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.
Western Pennsylvania has experienced an epidemic of
heroin and opioid abuse in the past 8-10 years. According
CDC data, Pennsylvania had the eighth-highest drug
overdose mortality rate in the U.S. A consortium of the
Drug and Alcohol Commission (AICDAC) and 9 partners
created the Nurse Navigator and Recovery Specialist
Outreach Program to address substance use in the rural
counties of Armstrong, Clarion, and Indiana.
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)
Assistance in coordinating the providers'
medication-assisted treatment (MAT) program was added
after the first grant period.
- 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 visit 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
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
- 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.
Kami Anderson, Executive Director
Armstrong-Indiana-Clarion Drug and Alcohol Commission
724.354.2746 Ext. 302
Community health workers
Substance use and misuse
September 14, 2015
Date updated or reviewed
November 14, 2022
Suggested citation: Rural Health Information Hub,
Nurse Navigator and Recovery Specialist Outreach Program [online]. Rural Health Information Hub. Available at:
[Accessed 5 February 2023]
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.