Email UpdatesA significant number of patients who enter treatment for OUD may have multiple medical or psychosocial issues that should be addressed, including some that may be beyond the scope of the practice. In such cases, it is important to connect patients as necessary to providers better able to address issues outside the practice's scope. Care coordination involves “deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care.”1 Proper care coordination will help meet patients' needs and preferences and support their recovery.
All staff know their role on the team and in the care of the patient. The practice acts as part of an extended care team that includes the patient, a care coordinator, medical or behavioral specialists, as appropriate, and potentially connections to community resources. A well-developed communication and referral system is in place so that essential information is shared across the team with patient consent. Patients whose challenges are greater than can be met within the practice are successfully transferred to more intensive treatment settings in a safe and effective manner.
Coordinated, team-based approaches to care can enhance patient outcomes. Care coordination is an integral part of primary care treatment of all chronic health conditions, including OUD. Individuals with OUD often have multiple, complex needs and can benefit from well-coordinated care. Individualized patient care plans, as discussed in Whole-Person Care should detail specific needs and care coordination requirements.
Plan how to coordinate:
- Obtaining patient consent for information sharing as necessary;
- Communications across the care team;
- Referrals to and information sharing with external providers and systems; and
- Assistance with recovery support and other community-based services.
Transitions in care are times of increased vulnerability for patients. Their treatment may be disrupted, increasing the risk of resumed substance use, overdose, and death. Care coordination is more important than ever at times of transition between care settings. Care navigators2, case managers, health care navigators, or peer recovery coaches—whatever title is used in the community—can work with patients to guide them through the health care system and help prevent them from “falling through the cracks.” They can help advocate on behalf of the patient, ensure continuity, and remove barriers to accessing care. One study showed that the addition of recovery peer navigators improved continuous MOUD treatment retention.2
To ease transitions between providers, ensure patients understand clearly why they are being connected to another provider, how it will help them, and how it fits into the treatment plan they already understand and helped develop. Do not assume patients understand the benefits just because you told them once and the patients have a referral in their hand. Repeatedly check the patient's understanding and agreement (“I see the sense in this”) for transitions and referrals. Make warm handoffs whenever possible by introducing the referral provider to the patient directly.
Increasingly, residential treatment programs, emergency departments, hospitals, and jails/prisons are initiating patients on medications for OUD.3,4 Upon discharge, these settings need a place to refer these patients for buprenorphine maintenance. Primary care can be an ideal place to refer these patients for medication maintenance once they've begun to stabilize, as OUD is a chronic condition much like other conditions you treat in your practice. In addition, treating patients with MOUD maintenance when they have already been started on buprenorphine, is typically simpler than starting and stabilizing them, so this approach can be less time consuming.
To facilitate referrals from residential treatment programs, emergency departments, hospitals, and jails/prisons, consider meeting with representatives from these facilities and having an open discussion about the services your practice can offer. Be aware of the federal Physician Self-referral Law (Stark Law) and the Anti-Kickback Statute.5 Such a discussion could also focus on how to approach ongoing communication and information sharing. These relationships can be important to establish trust and promote collaboration.
Patients receiving medications for OUD may also at some time be treated in the emergency department or admitted to the hospital for an opioid-related overdose or other health condition. Maintaining continuity of treatment is critical to avoid recurrence of use and the risks that come with it. If possible, establish policies and processes to communicate and coordinate care for patients in these situations. These should, at a minimum, address continuation of medications for OUD and chronic pain management using nonopioid alternatives.6
In addition, consider providing your patients with wallet cards upon beginning medications for OUD that include the provider's name and contact information, as well as the patient's current medication and dosage. This card may serve as a reference point for hospital-based physicians and encourage them to reach out to the practice to alert staff the patient is in the hospital.
It may be necessary to coordinate care or advocate on behalf of patients with other systems, such as the criminal justice system, child welfare and family services, and faith-based groups. Within the guidelines of state and federal privacy regulations and with patient consent, be open to speaking with representatives from these systems and discussing the effectiveness of medications for OUD and the philosophy regarding treatment. With permission of patients, some providers may also write letters on behalf of their patients and speak about their progress in treatment.
Referrals of people leaving incarceration: A significant overlap between substance use and incarceration underscores the need for effective treatment programs within the criminal justice system and following release. It has been estimated that 65% of people in prison have an active SUD.7 Additionally, another 20% of inmates, while not meeting the official criteria for an SUD, were under the influence of drugs or alcohol at the time of their crime.7 The highest risk of overdose for individuals with OUD occurs within the first two weeks following their release from incarceration.7 During this period, the risk of opioid overdose is significantly elevated, with former inmates being up to 40 times more likely to die of an opioid overdose compared to the general population.8 This heightened risk is due to several factors, including reduced tolerance to opioids after a period of abstinence during incarceration and the challenges of reintegrating into society without adequate support.7,8
One carceral system that incorporated medications for OUD has shown that administering buprenorphine and other types of medications for OUD in a jail setting has reduced deaths immediately following release and increased the likelihood of people filling their first prescription of buprenorphine outside the jail.3
Effective pre-release planning can bridge the gap between incarceration and community reintegration,9 reducing the likelihood of return to use and recidivism. Beginning in 2023, some Medicaid 1115 waivers allow Medicaid to cover treatment for individuals with OUD during the last 30 days before their discharge from incarceration.10 These waivers aim to improve care transitions, increase continuity of health coverage, and reduce disruptions in care, improving health outcomes and reducing recidivism rates.11
Depending on a patient's needs, stage of care, and response to treatment, you may determine—ideally in consultation with the patient—that the patient would best benefit from receiving treatment in a different setting. For example, after diagnosing a patient with OUD, you may conclude that more intensive treatment is needed than your practice can provide. Or, if a patient continues to struggle in treatment, he or she may benefit from a more intensive level of care.
Develop and implement systematic policies, processes, and protocols to refer patients requiring a more intensive level of care. These should address any requirements for provider follow-up after referral, ideally establishing a closed loop referral process with ongoing communication and follow-up. Higher levels of care for OUD can be provided by settings such as:
- OTPs;
- Intensive outpatient settings; or
- Residential SUD treatment facilities.
- Don't send a paper or electronic referral to another provider and assume that will result in a successful care transition. Most referrals fail, and patients often do not follow up. It is essential to take a more active and coordinated approach in dealing with referrals and care transitions.
- Don't assume that the patient remembers why the transition or referral is taking place—how it will help them and how it fits their overall care. Don't assume that the referral paper will be meaningful to the patient.
- Don't use privacy regulations as an excuse for not sharing information across the care team. Instead, develop patient consent forms that allow sharing of essential information that will keep patients safe, and train staff to help patients understand the value of information sharing.
- Don't focus only on your role in addressing a patient's complex care needs. View yourself and your practice as part of an extended care team. Share information and contribute resources as you can.
Medications for Opioid Use Disorder Treatment Protocol TIP 63 (updated 2021)
1. Agency for Healthcare Research and Quality. Care Coordination. 2024. Accessed May 2, 2025. https://www.ahrq.gov/ncepcr/care/coordination.html
2. Giraldo A, Shah P, Zerbo E, Nyaku AN. The role of recovery peer navigators in retention in outpatient buprenorphine treatment: a retrospective cohort study. Ann Med. 2024;56(1):2355566. doi:10.1080/07853890.2024.2355566
3. Pourtaher E, Gelberg KH, Fallico M, Ellendon N, Li S. Expanding access to Medication for Opioid Use Disorder (MOUD) in jails: A comprehensive program evaluation. J Subst Use Addict Treat. 2024;161:209248. doi:10.1016/j.josat.2023.209248
4. Cao SS, Dunham SI, Simpson SA. Prescribing Buprenorphine for Opioid Use Disorders in the ED: A Review of Best Practices, Barriers, and Future Directions. Open Access Emerg Med. 2020;12:261-274. doi:10.2147/oaem.S267416
5. Office of Inspector General. Fraud & Abuse Laws. Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services. September 1, 2021. Accessed May 29, 2025. https://oig.hhs.gov/compliance/physician-education/fraud-abuse-laws/
6. Dalal S, Chitneni A, Berger AA, et al. Buprenorphine for Chronic Pain: A Safer Alternative to Traditional Opioids. Health Psychol Res. 2021;9(1). doi:10.52965/001c.27241
7. Abuse NI on D. Criminal Justice DrugFacts | National Institute on Drug Abuse (NIDA). June 1, 2020. Accessed February 26, 2025. https://nida.nih.gov/publications/drugfacts/criminal-justice
8. Ranapurwala SI, Shanahan ME, Alexandridis AA, et al. Opioid Overdose Mortality Among Former North Carolina Inmates: 2000-2015. Am J Public Health. 2018;108(9):1207-1213. doi:10.2105/AJPH.2018.304514
9. Haney JL. Treatment interrupted: factors associated with incarceration during opioid use disorder treatment in the United States. Journal of Substance Use. 2024;29(1):45-53. doi:10.1080/14659891.2022.2120431
10. Cohen C, Hernández-Delgado H, Robles-Fradet A. Medicaid Section 1115 Waivers for Substance Use Disorders: A Review.; 2021. Accessed March 16, 2025. https://healthlaw.org/wp-content/uploads/2021/06/FINAL_Medicaid-1115-Waivers-for-SUD-updated.pdf
11. Centers for Medicare and Medicaid Services. Opportunities to Test Transition-Related Strategies to Support Community Reentry and Improve Care Transitions for Individuals Who Are Incarcerated. Published online April 17, 2023.