The overdose crisis continues to have devastating consequences nationally and in Massachusetts. Although overdose mortality has decreased slightly in the past several years, overdose is still a critical issue in the state: MDPH estimates that 2,125 people died from overdose in Massachusetts in 2023.1
Hospitalization represents an important but often missed opportunity for intervention. People with opioid use disorder (OUD) who have been hospitalized have a high rate of overdose mortality in the year following discharge.2 During the post-discharge period, individuals with OUD are also at high risk for other adverse outcomes such as hospital readmission,3 and have low engagement in follow-up services.4
To provide needed support during this critical period, the Linkages to Care (LinC) program was established in June 2024 by RIZE Massachusetts Foundation (RIZE), a nonprofit foundation working to end the opioid overdose epidemic in MA. The program funds eight grantee organizations across the state over two years, with the goal of supporting individuals at risk of overdose by strengthening collaboration between hospitals, community-based organizations (CBOs), and others. This initiative was designed based on findings from a previous ICH report that highlighted the critical importance of connections to care after hospital discharge.
ICH is working with RIZE to support the evaluation of the LinC program, with the goal of providing lessons learned about building successful linkages between hospitals and CBOs. LinC grantee sites are implementing a number of strategies, in coordination with their hospital partners, to support individuals during the post-discharge period after being hospitalized for a substance use-related reason, including:
- Utilizing Recovery Coaches, Navigators, and other individuals with lived experiences to provide connections, direct referrals, and warm hand-offs from hospital partners to CBOs
- Building networks of connections within hospital systems and developing relationships between hospital partners and CBO staff
- Providing follow-up care to individuals, including referrals to services, distribution of harm reduction and other supplies, connection to multiple levels of substance use disorder (SUD) care, and support to address social determinants of health
Early findings from the LinC program are promising. Data are available for two out of the four reporting periods (July-Dec 2024 and Jan-May 2025). To help visualize this data over time, ICH created a ‘care cascade,’5 which shows how patients move from one step of care to the next—from hospital discharge to ongoing community care—to identify gaps and successes in the process. As shown in the figure below, the overall number of individuals entering the care cascade increased from reporting period 1 (N=125) to period 2 (N=184), representing an increase in referrals from hospital partners to CBOs. We also calculated the percentage of individuals ‘remaining’ in the care cascade after each drop off, which remained relatively consistent from period 1 to 2, despite the program scaling up during this period. The largest drop-off in the care cascade for both reporting periods was from ‘referral to CBO’ to ‘receiving outreach within 7 days’, demonstrating that this time period is an area for ongoing improvement. These preliminary data are promising, demonstrating that these programs are successfully scaling up their work, providing post-discharge connection.
Care cascade: All sites combined over time
In addition, findings showed that LinC program sites increased service provision from reporting period 1 to period 2 (results are shown below in monthly averages, to account for the different lengths of the reporting periods). Sites increased the number of referrals to ‘internal’ services (provided within the CBO), as well as ‘external’ services (outside the CBO), distribution of harm reduction and other supplies, and provision of street outreach. The most common referrals included SUD treatment, medical services, and other wraparound services, and the most commonly distributed supplies included naloxone, fentanyl test strips, safer smoking supplies and syringes, and clothing, food, and hygiene items.
Service provision over time: Increase in average monthly numbers
Upcoming data from the two remaining reporting periods will be used to track ongoing grantee progress, and ICH is also in the process of conducting qualitative interviews with staff members and clients to gain additional insights. However, these preliminary data show early successes of the LinC project in building linkages between hospitals and CBOs during the critical post-discharge period. Upcoming evaluation aims to further demonstrate which strategies have been the most successful and provide recommendations for the field.
Acknowledgments:
This project is funded by a grant from RIZE Massachusetts Foundation, a public-private partnership solely dedicated to funding solutions to end the overdose crisis.
1 Department of Public Health. (2024, June 15). DPH report: Massachusetts opioid-related overdose deaths decreased 10 percent in 2023. https://www.mass.gov/news/dph-report-massachusetts-opioid-related-overdose-deaths-decreased-10-percent-in-2023.
2 King, C., Cook, R., Korthuis, P. T., Morris, C. D., & Englander, H. (2022). Causes of death in the 12 months after hospital discharge among patients with opioid use disorder. Journal of addiction medicine.
3 Peterson, C., Liu, Y., Xu, L., Nataraj, N., Zhang, K., & Mikosz, C. A. (2019). US national 90-day readmissions after opioid overdose discharge. American journal of preventive medicine, 56(6), 875-881.
4 Naeger, S., Mutter, R., Ali, M. M., Mark, T., & Hughey, L. (2016). Post-discharge treatment engagement among patients with an opioid-use disorder. Journal of Substance Abuse Treatment, 69, 64-71.
5Socías, M. E., Volkow, N., & Wood, E. (2016). Adopting the ‘cascade of care’ framework: an opportunity to close the implementation gap in addiction care?. Addiction (Abingdon, England), 111(12), 2079.