Strategies to Support Care Transitions for Patients With Opioid Use Disorder: Pathways and Partnerships for Success

Background: The Screening, Brief Intervention, and Referral to Treatment (SBIRT) model has been adapted for hospitals to address opioid use disorder (OUD). While most hospitals conduct screening and brief interventions, many do not offer referrals to further treatment, often due to limited external partnerships. There is limited evidence on which types of partnerships hospitals should prioritize to support care transitions. Methods: We conducted a survey of U.S.-based experts in addiction medicine and research to identify strategies for improving transitions and partnerships. Participants ranked 5 organization types that hospitals should prioritize for partnership development and listed specific actions to enhance transitions. We calculated mean rankings and analyzed strategies listed. Results: Experts ranked specialized addiction treatment programs, primary care clinics affiliated with hospitals, and harm reduction services as the top priorities for partnerships. Suggested strategies to support transitions clustered into 5 categories: (1) structured care transition programs within hospitals; (2) programs to address social and material needs; (3) data and reporting – internally and externally; (4) low-barrier policies shared among partners; and (5) creating community networks. Conclusions: Findings have the potential to support hospitals in prioritizing key partnerships and implementing actionable strategies to improve OUD care transitions through structured programs, material supports, and better data coordination.