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.

  1. Mace S, Siegler A, Wu KC. Overdose Response and Linkage to Care: A Roadmap for Health Departments. National Council for Mental Wellbeing; 2021. https://www.thenationalcouncil.org/wp-content/uploads/2022/02/Overdose-Response-and-Linkage-to-Care-Roadmap-1-November-2021.pdf
  2. Vivolo-Kantor AM, Seth P, Gladden RM, et al. Vital Signs: Trends in Emergency Department Visits for Suspected Opioid Overdoses - United States, July 2016-September 2017. MMWR - Morbidity & Mortality Weekly Report. 2018;67(9):279-285.
  3. Guy GP, Pasalic E, Zhang K. Emergency Department Visits Involving Opioid Overdoses, U.S., 2010-2014. Am J Prev Med. 2018;54(1):e37-e39. doi:10.1016/j.amepre.2017.09.003
  4. Miller AC, Polgreen PM. Many Opportunities to Record, Diagnose, or Treat Injection Drug-related Infections Are Missed: A Population-based Cohort Study of Inpatient and Emergency Department Settings. Clin Infect Dis. 2019;68(7):1166-1175. doi:10.1093/cid/ciy632
  5. Bronson J, Stroop J, Zimmer S, Berzofsky M. Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007-2009. https://bjs.ojp.gov/content/pub/pdf/dudaspji0709.pdf
  6. National Center on Substance Abuse and Child Welfare. Child Welfare and Alcohol and Drug Use Statistics. National Center on Substance Abuse and Child Welfare. Published 2020. Accessed September 19, 2022. https://ncsacw.acf.hhs.gov/research/child-welfare-and-treatment-statistics.aspx
  7. Arria AM, Caldeira KM, Allen HK, Bugbee BA, Vincent KB, O’Grady KE. Prevalence and incidence of drug use among college students: an 8-year longitudinal analysis. Am J Drug Alcohol Abuse. 2017;43(6):711-718. doi:10.1080/00952990.2017.1310219
  8. Carroll JJ, Asher A, Krishnasamy V, Dowell D. Linking People with Opioid Use Disorder to Medication Treatment. Published online 2022. Accessed June 8, 2022. https://www.cdc.gov/drugoverdose/pdf/pubs/Linkage-to-Care_Edited-PDF_508-3-15-2022.pdf
  9. Wen H, Hockenberry JM, Borders TF, Druss BG. Impact of Medicaid Expansion on Medicaid-covered Utilization of Buprenorphine for Opioid Use Disorder Treatment. Med Care. 2017;55(4):336-341. doi:10.1097/MLR.0000000000000703
  10. Jones CM, Campopiano M, Baldwin G, McCance-Katz E. National and State Treatment Need and Capacity for Opioid Agonist Medication-Assisted Treatment. Am J Public Health. 2015;105(8):e55-63. doi:10.2105/AJPH.2015.302664
  11. Hinde J, Hayes J, Mark T, Bernstein S, Karon SL. State and Local Policy Levers for Increasing Treatment and Recovery Capacity to Address the Opioid Epidemic: Final Report. Office of the Assistant Secretary for Planning and Evalutaion, U.S. Department of Health and Human Services; 2017. Accessed May 28, 2019. https://aspe.hhs.gov/basic-report/state-and-local-policy-levers-increasing-treatment-and-recovery-capacity-address-opioid-epidemic-final-report
  12. Reif S, Creedon TB, Horgan CM, Stewart MT, Garnick DW. Commercial Health Plan Coverage of Selected Treatments for Opioid Use Disorders from 2003 to 2014. J Psychoactive Drugs. 2017;49(2):102-110. doi:10.1080/02791072.2017.1300360
  13. Connery HS. Medication-assisted treatment of opioid use disorder: review of the evidence and future directions. Harv Rev Psychiatry. 2015;23(2):63-75. doi:10.1097/HRP.0000000000000075
  14. Taylor RM, Minkovitz CS. Warm Handoffs for Improving Client Receipt of Services: A Systematic Review. Matern Child Health J. 2021;25(4):528-541. doi:10.1007/s10995-020-03057-4
  15. Dunphy C, Peterson C, Zhang K, Jones CM. Do out-of-pocket costs influence retention and adherence to medications for opioid use disorder? Drug Alcohol Depend. 2021;225:108784. doi:10.1016/j.drugalcdep.2021.108784
  16. McClellan C, Moriya A, Simon K. Users of retail medications for opioid use disorders faced high out-of-pocket prescription spending in 2011-2017. J Subst Abuse Treat. 2022;132:108645. doi:10.1016/j.jsat.2021.108645
  17. Liebschutz JM, Crooks D, Herman D, et al. Buprenorphine treatment for hospitalized, opioid-dependent patients: a randomized clinical trial. JAMA Intern Med. 2014;174(8):1369-1376. doi:10.1001/jamainternmed.2014.2556
  18. D’Onofrio G, Chawarski MC, O’Connor PG, et al. Emergency Department-Initiated Buprenorphine for Opioid Dependence with Continuation in Primary Care: Outcomes During and After Intervention. J Gen Intern Med. Published online February 13, 2017. doi:10.1007/s11606-017-3993-2
  19. Wakeman SE, Kane M, Powell E, Howard S, Shaw C, Regan S. Impact of Inpatient Addiction Consultation on Hospital Readmission. J GEN INTERN MED. 2021;36(7):2161-2163. doi:10.1007/s11606-020-05966-0
  20. Barry CL, Epstein AJ, Fiellin DA, Fraenkel L, Busch SH. Estimating demand for primary care-based treatment for substance and alcohol use disorders. Addiction. 2016;111(8):1376-1384. doi:10.1111/add.13364
  21. Fiellin DA, Moore BA, Sullivan LE, et al. Long-term treatment with buprenorphine/naloxone in primary care: results at 2-5 years. Am J Addict. 2008;17(2):116-120. doi:10.1080/10550490701860971
  22. Soeffing JM, Martin LD, Fingerhood MI, Jasinski DR, Rastegar DA. Buprenorphine maintenance treatment in a primary care setting: outcomes at 1 year. J Subst Abuse Treat. 2009;37(4):426-430. doi:10.1016/j.jsat.2009.05.003
  23. Green TC, Clarke J, Brinkley-Rubinstein L, et al. Postincarceration Fatal Overdoses After Implementing Medications for Addiction Treatment in a Statewide Correctional System. JAMA Psychiatry. 2018;75(4):405-407. doi:10.1001/jamapsychiatry.2017.4614
  24. Deutsch SA, Donahue J, Parker T, Hossain J, Loiselle C, De Jong AR. Impact of Plans of Safe Care on Prenatally Substance Exposed Infants. The Journal of Pediatrics. 2022;241:54-61.e7. doi:10.1016/j.jpeds.2021.10.032
  25. Naeger S, Mutter R, Ali MM, Mark T, Hughey L. Post-Discharge Treatment Engagement Among Patients with an Opioid-Use Disorder. J Subst Abuse Treat. 2016;69:64-71. doi:10.1016/j.jsat.2016.07.004
  26. Auty SG, Lipson SK, Stein MD, Reif S. Mental health service use in a national sample of college students with co-occurring depression or anxiety and substance use. Drug and Alcohol Dependence Reports. 2022;2:100025. doi:10.1016/j.dadr.2022.100025
  27. Byrne KA, Roth PJ, Merchant K, et al. Inpatient link to peer recovery coaching: Results from a pilot randomized control trial. Drug and Alcohol Dependence. 2020;215:108234. doi:10.1016/j.drugalcdep.2020.108234
  28. Samuels EA, Baird J, Yang ES, Mello MJ. Adoption and Utilization of an Emergency Department Naloxone Distribution and Peer Recovery Coach Consultation Program. Acad Emerg Med. 2019;26(2):160-173. doi:10.1111/acem.13545
  29. Scott CK, Grella CE, Nicholson L, Dennis ML. Opioid recovery initiation: Pilot test of a peer outreach and modified Recovery Management Checkup intervention for out-of-treatment opioid users. Journal of Substance Abuse Treatment. 2018;86:30-35.
  30. National Institutes of Health. Methadone and buprenorphine reduce risk of death after opioid overdose. National Institutes of Health (NIH). Published June 19, 2018. Accessed June 8, 2022. https://www.nih.gov/news-events/news-releases/methadone-buprenorphine-reduce-risk-death-after-opioid-overdose
  31. Wakeman SE, Larochelle MR, Ameli O, et al. Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder. JAMA Network Open. 2020;3(2):e1920622.
  32. Mital S, Wolff J, Carroll JJ. The relationship between incarceration history and overdose in North America: A scoping review of the evidence. Drug Alcohol Depend. 2020;213:108088. doi:10.1016/j.drugalcdep.2020.108088
  33. Stoové MA, Dietze PM, Jolley D. Overdose deaths following previous non-fatal heroin overdose: record linkage of ambulance attendance and death registry data. Drug Alcohol Rev. 2009;28(4):347-352. doi:10.1111/j.1465-3362.2009.00057.x
  34. Thumath M, Humphreys D, Barlow J, et al. Overdose among mothers: The association between child removal and unintentional drug overdose in a longitudinal cohort of marginalised women in Canada. Int J Drug Policy. 2021;91:102977. doi:10.1016/j.drugpo.2020.102977
  35. U.S. Substance Abuse and Mental Health Services Administration. The Sequential Intercept Model (SIM). SAMHSA. Published 2022. Accessed August 15, 2022. https://www.samhsa.gov/criminal-juvenile-justice/sim-overview
  36. Substance Abuse and Mental Health Services Administration. Use of Medication-Assisted Treatment for Opioid Use Disorder in Criminal Justice Settings. Substance Abuse and Mental Health Services Administration (US); 2019. Accessed August 24, 2022. https://store.samhsa.gov/sites/default/files/d7/priv/pep19-matusecjs.pdf
  37. Kaplan-Dobbs M, Kattan JA, Tuazon E, Jimenez C, Saleh S, Kunins HV. Increasing Access to Buprenorphine in Safety-Net Primary Care Clinics: The New York City Buprenorphine Nurse Care Manager Initiative. American Journal of Public Health. 2021;111(2):215-218.
  38. Kaplowitz E, Truong A, Macmadu A, et al. Anticipated Barriers to Sustained Engagement in Treatment With Medications for Opioid Use Disorder After Release From Incarceration. J Addict Med. Published online August 2, 2022. doi:10.1097/ADM.0000000000001029
  39. Heller D, Bradley O’Brien D, Harocopos A, et al. RxStat: Technical Assistance Manual. Published online 2014. Accessed April 5, 2021. http://www.pdmpassist.org/pdf/PDMP_admin/RxStat-3.pdf
  40. Comprehensive Opioid, Stimulant, and Substance Abuse Program. Overdose Fatality Review. BJA’s Comprehensive Opioid, Stimulant, and Substance Abuse Program (COSSAP). Published 2022. Accessed September 7, 2022. https://www.cossapresources.org/Tools/OFR
  41. Knapp M. How a Local Health Department Garnered Stakeholder Support to Establish a Fatality Review Team. Published online 2023. Accessed October 9, 2023. https://www.cossup.org/Content/Documents/OFR/2023Forum/How_Local_County_Health_Department_Garnered_Stakeholder_Support_to_Establish_Fatality_Review_Team.pdf
  42. Durham County NC. Community Linkages To Care (CLC) Peer Support Program. Public Health Durham County NC. Published 2023. Accessed October 10, 2023. https://www.dcopublichealth.org/services/health-education/opioid-substance-use-and-addiction-services/community-linkages-to-care-clc-peer-support-program
  43. Brooklyn JR, Sigmon SC. Vermont Hub-and-Spoke Model of Care for Opioid Use Disorder: Development, Implementation, and Impact. J Addict Med. 2017;11(4):286-292. doi:10.1097/ADM.0000000000000310