Journal Article

Forging hospital and community partnerships to enable care coordination for opioid use disorder

Fenstemaker, Cheyenne, Pagán, José A., Franz, Berkeley, Lindenfeld, Zoe, Chang, Ji Eun, Cronin, Cory E., Lai, Alden Yuanhong

2025

Overview

Background Programs that aim to increase access to substance use disorder (SUD) treatment in hospital-based settings have proliferated in recent years. These efforts include transitional opioid programs (TOPs), which navigate patients to community-based SUD treatment programs post-discharge. Successful navigation from TOPs to outpatient treatment hinges on effective coordination between hospitals and post-discharge endpoints, yet it is unclear how hospitals can best develop effective partnerships with outpatient treatment organizations. The objective of this study is to synthesize the common themes underpinning the development of partnerships to facilitate care transitions between TOPs and ongoing SUD treatment. Methods Qualitative study with staff and providers from hospitals affiliated with four safety-net health systems ( n  = 21) and leaders from community-based organizations (CBOs) and treatment facilities that had established referral partnerships with one of the four health systems in our study ( n  = 4). Results Analysis of interview transcripts revealed seven common themes that underpinned the development of care transitions partnerships: (1) Active, intentional outreach; (2) Responding to a community need; (3) External Enabling Factors; (4) Leveraging reputations and community connections; (5) Focusing on operations; (6) Reciprocal relationships; and (7) Building Infrastructure and Processes to Ensure Collaboration. The seven identified themes were categorized into three groups corresponding to different partnership development stages. The first group revolves around the initial stage of meeting and developing a relationship (themes #1–4). The second set focuses on navigating and resolving challenges that arise in the partnership (themes #5–6). Lastly, the third group pertains to sustaining a partnership long-term (theme #7). Conclusions This study identifies seven core themes underlying the development of care transition partnerships for SUD patients within four safety net health systems and their CBO partners. These themes demonstrate how partner organizations can establish the trust, reciprocity, and commitment necessary to support patients through the critical transition period.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Accountable care organizations / Analysis / Care coordination / Care transitions / Community / Community Health Services - organization & administration / Community organizations / Community-Institutional Relations / Coordination / Data analysis / Data collection / Discharge / Drug overdose / Drug use / Emergency medical care / Evidence-based medicine / Health / Health care / Health Psychology / Health services / Hospitals / Humans / Indigent care / Infrastructure / Interviews / Leadership / Medical referrals / Medical treatment / Medicine / Medicine & Public Health / Narcotics / Navigation / Nonprofit organizations / Opioid use disorders / Opioid-Related Disorders - therapy / Opioids / Organizations / Outpatient treatment / Partnerships / Patients / Pharmacology/Toxicology / Psychopharmacology / Public Health / Qualitative Research / Reciprocity / Safety / Safety-net Providers - organization & administration / Social Work / Substance abuse / Substance abuse treatment / Substance use disorder / Substance use disorders / Teams / Treatment programs