Referrals and Care Coordination

Coordinated, team-based approaches to care can enhance patient outcomes. Care coordination is an integral part of primary care for the treatment of all chronic health conditions. Individuals with opioid use disorders often have multiple, complex needs and can particularly benefit from coordinated care. Individualized patient care plans, as discussed later in Patient-Centered Care, should detail specific needs and care coordination requirements.

Practices should plan how to coordinate:

• Communication 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 of care are times of particular 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. 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.

To ease transitions between providers, practice staff should 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. Providers cannot assume patients understand the benefits just because they told them once and the patients have a referral in their hand. They should repeatedly check for the patient’s understanding and agreement (“I see the sense in this”) for transitions and referrals.

Depending on a patient’s needs, stage of care, and response to treatment, providers 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 opioid use disorder, providers may use the ASAM level of care criteria or another assessment (as discussed in Screening and Diagnosis) to determine that more intensive treatment is needed. Or, if a patient continues to struggle in treatment, he or she may benefit from a more intensive level of care.

Practices should develop and implement systematic policies, processes, and protocols for the referral of patients requiring a more intensive level of care. These should address any requirements for provider followup after referral and information sharing.

Emergency departments and hospitals may be sources of referrals for a medication-assisted treatment (MAT) program. In that case, it may be a good idea to meet with representatives from the hospital and have an open discussion about the services the program offers and how to approach ongoing communication and information sharing. These relationships can be important to establish trust and promote collaboration.

Patients in an MAT program 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. Practices should establish policies and processes to communicate and coordinate care for patients in these situations. These should, at a minimum, address continuation of medications for opioid use disorder and chronic pain management using nonopioid alternatives.

Practices should also consider providing their patients with wallet cards upon intake into the MAT program 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 Federal and State privacy regulations and patient consent, providers should be open to speaking with representatives from these systems and discussing the effectiveness of MAT 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.