Overdose Measures Matter

Indicator Profile

Percent of people referred who initiate care

Category: Linkage to Care

Audience: ConvenerProgram Implementer

Data Type: Quantitative

Indicator Overview

Description:

Percent of people who were referred to care and services who initiate care.

This indicator tracks individuals after they were referred to care and services to see if they initiate or receive the care and services they were referred to.

Rationale:

Knowing the number of referrals made demonstrates how programs are performing in the first step of linking people to needed care and services. This indicator tracks the next step – whether people who were referred to care and services, actually receive it.1

By examining the percent of people who initiate care, organizations can assess the “success” of referral efforts.

Further exploration of referral outcomes by demographics, referral source (where the referral was made) and referral destination (what the referral was for) may help to identify the factors related to successful vs. unsuccessful referrals. In other words, who is most likely to receive care and services, following a referral? Analyzing the data in this way may allow for a more nuanced understanding of where capacity can be strengthened to support referral outcomes.

However, this indicator is likely to be difficult for many users to report because it requires tracking person-level data at the point of referral and initiation of care. Often, these data are tracked within different organizations and therefore may require sharing data across organizations and matching data across data systems.

Related Indicators:

To understand 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, consider tracking the number of referrals to care and services.

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 provider). 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.

Care and services include 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.

People referred refers to the unique number of people who received a referral to a program. Although one person may have received multiple referrals, they should only be counted once.* This is the denominator for this indicator.

People referred who initiate care and services refers to the unique number of people who received a referral to a program and obtained care and services from that program – in other words, received a “successful” referral.* This is the numerator for this indicator.

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. In contrast, in a passive 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 passive 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.

*Note: Because this indicator tracks the unique number of people who start care after being referred, each person should only be counted once, even if they receive multiple referrals. If one person receives several referrals but only one leads to care, they would be counted as having initiated care and be included in both the numerator and denominator.

To address challenges with multiple referrals, you could narrow the scope of this indicator. For example, you might focus only on referrals to specific types of services, such as harm reduction programs or services provided by a specific organization. In addition, you could limit the timeframe for referral, such as only counting those made within the past six months. These are just suggestions – choose the approach that works best for your organization.

Numerator and Denominator:

Numerator: Number of people referred to care and services who initiate care

Denominator: Number of people referred to care and services

Ways to Examine the Data:

  1. Referral source or setting where the referral was made (e.g., hospital or emergency department, syringe service program (SSP), emergency medical services, public safety, etc.)
  2. Referral destination or setting where people are referred (e.g., evidence-based substance use treatment such as MOUD; mental health treatment; harm reduction services; medical or physical health services; social services, etc.)
  3. Participant demographics (e.g., race, ethnicity, sex, gender, priority population, age group, language, housing status)
  4. Type of referral (e.g., active or passive) This data may help inform future efforts to understanding what factors might be associated with care initiation.
  5. Time frame between the date of referral to initiation of care

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

Data Sources:

Referrals are typically tracked by the programs providing the referral. Service initiation is typically tracked by the organization providing the service.

  • Referral logs from organizations providing the referral, electronic health records (EHRs) from healthcare settings
  • Program records, enrollment and/or registration records from organizations providing and receiving the referral

Data Collection Methods:

Collecting this data may include a review of programmatic data, case notes, records and logs tracked by organizations involved in making and accepting referrals.

  • Programs providing the referrals: Track who received referrals to what program or service
  • Programs accepting the referrals: Track who initiated care or services from your program

Once these data sources are identified, tracking an individual from the point of referral to receipt of services may require combining multiple data sources. This means being able to track people across different systems and often involves sharing their name, date of birth or other personal information. When tracking personally identifiable information, it is important to comply with data privacy laws in order to protect the privacy and confidentiality of all participants.

Application and Considerations

Suggested Use:

Program Implementer

  • To monitor referral outcomes and determine what happens after people are referred to a program or service
  • To identify differences in service initiation after being referred
  • To find out which services the people you serve are most likely to use

Community Convener

  • To identify gaps or differences in service initiation after being referred
  • To support community-level assessment and evaluation efforts. Potential questions include: Which referrals are most likely to be successful? Which are least likely to be successful? What factors might be associated with successful referrals?
  • To help communities leverage resources
  • To support collaboration across organizations, agencies and sectors

Health Access Considerations:

You may want to consider:

  • Are referrals being provided equitably to clients? To what extent are referrals provided in communities disproportionately affected by overdose and to populations historically underserved by services?
  • Are there population differences in care initiation following a referral? Who is more likely to initiate care? Who is less likely? What are some factors associated with the likelihood of initiating care?
  • What proportion of these referrals are warm handoffs? Who typically receives a warm handoff? Are warm handoffs more likely to lead to initiation of care?
  • Why might some referrals not lead to initiation of care?
  • How long does it usually take for someone to start care after getting a referral? What factors influence this?
  • Are there local policies or protocols that govern how referrals are made and accepted? How might this affect people seeking care and services?
  • What is the referral process like for the person seeking care? Are there challenges or barriers that are being overlooked by programs?
  • What opportunities exist for people who are being missed in your services and therefore, not being linked to care?

Evaluation Considerations:

Limitations:

  • Challenging to track. This indicator likely requires combining datasets and matching individuals across data systems
  • Does not track if people continue to use the service after initiation
  • Does not track quality of services provided
  • Does not track reasons for unsuccessful referrals
  • Does not consider personal experiences of participants throughout the referral process
  • Does not track extent to which individuals receive referrals to care and services that they need

Policy Considerations and Resources:

Additional Resources

Examples:

  • Langabeer, J., Champagne-Langabeer, T., Luber, S. D., Prater, S. J., Stotts, A., Kirages, K., ... & Chambers, K. A. (2020). Outreach to people who survive opioid overdose: Linkage and retention in treatment. Journal of Substance Abuse Treatment, 111, 11-15.
    https://www.jsatjournal.com/article/S0740-5472(19)30139-4/fulltext
  • Casey, S. K., Howard, S., Regan, S., Romero, A., Powell, E. A., Kehoe, L., ... & Wakeman, S. E. (2024). Linkage to Care Outcomes Following Treatment in A Low-Threshold Substance Use Disorder Bridge Clinic. Substance Use & Addiction Journal, 29767342241261609.
    https://journals.sagepub.com/doi/full/10.1177/29767342241261609

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
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