Need: To properly address and treat patients who have concurrent substance abuse and chronic healthcare issues.

Intervention: A referral system was created that utilizes Community Health Workers (CHWs) in a drug and alcohol treatment setting.

Results: This program has reduced hospital emergency visits and hospital readmissions for patients since its inception.



Promising (About evidence-level criteria)



 Western Pennsylvania has experienced an epidemic of heroin and opiate abuse in the past 8-10 years. As of 2014, Pennsylvania had the seventh highest drug overdose mortality rate in the U.S. The Nurse Navigator & Recovery Specialist Outreach Program was created to serve those in the counties of Armstrong, Clarion, and Indiana, Pennsylvania, who have problems with substance abuse. This program is the work of a consortium made up of the Armstrong-Indiana-Clarion Drug and Alcohol Commission (AICDAC) and 9 partners. Substance abuse 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 abuse, while preventing and treating chronic illnesses related to substance abuse. 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 goal for the program 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 2012-2015 Federal Office of Rural Health Policy Rural Health Care Services Outreach grant. 

Services offered

This program provides an array of services to clients including:

  • Health and resiliency education
  • Physical and behavioral health planning
  • Substance abuse treatment services
  • Outreach services
  • Case management services
  • Wellness groups and therapy sessions
  • Recovery support 


In 3 years, this program has assisted 364 clients, with at least 2,433 client encounters taking place. The program has been able to reduce client visits to the emergency department each year, with 91% of clients having 1 or more ER visit during the first year, 63% in year two, and 59% in year three. The program has also seen a decline in clients with 1 or more hospital admissions, with 50% in year one, 34% in year two, and 27% in year three. Clients’ positive perceptions of their health have increased to 88% during the length of this program as well.

The Nurse Navigator and Recovery Specialist Outreach Program is featured in RAC’s Mental Health and Substance Abuse Toolkit Program Clearinghouse. 


Challenges that the program has encountered include: 

  • 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 record keeping system between physicians and treatment providers
  • The stigma of behavioral health issues



In order to successfully create a similar program in other communities:

Create a consortium of key influencers and make sure that decision makers at the provider agencies, area hospital, and doctors’ offices are part of it

Partner with substance abuse and mental health providers and get them involved with the program 

Work together to develop efficient ways to exchange information

Be cognizant of all data relating to program and keep it accurate

Start small to work out all the kinks, then expand to other counties



Outreach Sourcebook, 2012-2015, Federal Office of Rural Health Policy


Contact person

Kami Anderson, Executive Director

Armstrong-Indiana-Clarion Drug and Alcohol Commission

724.354.2746 Ext. 302



  • Care coordination
  • Community health workers
  • Health conditions
  • Substance abuse


States served



Date added

September 14, 2015


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 RAC for your convenience. The programs described are not endorsed by RAC 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.