Linkage to Care Across County Systems: A NACo Opioid Solutions Strategy Brief

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“Linkage to care . . . ensures people have an opportunity to participate in care when they are ready.” 

— National Council for Mental Wellbeing1

What is linkage to care across county systems?

Counties operate and fund systems of service that regularly interface with people affected by substance use, such as hospitals, jails, courts and community colleges.

  • People living with undiagnosed opioid use disorder (OUD) may visit emergency departments for reasons related to their substance use, such as experiencing a nonfatal overdose or developing an infection, or with health concerns unrelated to OUD.2–4
  • An estimated 63 percent of people incarcerated in county jails are living with a substance use disorder.5
  • Nearly 40 percent of children in the foster system were removed from their homes for parental use of alcohol or other drugs.6
  • Community colleges are also important institutions to include in linkage to care strategies, as prescription medication misuse is more prevalent among college-aged students.7

As the owners and operators of these systems, counties are well positioned to link community members with evidence-based options for care, especially medications for opioid use disorder (MOUD).8

County agencies and contractors can directly assist those in need of treatment with linkage to and engagement in care in several ways:

  • Assisting with enrollment in Medicaid or other health insurance.9
  • Building treatment capacity by expanding the number of active MOUD prescribers working in county hospitals, public health departments or in the community.10,11
  • Developing reliable referral networks for connecting people to treatment that fits their insurance status, personal needs and personal choices.12,13
  • Implementing procedures for warm hand-offs to treatment or services available through those referral networks.14 
  • Ensuring that the costs of treatment and medications are covered, whether through Medicaid or other health insurance reimbursement, block grants, general revenue or opioid settlement funds.15,16

What evidence supports linkage to care across county systems?

Many linkage-to-care strategies have been proven effective in settings under county authority, including: 

  • Buprenorphine induction during inpatient care or in the emergency department at county hospitals;17–19
  • OUD diagnosis and MOUD initiation in primary care settings, including clinics operated by county public health departments;20–22
  • MOUD initiation during incarceration and linkage to community-based care upon release;23
  • Linkage to MOUD treatment through county social service agencies in the context of well-implemented Plans of Safe Care for families with substance-involved pregnancies;24
  • Linkage to MOUD treatment from an outpatient mental health service provider,8,25 as utilization of these services is more common among college students who use drugs compared to their peers;26 and
  • Engagement with trained peer navigators and recovery coaches across all health and human services organizations supported by the county.27–29

In addition to linking residents to care, counties are well positioned to increase treatment capacity. Access NACo’s Strategy Brief on increasing access to treatment. 

Are there risks to my community or institution if we don’t pursue linkage to care across county systems?

Yes.

Treatment with methadone and buprenorphine, which reduce cravings and reduce overdose risk by binding to opioid receptors, are the only treatments for OUD proven to protect against overdose.30,31 County systems and agencies regularly interface with people living with OUD at their moment of highest overdose risk, including those recently released from jail,32 those being treated for non-fatal overdose33 and those at risk of having their children removed for parental substance use.34 Failing to connect at-risk persons with life-saving MOUD treatment may increase fatal overdoses in the community.

Further, the Americans with Disabilities Act (ADA) offers protections to people who are receiving treatment for a substance use disorder. Discrimination against persons receiving MOUD treatment is considered a violation of the ADA and could be grounds for legal action.

What are best practices for implementing linkage to care across county systems?

  • Develop a sequential intercept model to identify existing points of contact, gaps in care and opportunities to link residents with the treatment and services they desire.35
  • Create a county-wide referral network for linkage to MOUD. Seek connections with providers that offer, but do not mandate, psychotherapy alongside MOUD treatment.36
  • Hire Nurse Care Managers and other skilled clinical professionals in hospitals and clinics to support MOUD prescribers in increasing their patient load.37
  • Hire peer support specialists to provide social support and recovery services to persons with OUD referred to treatment and other services.27–29
  • Support the cost of treatment and medications for those who are uninsured, underinsured and/or ineligible for Medicaid to prevent early treatment drop out.38
  • Utilize collaborative models like RxStat or Overdose Fatality Reviews to improve the coordination of services and operational knowledge across county agencies.39,40

Learn more about the Overdose Fatality Review process.

What are some examples of successful linkage to care across country systems?

In 2022, the Legislature of Broome County, N.Y. commissioned a new team within the county health department: the Accidental Injury and Death Review. That team was charged with implementing and operating a multi-disciplinary Overdose Fatality Review effort within the county. With the assistance of a dedicated, full-time facilitator — and following best practice guidance from the U.S. Bureau of Justice Assistance40 — the county invested several months in one-on-one engagement with local stakeholders in order to explain how Overdose Fatality Review programs operate, solicit participation and establish necessary confidentiality agreements. The Accidental Injury and Death Review team held its first meeting in April 2023 and conducted its first Overdose Fatality Review the following month.41

The Public Health Department of Durham County, N.C. began operating a Community Linkages to Care (CLC) Peer Support Program in 2019. The program aims to connect people at risk of opioid overdose with support in accessing harm reduction, housing, food and employment services. State-certified peer support specialists form the backbone of this program, providing outreach, peer mentoring, naloxone access and linkage to treatment and other services. Durham County residents can access CLC services through a referral (from local EMS, local hospitals or the county jail) or by calling peer support specialists directly via local phone numbers available on the county website.42

In Vermont’s hub-and-spoke model of MOUD delivery, patient assessment and treatment initiation takes place in specialized “hub clinics,” that then refer stabilized patients out to “spokes” — community-based service providers offering substance use treatment, pain management, residential services or anything else that might be indicated. Each “spoke” clinic is supported by a registered nurse and a licensed behavioral health provider for every 100 patients receiving MOUD, partially funded through state Centers for Medicare and Medicaid.43 Vermont’s hub-and spoke model operates at the state level, but the principles of this effective system of treatment and referral can be reproduced at the county level.

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Author

Jennifer J. Carroll, PhD, MPH

Dr. Carroll is a medical anthropologist, research scientist and subject matter expert on substance use and public health. She is currently an Assistant Professor of Anthropology at North Carolina State University.

Additional Resources

Guidance on linkage to care across settings

Guidance on improving linkage to care through Medicaid

Strategies for interagency coordination and knowledge transfer

Providers Clinical Support System (PCSS)
PCSS is a coalition of healthcare organizations, led by the American Academy of Addiction Psychiatry, dedicated to expanding and improving the clinical care of substance use disorders. Their website hosts numerous informational resources, toolkits and webinars outlining best practices for the clinical management of substance use disorders and MOUD treatment. PCSS also offers direct mentorship for clinicians offering substance use treatment.

Opioid Response Network (ORN)
The ORN is a technical assistance collaboration between the American Academy of Addiction Psychiatry and the Addiction Technology Transfer Center at Columbia University. The ORN has local consultants in all 50 states and nine U.S. territories to provide communities with technical assistance and education on the prevention and treatment of OUD.

Opioid and Stimulant Implementation Support Training and Technical Assistance (OASIS-TTA)
OASIS-TTA, hosted by the University of California, Los Angeles, is an online repository of resources and toolkits for establishing MOUD services in a variety of health and social service settings. OASIS-TTA also accepts direct requests for technical assistance.

Rural Communities Opioid Response Program – Technical Assistance (RCORP-TA)
RCORP-TA is a multi-year initiative by the Health Resources and Services Administration (HRSA) that offers numerous online technical assistance resources related to linkage to care at re-entry.

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