Less than 4 of 23M people with SUD receive any care, with a fraction of those receiving evidence-based care despite that coordinated care, medication assisted treatment (MAT), peer recovery coaching and social determinants all correlate to better outcomes.
The provider landscape consists of hospitals, primary care, outpatient, inpatient, specialty behavioral health clinics, social service agencies, and housing providers – all of which are disconnected from one another and maintain competing priorities.
The current treatment system is designed to deliver urgent, one-time interventions and fails to promote wholistic, long-term recovery that includes ongoing coach support, provider coordination , access to community resources, and personalized care planning.
When a patient is admitted to the ED and is suspected of having SUD, we send an automated EMR alert.
The patient is assessed for SUD and is linked to a member of our care team for onboarding. If necessary, MAT is initiated.
In-person or remotely, we work with the patient to understand biopsychosocial needs to develop a post-discharge plan.
A peer recovery coach is assigned to the patient to work with them in following their care plan and addressing obstacles.
With consent, our care coordinator will refer the patient into outpatient care with vetted network providers.
We will collaborate with providers and engage the patient to assist in addressing their needs as they build recovery capital.
Addressing any underlying behavioral health issues and concerns
Addressing the 12 social determinants of health tailored to a patient's life
Assessing any chronic conditions and developing a plan for healthier living
Identifying & fostering relationships with key members of social support
Identifying underlying triggers and developing healthy coping skills
Addressing roadblocks to recovery like personal & familial relationships