Promoting Addiction Care Transitions Across Healthcare Settings

Noa Krawczyk, PhD
NYU Grossman School of Medicine

ABSTRACT:
Transitions from hospital-based care to community treatment represent a key implementation challenge in the continuum of care for opioid use disorder (OUD). While substantial progress has been made in implementing hospital-based initiation of medications for opioid use disorder (MOUD), less attention has focused on the strategies that ensure continuity of care following discharge. This gap reflects a broader challenge in moving from intervention adoption within discrete settings to sustained, cross-setting care delivery. This lecture presents findings from a multi-method research program aimed at characterizing and advancing the implementation of OUD care transition strategies. A scoping review identifies gaps in the evidence base and highlights limited specification and evaluation of transition interventions. A national survey of hospitals describes heterogeneity in implementation approaches and variable use of evidence-informed strategies. Results from a Delphi panel are used to introduce a taxonomy of care transition strategies designed to improve conceptual clarity, measurement, and comparability across studies. Finally, qualitative findings from hospital staff and patient interviews illustrate key implementation determinants, including organizational constraints, workflow misalignment, and facilitators such as peer support and  care coordination. Together, these findings underscore the need for theory-informed, system-level implementation strategies to support continuity of care, with relevance for other transitions, including those from criminal justice settings.