment, and/or life roles
 Plan to return to community living with any above deficit
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