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.

  1. The 2018 Overdose Response Strategy Cornerstone Project. White House Office of National Drug Control Policy; 2018. https://www.hidtaprogram.org/pdf/cornerstone_2018.pdf
  2. Taylor RM, Minkovitz CS. Warm Handoffs for Improving Client Receipt of Services: A Systematic Review. Matern Child Health J. 2021;25(4):528-541. doi:10.1007/s10995-020-03057-4
  3. Carroll JJ, Asher A, Krishnasamy V, Dowell D. Linking People with Opioid Use Disorder to Medication Treatment. Published online 2022. Accessed June 8, 2022. https://www.cdc.gov/drugoverdose/pdf/pubs/Linkage-to-Care_Edited-PDF_508-3-15-2022.pdf
  4. Williams AR, Nunes EV, Bisaga A, Levin FR, Olfson M. Development of a Cascade of Care for responding to the opioid epidemic. Am J Drug Alcohol Abuse. 2019;45(1):1-10. doi:10.1080/00952990.2018.1546862
  5. Stewart MT, Coulibaly N, Schwartz D, Dey J, Thomas CP. Emergency department-based efforts to offer medication treatment for opioid use disorder: What can we learn from current approaches? J Subst Abuse Treat. 2021;129:108479. doi:10.1016/j.jsat.2021.108479
  6. Blevins CE, Rawat N, Stein MD. Gaps in the Substance Use Disorder Treatment Referral Process: Provider Perceptions. J Addict Med. 2018;12(4):273-277. doi:10.1097/ADM.0000000000000400
  7. U.S. Substance Abuse and Mental Health Services Administration. The Sequential Intercept Model (SIM). SAMHSA. Published 2022. Accessed August 15, 2022. https://www.samhsa.gov/criminal-juvenile-justice/sim-overview
  8. Comprehensive Opioid, Stimulant, and Substance Abuse Program. Overdose Fatality Review. BJA’s Comprehensive Opioid, Stimulant, and Substance Abuse Program (COSSAP). Published 2022. Accessed September 7, 2022. https://www.cossapresources.org/Tools/OFR
  9. Young ND, Mathews BL, Pan AY, Herndon JL, Bleck AA, Takala CR. Warm handoff, or cold shoulder? An analysis of handoffs for primary care behavioral health consultation on patient engagement and systems utilization. Clinical Practice in Pediatric Psychology. 2020;8(3):241-246. doi:10.1037/cpp0000360
  10. Pace CA, Gergen-Barnett K, Veidis A, et al. Warm Handoffs and Attendance at Initial Integrated Behavioral Health Appointments. Ann Fam Med. 2018;16(4):346-348. doi:10.1370/afm.2263
  11. Starmer AJ, Spector ND, Srivastava R, et al. Changes in Medical Errors after Implementation of a Handoff Program. New England Journal of Medicine. 2014;371(19):1803-1812. doi:10.1056/NEJMsa1405556
  12. Horevitz E, Organista KC, Arean PA. Depression Treatment Uptake in Integrated Primary Care: How a “Warm Handoff” and Other Factors Affect Decision Making by Latinos. PS. 2015;66(8):824-830. doi:10.1176/appi.ps.201400085
  13. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474
  14. Bernstein SL, D’Onofrio G. Screening, treatment initiation, and referral for substance use disorders. Addiction Science & Clinical Practice. 2017;12(1):18. doi:10.1186/s13722-017-0083-z
  15. Samuels EA, Baird J, Yang ES, Mello MJ. Adoption and Utilization of an Emergency Department Naloxone Distribution and Peer Recovery Coach Consultation Program. Acad Emerg Med. 2019;26(2):160-173. doi:10.1111/acem.13545
  16. Herring AA, Schultz CW, Yang E, Greenwald MK. Rapid induction onto sublingual buprenorphine after opioid overdose and successful linkage to treatment for opioid use disorder. The American Journal of Emergency Medicine. 2019;37(12):2259-2262. doi:10.1016/j.ajem.2019.05.053
  17. Carroll GG, Wasserman DD, Shah AA, et al. Buprenorphine Field Initiation of Rescue Treatment by Emergency Medical Services (Bupe FIRST EMS): A Case Series. Prehospital Emergency Care. 2021;25(2):289-293.
  18. Davis CS, Carr DH, Glenn MJ, Samuels EA. Legal Authority for Emergency Medical Services to Increase Access to Buprenorphine Treatment for Opioid Use Disorder. Ann Emerg Med. 2021;78(1):102-108. doi:10.1016/j.annemergmed.2021.01.017
  19. Clark SA, Davis C, Wightman RS, et al. Using telehealth to improve buprenorphine access during and after COVID-19: A rapid response initiative in Rhode Island. J Subst Abuse Treat. 2021;124:108283. doi:10.1016/j.jsat.2021.108283
  20. North Carolina Department of Health and Human Services, Injury and Violence Prevention Branch. Post-Overdose Response Team (PORT) Toolkit. Published online 2020. Accessed September 9, 2022. https://files.nc.gov/ncdhhs/Post-Overdose-Response-Toolkit.pdf
  21. Frost MC, Williams EC, Kingston S, Banta-Green CJ. Interest in Getting Help to Reduce or Stop Substance Use Among Syringe Exchange Clients Who Use Opioids. J Addict Med. 2018;12(6):428-434. doi:10.1097/ADM.0000000000000426
  22. Latkin CA, Davey MA, Hua W. Needle exchange program utilization and entry into drug user treatment: is there a long-term connection in Baltimore, Maryland? Subst Use Misuse. 2006;41(14):1991-2001. doi:10.1080/10826080601026027
  23. Strathdee SA, Celentano DD, Shah N, et al. Needle-exchange attendance and health care utilization promote entry into detoxification. J Urban Health. 1999;76(4):448-460. doi:10.1007/BF02351502
  24. Hagan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. J Subst Abuse Treat. 2000;19(3):247-252.
  25. Des Jarlais DC, Nugent A, Solberg A, Feelemyer J, Mermin J, Holtzman D. Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas - United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64(48):1337-1341. doi:10.15585/mmwr.mm6448a3
  26. Bachhuber MA, Thompson C, Prybylowski A, Benitez J, Mazzella S, Barclay D. Description and outcomes of a buprenorphine maintenance treatment program integrated within Prevention Point Philadelphia, an urban syringe exchange program. Subst Abus. 2018;39(2):167-172. doi:10.1080/08897077.2018.1443541
  27. Prevention Point Philadelphia. STEP | Prevention Point. Prevention Point. Published 2020. Accessed December 6, 2020. https://ppponline.org/medical-services/step
  28. Howard Center. Syringe Exchange and Overdose Prevention. Published 2019. Accessed May 31, 2019. http://howardcenter.org/substance-use/needle-exchange-free-hiv-hepatitis-screening/
  29. Harrington D. The Kraft Center for Community Health at MGH mobilizes care for opioid use disorder to Boston’s most vulnerable. Boston Health Care for the Homeless Program. Published January 11, 2018. Accessed May 31, 2019. https://www.bhchp.org/blog/kraft-center-community-health-mgh-mobilizes-care-opioid-use-disorder-bostons-most-vulnerable
  30. Hood JE, Banta-Green CJ, Duchin JS, et al. Engaging an unstably housed population with low-barrier buprenorphine treatment at a syringe services program: Lessons learned from Seattle, Washington. Substance Abuse. 2019;0(0):1-9. doi:10.1080/08897077.2019.1635557
  31. Carter J, Zevin B, Lum PJ. Low barrier buprenorphine treatment for persons experiencing homelessness and injecting heroin in San Francisco. Addiction Science & Clinical Practice. 2019;14(1):20. doi:10.1186/s13722-019-0149-1
  32. U.S. Centers for Disease Control and Prevention. Tribal Syringe Services Program Helps Reduce Harm from Injection Drug Use. Public Health Professionals Gateway. Published 2020. Accessed October 29, 2021. https://www.cdc.gov/publichealthgateway/field-notes/2020/cherokee-hepatitis.html
  33. Winograd RP, Wood CA, Stringfellow EJ, et al. Implementation and evaluation of Missouri’s Medication First treatment approach for opioid use disorder in publicly-funded substance use treatment programs. J Subst Abuse Treat. 2020;108:55. doi:10.1016/j.jsat.2019.06.015
  34. Carroll JJ. Evidence Based Medicine and the Construction of Moral Agency in Ukraine. Cargo Journal for Cultural / Social Anthropology. 2011;9(1-2):25-50.
  35. Boilevin L, Chapman J, Deane L, et al. Research 101 : A Manifesto for Ethical Research in the Downtown Eastside. Published online March 15, 2019. doi:10.14288/1.0377565
  36. Cernasev A, Hohmeier KC, Frederick K, Jasmin H, Gatwood J. A systematic literature review of patient perspectives of barriers and facilitators to access, adherence, stigma, and persistence to treatment for substance use disorder. Explor Res Clin Soc Pharm. 2021;2:100029. doi:10.1016/j.rcsop.2021.100029
  37. Facher L. In a nationwide first, New Jersey authorizes paramedics to start addiction treatment at the scene of an overdose. STAT. Published June 26, 2019. Accessed September 7, 2022. https://www.statnews.com/2019/06/26/new-jersey-paramedics-buprenorphine/
  38. MetroHealth. Thrive ED Peer Support Program. Programs. Published 2022. Accessed September 7, 2022. https://www.metrohealth.org:443/office-of-opioid-safety/programs
  39. Capecodtoday Staff. AIDS Support Group of Cape Cod Receives Grant for Harm Reduction Services. Cape Cod Today. https://web.archive.org/web/20181010212758/http://capecodtoday.com/article/2018/10/10/242685-AIDS-Support-Group-Cape-Cod-Receives-Grant-Harm-Reduction-Services. Published October 10, 2018. Accessed September 7, 2022.

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