(171) Bridging Care: Patient Navigation and Support Team Within an Addiction Consult Service

Background &

Introduction: Hospitalized patients with substance use disorder (SUD) often experience high rates of patient-directed discharged (PDD), fragmented care transitions, and poor linkage to treatment. Addiction Medicine Consultant Services (AMCS) improve initiation of medications for opioid and alcohol use disorders, but persistent social and systemic barriers such as housing instability, insurance gaps, legal involvement, and limited social support persist and hinder recovery. In July 2025, we implemented a dedicated AMCS patient navigation and support consult order at a large urban academic medical center to facilitate systematic referral to a team aimed at addressing socioeconomic barriers to recovery. The team, composed of social workers (SW), certified recovery specialists (CRS), and community health workers (CHW), works alongside AMCS clinicians during hospitalization and provides motivational engagement, harm reduction counseling, linkage to treatment programs, and facilitation of warm handoffs to outpatient care to promote continuity and reduce gaps during care transitions from hospital to community-based treatment This study summarizes initial data on consult order uptake and patient characteristics, as well as linkage to the AMCS-associated outpatient clinic that provides primary care, addiction medicine, and behavioral health services. We conducted a descriptive retrospective analysis of navigation and support consult order use during the first 6 months of implementation (7/1/2025 - 12/31/2025). We summarized patient demographics, uptake of the navigation and support consult orders, navigation and support outreach contacts, and two linkage outcomes: referrals to the AMCS-associated outpatient clinic and completed AMCS outpatient clinic visits. All data were extracted from the electronic health record (EHR). Categorical variables were summarized using frequencies and percentages, and continuous variables were summarized using median and interquartile ranges (IQR). Between 7/1/2025 and 12/31/2025, 884 patients were seen by AMCS across 1,152 inpatient encounters during which 9 61 navigation and support consult orders were placed. Overall, 744 patients (84%) had ≥ 1 navigation and support consult order placed, and 640 patients (86%) ≥ 1 navigation and support consult fulfilled (86%). Uptake of navigation and support orders increased after implementation and was sustained over time. Consult order volume increased more than 6-fold from 26 consult orders placed in the first month to 170 orders in the second month. Growth continued at a slower rate, with a 7% increase from month 2 to 3 (182 orders), 19% increase from month 3 to 4 (216 orders), stabilization from month 4 to 5 (214 orders), and –29% decrease from month 5 to 6 (153 orders).

During this period, the navigation and support team completed 2,520 outreach contacts to patients of which 2,417 (96%) occurred during in-person encounters. Among patients with a completed navigation and support consult, the median (IQR) age was 43 (37-53), 63% were non-Hispanic White, 23% non-Hispanic Black, and 11% Hispanic. Most patients were insured through Medicaid (72%), followed by commercial insurance (11%), dual Medicaid-Medicare (10%), Medicare (5%), and other/unknown plans (3%). Following hospitalization, 78 patients were referred to the AMCS-associated outpatient clinic, including 54% of patients who did not have a documented primary care provider (PCP) prior to referral. Among those referred, 47 patients (60%) had at least one encounter at the AMCS-outpatient clinic. Conclusion &

Discussion: Implementation of a dedicated AMCS patient navigation and support consult order was rapidly adopted with sustained high uptake over the first 6 months suggesting substantial interest, as well as a recognized need for services addressing social and structural barriers to SUD care. The high proportion of patients receiving completed navigation and support consults, together with large volume of outreach contacts, demonstrates the feasibility of integrating a multidisciplinary navigation and support team into inpatient AMCS workflow. Initial linkage outcomes suggest that this model may help reduce gaps in care transitions following hospitalizations. Referral to the AMCS-associated outpatient clinic, particularly among those without a documented PCP, represents an important step in improving engagement in longitudinal SUD-care. As an early implementation evaluation, this study is descriptive and not designed to assess clinical effectiveness. Therefore, future studies should evaluate how the broader scope of navigation activities may impact patient-centered outcomes, including treatment retention, patient-directed discharge, acute care utilization, and linkage to community-based services.