Bridging the Gap: Supporting Individuals with SUD Beyond Treatment

June 16, 2025

Alexandra Plante, Author & Senior Advisor in the Strategy Office of the National Council for Mental Wellbeing

Tom O’Connor, Editor & Publisher

Topic

Substance use disorder (SUD) recovery is a complex, lifelong process requiring coordinated support across health care, social services, and community systems. Unlike other chronic conditions, SUD is episodic and has uniquely high stakes due to the lethality of the current drug supply. The lethality of today’s drug supply means that a gap in care or a recurrence of symptoms can quickly become fatal. 

Treating SUD as a chronic condition, with long-term management and sustained care coordination, is essential for improving outcomes and saving lives. Effective care coordination addresses the overlapping challenges of SUD, including co-occurring mental health conditions, social drivers of health (e.g., housing instability, unemployment, and legal issues), and transitions between treatment phases. 

However, current systems are fragmented and inconsistent, leaving people vulnerable to disengagement, recurrence of symptoms, and overdose. Standardizing care coordination for SUD is crucial to bridging these gaps and ensuring people receive timely, integrated, lifesaving support. 

Author Alexandra Plante joins us again. She has consulted with U.S. federal agencies, state policymakers, and international organizations, including the United Nations Office on Drugs and Crime (UNODC). Alexandra is a current Fulbright Specialist in SUD and a Doctor of Medical Science (DMSc) candidate. 

Additional Information For You

According to Alexandra Plante:

Let’s be clear. We’re not failing people with substance use disorders (SUDs) because treatment doesn’t work. We’re failing them because we abandon them between and after treatment.

SUD Care Coordinators

Care coordination is supposed to be the glue that holds recovery together. Instead, it's the gap everyone falls through.

The system is fragmented and under-resourced. Care Coordinators are often stretched thin, working remotely with little context for the communities they are meant to serve. There's no consistent training, shared standards, or real accountability.

Funding models prioritize short-term fixes over long-term recovery. And while we discuss scaling peer support, we haven't yet built the necessary infrastructure to make it a reality. Care coordination is often just a handoff when we need a follow-through.

A critical truth: We are not failing patients with substance use disorders (SUDs) because we lack effective treatments. We are failing them because, in the long term, sustained recovery often depends on what happens between and after treatment. That’s where care coordination comes in.

SUD care coordination is unique because it navigates multiple systems, including medical, behavioral health, physical health, social services, and community-based recovery 00resources. Standardizing care coordination, integrating social supports, and using technology to enhance communication across systems increases the likelihood of stability and long-term recovery for people facing addiction. 

Sadly, the current system remains fragmented, with care often too short-term, inconsistent, or insufficiently comprehensive. The immense potential of effective SUD care coordination is usually hindered by misaligned incentives, a lack of standardization, and structural gaps that leave people without the services they need.

One of the most significant gaps is due to the way payment models are structured. Today’s system prioritizes short-term interventions over chronic care approaches that support sustained recovery. Essential services, such as peer recovery programs and community-based care, remain underfunded due to a lack of financial incentives for long-term outcomes. Aligning payment models with long-term recovery can help bridge this gap, shifting the focus from crisis-driven care to lasting stability. 

In addition, payers fund many care coordinator positions directly, which can lead to a disconnect from the local fabric of the communities they serve. When care coordinators don’t live in the same neighborhood, county, or state, it becomes more challenging to comprehend the unique strengths, needs, and relationships that define a community’s support system. This contributes to missed referrals and inadequate support for transitions between service settings.

Financial misalignments are exacerbated by the lack of clear standards for who delivers care coordination, its structure, and the required training. Care coordinators have varying levels of knowledge about substance use disorder (SUD) treatment and recovery. Responsibilities fall to social workers, case managers, community health workers, and peer specialists; however, there is no universal framework that defines the role of care coordination or ensures consistent training for these roles. 

Beyond the lack of standardization, care coordination efforts also fall short in addressing the social determinants of health, which are crucial for recovery outcomes. Recovery involves not just treatment but also establishing a foundation for long-term well-being. For individuals with substance use disorders (SUD), many of whom encounter housing insecurity, prolonged unemployment, and legal obstacles stemming from interactions with the criminal justice system, building this foundation is profoundly complex. These structural challenges lead to chronic stress and instability, heightening individuals' susceptibility to relapse. Nevertheless, many care coordination programs neglect to address social determinants of health.

Peer support is a key tool for addressing these gaps. Individuals navigating recovery often engage more deeply with services when guided by someone with lived experience who understands the specific resources available in their community.

Still, even with more substantial peer support, care coordination must be scalable to serve everyone, not just the patients with the most acute needs. A significant barrier to scalability is the lack of technology to support it. Many providers still rely on outdated, manual processes, resulting in information gaps between provider systems and clinical and community settings. This can be incredibly challenging for people with SUD, who frequently move between health care, social services, and the criminal justice system — systems that rarely communicate effectively. Without interoperable health records, automated referrals, and real-time data sharing, care coordination remains reactive rather than proactive.

Care coordination is not simply present or absent; it exists on a spectrum. When fragmented, inconsistent, or lacking essential components such as knowledge of SUD, strong referral networks, and integration across care settings, these gaps may prevent patients from achieving the long-term recovery outcomes we want.

Too many people with SUD are left vulnerable during the high-risk periods between and after treatment, when the quality and comprehensiveness of care coordination determine whether recovery is sustained or lost. A system that delivers consistent, high-quality SUD care coordination shouldn’t be a luxury. It is necessary, and the cost of inaction is measured in life. 

Additional SUD Coordinator research

• The Centers for Disease Control and Prevention (CDC) has developed an Addiction Medicine Toolkit, which provides clinicians with an introductory overview of addiction medicine and offers strategies for its implementation. This Toolkit includes four modules. One training module focuses on Care Coordination in the Treatment of Substance Use Disorders. The three other CDC Overdose Prevention training modules are: Treatment of Substance Use Disorders: An Overview of Addiction Medicine, Treatment Options for Substance Use Disorders, and Effective Communication in Treating Substance Use Disorders. Physicians, nurses, and other healthcare professionals can obtain free continuing education for this training.

• The Substance Abuse and Mental Health Services Administration (SAMHSA) established an Interdepartmental Substance Use Disorders Coordinating Committee (ISUDCC) with federal and non-federal members to accomplish the following duties:

  
  

• Identify areas that require enhanced coordination of substance use disorder-related activities, such as research, services, support, and prevention efforts, across all relevant federal agencies.

  
  

• Identify and provide to the Secretary recommendations for improving federal programs for the prevention and treatment of, and recovery from, substance use disorders, including by expanding access to prevention, treatment, and recovery services.

  
  

• Analyze substance use disorder prevention and treatment strategies in different regions and populations in the United States and evaluate the extent to which federal substance use disorder prevention and treatment strategies are aligned with State and local substance use disorder prevention and treatment strategies.

  
  

• Make recommendations to the Secretary regarding any appropriate changes concerning the activities and strategies described in items (1) through (3) above;

  
  

• Make recommendations to the Secretary regarding public participation in decisions relating to substance use disorders and how public feedback can be better integrated into such decisions.

  
  

• Make recommendations to ensure that the Department of Health and Human Services and other federal agencies' substance use disorder research, services, supports, and prevention activities are not unnecessarily duplicative.

• The Pew Charitable Trusts published a report titled "Care Coordination Strategies for Patients Can Improve Substance Use Disorder Outcomes." " Overview: Care coordination is considered a hallmark of patient-centered treatment and has been shown to enhance health outcomes, increase patient satisfaction, and reduce costs. Care coordination involves organizing patient care activities and sharing information among all participants involved in an individual’s treatment plan to achieve safer and more effective outcomes. Furthermore, care coordination is increasingly recognized as a crucial element in innovative models for delivering medical care.

Why do individuals with SUD need care coordination? When substance use disorders (SUDs) are not addressed in the treatment of other conditions, patients may fail to take medications correctly, suffering additional consequences such as poor control of hypertension and diabetes, as well as an increased risk for various cancers and other illnesses. Furthermore, individuals with SUD experience higher rates of emergency department visits and hospital readmissions. When left untreated, SUDs are linked to high rates of injury, disability, and death. To improve outcomes, health professionals are developing care coordination approaches that address substance use disorders (SUDs), enhance patient engagement and retention in treatment, support better management of comorbid medical conditions, and ensure successful connections to medical and behavioral interventions. Care coordination models for individuals with SUD share many core features but differ in their designation of the entity or individual primarily responsible for coordinating care, where the coordination occurs, and how it is financed.

Alexandra Plante earned a Doctor of Medical Science in Healthcare Business Administration from Northeastern University, a Master’s Degree in Quantitative Research in Communication from the University of Buffalo, and a Bachelor’s Degree in Communication from the University of Massachusetts Amherst.