Multidisciplinary Strategies to Improve Transitions of Care for Patients with Opioid Use Disorder: A Clinical Quality Improvement Study

Abstract

Background: The period immediately following hospital discharge is a critical time of physical and social vulnerability for patients with opioid use disorder (OUD). Transitions from inpatient to outpatient care are often marked by fragmented services, interruptions in medication for opioid use disorder (MOUD), and delays in connecting patients with community treatment. These gaps may increase risks of overdose, emergency department (ED) use, and hospital readmission. Passive referral practices often fail to ensure timely and sustained treatment engagement, highlighting the need for structured, multidisciplinary transition strategies.

Methods: We conducted a quality improvement cohort study evaluating a standardized transition-of-care (TOC) pathway at an urban academic medical center. The pathway included three phases: inpatient OUD identification and MOUD initiation or continuation; multidisciplinary bedside navigation involving addiction clinicians, nurses, social workers, and Peer Recovery Support Specialists (PRSSs); and active warm handoffs to outpatient care. Interventions included standardized screening, direct scheduling of outpatient appointments within 48 to 72 hours, bedside naloxone distribution, electronic health record handoffs, and structured follow-up. Outcomes were compared with a historical cohort receiving traditional discharge planning.

Results: Patients receiving the multidisciplinary TOC intervention demonstrated significant improvements in treatment engagement and continuity of care. Outpatient appointment attendance within 72 hours and 30-day MOUD continuation increased substantially compared with historical controls. PRSS engagement was independently associated with greater outpatient attendance and reductions in 30-day all-cause ED visits and hospital readmissions.

Conclusions: Multidisciplinary TOC pathways may improve OUD treatment continuity by addressing clinical, social, and organizational barriers to care. Integrating inpatient MOUD, peer recovery support, social navigation, harm reduction, and active warm handoffs may provide a scalable strategy for strengthening connections between hospital and community-based addiction treatment.

Keywords: opioid use disorder, medication for opioid use disorder, transitions of care, multidisciplinary care, peer recovery support, warm handoffs, care coordination, hospital discharge, treatment retention, healthcare utilization

DOI: 10.7176/JMPB/76-03

Publication date: July 31^st 2026