Bridge to Care Case Studyfrom the OUID/STUD series: Advancing linkage and retention in healthcare settings for patients with opioid use disorder and stimulant use disorder
Geisinger Health System Case Study: Bridge to Care
Background
Geisinger, a Danville, Pa.-based integrated health system with 10 hospitals serving communities across central and northeastern Pennsylvania, found that many patients with a substance use disorder (SUD) still left its emergency departments and hospitals without appointments, referrals or clear pathways to ongoing addiction treatment. Staff managing discharge planning often lacked the time or specialized addiction expertise needed to coordinate follow-up care, while clinicians prioritized acute medical stabilization over discharge planning and care transitions.
To improve those care transitions, Geisinger teams used the AHA HRET Bridge to Care toolkit to develop a referral strategy focused on identifying the needs of hospitalized patients with SUD earlier and connecting them with addiction treatment services after discharge.
Implementation
Creating More Consistent Transitions Into Addiction Care
To create a more consistent referral and follow-up process, clinical teams partnered with information technology (IT) staff to expand an existing electronic health record (EHR) referral order already used for outpatient medication-assisted treatment services.
Teams configured the order to identify hospitalized patients with possible SUD based on Clinical Opiate Withdrawal Scale scores, Clinical Institute Withdrawal Assessment scores, inpatient substance use screening questionnaires and emergency department triage questions. Once staff placed a referral, addiction coordinators at outpatient medication-assisted treatment (MAT) clinics reviewed the patient’s medical record, identified the appropriate level of care and contacted patients after discharge to help connect them with inpatient addiction treatment, outpatient MAT, therapy and other recovery services. Some hospitals also expanded certified recovery specialist programs as part of the broader effort.
Starting with a Pilot Hospital and Clinic
Rather than launching the new referral process systemwide in early 2026, Geisinger piloted the workflow at one hospital and one outpatient MAT clinic that already had strong working relationships with addiction medicine teams. Staff wanted to better understand referral volume, coordination challenges and operational issues before expanding the process to additional sites.
During the pilot, teams found that staff across hospitals differed in their familiarity with addiction treatment and comfort with new referral practices. Teams at smaller community hospitals often showed greater openness to collaboration with addiction treatment providers, while staff at larger, high-acuity hospitals managing trauma and surgical volumes focused more heavily on emergency department throughput, bed capacity and discharge timelines.
Continuing the Momentum
At the time this case study was developed, the IT staff was still building the EHR infrastructure needed to support the new referral process, and teams had not yet expanded the workflow across all hospitals and outpatient clinics.
During implementation, addiction medicine and operational teams found that staffing turnover, competing priorities and differences in hospital workflows continued to disrupt referral efforts despite ongoing education and relationship building.
Teams also emphasized the importance of creating multiple opportunities to connect patients with treatment throughout hospitalization and after discharge. In addition to the referral process, teams planned to continue expanding certified recovery specialist programs and collaborating with pharmacy teams to connect hospitalized patients with addiction medications before discharge.
This work was supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services as part of a financial assistance award totaling $910,000 with 100 percent funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. government.