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Best practice №32

Ensure referral and linkage to other necessary services/resources at discharge

by Emillie R. Feenan, Jacqueline Rad, Mimi Leza

Last updated October 7th, 2020

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Other community agency referrals are needed to ensure that both the mother’s and newborn’s basic needs are met. These referrals can include WIC, family resource centers, parenting classes, the Department of Social Services, support groups, local treatment centers at a level of care appropriate to the patient’s assessed needs, peer support, and recovery groups. 

Why we are recommending this best practice

A collaborative and multidisciplinary approach to providing support to mothers and newborns affected by opioid use disorder (OUD) is necessary to ensure that the dyad has all basic needs met. Other service providers and agencies can influence a woman’s decisions for care and treatment. A more comprehensive approach to supporting the family is taken when multiple agencies and service providers are engaged. 

Strategies for implementation

  • Ensure staff training on local resources and eligibility criteria, as well as the referral process.  

  • Routinely engage hospital social work to support these activities.

  • Maintain or ensure access to a comprehensive listing of resources for easy reference when needs are identified.  

  • Determine if an agency is providing services to the family that include case management and care coordination. 
    • If there is an agency that is already involved with the family, ensure access and determine the needs and gaps in services that the family may have.  

  • Identify agencies that may be available to address the needs of the family.  

  • Make direct referrals whenever possible; ensure that the referral is received by the agency or program. 
    • Make follow-up outpatient appointments for postpartum follow-up.  
    • “The American College of Obstetricians and Gynecologists recommends a revised approach to postpartum care, including a postpartum visit within the first three weeks postpartum and a comprehensive exam at or before 12 weeks after delivery (ACOG, 2018). However, women with substance use disorders (SUDs) may benefit from additional support. Providers should consider scheduling an initial postpartum visit within 1-2 weeks after delivery, and biweekly until at least 6 weeks” (SAMHSA, 2018; Alliance for Innovation in Maternal Health, 2018). 

  • Inform the patient of the referral and provide contact information and information regarding the services to which they are being referred. This includes reporting to CPS.  
    • When there are no safety concerns, the provider should try to openly discuss referrals to Child Protective Services (CPS) and reassure the parent that it may be an opportunity for the family to receive additional support. This should only be done when deemed safe and when the conversation would benefit the family. 
    • Utilize warm handoffs. Refer to Best Practice #30

  • Schedule follow-up appointments before discharge. 
    • Appointments should include, but are not limited to:  
      • Recommended routine maternal appointments at one to two and six weeks postpartum.
      • Public health and/or home health home visit within three days of discharge.  
      • Recommended routine newborn appointments within 24-72 hours after discharge.

  • Where possible, provide or engage care navigators to support mothers in accessing service referrals and identifying additional needs. 


Emillie R. Feenan


Emillie began working in Lake County Public Health in 2015 as a Public Health Nurse in the California Children’s Services Program and Home Visitation Program, and has worked in different capacities in the department for the last five years. She currently provides oversight to the Maternal Child and Adolescent Health Program and the Nurse Home Visiting Program. As the MCAH Director, Emillie has works with a number of community stakeholders to address perinatal substance use in Lake County, and to create a recovery ecosystem where there is no wrong door into accessing services.

Jacqueline Rad


Jacqueline Rad  is the nurse manager for the Family Birth Center at Sutter Lakeside Hospital where she provides patient-centered care to mothers and newborns exposed to opioids, and teaches providers and nurses about the challenges these families face.

Mimi Leza


Mimi Leza is the Perinatal Services Coordinator for Ventura County Public Health and currently the co-chair of the Perinatal Substance Use Taskforce of Ventura County. Her background is in Pediatric nursing with extensive experience in caring for NICU babies with NAS and children with prenatal substance use exposure. As a Public Health Nurse, she specialized in providing case management for pregnant and parenting women with SUD and recruiting and training perinatal providers in the SBIRT process.