Warm Hand-Offs: A NACo Opioid Solutions Strategy Brief

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"[A warm hand-off] is more than the provision of information or referrals – it is compassionate and non-coercive accompaniment to an appropriate care provider.” 

– White House Office of National Drug Control Policy1

What are warm hand-off programs?

A warm hand-off is a form of referral to treatment or other services. A typical referral gives someone information about how to reach the services they need but may leave them to contact those services on their own. In contrast, a warm hand-off is a transfer of care between service providers through face-to-face, phone or video interaction in the presence of the person being helped.2 Local stakeholders can design warm hand-off programs using the following steps:

  1. Local stakeholders collaborate to identify potential points of contact with community members in need of substance use treatment. These stakeholders include health care providers, social service providers, people who are receiving substance-use related services and peer counselors. Points of contact typically include emergency departments, primary care clinics, syringe services programs (SSPs), social services agencies, jails and schools.3,4
  2. Healthcare providers, social service providers and community partners with capacity to accept new clients are identified and invited to participate in a local referral network.5,6
  3. Stakeholders and participating providers collaborate to establish acceptable procedures for communication, data management and the delivery of warm hand-offs across agencies.

Several approaches for identifying potential points of contact with people at risk of overdose have been developed. These include: 

Sequential Intercept Mapping (SIM): a method for conceptualizing how individuals move through a local system (e.g., criminal justice or behavioral health continuum of care) to identify and maximize opportunities for linkage to care. Key community stakeholders receive evidence-based overdose prevention and linkage to care training. They then collaborate to locate points of contact with community members in need, build procedures for linkage to care and share resources across agencies to fill gaps in service.7

Overdose Fatality Review (OFR): a practice of confidential individual death reviews by an interdisciplinary team of stakeholders and service providers. Participating stakeholders include representatives from public health, first responder agencies, harm reduction organizations and directly impacted populations. Providers represented on the team include primary care providers, mental health providers and social service practitioners. By investigating what could have been done to prevent these and similar deaths, OFR participants break down silos across service agencies, identify gaps in services and find missed opportunities for intervention and linkage to care.8 

What evidence supports the use of warm hand-off programs?

Warm hand-offs improve the efficacy and efficiency of treatment referrals in several ways. Warm hand-offs are associated with better treatment engagement9,10 and fewer medical errors during the transfer of care.11 A patient’s interest in continuing care is influenced by the quality of their relationships with service providers and the quality of the referral process they go through,12 both of which can be improved through warm hand-off strategies.

Importantly, warm hand-off strategies have been found to increase patient engagement in substance use treatment when that hand-off connects them with integrated behavioral health services (e.g. clinics that offer both primary care and addiction treatment) at safety-net hospitals that provide care regardless of ability to pay.10

Research supports warm hand-offs to evidence-based treatment in several settings:

Emergency departments: Patients offered a warm hand-off to treatment with medications for opioid use disorder (MOUD) from an emergency physician are more than twice as likely to accept care13 and a high proportion remain engaged in care two months later.14 A warm hand-off from the emergency department is even more effective when trained peer recovery staff are on hand to engage the person in need of treatment, nearly doubling the acceptance of a referral to MOUD at discharge.15

See how trained peer recovery coaches can link people to treatment in emergency departments.

Emergency medical services (EMS): EMS personnel often encounter people in need of MOUD when responding to accidental overdose. After using naloxone to revive and stabilize someone who experienced an overdose, EMS can administer a first dose buprenorphine to begin medication treatment immediately16 and then provide a warm hand-off to an outpatient buprenorphine prescriber the next day without transporting the person to a hospital.17

Post-overdose response teams: EMS or other healthcare professionals can follow up the day after responding to an overdose, administer a first dose of buprenorphine to the person who overdosed (if desired) and provide a warm hand-off to treatment.18 Emergency departments can follow up by phone with patients who were recently treated for overdose but were not linked with MOUD prior to discharge.19 Finally, teams of peer support specialists, outreach professionals and/or community health workers can call or visit a person who has overdosed 24-72 hours later to offer harm reduction services and, if desired, a warm hand-off to treatment.20

Syringe services programs: Studies have shown that people who engage in services offered by SSPs are more likely to successfully reduce their substance use,21 enter treatment22,23 and remain engaged in treatment24 than those who do not. Most SSPs already provide referrals and warm hand-offs to multiple forms of treatment, including MOUD,25 and many offer MOUD treatment onsite, including SSPs in Philadelphia, Pa.,26,27 Burlington, Vt.,28 Boston, Mass.,29 Seattle, Wash.,30 San Francisco, Calif.31 and on the reservation home of the Eastern Band of Cherokee Indians in North Carolina.32

While warm hand-off programs improve efficiency of referrals and enhance engagement with treatment, research suggests the quality of the referral process and the patient-provider relationship may be factors in the effectiveness of connecting individuals to the treatment they need.12

Are there best practices for establishing or operating warm hand-off programs?

  • Support a “Medication First” approach by prioritizing rapid, low-barrier access to MOUD even before the warm hand-off to sustained treatment services takes place. This approach significantly increases entry into treatment.33
  • Allocate funding for additional follow-up and peer support services to assist people experiencing comorbidities like HIV, homelessness and/or mental health concerns in navigating health care systems and engaging in care.26
  • Include people with lived and living experience of substance use in the planning, management and implementation of warm hand-off programs.34,35
  • Fight stigma and misinformation by voicing strong, unambiguous support for medication as an evidence-based treatment for OUD. Stigma and misinformation about OUD and medications that treat OUD pose significant and persistent barriers to people getting the care they need.36

What are some examples of effective warm hand-off programs?

Paramedics in Contra Costa County, Calif. are equipped with buprenorphine and, under a medical supervisor, administer that medication to people who have experienced an overdose once the overdose has been reversed and the person has been stabilized.18,37

MetroHealth Medical Center of Cuyahoga County, Ohio embeds state certified peer support specialists in the emergency department and in inpatient and outpatient units. Peer support specialists are available 24/7 and offer on-demand warm hand-offs to recovery services and substance use treatment as well as buprenorphine induction with an advanced practice provider.38

AIDS Support Group in Barnstable County, Mass. partners with Duffy Health Services, a substance use treatment and MOUD provider, to provide SSP participants with expedited access to MOUD through warm hand-offs between the SSP and the clinic. The partnership supports engagement in treatment and harm reduction services through a health navigator located at the SSP.39

These and many other model programs are described online at the Brandeis Opioid Resource Connector.

Visit the Brandeis Opioid Resource Connector

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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

Rural Communities Opioid Response Program – Technical Assistance (RCORP-TA)
RCORP-TA is a multi-year initiative by the U.S. Health Resources and Services Administration (HRSA) that offers numerous online technical assistance resources, including many on the topic of expanding MOUD access and building new pathways into treatment.

Opioid Response Network (ORN)
The ORN is a technical assistance collaboration between the American Academy of Addiction Psychiatry and 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.

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