Bridging the Gap: How Case Management Supports Recovery in Rural Communities

BY LORI TANNER, MSN, RN, CCM, AND AMANDA HAWTHORNE, MSW, LCSW, QS
In the heart of our rural community, where healthcare resources are limited and substance use disorder continues to devastate lives, our hospital’s medications for opioid use disorder (MOUD) clinic has become a beacon of hope.

As a registered nurse case manager, I have had the privilege of having a seat at the table in discussions of how to utilize opioid funding. This led to establishing our MOUD program and ensuring that those struggling with substance use disorder receive the comprehensive care they deserve.

How it all started

It started with a conversation. Our county was going to be receiving some state funding to help with the opioid epidemic. But, how could we be effective with these dollars? An analysis was done in the county of our current resources and of the gaps that we still faced. Several community leaders got together to brainstorm. The gaps seemed so daunting.

Then patient Bob, we will call him, entered our ER. He was in active withdrawal from a long history of fentanyl use. Case management was consulted, and I asked him if he was willing to consider a detox or inpatient recovery program. He adamantly refused. This patient was still employed, and he feared entering a program would jeopardize his job. The ER physician that day asked if we could get him outpatient treatment quickly and he could help bridge the gap with a Suboxone prescription.

It was then that we realized we had the puzzle pieces; we just needed to put the puzzle together. Pain management was holding clinic on our campus, and we had just hired a licensed clinical social worker to join our case management team. We had a pharmacy on site to dispense medication. Now, we had some funding to help address the other missing pieces like a peer specialist, a paramedicine program, and transportation. And just like that, our outpatient Recovery Outreach Clinic (ROC) was born.

A Holistic Approach to Recovery

Our MOUD clinic is more than just a place to receive medication. It is a lifeline that provides wraparound services to address the complex needs of our patients. We offer free-of-charge resources, including:

• Medication-Assisted Treatment, now commonly called medication for opioid use disorder (MOUD): FDA-approved medication such as buprenorphine and naltrexone (Suboxone) help reduce cravings and withdrawal symptoms, giving patients a stable foundation for recovery. Our clients are able to attend clinic with our pain management physician and receive urine drug screens. Our pain management physician then provides the prescription to our hospital pharmacy. Our hospital pharmacy fills the prescription while the client is on-site for immediate dispense. This aligns with recent research which found that emergency department initiation of buprenorphine significantly increased the odds of patients receiving ongoing prescriptions and achieving continuity of care—especially important in high-risk populations (Samuels et al., 2024).
• Mental Health Counseling: Our licensed clinical social worker provides therapy to address the underlying trauma, anxiety, and depression that often accompany substance use disorder. This is a mandatory requirement of our program. This can also be provided in telehealth format.
• Case Management and Social Services: As case managers, we connect patients to essential services, including housing support, transportation, employment assistance, and food security programs. We anticipated the need for transportation services and were able to build this into our budget. This has been a great asset to our clients, as many of them have no means of transportation and the resources for transportation in our rural community is slim. We found a non-emergent medical transport company to collaborate with us, and we pay them from our funding.
• Referral to Community Partners: We have a team approach with our local fire-rescue paramedicine partner and peer support specialist. We also strongly encourage group classes at a local organization that was formed by a grassroots community of recovering individuals and their families. This local organization creates a support network that fosters long-term recovery.

Overcoming Barriers in Rural Healthcare

Providing substance use disorder treatment in a rural setting comes with unique challenges—limited access to resources, limited access to care, stigma surrounding substance use disorder and medication assisted treatment, and transportation difficulties. Our team is addressing these barriers by:

• Utilizing Telehealth Services when appropriate: Virtual counseling and psychiatry will be offered via telehealth. This helps increase care for patients living in remote areas or that may not have transportation available. Research shows that telehealth-delivered MOUD, particularly buprenorphine, is not only feasible but also effective in maintaining engagement and reducing opioid use in rural populations (Zhu et al., 2021).
• Engaging the Community: We conduct outreach events to educate local leaders and residents on the importance of harm reduction and compassionate care. We are spreading the word about our program in hopes of reducing the stigma behind substance use disorder and the accessibility of treatment.
• Integration into Primary Care: Our offices and therapy room are held in a primary care setting. We hope to normalize MOUD and mental health as an essential component of healthcare rather than a last resort.

Case Management: The Heart of the Program

We as case managers play a crucial role in bridging the gap between medical treatment and real-world recovery. Our role extends beyond coordinating appointments; we advocate for our patients and advocate for change, help patients navigate complex systems, and empower them to take control of their health. By building trust and fostering relationships, we help individuals regain stability and purpose. According to the Opioid Use Disorder Case Management Guide from CMSA, case managers are essential in reducing barriers to care, facilitating warm handoffs, and maintaining communication across the continuum, especially in rural and underserved settings (CMSA, 2023).

Looking Ahead

As we continue to grow our program, we aim to expand this year by becoming a CORE network site in the state of Florida. This is an initiative to provide a 24/7 access site in our ER for patients experiencing overdose, suspected overdose or that just want help to have immediate access to treatment. They will also receive a warm handoff with a peer specialist and dispensing of buprenorphine by our paramedicine partner until they come to see us at our Recovery Outreach Clinic. This will help us further improve access to care.

By sharing our experiences, we hope to inspire other rural healthcare systems to develop similar initiatives. At the core of our work is a simple but powerful belief: Everyone deserves a chance at recovery, regardless of their circumstances. Through dedicated case management and a holistic approach to care, we are proving that healing is possible-one patient, one family, and one community at a time.

References

CMSA. (2023). Opioid use disorder case management guide. Case Management Society of America. https://cmsa.org/opioid-use-disorder-case-management-guide/

Samuels, E. A., Ross, J. S., Mustafa, S. B., Patry, G., & Beaudoin, F. L. (2024). Emergency clinician buprenorphine initiation, subsequent prescriptions, and continuous prescriptions. JAMA, 331(12), 1033–1041. https://doi.org/10.1001/jama.2024.2155

Zhu, Y., Cofie, L. E., & Doshi, R. (2021). Telehealth and opioid use disorder treatment: A systematic review. Journal of Substance Abuse Treatment, 124, 108288. https://doi.org/10.1016/j.jsat.2020.108288

Lori Tanner, MSN, RN, CCM, is a dedicated nurse case manager with over 21 years of experience in healthcare. She currently serves patients at Baker County Medical Center and the Baker County Recovery Outreach Clinic, where she specializes in rural health and substance use disorder treatment. Lori is actively involved with the Case Management Society of America (CMSA), contributing to professional growth and advocacy for best practices in case management. Her work reflects a deep commitment to improving access to care in underserved communities and supporting individuals on their path to recovery.

Amanda Hawthorne, MSW, LCSW, QS, is a licensed clinical social worker and qualified supervisor with 8 years of experience serving individuals and families across rural communities. She currently provides clinical services at Baker County Medical Center and the Baker County Recovery Outreach Clinic, where she specializes in substance use treatment. Amanda brings a person-centered, strengths-based approach to her work, supporting clients through recovery while addressing social determinants of health. Her practice is grounded in the principles of equity, accessibility, and community engagement.

Image credit: ISTOCK.COM/TIMSA