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Rural Health Information Hub

Nurse Navigator and Recovery Specialist Outreach Program

  • Need: To properly address and treat patients who have concurrent substance use and chronic healthcare issues.
  • Intervention: A referral system utilizes community health workers (CHWs) in a drug and alcohol treatment setting. A registered nurse helps with providers' medication-assisted treatment programs.
  • Results: This program has reduced hospital emergency visits and hospital readmissions for patients since its inception.


Promising (About evidence-level criteria)


Armstrong-Indiana-Clarion Drug and Alcohol Commission logo To address substance use in the rural Pennsylvania counties of Armstrong, Clarion, and Indiana, a consortium of the Armstrong-Indiana-Clarion Drug and Alcohol Commission (AICDAC) and 9 partners created the Nurse Navigator and Recovery Specialist Outreach Program.

Substance use and addiction can lead to many chronic health conditions and death. To address these co-occurring needs, AICDAC implemented a Care Coordinator/Manager Model framework for a program designed to reduce substance use while preventing and treating chronic illnesses related to substance use. This model enlists the case management services of a peer Recovery Specialist and the expertise of a registered nurse (Nurse Navigator) to navigate the healthcare system and provide resources to clients.

The program's goal is to improve clients' perceptions of their overall health and wellness, improve coping strategies and symptom management, improve communication between the clients and their physicians and treatment providers, and reduce the number of emergency visits and hospitalizations. This is done through client education, provider education, and coordination between a client's physical and behavioral health providers. The first use of this program was in Armstrong County. In the program's second and third years, it expanded to the counties of Clarion and Indiana.

This program was funded by a 2012-2015 Federal Office of Rural Health Policy (FORHP) Rural Health Care Services Outreach grant and is currently funded by a Health Resources and Services Administration (HRSA) Rural Communities Opioid Response Program (RCORP) Implementation grant.

Assistance in coordinating the providers' medication-assisted treatment (MAT) program was added after the first grant period.

Services offered

  • Health and resiliency education
  • Education to college nursing majors and community groups on the use of naloxone
  • Education and support groups for topics like hepatitis C and wellness
  • Physical and behavioral health planning
  • Substance use treatment services
  • Outreach services
  • Case management services
  • Wellness groups and therapy sessions
  • Recovery support
  • Hepatitis C testing, education, and support
  • Narcan training and distribution
  • MAT management for agency clients and collaboration with their MAT provider and primary care provider


In three years, this program assisted 364 clients, with at least 2,433 client encounters taking place. The program has been able to reduce emergency department (ED) visits each year, going from 91% of clients having one or more ED visits during the first year, to 63% in year two, to 59% in year three.

The program has also seen a decline in clients with one or more hospital admissions, from 50% in year one, to 34% in year two, to 27% in year three. Clients' positive perceptions of their health have increased to 88% during this program as well.

In October 2018, AICDAC was the recipient of a $500,000 grant to collaborate with residential treatment facilities to have each facility accept clients on all three types of MAT. As part of that grant, a full-time Nurse Navigator was included for each agency to coordinate the client's MAT needs and applications.

One outpatient provider (Open Door) who initially started the Nurse Navigator program continues to employ the same person in that position and greatly appreciates the work that she does. A second outpatient provider (ARC Manor) eliminated the position after the first grant ended but has since re-added the position after finding that it was integral to the program and to providing MAT services. A third provider (CenClear Services) added a Nurse Navigator to their staff one year ago and has had very positive results.

The Nurse Navigator and Recovery Specialist Outreach Program is also featured in RHIhub's Prevention and Treatment of Substance Use Disorders Toolkit Program Clearinghouse.


  • Employee turnover that made for difficult staffing shortages during the program
  • Communication hardships, as confidentiality laws can be confusing to navigate
  • Lack of a unified recordkeeping system between physicians and treatment providers
  • The stigma of behavioral health issues


  • Create a consortium of key influencers and make sure that decision-makers at the provider agencies, area hospital, and doctors' offices are involved.
  • Partner with substance use and mental health providers and get them involved with the program.
  • Work together to develop efficient ways to exchange information.
  • Be cognizant of all data relating to the program and keep it accurate.
  • Start small so you can identify and fix any issues, then expand to other counties.

Contact Information

Kami Anderson, Executive Director
Armstrong-Indiana-Clarion Drug and Alcohol Commission
724.354.2746 Ext. 302

Care coordination
Community health workers
Health conditions
Substance use and misuse

States served

Date added
September 14, 2015

Date updated or reviewed
November 14, 2022

Suggested citation: Rural Health Information Hub, 2022. Nurse Navigator and Recovery Specialist Outreach Program [online]. Rural Health Information Hub. Available at: [Accessed 22 May 2024]

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.