Strategies to Support Care Transitions for Patients With Opioid Use Disorder: Pathways and Partnerships for Success

Introduction

Hospitalization is a critical time to engage people with opioid use disorder (OUD).^1,2 Patients with OUD have high rates of morbidities, including overdose and infectious diseases requiring frequent hospitalization.^3,4 An estimated 1 of every 9 hospitalized patients in the United States (US) has an OUD-related diagnosis. ⁵ Emergency departments (EDs) historically have been ill-equipped to screen for OUD, initiate care, and make referrals, leading to frequent readmissions.^6,7 Hospital initiatives that include better screening, initiation of medication for opioid use disorder (MOUD), and referrals are seen as promising ways to treat OUD more effectively.^8-10

The Screening, Brief Intervention, and Referral to Treatment (SBIRT) model, extensively applied in primary care for alcohol use disorder, has been adapted for hospitals to address OUD.^8,11,12 The adapted SBIRT model includes widespread screening, ED-initiated MOUD, and coordinated transitions to outpatient care. ¹³ Although hospital-based SBIRT programs widely implement screening and brief interventions, with screening rates exceeding 80% in some settings, ¹⁴ studies show that referrals and transitions to further treatment remains limited. Referral rates range around 10% to 25% for those screened, with even lower rates of kept referral appointments – as low as 0% in some estimates. ¹⁵ These studies indicate that most US hospitals are unable to offer transition interventions despite high need.

Prior research on barriers and facilitators to SBIRT implementation has found that limited community partnerships is among the most critical barriers to initiating treatment in the ED, as hospitals need strong partnerships for referrals and successful care coordination.^14,16 The availability of community-based partners to sustain care after discharge is a key facilitator to successful referral to treatment specifically. ¹⁶ Recent work has begun identifying strategies to support care transitions for patients with OUD following hospitalization. These studies highlight that evidence remains limited regarding which types of partnerships hospitals should prioritize and how partnership development strategies might be operationalized in practice.

To address this knowledge gap, the present study sought expert perspectives on the most critical partnerships that hospitals should prioritize to support OUD patient transitions, as well as strategies to build partnerships and facilitate care transitions between hospitals and partner organizations. These questions were part of a larger study focused on implementation strategies to enhance the adoption of SBIRT for OUD in safety-net hospitals. Findings from this study can inform SBIRT implementation in hospitals by highlighting strategies to strengthen partnerships and improve care transitions, a critical but underemphasized component of SBIRT adoption.

Methods

Results

Strategies to Support Successful Transitions

Of the 23 invited recipients, 20 accepted the invitation to participate, and of these, 2 dropped out. Demographic and professional characteristics of survey participants are described in Supplemental Table 1.

Experts listed several strategies to support successful transitions and partnership development, which fell into 5 categories: (1) structured care transition programs within hospitals; (2) programs to address patients’ social and material needs; (3) data and reporting – internally and externally; (4) low-barrier policies shared amongst partners; and (5) creating community networks. Response frequencies varied across categories because not all participants mentioned each category. The specific strategies listed within each category are presented below and in Figure 1.

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Figure 1.

Strategies to support partnership development and optimize care transitions for patients with OUD.^a

Category 1: Structured Care Transition Programs Within Hospitals

All participants (n = 18, 100%) listed having a formal care transitions program for hospitalized OUD is critical to support both partnerships and care transitions. Specific program components included recruiting interdisciplinary staff, including addiction medicine MDs, social workers, care navigators, nurses, and peer workers, and placing them in multiple settings throughout the hospital, including the ED and inpatient units. Participants also listed specific processes for these programs, which included educating patients using teach-back methods, involving family members in discharge processes, having nurses conduct follow-up calls or home visits, and having care coordinators schedule follow-up visits for patients and send reminders for upcoming appointments.

For peer workers, participants described strategies such as meeting patients during hospitalization, maintaining engagement after discharge, encouraging attendance at follow-up appointments, assisting with problem-solving to address barriers to care, and accompanying patients to appointments. For care coordinators, participants noted the importance of using patient-centered strategies to optimize care transitions; this included educating patients about local treatment options (ie, types of care offered by different organizations and general education about types of treatment), and helping patients identify a treatment provider that would be acceptable from the patient’s perspective and that accepts their insurance. Finally, participants noted that having addiction MDs initiate MOUD in the hospital or provide prescriptions for patients unable to make follow-up appointments was a critical component of an OUD transitions program.

Category 2: Address Patients’ Social and Material Needs

To enhance successful transitions, participants (n = 7, 38.8%) listed strategies that address patients’ non-medical needs. This included supplying cell phones to patients – and having social workers submit documentation/applications to Medicaid on their behalf of patients – to enhance patients’ ability to follow up with addiction treatment, medical care, and social services; partnering with the Department of Motor Vehicles (DMV) and state governments to issue state IDs or equivalents to patients who do not have them, as patients are required to have an ID to fill a suboxone prescription, enroll in a Methadone program, and access social services; provide transportation assistance, which may include identifying the transportation landscape in the community (ie, what options are available and the cost of each), developing a system for identifying patients’ transportation needs and feasible transportation strategies to meet those needs, and obtaining funding to support transportation assistance (ie, app-based rideshare services); and providing pharmacy navigation services and prescription assistance to facilitate MOUD access.

Category 3: Data and Reporting – Internally and Externally

Participants (n = 6/18, 33.3%) listed strategies to enhance data collection and sharing both internally and externally among referral endpoints and other stakeholders. Internally, this included tracking the number of patients with identified OUD, linkage recommendations, and linkage outcomes, and building into electronic health record (EHR) systems, such as pre-populating referral information. A related strategy was to use data collected to conduct routine evaluation and monitoring of referral processes that are not working well (ie, patients do not reach referral endpoints or miss follow-up appointments), and to examine cases that are referred externally to identify gaps. Participants also noted the need for hospitals to share data on patients’ medical, OUD, and social needs with referral endpoints and patients’ primary care providers, and for external organizations to share data on patients’ transitions back to hospitals.

To enable this bidirectional information sharing, participants noted the importance of improving EHR capacity at both hospitals and referral endpoints to promote interoperability. Lastly, participants discussed how insurers and state governments could use data on transitions; specifically, that insurers could tie payment to successful referrals by using referral data to reward or penalize hospitals based on their performance, and that state governments can referral data as an indicator in their weighting algorithms for assigning new Medicaid enrollees into managed care plans.

Category 4: Low-Barrier Policies Shared Amongst Partners

To increase rates of successful referrals, participants (n = 6/18, 33.3%) noted strategies related to low-barrier scheduling and appointment policies amongst hospital and community partners. This included ensuring that appointments are available on a timely basis, having flexible appointment times, holding times for walk-in visits, maintaining similar hours of operations to partner organizations, and having a single phone number with texting capabilities where patients can receive transitional support or troubleshoot barriers they encounter in scheduling or attending appointments.

Category 5: Creating Community Networks

Several strategies listed by participants (n = 7/18, 38.8%) centered around the creation of community-wide networks to support patients with OUD transition between care settings. This included disseminating information on established, successful partner organizations broadly within communities, hiring hospital MDs, RNs, or social workers who work part-time in external treatment organizations, and developing strong relationships with a single “point person” at referral endpoints who will respond to email and phone calls.

Organization Type Ranking

The results of the organization ranking exercise can be found in Table 1. Specialized addiction treatment programs (including residential treatment programs and OUD treatment programs) were ranked as highest priority amongst participants (1.96, SD = 1.27), followed by community-based outpatient primary care clinics affiliated with the hospital system (2.6, SD = 1.50), and harm reduction services (3.06; SD = 0.96). Non-profit advocacy organizations were ranked as lowest priority for partnership formation (5.86; SD = 0.91). When asked to suggest additional organization types beyond those listed in the survey, participants identified governments (n = 1), bridge clinics and similar models (n = 1), and Medicaid payers (n = 1) as important partners.

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Table 1.

Ranking of the Type of Organizations Hospitals Should Prioritize When Developing Partnerships to Support Successful Care Transitions for Patients With Opioid Use Disorder (n = 18).

Organization type	Mean rank (SD)
Specialized addiction treatment programs (including residential programs and OUD treatment programs)	1.93 (1.27)
Community-based outpatient primary care clinics affiliated with the hospital/health system	2.6 (1.50)
Harm reduction services	3.06 (0.96)
Social services to address social determinants of health	3.86 (1.50)
Community based outpatient primary care clinics not affiliated with the hospital/health system	4.46 (1.47)
Non-profit advocacy organizations	5.86 (0.91)

Discussion

This study leveraged the expertise of addiction medicine physicians and OUD experts to identify the referral endpoints hospitals should prioritize in partnerships to enhance care transitions for OUD patients, and strategies to support partnership development and successful transitions. Given the established relationship between OUD treatment engagement and improved OUD outcomes (Clark et al., 2015; Sordo et al., 2017; The National Academies Press, 2019) it is unsurprising that the most highly ranked referral endpoints were specialized OUD treatment programs and other settings where MOUD can be accessed. It is also notable that primary care clinics not affiliated with hospitals were ranked less highly than other organizations. Previous literature has documented how difficulties related to data sharing, referral processes, and OUD treatment philosophies between health care organizations can hinder communication and negatively impact the development of partnerships^16,18,19; given these challenges, time and resource-strapped hospitals may lack bandwidth to reach beyond their own organization in search of external partners.

Yet, several of the strategies identified as being critical to support treatment linkages did focus on partnership development, and can support hospitals in overcoming barriers related to communication and coordination of referrals. These included strategies related to enhancing data sharing capabilities to support bidirectional information sharing, as well as creating networks of providers staffed in both hospitals and external organizations. Enhancing data sharing capabilities and implementing improvements to EHRs can require significant financial and infrastructure investments that may be less feasible in resource-constrained settings. However, creating networks of providers by leveraging existing community partnerships or repurposing existing care coordination structures can be a more attainable strategy even in low-resource environments. Overall, developing partnerships for OUD care transitions remains an understudied component of OUD treatment research, and future studies should compare transition outcomes for OUD patients between organizations with different partnership models.

This study is subject to limitations. First, this study relied on a small, non-representative convenience sample, which introduces potential bias and limits the generalizability of the findings. Additionally, 2 participants dropped out during the study, further reducing the already small sample size and introducing potential attrition bias. Second, although participants were asked to suggest additional referral endpoints in addition to the ones presented in the survey, these were not included in the ranking Third, we identified organization types for the ranking based on an informal literature review rather than a systematic search, which may have resulted in omission of some relevant referral endpoints. Similarly, the transition strategies listed by participants are not exhaustive of all possible strategies, and we acknowledge that others may still exist in the field. Fourth, participants were not asked to provide rationales for their organization rankings, which limits interpretation of the reasons behind their choices. Finally, although we asked participants specifically to focus on strategies that may facilitate the development of partnerships, most focused instead on strategies to improve care transitions generally.

Despite these limitations, this study is an important contribution to the literature focused on SBIRT and OUD treatment by having national experts in hospital-based OUD – many of whom have direct experience implementing SBIRT for OUD – identify strategies to support an underemphasized component of the SBIRT model: referral to treatment. These results are particularly salient given the current funding environment, in which hospitals may have limited additional resources to devote to expanding their own OUD treatment services; future research should explore perspectives on recent funding changes, as these insights could provide critical understanding of contextual factors currently influencing implementation. Within this context, strategies to support successful patient transitions to external OUD treatment settings are critical. The findings of this study can provide insights for hospitals as they consider partnerships that could facilitate OUD care transitions, as well as potential strategies that can support these transitions, such as embedded structured transition programs, addressing patients’ material needs, and improving data sharing.

Supplemental Material