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Rural Health Information Hub

Rural Recovery Housing, with Ernie Fletcher and Erica Walker

Date: September 5, 2023
Duration: 32 minutes

Erica Walker Governor Ernie Fletcher An interview with Governor Ernie Fletcher, co-founder and Chief Medical Officer of the Fletcher Group, and Erica Walker, Outreach and Engagement Specialist for the Fletcher Group. We discuss the ways in which recovery housing brings together communities in order to facilitate the healing of people with substance use disorders.

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Organizations and resources mentioned in this episode:


Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved. This is an episode about recovery housing.

Today I'm speaking with Ernie Fletcher, co-founder and Chief Medical Officer of the Fletcher Group. He's also a physician and a former governor of Kentucky. Also joining us is Erica Walker, Outreach and Engagement Specialist for the Fletcher Group. Thank you both for joining us today.

Gov. Ernie Fletcher: It's our pleasure. Thank you.

Erica Walker: Thanks, Andrew. Thanks for having us. Glad to be here.

Andrew Nelson: To get started, can you tell us a little bit about the Fletcher Group and its designation as a Rural Center of Excellence?

Gov. Ernie Fletcher: About five years ago, we developed Fletcher Group, and it was based on work that I'd done as governor of Kentucky at that point, with actually a team, and an individual by the name of Don Ball, who had a lot of the ideas behind it and worked in Lexington at a place called the Hope Center. We developed Recovery Kentucky. Fast-forward from that year of 2004, we have 18 of those centers in Kentucky. At least six are in rural areas. And they provide services where individuals go into recovery, and they may stay anywhere from six to 24 months, depending on their recovery pathway. We kind of took that example because we had 12 years of data done by the University of Kentucky showing a very good efficacy on helping folks negotiate recovery.

We took that basic plan, expanded it nationally, and we applied for one of HRSA's grants. It was an RCORP grant, or a Rural [Communities] Opioid Response Program. And we were selected as one of the Rural Centers of Excellence, focusing on recovery, with recovery housing being a big part of that. We're now finishing up the fourth year of that grant and we're going into another five years of a program to continue this Center of Excellence. We have provided technical assistance across 46 states, thousands of technical assistance encounters. We've helped develop a number of recovery houses. We've come into a community and really helped them build a response to recovery. And so far it's been exhilarating, very effective. We've been able to help a lot of communities do that.

Andrew Nelson: Can you tell us a bit about recovery in general? What elements are needed to allow people to be successful in recovery, and how often are those elements found in rural communities?

Erica Walker: So I would say that it really takes a network of individuals and organizations that are really dedicated to helping people overcome substance use. And just some examples that come to mind quickly are the justice system, healthcare, treatment providers, recovery support services such as recovery housing, self-help programs, the faith-based community, employers. It really takes all of the different parts of the community working together. And I would say that rural communities have so many strengths, but a lot of times some of these pieces may be missing or they may have just not been working together. So we really try to work with these rural communities to see what their strengths are, but also where the gaps are and how we can help them connect stakeholders to build a really quality program.

Andrew Nelson: Can you tell us specifically, what is recovery housing and why is it needed in rural communities?

Gov. Ernie Fletcher: Recovery housing is a broad spectrum of services, but it differs from what folks may refer to as Housing First. And the fact that it is sober living, folks can be on medication-assisted treatment, but it requires that people not use drugs illicitly. The other thing about recovery housing is it really treats some of the health-related social needs of what's been referred to as social determinants. And in a chronic disease, about 80% of the impact, at least, of having efficacy and how you treat an individual has to include those social determinants. An SUD, or substance use disorder, is a chronic disease, but it's a chronic disease that has a tremendous impact on social connections, on the ability to be employed. Often folks have been justice-involved, so they end up losing maybe their job, getting disconnected from their family and friends.

And not only that, but they may end up being homeless or arrested, as I mentioned. So recovery housing provides a safe place for recovery. It provides supportive services. There's several levels. The National Alliance for Recovery Residences, NARR, sets up four levels that go all the way from what we call an Oxford House, which is just a self-governed house, but folks that come together that are in recovery and live in the house and work together to maintain their sobriety. It doesn't provide any wraparound services within the house, but often people are involved in mutual health groups such as AA or Celebrate Recovery. You get up to a Level Four, and they may have a lot of clinical support. So it may have a lot of programming within the house. People may not be employed. They focus totally on their recovery for a while.

And it depends on the acuity of how significant the SUD is and how much it's impacted an individual's life and how much support they really need. So recovery housing is a spectrum of services that are provided. It's important in rural communities because housing is often an issue and the rural communities, they often have the resources, but they don't necessarily have the structure to bring those resources together and, and to really use those resources. So I think it's extremely important in rural communities, because they do have less access to healthcare. Transportation becomes an issue and that's why you need the recovery housing and rural communities.

In rural communities, there's a disparity in the incidence of SUD, and it's higher in rural communities. And having those resources there for recovery housing where folks live and work in some cases is extremely important because of the challenges of transportation. We do a lot of work out west and you're talking about some large states where it may be significant distances to resources if you don't really supply those in rural communities.

Erica Walker: Ernie really did a good job of covering a Level One and then the highest level, Level Four. But in between you have a Level Two and Three. So in a Level Three recovery house, for example, they often provide case management services. They offer life skills, parenting classes, and kind of a lot of social in-house services that they can provide, and a lot of peer-led groups and classes that can help an individual enter and maintain long-term recovery.

Gov. Ernie Fletcher: Peer support services and having someone with lived experience has been shown in research to be extremely effective. And that's true not only in this, but the same thing in cancer, diabetes — having peers really share their experiences makes a tremendous impact on recovery for individuals.

Part of recovery is meaning and purpose. If you go through AA, which is an evidence-based program, if you look at some of the requirements or responsibilities along that Twelve Steps, it's in order to help others. And that's part of the therapy, it's a mutual benefit. And being able to provide help to other individuals and really understanding what they're going through is important.

Erica Walker: I couldn't agree more. As a person in long-term recovery myself for coming up on 17 years, I would say that helping someone else is, in my opinion, the key to success. In the Twelve Steps it talks about, “If nothing else is working, if you're in a rut, if you're having a hard time and nothing else works, then working with somebody else struggling with addiction will save the day.” And I've seen that time and time again. I think you get a level of engagement and rapport. It's just hard for anything else to compare to. So it's such a crucial component. Something I fell in love with working in the Recovery Kentucky model that Governor Fletcher and his administration started in the early 2000s. And I've been just really an advocate for the peer-led social model ever since. Just the quality of recovery people gained through that model is hard to describe.

Gov. Ernie Fletcher: The other thing I want to add, Andrew, on the recovery housing, and that's that healing of the brain takes time; 9-12 months before you really start to see a good resolution of those changes in the frontal lobe and even down into the limbic system, their amygdala. A lot of the clinical programs are 30-days only. And what we see, there's a lot of reuse after that because they don't have long enough to be in a supportive environment in order to really potentiate that healing of the frontal lobe, specifically. What we often find is individuals go through those 30-day programs, it's then good to transition to a recovery house where they can continue to get that support services and really a lot of the support and education that Erica mentioned as well, because these folks have had sometimes their life really turned upside down and they have to start somewhat from the beginning in a way to restructure their habits and what they're doing and their purpose and meaning and that recovery housing gives as a cost-effective way really at providing services over a longer period of time.

Erica Walker: I would agree. And just to add to that, I worked on the clinical side of things as a drug and alcohol counselor and a trauma therapist for a while. And it's wonderful, meaningful work, but I realized so quickly working in an outpatient setting that it didn't matter how good of a counselor I was, if they didn't have a safe, healthy environment to live in and to be at while they were trying to recover. So another reason that this work is so important.

Andrew Nelson: What are some of the impacts and returns on investment that you've seen from recovery housing programs in rural communities?

Gov. Ernie Fletcher: When we are looking at the cost of recovery housing versus clinical intensive inpatient services, you can really get about nine months of service in a recovery house, say a Level Three, versus 30 days in an intensive inpatient program. And the outcomes really have been shown to be better the longer an individual can have those supportive services wrapped around them. I mentioned the University of Kentucky does research outcomes for Recovery Kentucky, and they've shown a direct ROI, return on investment, for recovery housing, you know, around $2.70. That's direct. When you look at indirect and some of the other things such as reduction in healthcare cost, you start to get up around $8 for every dollar invested, or higher.

So it's really a good return on investment. We're working in Vermont, which is a very rural state. We did an analysis for them, and they could use 200 to 300 more beds, recovery housing beds to serve that state. It's a small state, relatively speaking, but what we find is that because Medicaid and some of the payers don't pay for recovery housing, or the services in recovery housing, it's a little more difficult to fund recovery housing, especially those that don't require rent from an individual. So it is a great return on investment. We're beginning to see states now starting to provide reimbursement, which is going to help expand those services. And we've really done a lot of work in what we call value-based payment for recovery housing and are looking at programs in state, including Kentucky, and working with Vermont, at least beginning to help implement some reimbursement mechanisms for recovery housing, where you get a very good ROI on their investment.

Erica Walker: I thought this would be a good time to talk about our economic calculator that our research team created. And it's basically just a real simple way for recovery houses to enter their daily capital cost for building or developing the program, operational cost, and they can really get a return on investment calculation. And we recently conducted one for one of the programs I worked with in Kentucky. This was a larger facility, but overall to build this facility and operate, it was around $14 million, and they found around a $27 return on investment for every dollar invested. And if you really think about what these calculations look like in real life, if you have one individual who is an IV drug user, that you get them into recovery and they avoid having infections, having to have heart surgeries, and all kinds of complicated medical procedures, you've saved millions just on one person. So I'm under the belief that all of these return on investments are very conservative. But it's wonderful that we have this tool now because we're taking these houses who didn't have this calculation before, and we can do this calculation for them and really give them something to show their local stakeholders and funders that represents the work they're doing.

Andrew Nelson: Yeah, it's really neat to see something like that that not only seems to be more effective but actually has that increased return on investment as well. Seems like everybody's winning, everybody's coming out ahead.

Erica Walker: Absolutely.

Andrew Nelson: Can you tell us about who pays for recovery housing? Is that something that's generally covered by insurance?

Gov. Ernie Fletcher: There's only a few states that actually pay for services in recovery housing, or pay for recovery housing. Most payers don't pay for that. They'll pay for the clinical model, or maybe in a Level Four, but when you get in Level Two and Three, which really provides a great service with great outcomes at a much lower cost, because you don't have a lot of the overhead cost of clinical services of physicians, et cetera, even though physicians could be involved, they're not as intentionally involved. It's more focused around the social model, as Erica mentioned, and peer support. So what we're doing in work is in order to expand recovery housing, and good recovery housing; unfortunately recovery housing has some abuse in it. I'm in Florida and it's a state that is known for some of the abusive practices in recovery housing for people to pay for referrals and houses not tracking outcomes, not providing the services that they promised. And that's impeded our effort to get insurance to pay for it.

But our view of this, and we're working on a what we call an alternative payment method or value-based payment, is where you set up quality outcomes measured and you provide reimbursement for the services provided in the house. And that way it's under a care plan, which would qualify for Medicaid and a lot of other healthcare plans. What we're doing, if you look at the number of overdose deaths, is helping, but it's not working to the extent that we'd like it to. And I think we're going to have to look at more of addressing those social determinants. We have to start with harm reduction. It's very important, but you've got to go well beyond that in supporting these individuals with their health-related social needs, and recovery housing does that. And once I think we begin to see that, we'll begin to get insurance companies or payers and government payers providing some reimbursement for those services.

Andrew Nelson: Projects like recovery housing can often encounter this kind of “Not In My Backyard” attitude. People might recognize, “Sure, there's a need for this service, but I don't really want it to be provided around me. I don't want to have to see that.” Have you found ways to help communities see the positives of recovery housing in their communities, and overcome that mindset?

Gov. Ernie Fletcher: We've run into “Not in my backyard,” or NIMBY, quite a bit. And I think it's important from the outset, if you're looking at a program, to really be proactive in educating and showing folks that these are not only safe when they're done well in the right locations, they don't impact their property values that people get worried about. And actually, it provides a service and uplifts the community. We often involved faith-based communities, which helps with that. As we bring the faith-based communities, we start working on stigma, which is a real issue around SUD. And so that helps reduce that NIMBYism. And we've been able to do that in a number of communities. Some which we started out that had some real opposition. We also work with the University of Rochester that has a program where they bring in a facilitator and do some town hall type meetings and really share a lot of information on what SUD is, how it impacts most families now have been impacted some way with SUD at least most people know a friend or somebody that's overdosed now or had a tremendous impact with SUD, so that helps.

Erica Walker: I agree that being proactive meeting with local stakeholders, something we always did when I was working in recovery housing is we invited the community in. They had an open invitation to come sit in, meet with our residents, see the home, sit in what we call a therapeutic community meeting, and just really see what we do. And I think it lifted the veil of mystery, and they were able to see that these were just wonderful people trying to get their lives back together. And, you know, something else I think is really important is community involvement. You know, we had some NIMBY issues in a house I worked in many years ago, and we had a flood in that community, and the residents at our center went out, helped clean up, they helped pack things, rescue people. I mean, they were fully involved from the day that it happened. And after that point, the whole community perspective changed. You know, they packed groceries for the elderly. They're just…people in recovery are I think six times more likely to volunteer in their local communities. They make great neighbors. And that was something we had in place, was good neighbor policies. We had a grievance procedure if they had if there was an issue, because some people make mistakes, things do happen. But that was far and few between, but we did have a process for neighbors to let us know if something was going on we need to know about. So I think it really is transparency and getting to know your community, being involved in the community, and it's also all about the culture in a home. We really created a culture of love and respect not only for one another in the home, but also for the community. And we wanted you know, it was really a sentiment that we wanted the community to see us as a positive influence and all the residents did a really good job of carrying that message.

Gov. Ernie Fletcher: Culture's extremely important. I'm going to use the Native American population as an example, very often a very rural population as well. There's a program called White Bison, which takes the Twelve Steps and really modifies it for the cultural differences or particularly unique cultural aspects of the Native American community. And that is very important, and people can't relate to it. I know they have the sweat houses. There's some other things that among Native American populations that are extremely important in their traditions. It is very important to understand that you have some differences between factors culturally, the difference between Appalachia and say, the western part of the US. There's cultural differences there. If you're really not aware of, informed about those cultural differences and really recognize them and modify your programs like that, I don't think they're near as effective.

Erica Walker: And I think it's something that Recovery Kentucky did very well, is there is a culture and a language within those programs. And the residents really went above and beyond to be a good representation of recovery. You know, we talked about attraction over promotion, “Carry yourself and live your life in a way that's attractive and other people will want recovery,” and they really exuded that. I think I always say that a home, a culture and a home should really be a good mixture of love, patience, and tolerance with accountability and structure. And I would say those are the keys to success, in my opinion.

Andrew Nelson: Can you go into a little greater depth about how partners can be engaged for successful recovery housing programs and help to create a positive recovery ecosystem?

Gov. Ernie Fletcher: You know, Andrew, I think we hit on something that is extremely important, and that's that especially in rural communities, for several reasons — one is that there's a lot of resources there, but they're often siloed. So bringing a lot of partners together will help bring a synergy between those resources that may not have been realized otherwise. Secondly, it becomes a community effort and that helps reduce the NIMBYism substantially. I'll take an example. In some communities we go in, you want to bring in a justice system, for example, building a recovery housing, that may not seem intuitive right off the bat, but oftentimes they have a lot of individuals that they can divert into that program and we get much better outcomes than just incarcerating those individuals. Secondly, the educational institutions — one community, it was the community college and technical college that provided, helped provide the land to develop the recovery house and the programs. As we look at moving folks into meaningful employment, having those educational partnerships are extremely important because having meaningful employment, meaning and purpose again, is an important part of building what we call recovery capital or resiliency.

You start bringing in the hospital, the healthcare, the provider system, bring in faith-based communities, bringing in transportation, the housing organizations — you always have some individuals or groups that are working with the communities on addiction and recovery. There's a lot of work generally already going on in a community. And it's important when you go into a community to engage those folks and kind of come alongside and work with what they're doing and help build their work. We don't come in on a white horse and have all the answers, let me put it that way. You can bring the partners together and oftentimes those partners know the needs and have the answers. We can just be helpful bringing the synergy and convening those individuals to allow them to bring their resources and knowledge together. And it's extremely important that brings that very positive recovery ecosystem.

Erica Walker: I was just thinking about a real example that I experienced of partnerships. We had at one of the programs I worked at, we had a local probation and parole officer, and he was a very strict guy, wonderful person, but he was very strict, he would very much lean towards the criminal justice side, and we ended up making him an office space in the recovery program. He would come in and see his clients there. And it was just a complete transformation and his whole attitude and outlook towards recovery. He began getting involved in the recovery journey. He became more about second chances and giving people a hand up. So I think those partnerships and letting people come in, become invested in your program, is really a game changer.

Gov. Ernie Fletcher: I mentioned the educational institution, but employers and workforce development groups are very important. Again, moving people from a life that's been tremendously disrupted and getting them into a life of meaning and purpose is extremely important. So bringing those components of making sure that you can provide individuals a pathway of where they are able to get into some employment that fits who they are, their skillset, their interest, and it's something they can really joyfully embrace. And that's extremely important in bringing that component.

Erica Walker: I'm glad you remembered to mention that because I truly believe in my own personal recovery, getting into college and finding a career pathway was one of the crucial pieces for me. I always say once I found the meaning and purpose in my life and it met up with my career goals, it's just been transformational in my life.

Gov. Ernie Fletcher: There's been several studies on connection and human connections, how important that is in health and well-being. There's a risk study that done on twins still going on, I think, it's a longitudinal study that really shows those connections, tremendously important in predicting health and wellbeing of individuals. The Harvard longitudinal study that shows that those connections are more important than genetics or what your economic background is, as far as demographic background. But those human connections are important. And I'm going to go to expand it and kind of call it loving human connections where people care about one another, is essential for recovery. Dr. Best, who's done a lot of research on this out of the United Kingdom, has said the opposite of addiction is connection. Bringing those partnerships can generate greater connection.

Andrew Nelson: Is there any advice you have for communities or organizations that don't have a recovery housing program right now, but might want to implement one?

Gov. Ernie Fletcher: Yeah. Call Erica. Give us a call. But first thing is, and I'm going to use an example — we were down in Polson, which is a small town in Montana, and there was a Native American group that had been working several years on trying to get a recovery house up. And we came in and talked to them and provided some advice and some technical assistance. But the bottom line, all they needed was to have the confidence that they could do it and move forward to take the risk. And a lot of times rural communities have the resources and the program; it's good to have somebody come alongside and really show them the pathway, but not only that, but for them to realize that, “Hey, we can do this.” And that sounds very simple, but oftentimes that confidence is generated by just having a group come in and say, “Look, it's been done, here are some of the elements that you can do it.” It really spurs a lot of activity and, and that particular example, they had the house up in six months.

Erica Walker: Some of the things that came to mind for me was really doing your homework. Getting to know if it's a community you've lived and worked in, then you probably know your community pretty well. But I'll meet with folks and they'll say, “Well, I want to open a women's recovery house.” And I'm like, “Okay, well, who will be your referral sources?” So, you know, it's like, “Is there a greater need in my community to serve men or women?” Just thinking about things like that, a needs assessment. We have all kinds of toolkits and resources to help people accomplish those types of things. So just really doing your homework, getting to know your stakeholders and of course, reaching out to someone for technical assistance, whether it's us or other folks who have operated recovery houses that would be willing to come alongside you. I think that's probably the best advice I could give. It takes a village. It really does.

Gov. Ernie Fletcher: We've got a learning center, you can go to and, and the courses are free. We've got probably more than 60 or 70 courses there, and folks can begin to look what it takes. And the toolkits that Erica mentioned are on there in an educational format. There's also a lot of information on our website about developing recovery housing and some of the things that are needed, but Erica hit the point, it's doing your research. Your due diligence, like you would do in any project, is extremely important. Unfortunately, most rural communities are in need of recovery housing because of the impact of this epidemic. But it does help to point out what that need is and what the largest need is Erica mentioned, so that she can have a very focused program to address the most significant needs of the community.

[We] just really appreciate the work you all do and giving us the opportunity to share this. Our response around the nation and why we have had projects in 46 states is, there's a lot of folks out there wanting to develop more support for folks in their communities. It's a joy to work with those individuals because they have a passion and interest. And so thank you for the opportunity to be here. The work that you all do, it is, it changes lives. It transforms life takes a lot of work, but it's very rewarding for communities when they see what they've developed and start seeing folks that have had their lives transformed.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. In this episode, we spoke with Ernie Fletcher, co-founder and Chief Medical Officer of the Fletcher Group, as well as Erica Walker, Outreach and Engagement Specialist for the Fletcher Group. Look in our show notes for more information about their work and visit for all things pertaining to rural health.