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
Northwell Health Case Study: Bridge to Care
Background
Northwell Health is the largest healthcare provider and private employer in New York state, with more than 100,000 employees, more than 700 care sites and 25 emergency departments. As part of the AHA HRET Bridge to Care initiative, Northwell focused on improving follow-up care, overdose prevention and connections to addiction treatment after hospitalization for patients with opioid use disorder (OUD). While clinicians often identified patients who could benefit from additional support, teams did not always consistently connect those patients with ongoing treatment and services after discharge.
Leaders also wanted to increase how often clinicians offered FDA-approved medications for addiction treatment during hospitalization and at discharge. Patients often encountered barriers to recovery after leaving the hospital, including limited access to treatment programs, inconsistent follow-up and difficulty navigating next steps in care.
Implementation
Using Data and Staff Feedback to Guide Improvement
To better understand those barriers, Northwell teams reviewed electronic health record (EHR) data, analyzed referral and prescribing trends, and gathered feedback from frontline clinicians across the health system.
In late 2025, Northwell began transitioning from legacy Allscripts/Altera products to Epic across the health system. Leaders said the previous system often required staff to pull separate reports and conduct time-intensive analyses to track referral activity, naloxone distribution and addiction treatment prescribing patterns. After the transition, Northwell teams built dashboards directly into Epic so hospital leaders and front-line teams could more easily monitor screening results, referral activity and treatment trends across sites.
Implementing New Workflows and Expanding Education
As part of its Bridge to Care work, Northwell focused on improving how clinicians identified patients with substance use needs and connected them with overdose prevention resources and follow-up care after hospitalization.
After the first Epic implementation wave launched in November 2025, clinicians, operational leaders and IT teams added new overdose prevention and referral prompts to the EHR. When nurses or physicians documented drug use during screening, for example, part of that workflow involved prompting clinicians to offer overdose prevention education and naloxone rescue kits before discharging patients with positive drug screens. The system also notified social workers or health coaches to follow up with patients about outpatient OUD treatment options and ongoing care needs.
As additional hospitals transitioned to Epic, Northwell educators and program leaders met with social workers and frontline clinicians across the health system to review documentation requirements, referral processes and overdose prevention practices tied to the new workflows. Teams also provided additional education about marijuana screening and medications for OUD.
Leaders said in addition to an increase in auto-generated consults based on screening scores for care during the patient’s stay, clinicians began submitting more referral orders for post-discharge follow-up. An average of 14 referrals to treatment per month were received from the first wave of sites live on Epic, with a record high of 25 in March 2026. Teams also reported that clinicians asked more detailed questions about buprenorphine, withdrawal management and follow-up care during education sessions, which leaders viewed as a sign that staff had become more engaged in addiction treatment and overdose prevention efforts.
Building Culture Change Across the Organization
Northwell leaders said discussions during the Bridge to Care initiative helped teams identify additional opportunities to strengthen education, stakeholder engagement and relationship-building across the health system.
Many clinicians initially felt uncertain about how to support patients with substance use disorder or connect them with treatment, particularly in busy inpatient and emergency care settings.
Continuing the Momentum
To address those concerns, Northwell educators, addiction specialists and clinical leaders encouraged staff to reflect on how they discussed substance use, screened patients and approached addiction treatment conversations. Leaders said these discussions helped staff better understand substance use disorder as a chronic disease rather than a moral failing.
Leaders also said clinicians across the system became more comfortable discussing addiction treatment, asking questions about medications for OUD and involving addiction specialists earlier in patient care. At Lenox Hill Hospital, addiction psychiatry leaders worked directly with inpatient medical teams to increase clinician comfort and referral to buprenorphine treatment and consultation workflows. Those efforts had a positive impact on discharge planning workflows for the social work team, as continuing care with buprenorphine is more readily available than continuing care with methadone in the surrounding community.
Northwell leaders said the organization’s strategy depended on broad engagement across the health system, including physicians, nurses, social workers, pharmacists, peer recovery specialists, pharmacy, emergency medical services staff, front desk staff and community outreach teams.
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.