Overdose Measures Matter

Indicator Profile

Number or percent of referrals to care and services (If unable to calculate a percentage, collect “Number of referrals to care and services.")

Category: Linkage to Care

Audience: ConvenerFunderProgram Implementer

Data Type: Quantitative

Indicator Overview

Description:

Percent of referrals to care and services

This indicator is intentionally broad so that you can select which services, from a referral standpoint, are most important to track.

Rationale:

Knowing the number of referrals made demonstrates how programs are performing in the first step of linking people to needed care and services without needing to request or collect individual-level data.1

For programs that collect individual level data and know the number of unique individuals, a percentage of referrals made can be calculated. If a program does not collect individual data or use unique identifiers, a rough percentage could be made by calculating the percentage in shorter time increments. For instance, a program may not have repeat users in one day or in one week thus, the percentage could be calculated and reported as the percent of referrals for that time period. To report on this indicator for a grant application or to a funder for a longer time period, a rough average could be given.

Tracking referrals can help organizations assess the extent to which they are engaging in efforts to link program participants to needed resources in the community.

Additionally, examining the frequency of referrals by referral source (where the referral was made) and referral destination (what the referral was for) can help identify gaps, opportunities for expansion, and provide justification for funding decisions and resource prioritization. Further disaggregating the data by setting (e.g., harm reduction program, jail, hospital, etc.) will allow for a more nuanced understanding of where capacity can be strengthened to support referrals.1

Related Indicators:

Programs could further explore the needs of participants by collecting the number or percent of people who report they receive the care and services they need and any barriers to receiving services.

Although more difficult to collect and report, program implementers and conveners may want to know the percent of people referred who initiate care.

Indicator Details

Definitions:

A referral includes any formal connection to care and services. During a referral, a provider engages in conversation with the participant about their specific needs and tailors referrals to them (e.g., warm hand-off, scheduling an appointment, making a phone call to establish a connection between the participant and community service provide.) For this indicator, referrals include any connections to care made by clinicians, social workers, social service providers, community organizations, law enforcement, navigators, peer support specialists or other relevant sources. Although referrals are typically more effective with a warm hand off, for this indicator, we suggest counting all types of referrals made.

Number of referrals is the unique number of referrals made during each encounter. For example, if an individual is referred to both harm reduction services and housing services during a single encounter, this may count as two separate referrals: one for harm reduction and one for housing. If this same individual returns one week later and receives another referral to harm reduction services, this would count as a third referral. Although this is the recommended approach to tracking this indicator, consider what method might be most feasible and useful for your organization.

Percent of referrals is the result of a calculation where the number of referrals is divided by the number of (unique) service encounters.

Warm handoff includes in-person/video/phone conversations during which the individual, the organization making the referral and the organization receiving the referral all are present. Another view of a warm handoff is providing a non-coercive way to personally escort a client to the next step in their journey. Providing a warm handoff is best suited for situations where clients express their readiness for the next step.2 In contrast, in a cold referral, an individual may be given information about how to reach the services they need but would need to contact them on their own. The cold referral is best suited when an organization is just providing information or when the client has expressed they are not yet ready for the referral.

Care and services may be defined as a broad range of health, wellness and social services such as harm reduction, mental health, medical care (e.g., Hepatitis C and HIV services or other medical services such as primary medical or OBGYN care), treatment for substance use disorder and housing services.

Numerator and Denominator:

Numerator: Number of referrals to care and services

Denominator: Number of (unique) care and service encounters

Ways to Examine the Data:

  1. Referral destination What services were people referred to? (e.g., evidence-based substance use treatment (i.e., MOUD); mental health treatment; harm reduction services; medical or physical health services; social services, etc.) What unique organizations were people referred to?
  2. Referral source Where were people referred from?
  3. Referral source setting From what type of setting was the referral made? (e.g., hospital or emergency department, syringe service program, emergency medical services, public safety, etc.)
  4. Participant demographics (e.g., race, ethnicity, sex, gender, priority population, language, housing status)
  5. Type of referral Was the referral a warm or a cold handoff? Consider tracking the type of handoff. This data may help inform future efforts to understanding what factors might be associated with care initiation.

Note: Collection of data may require additional funding and staff support

Learn more about collecting demographic data. This type of data collection may require specialized training, skill and financial resources.

Data Sources:

  • Encounter or service-level data from organizations providing the referral
  • Program records, enrollment and registration records
  • Referral logs
  • Electronic medical records
  • Individuals who received referrals

Data Collection Methods:

  • Tracked by programs providing the referral
  • Review or analysis of programmatic data from program tracking the referral
  • Discussions with individuals who received referrals

Application and Considerations

Suggested Use:

Program Implementer

  • To understand how many referrals may be typical for a specified time period
  • To identify potential gaps and disparities in referrals
  • To understand which services are needed most by the populations you serve

Community Convener

  • To identify gaps in referrals
  • To support community-level assessment and evaluation efforts
  • To help communities leverage resources
  • To facilitate collaboration across organizations, agencies and sectors

Funder

  • To determine the extent to which a program is providing the types of services for which they are being funded
  • To demonstrate how programs are performing in the first step of the cascade of care by linking people to needed services
  • To identify where people are referred, potential gaps and opportunities to improve linkage to care services
  • To justify funding decisions and resource prioritization

Health Access Considerations:

You may want to consider:

  • To what extent are organizations across different settings providing referrals?
  • Are referrals being provided equitably to clients? To what extent are referrals provided in communities disproportionately affected by overdose? To populations historically underserved?
  • What proportion of these referrals are warm handoffs? Are warm handoffs more likely to occur in certain circumstances?
  • What types of services are available? Where? Are they accessible to all people you serve?
  • Are there services that people need that aren’t currently available in the community? Are there services that people need that aren’t taking referrals?
  • Are there services available that are not getting referrals?
  • Are specific populations being prioritized for specific services? For example, if housing is limited, are only families being prioritized for housing? If resources are limited, how does this impact the referral process?

Evaluation Considerations:

Limitations:

  • Does not track referral outcomes
  • Does not track extent to which all individuals at risk of overdose receive referrals to care and services that they need
  • Does not track time from referral to initiation of services
  • Does not assess the quality of services
  • Does not track number of individuals referred
  • Data quality may be impacted by incomplete records or data

Policy Considerations and Resources:

Additional Resources

Examples:

References:

  1. Ussery, E. N., Rennick, M., Vivolo-Kantor, A. M., Scott, S., Davidson, A. J., Ishikawa, C., Williams, A. R., & Seth, P. (2024). Developing a Cascade of Care Framework and Surveillance Indicators to Monitor Linkage to and Retention in Care for Substance Use Disorder. Public health reports (Washington, D.C. : 1974), 333549241266994.
    https://journals.sagepub.com/doi/10.1177/00333549241266994
  2. Escobar, E.R., Pathak, S. Blanchard, C.M. (2021). Screening and referral care delivery services and unmet health-related social needs: a systematic review. Preventing Chronic Disease, (18).
    https://pmc.ncbi.nlm.nih.gov/articles/PMC8388203/
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