Linkages to Care (LinC)

Recent RIZE-funded research shows that individuals who survive a nonfatal overdose are at increased risk for future overdose, and linking individuals post-overdose to ongoing services through outreach and engagement strategies is likely to save lives. The Linkages to Care (LinC) grant program promotes broad-based, multi-stakeholder networks between hospitals, inpatient treatment providers, outpatient treatment providers, community-based organizations, clients and their families, and other key stakeholders to improve linkages to social needs, community, and recovery supports. As such, this grant program will help to strengthen linkages between levels or types of care by utilizing engagement strategies, removing barriers to access, and fostering shared care management through a network of partners consisting of treatment, recovery, and harm reduction organizations and healthcare providers.

    In June 2024, RIZE awarded nearly $2 million in LinC grant funding to the following eight organizations:

    • AIDS Support Group of Cape Cod has been awarded $247,566 to adapt and further develop its Post Overdose Support Team (POST) Program as a linkage with Duffy Health Center and Gosnold Behavioral Health. This initiative aims to engage, link, connect/refer, monitor, and follow up with individuals requiring care linkages after an inpatient stay, which could include hospitalization, EMT response to overdose, and participation in inpatient detox programs or partial hospitalization programs. The LinC grant will facilitate the creation of the Post Inpatient Linkages Program and enable the organization to hire a full-time staff member, the LinC Navigator to enhance outreach, collaborations, and partnerships.
    • Community Health Connections has been awarded $250,000 to expand its services by partnering with local Emergency Departments (EDs) at hospitals like UMass Memorial HealthAlliance and Heywood Hospital. The organization will refer patients to detox facilities, recovery programs, and services based on their needs, and assess them for potential medication for opioid use disorder or Office-Based Addiction Treatment (OBAT) services. Additionally, recovery coaches will be deployed to engage patients in the ED or hospitalized, working to establish individualized recovery goals and minimize barriers to care. The program’s goal is to create a strong network of partnerships within local hospital systems to enhance the effectiveness and reach of substance use disorder (SUD) services.
    • Lowell House, Inc. has been awarded $250,000 to collaborate with Lowell General Hospital/Tufts Medicine on providing support for individuals after inpatient stays and emergency department visits. The program will offer evening and weekend recovery coaching, as well as naloxone and safe use kits for discharging patients. Oversight will be provided by a recovery coach supervisor and regular meetings with hospital staff will be held. Lowell House, Inc. has a full range of services and a strong network of collaborators, making it well positioned to provide care coordination within the Merrimack Valley for those in need of SUD services. Additionally, the organization will address barriers such as limited staff availability during non-business hours and transportation by providing transportation assistance and varying levels of support based on patient choice.
    • Metro Boston Alive (MBA) has been awarded $250,000 in linkage with Mass General Hospital (MGH) to enhance its support for individuals of color requiring extensive care coordination post-discharge by hiring a part-time Community Health Intake Coordinator (CHIC). This role focuses on aiding patients discharged from MGH inpatient services, guiding them through their treatment plans, and addressing challenges related to social determinants of health. The CHIC or a recovery coach connected to MBA will engage with patients both prior to discharge and at their initial MBA meeting.
    • North Shore Community Health (NSCH) has been awarded $249,956 to combat the opioid crisis through overdose prevention and harm reduction, improving access to care for SUD patients in linkage with Mass General Brigham – Salem Hospital. NSCH will do this by 1) Reducing loss to follow-up post-hospital discharge by embedding SUD Treatment Navigators in local hospitals for seamless transitions back to NSCH, 2) Facilitating patient navigation across different treatment options by employing treatment navigators to coordinate with community resources and referrals to a variety of services, including Intensive Outpatient Programming and withdrawal management, 3) Addressing transportation barriers by coordinating immediate transport services for SUD patients needing to access higher-level care, 4) Providing naloxone at all health center locations to both patients and staff, overcoming financial obstacles to ensure readiness in overdose situations.
    • The Somerville Homeless Coalition (SHC) has been awarded $250,000 to address homelessness by linking in-patient care for substance use disorders with outpatient follow-up and referrals in partnership with Community Health Alliance’s Healthcare for the Homeless (HCH) program. Together, SHC and HCH focus on connecting individuals with care for substance use, mental health, and chronic health issues, ensuring a continuum of care from in-patient treatment to community-based support. With the LinC grant funding, SHC aims to continue and expand these essential services.
    • The Pettengill House (PGH) has been awarded $247,832 to enhance and expand its comprehensive range of support services aimed at improving health, well-being, and safety for individuals and families struggling with SUD and behavioral health (BH) issues. PGH came together with lead partners Beth Israel Lahey Health Anna Jaques Hospital, outpatient SUDs/BH provider Link House, Inc., and law enforcement/social work partnership Essex County Outreach, to create Behavioral Event and Substance Support Taskforce (BESST), a collaborative community task force driven to improve quality and continuity of care, increase equitable access, share information and resources, increase accountability, and streamline delivery of services. By strategically utilizing funding in these areas, PGH’s BESST team aims to significantly improve the accessibility, quality, and effectiveness of the support services offered to individuals and families, contributing to better health outcomes, increased safety, and overall well-being in the community.
    • Wednesday’s Meeting DBA Whose Corner Is It Anyway has been awarded $250,000 to improve healthcare responses to overdoses through several initiatives in linkage with Baystate Health: 1) developing a peer-written safety plan form for Baystate ED clinicians to use with overdose patients, 2) co-designing a training program with SafeSpot (formerly known as the MA Overdose Prevention Hotline), targeting Baystate ED providers to promote SafeSpot services to patients using stimulants and/or opioids, 3) forming a street outreach team to promote Safe Spot within vulnerable communities, particularly focusing on unhoused members, and 4) offering CPR and opioid overdose reversal training to staff, members, and their families, focusing on efficient naloxone and oxygen pump usage.