4 Key Steps to Integrated Care Coordination for the Opioid Crisis


Substance use disorder is one of the nation’s most urgent population health management issues, not only because of its effect on individuals, but also because of the financial impact on hospitals and the rest of the healthcare system. Between 2000 and 2012, adult hospitalizations due to opioid misuse doubled. In 2015, more than 33,300 individuals across the nation died as a result of Opioid misuse. Communities across the nation are searching for ways to help individuals out of a problem that can feel inescapable. The 21st Century Cures act passed in December 2016 provides $1 billion in federal grants to help states deal with the Opioid crisis. This is great news, but there is still a lot of work to be done in determining the best way to care for these vulnerable individuals. Enter care coordination.

Individuals struggling with opioid use disorder issues are high risk and complex to manage. They are also very costly due to frequent visits to the ER. Tight coordination between treatment providers across the care continuum is essential in order to improve patient outcomes and prevent relapses and hospital re-admissions. Some of these providers could include: emergency shelters, hospitals, substance abuse treatment centers, and mental health facilities.

In order to effectively coordinate care for patients with substance abuse disorder, providers must have the ability to share patient data, including: medication status, hospital discharge summaries, care plans, referral orders, and emergency housing info. According to the Massachusetts eHealth Institute, there are four key steps in order to provide integrated care coordination for individuals with substance use disorder:

  1. Develop an integrated workflow at each provider
  2. Create consistent referral and privacy protocols between providers
  3. Establish content, data set, and formatting standards
  4. Create an integrated technical infrastructure to connect and support all providers

One community that has created an innovative solution for helping individuals with substance use disorder is Nashua, New Hampshire. The Partnership for Successful Living in Nashua is a collaboration of six agencies who work together to coordinate care for vulnerable individuals, including those with substance use disorder. Their services include residential, primary, behavioral care, and support services such as housing. Upon entering the program, trained Licensed Alcohol and Drug Counselors (LADC) perform a comprehensive intake and assessment individuals. Based on the recommendations of the LADC, the individual is enrolled in a Medical Respite program that includes case management, medical respite, behavioral health, and partial hospitalization. They could also be referred to Keystone Hall comprehensive residential and outpatient substance center. Because all six members of the Partnership for Successful Living use the ClientTrack Care Coordination platform, they are able to track the progress of program participants from start to finish and share vital patient information between all providers.

The Opioid crisis is only going to get worse. As organizations continue to grow and provide more services for individuals in the community, our care coordination platform will continue to provide the needed tools to assess, track, and manage program outcomes and the flexibility to grow with the programs.

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