Care Coordination and Patient Referral Sources

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.