Filling the Gaps in SUD Care Coordination

A critical truth: We are not failing patients with substance use disorders (SUDs) because we lack effective treatments. We are failing them because 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 requires navigating both medical and nonmedical systems, including behavioral health, physical health, social services and community-based recovery resources. As opposed to other chronic conditions, the risk of symptom recurrence in SUD is shaped by more than just clinical treatment; it is also shaped by social stability, stigma and ongoing access to peer and community support.

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

One of the biggest gaps is due to the way payment models are structured. Today’s system prioritizes short-term interventions over the chronic care approaches that support sustained recovery. Without financial incentives for long-term outcomes, essential services like peer recovery programs and community-based care remain underfunded. Aligning payment models with long-term recovery can help bridge this gap, shifting the focus from crisis-driven care to lasting stability.

In addition, many care coordinator positions are funded directly by payers, 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 even state, it becomes harder to understand the unique strengths, needs and relationships that shape a community’s support system. This contributes to missed referrals and inadequate transition support between service settings.

Financial misalignments are worsened by the lack of clear standards for who delivers care coordination, how it is structured and what training is required. Care coordinators have varying levels of knowledge about SUD treatment and recovery. Responsibilities fall to social workers, case managers, community health workers and peer specialists, yet no universal framework defines the role of care coordination or ensures consistent training.

Beyond the lack of standardization, care coordination efforts also fall short in addressing social drivers of health, which play a key role in recovery outcomes. Recovery is not just about treatment; it is about creating a foundation for long-term wellbeing. For people with SUD, many of whom face housing insecurity, prolonged periods of unemployment and legal challenges related to involvement with the criminal justice system, building this foundation is especially complex. These structural challenges create chronic stress and instability, increasing people’s vulnerability to recurrence. Nevertheless, many care coordination programs fail to consider social drivers of health.

Peer support is a key tool that can address these gaps.

Individuals navigating recovery often engage more deeply with services when guided by someone with lived experience, someone who also understands the specific resources available in their community.

Still, even with stronger peer support, care coordination must be scalable so it can serve everyone, not just the patients with the most acute needs. A major 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 across clinical and community settings. This can be especially 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 it is 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 to see.

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 a necessity, and the cost of inaction is measured in lives lost.