Medical hospitalizations are common among people with substance use disorders (SUD) and represent important opportunities for engagement, treatment initiation, and linkage to follow-up care. However, hospitalizations are also destabilizing events marked by an elevated risk of death and readmission in the period immediately following hospital discharge. There is currently no consensus on the best way to support patients with SUD as they transition from the hospital to follow-up care in the community after discharge. Care transitions span multiple care settings and are influenced by a wide array of medical, psychosocial, and environmental factors. Given their complexity, it is crucial to engage a diverse array of partners to collaboratively set research priorities, define outcomes, and design interventions to improve care in this area. Key partners include people with lived substance use experience, hospital-based clinicians, social workers, addiction specialists, peer navigators, primary care clinicians, and more. A community-engaged research framework is essential to promote equitable contribution from this diverse group of collaborators. In this article, we share our protocol for a community engagement project called COmmunity Network to Navigate and Enhance Care Transitions and describe how we integrated core principles of community-engaged research into its design.
HebertAHHillAL.Impact of opioid overdoses on US life expectancy and years of life lost, by demographic group and stimulant co-involvement: a mortality data analysis from 2019 to 2022. Lancet Reg Health Am. 2024;36:100813. doi:10.1016/j.lana.2024.100813
BearnotBFineDRRigottiNABaggettTP.Access to treatment for drug use disorders at US Health Centers: a national study. J Gen Intern Med. 2019;34(12):2723-2725. doi:10.1007/s11606-019-05043-1
4.
BearnotBRigottiNABaggettTP.Access to Treatment for alcohol use disorder at US Health Centers: a national study. J Gen Intern Med. 2018;33(12):2040-2042. doi:10.1007/s11606-018-4631-3
5.
Substance Use Disorder Treatment for People With Co-Occurring Disorders: Updated 2020. 2020. SAMHSA/CSAT Treatment Improvement Protocols.
6.
American Society of Addiction Medicine. The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. 2020.
7.
SuenLWMakamANSnyderHR, et al. National prevalence of alcohol and other substance use disorders among emergency department visits and hospitalizations: NHAMCS 2014-2018. J Gen Intern Med. 2022;37(10):2420-2428. doi:10.1007/s11606-021-07069-w
8.
BernsteinEYCalcaterraSLChopraVEdelmanEJKruseGR.Prevalence of hospitalizations among a national sample of U.S. adults with substance use disorders. Ann Intern Med. 2025;178:900-903. doi:10.7326/ANNALS-24-03385
9.
EnglanderHDobbertinKLindB, et al. Inpatient addiction medicine consultation and post-hospital substance use disorder treatment engagement: a propensity-matched analysis. J Gen Intern Med. 2019;34:2796-2803. doi:10.1007/s11606-019-05251-9
10.
EnglanderHJonesAKrawczykN, et al. A Taxonomy of hospital-based addiction care models: a scoping review and key informant interviews. J Gen Intern Med. 2022;37(11):2821-2833. doi:10.1007/s11606-022-07618-x
11.
McNeelyJWangSSRostam AbadiY, et al. Addiction consultation services for opioid use disorder treatment initiation and engagement: a randomized clinical trial. JAMA Intern Med. 2024;184(9):1106-1115. doi:10.1001/jamainternmed.2024.3422
12.
OberAJMurray-KrezanCPageK, et al. Hospital addiction consultation service and opioid use disorder treatment: the START randomized clinical trial. JAMA Intern Med. 2025;185:624-633. doi:10.1001/jamainternmed.2024.8586
13.
SalvalaggioGDongKAHyshkaE, et al. Impact of an addiction medicine consult team intervention in a Canadian inner city hospital on acute care utilization: a pragmatic quasi-experimental study. Subst Abuse Treat Prev Policy. 2022;17(1):20. doi:10.1186/s13011-022-00445-7
14.
TrowbridgePWeinsteinZMKerenskyT, et al. Addiction consultation services—linking hospitalized patients to outpatient addiction treatment. J Subst Abuse Treat. 2017;79:1-5. doi:10.1016/j.jsat.2017.05.007
15.
WakemanSEMetlayJPChangYHermanGERigottiNA.Inpatient addiction consultation for hospitalized patients increases post-discharge abstinence and reduces addiction severity. J Gen Intern Med. 2017;32(8):909-916. doi:10.1007/s11606-017-4077-z
16.
WeinsteinZMChengDMD’AmicoMJ, et al. Inpatient addiction consultation and post-discharge 30-day acute care utilization. Drug Alcohol Depend. 2020;213:108081. doi:10.1016/j.drugalcdep.2020.108081
17.
WeinsteinZMWakemanSENolanS.Inpatient addiction consult service: expertise for hospitalized patients with complex addiction problems. Med Clin North Am. 2018;102(4):587-601. doi:10.1016/j.mcna.2018.03.001
18.
InczeMAHueblerSBaylisJD, et al. Mortality among veterans with opioid use disorder after medical hospitalization. JAMA Intern Med. 2025;185:734-736. doi:10.1001/jamainternmed.2025.0356
19.
KingCCookRKorthuisPTMorrisCDEnglanderH.Causes of death in the 12 months after hospital discharge among patients with opioid use disorder. J Addict Med. 2022;16(4):466-469. doi:10.1097/ADM.0000000000000915
20.
InczeMAHueblerSSzczotkaKGrantSKerteszSGGordonAJ.Expert panel consensus on the effectiveness and implementation of models to support posthospitalization care transitions for people with substance use disorders. J Addict Med. 2024;18(6):696-704. doi:10.1097/ADM.0000000000001369
21.
InczeMAKelleyATJamesH, et al. Post-hospitalization care transition strategies for patients with substance use disorders: a narrative review and taxonomy. J Gen Intern Med. 2024;39:837-846.
22.
JamesHMorganJTiLNolanS.Transitions in care between hospital and community settings for individuals with a substance use disorder: a systematic review. Drug Alcohol Depend. 2023;243:109763. doi:10.1016/j.drugalcdep.2023.109763
23.
KrawczykNMillerMEnglanderH, et al. Toward a consensus on strategies to support opioid use disorder care transitions following hospitalization: a modified Delphi process. J Gen Intern Med. 2025;40:1048-1058. doi:10.1007/s11606-024-09108-8
24.
AboumatarHNaqibuddinMChungS, et al. Effect of a hospital-initiated program combining transitional care and long-term self-management support on outcomes of patients hospitalized with chronic obstructive pulmonary disease: a randomized clinical trial. JAMA. 2019;322(14):1371-1380. doi:10.1001/jama.2019.11982
25.
BengeCPouliotJMuldowneyJAS3rd. Evaluation of a clinical pharmacist specialist transition of care pathway to manage heart failure readmissions during a provider shortage. J Pharm Pract. 2022;35(6):929-939. doi:10.1177/08971900211017484
26.
BlumerVGayowskyAXieF, et al. Effect of patient-centered transitional care services on patient-reported outcomes in heart failure: sex-specific analysis of the PACT-HF randomized controlled trial. Eur J Heart Fail. 2021;23(9):1488-1498. doi:10.1002/ejhf.2312
27.
BodenLCastellsagueMPerrenoudLCimarelliGSchneiderMPGastaldiG.Transition hopital-ambulatoire : les enjeux pour les patients avec un diabete sucre [Hospital to home transition of care: challenges for patients with type 2 diabetes]. Rev Med Suisse. 2021;17(741):1087-1090.
28.
BurdickTEMoranDSOliverBJ, et al. Transitional care management quality improvement methods that reduced readmissions in a rural, primary care system. J Am Board Fam Med. 2022;35(3):537-547. doi:10.3122/jabfm.2022.03.190435
29.
ChauhanUMcAlisterFA.Comparison of mortality and hospital readmissions among patients receiving virtual ward transitional care vs usual postdischarge care: a systematic review and meta-analysis. JAMA Netw Open. 2022;5(6):e2219113. doi:10.1001/jamanetworkopen.2022.19113
30.
CoeABMoczygembaLROgbonnaKCParsonsPLSlattumPWMazmanianPE.Low-income senior housing residents’ emergency department use and care transition problems. J Pharm Pract. 2018;31(6):610-616. doi:10.1177/0897190017734763
31.
CorsinoLPadillaBI.A transition of care model from hospital to community for Hispanic/Latino adult patients with diabetes: design and rationale for a pilot study. Pilot Feasibility Stud. 2022;8(1):246. doi:10.1186/s40814-022-01203-z
32.
CoskunSDuyguluS.The effects of Nurse Led Transitional Care Model on elderly patients undergoing open heart surgery: a randomized controlled trial. Eur J Cardiovasc Nurs. 2022;21(1):46-55. doi:10.1093/eurjcn/zvab005
33.
Balls-BerryJEAcosta-PerezE.The use of community engaged research principles to improve health: community academic partnerships for research. P R Health Sci J. 2017;36(2):84-85.
34.
IsraelBACoombeCMCheezumRR, et al. Community-based participatory research: a capacity-building approach for policy advocacy aimed at eliminating health disparities. Am J Public Health;100(11):2094-102. doi:10.2105/AJPH.2009.170506
BannMCullenRde BoerCHrachovecDRozlerABlumeG.A climate of stigma, uncertainty, and distrust: stakeholder perception of barriers to SNF placement for patients with opioid use disorder treated with methadone. J Gen Intern Med. 2024. doi:10.1007/s11606-024-09100-2
38.
KlusaritzHBilgerAPatersonE, et al. Impact of stigma on clinician training for opioid use disorder care: a qualitative study in a primary care learning collaborative. Ann Fam Med. 2023;21(Suppl 2):S31-S38. doi:10.1370/afm.2920
39.
NybladeLStocktonMAGigerK, et al. Stigma in health facilities: why it matters and how we can change it. BMC Med. 2019;17(1):25. doi:10.1186/s12916-019-1256-2
40.
PaquetteCESyvertsenJLPolliniRA.Stigma at every turn: Health services experiences among people who inject drugs. Int J Drug Policy. 2018;57:104-110. doi:10.1016/j.drugpo.2018.04.004
41.
StoneEMKennedy-HendricksABarryCLBachhuberMAMcGintyEE.The role of stigma in U.S. primary care physicians’ treatment of opioid use disorder. Drug Alcohol Depend. 2021;221:108627. doi:10.1016/j.drugalcdep.2021.108627
42.
Humphrey-MurtoSVarpioLWoodTJ, et al. The use of the Delphi and other consensus group methods in medical education research: a review. Acad Med. 2017;92(10):1491-1498. doi:10.1097/ACM.0000000000001812
43.
InczeMAHueblerSGrantSGordonAJ.Using the Delphi process to prioritize an agenda for care transition research for patients with substance use disorders. Subst Use Addctn J. 2024;45(3):523-528. doi:10.1177/29767342241246762
44.
JandhyalaR.Delphi, non-RAND modified Delphi, RAND/UCLA appropriateness method and a novel group awareness and consensus methodology for consensus measurement: a systematic literature review. Curr Med Res Opin. 2020;36(11):1873-1887. doi:10.1080/03007995.2020.1816946
45.
KhodyakovDGrantSDengerB, et al. Using an online, modified Delphi approach to engage patients and caregivers in determining the patient-centeredness of Duchenne muscular dystrophy care considerations. Med Decis Making. 2019;39(8):1019-1031. doi:10.1177/0272989X19883631
46.
NasaPJainRJunejaD.Delphi methodology in healthcare research: how to decide its appropriateness. World J Methodol. 2021;11(4):116-129. doi:10.5662/wjm.v11.i4.116
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