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
Providence Swedish Health System Case Study: Bridge to Care
Background
Leaders at Providence St. Peter Hospital in Olympia, Wash. sought to strengthen how inpatient teams support patients with opioid use disorder (OUD) during hospitalization and connect patients with ongoing treatment and recovery resources after discharge. A clinical leader spearheaded the effort after identifying opportunities to improve care coordination, reduce stigma and strengthen partnerships with community organizations providing addiction treatment and recovery support.
As part of the AHA HRET Bridge to Care initiative, Providence Swedish developed an action plan focused on improving bedside nursing education for sublingual buprenorphine administration, patient teaching and inpatient care transitions. The organization aligned this work with broader AHA strategies focused on reducing stigma, improving inpatient clinician education and strengthening linkage to ongoing treatment after discharge.
Implementation
Building a More Compassionate and Informed Approach to Inpatient Care
Historically, the hospital’s inpatient teams focused on treating medical complications associated with substance use disorder, including infections such as osteomyelitis, without consistently addressing underlying addiction. Some nurses and clinicians also felt they lacked tools to support patients with OUD. Staff often struggled to decide how much opioid pain medication to give hospitalized patients, how to manage withdrawal symptoms and how to respond when patients continued using illicit, non-prescribed fentanyl or other opioids during inpatient stays.
Before joining the Bridge to Care initiative, the clinical leader had already begun educating nurses, hospitalists and emergency department staff about the range of evidence-based approaches to caring for patients with substance use disorder. During spring 2026, nursing, pharmacy and physician partners developed a more structured education effort focused on buprenorphine administration, patient teaching and inpatient care transitions.
By March 2026, the interdisciplinary team had completed an initial draft of educational materials for bedside nurses focused on buprenorphine pharmacology, medication administration and patient teaching. Nursing educators across inpatient units and the family practice residency buprenorphine clinic later reviewed, refined and distributed the content to frontline staff during spring 2026.
Through the education effort, nurses learned how to properly administer sublingual buprenorphine and teach patients how to take the medication correctly during hospitalization. The team also used the education process to reduce stigma and improve interactions between staff and patients with OUD. The team also shared patient stories and provided frontline education to help staff better understand how treatment and recovery can improve patient outcomes. Nurse educators and nurse champions who engaged in training opportunities increasingly encouraged their colleagues to consider buprenorphine treatment and addiction-focused interventions earlier during hospitalization.
Strengthening Discharge Planning and Community Connections
In addition to inpatient education, leaders worked to strengthen how staff connected hospitalized patients with outpatient addiction treatment and recovery support before patients left the hospital. While information on treatment programs and community resources was routinely provided, many patients required additional individualized support to successfully engage with ongoing care.
Teams added local referral information into electronic discharge planning tools so case managers and discharge planners could more easily connect patients with methadone clinics, outpatient buprenorphine programs and other community addiction treatment services. Staff also educated case managers and inpatient teams about available local treatment options and how to help patients access those services before discharge.
Continuing the Momentum
Frequent turnover among case management staff required teams to repeatedly train new staff on local addiction treatment resources, referral processes and discharge planning workflows for patients with substance use disorder.
Teams also recognized that many patients needed additional support to successfully connect with outpatient treatment after leaving the hospital. Staff often needed to help patients identify transportation options, coordinate follow-up plans and understand how to access addiction treatment services in the community.
At the time this case study was developed, Providence Swedish leaders continued refining and distributing nursing education materials across inpatient units and outpatient clinic settings. The organization planned to revise the educational content based on staff feedback and continue expanding clinician education related to substance use disorder care.
Long-term success will require continued interdisciplinary collaboration among nursing, pharmacy, medicine, case management and community partners. The project lead also emphasized that improving care for patients with OUD depends on changing organizational culture over time through education, relationship-building with community partners and more compassionate engagement with patients during hospitalization.
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.