People admitted to hospitals for alcohol and substance use disorders are often not connected with appropriate treatment when they are discharged. The lack of coordinated care reduces the likelihood that individuals will receive the necessary services and supports to recover from addiction, and increases the likelihood of repeat hospital visits. In Pennsylvania’s Allegheny County, alcohol and substance use disorders are among the top three reasons for hospitalization, prompting two of the Pittsburgh region’s largest health systems, Allegheny Health Network and University of Pittsburgh Medical Center, to partner with local health plans and the Pennsylvania Department of Human Services to address substance use disorder as an underlying cause of hospital admissions.

The Center for Health Care Strategies (CHCS) provided consultation and technical support to assist this unique collaboration in achieving its goals of increased initiation and engagement in treatment for substance use disorder, improved health outcomes, and reduced avoidable emergency room visits, repeat hospitalizations, and overall costs. Through the two-year pilot, which began initial planning in Fall 2013 and launched in early 2015, the participating hospitals used peer navigators and social workers to build rapport with individuals identified with substance use disorder in the emergency room or upon inpatient admission. Upon discharge, identified individuals are referred to a community-based peer navigator or health plan care manager, with ongoing follow-up to ensure that the individual is engaged in appropriate treatment.

The pilot project was launched through the federal Adult Medicaid Quality Grant Program: Measuring and Improving the Quality of Care. It is modeled after Project Engage, a successful initiative developed by Christiana Care Health System in Wilmington, Delaware.