Emergency Departments as Bridges to Recovery
A Statewide Strategy for Addiction Care Expansion
Carilion Clinic packaged a proven emergency department model for initiating opioid use disorder treatment at the point of crisis into a free training toolkit, monthly continuing medical education webinars, and on-site coaching. Then it used state opioid settlement and public health funding to help hospital systems across Virginia adopt it without having to build the program from scratch.
The Challenge They Were Addressing
For years, a person who arrived at a Virginia emergency room in opioid withdrawal was often treated as the patient no one wanted. Staff stabilized the immediate medical issue, sent the person back out the door, and watched many of them cycle back through the same ER weeks later. Emergency physicians had received almost no addiction training in medical school, so the visit rarely connected the patient to ongoing treatment. The clinical tools to change that already existed, but they were not standard practice.
Carilion Clinic had a head start on the answer. Cheri Hartman, PhD, and David Hartman, MD, had opened one of the state's first office-based opioid treatment clinics, built around medication for opioid use disorder. In December 2018, Dr. John Burton, then chair of the Carilion emergency department, returned from a conference where Dr. Gail D'Onofrio of Yale presented her research on starting buprenorphine in the ER. He told the Hartmans the hospital had an obligation to act, and asked for one commitment in return: any patient started on buprenorphine in the ER had to get into the clinic quickly, before the prescription ran out. The team agreed to work through lunch and come in early to keep that promise.
That single ED bridge program produced data strong enough to change minds across Virginia. In the first study year, 82% of patients started on treatment in the Carilion ER linked to follow-up care, with retention rates the team presented at conferences in Madrid and elsewhere. By 2022 and 2023, the Virginia Department of Health wanted that result to spread to other hospitals. The problem shifted from proving the model worked to helping other communities adopt it without having to start over.
What They Built
The expansion project turned a working clinical program into a set of resources other hospitals could pick up and use. At its center is the Virginia ED Bridge Training Toolkit, a curated compendium built on years of quality-improvement data. It pulls together the relevant research, ready-to-use clinical tools, and short videos, including footage of Dr. D'Onofrio describing the model she developed at Yale. The intent is plain: a hospital that wants to start an ED bridge program can open the toolkit, pick the elements it needs, and skip the work of building each piece on its own.
A toolkit on a shelf does not change practice, so the project wrapped live support around it. Carilion subject-matter experts who still do this work day-to-day, including Dr. Annie Ickes, are available for targeted training and technical assistance calls when a hospital has a question that the documents do not answer. The first hospitals were recruited with federal ARPA funds to bring seven health care systems on board. The team brought on six pioneer systems, with Carilion as the seventh originator, and visited each one for on-site training followed by individual monthly meetings.
When DMAS added Opioid Abatement Authority funding in 2024, the project added a statewide layer to the one-on-one work. That layer is a series of monthly CME webinars on evidence-based emergency department practices, paired with an anti-stigma campaign. The webinars opened with the Carilion quality improvement results, then covered the model's components, special populations such as pregnant patients and youth, and emerging street threats such as xylazine. Every session is recorded and linked from the toolkit, so the training does not expire when the live event ends.
Two design choices run through the whole model. The first is a clinical commitment that patients started on buprenorphine in the ER move to a follow-up clinic within days, not weeks, so treatment does not lapse. The second is hospital-based peer recovery specialists, who meet patients in the ER. Carilion data showed that patients were twice as likely to succeed with a peer linkage, and that in the first year, every patient connected to a peer reached follow-up care.
Key Program Components
Who You Need at the Table
What made a willing partner essential vs. optional?
The partners the model cannot run without are the ones that supply either credibility or money. A trusted emergency physician champion is the first. Clinicians change practice when a respected colleague tells them, from the heart, that this work saves lives, not when they are assigned a video to watch. Carilion saw the same pattern play out with Dr. Keith White at Ballad Health and Dr. Martinez at Valley Health: the first presentation lands when a trusted local doctor delivers it. The funders are the second. Public health and opioid settlement dollars from VDH and DMAS paid for the data systems, the peer specialists, and the staff time that turn a good idea into a standing program.
Helpful partners widen the model's reach without being required on day one. Pharmacists can tip a hesitant hospital toward adoption once they understand buprenorphine's safety profile. Telemedicine programs let patients fill a buprenorphine prescription quickly and can keep some people out of the ER entirely. Naloxone distribution from the ER adds a second point of contact. None of these is the starting point, but each one strengthens a program that already has its champion and its funding in place.
Budget Breakdown
What is the minimum viable budget to replicate this?
The work itself sits inside skills emergency clinicians already have, so the minimum budget is smaller than it looks. The toolkit is free, the clinical model is not expensive to run, and a trusted physician champion donates the most important ingredient: credibility. A county with roughly $75,000 can spread the model by funding the things that are hard to cover otherwise. The first is data: building analytics and electronic health record changes that make the right practice the easy practice and enable a hospital to see its own results. The second is peer recovery specialists, whose services are hard to bill and who roughly double a patient's odds of reaching follow-up care. Webinars and toolkit access carry almost no marginal cost once the materials exist.
What Worked and Why
Specific decisions or design features that drove success
Letting the data drive the project was the decision on which everything else rests. Carilion conducted detailed chart reviews from 2019 through 2023, entered the data into a REDCap database with audited data entry, and the results were strong enough to pull the state in. The first-year figure, 82% of ER patients linked to follow-up care, gave every later conversation a number to stand on. As Cheri Hartman put it, if the team had not had that compelling data, the expansion might never have happened.
Packaging the model into a free toolkit removed the biggest barrier to adoption: the fear of starting from zero. Rather than ask each hospital to assemble research, protocols, and training on its own, the project relied on existing work, including Dr. Andrew Herring's California protocols, and curated only top-tier sources into one place. A hospital can trust the contents because the project vouches for them, which matters in an era when anyone can find a study to support almost any claim.
Pairing every stigma presentation with a trusted local clinician is what changes attitudes. Across the hundreds of ED bridge programs now operating nationally, the team points to stigma as the most common barrier and to a respected colleague who educates peers in person as the most reliable answer. Carilion delivered its first presentation alongside Dr. Keith White at Ballad Health and Dr. Martinez at Valley Health, and the message landed each time because it came from inside the room rather than from a mandatory video.
Funding peer recovery specialists in the ER turned a good outcome into a great one. The data were blunt: patients with a peer linkage were twice as likely to succeed, and in the first year, every single patient who connected with a peer reached follow-up care. That single variable is what persuaded the state to fund peer access for hospitals throughout Virginia.
Celebrating the wins kept the clinical teams engaged. Emergency staff rarely learn what happens after a patient leaves, so the project circled back to tell them how many people crossed the bridge into recovery. Seeing the impact made the work rewarding, and the enthusiasm spread. The patient who used to be dreaded in the ER became the patient whom the staff knew how to help.
Early outcomes and data
82% of patients started on treatment in the Carilion ER linked to follow-up care in the first study year; 78% in the following year.
First-year peer data showed that every patient connected with a peer recovery specialist received follow-up care, and that peer linkage roughly doubled a patient's odds of success.
Reduced repeat ER visits as patients moved into ongoing treatment rather than cycling back through the emergency department.
16 CME webinars delivered, with a 17th scheduled for July 28, averaging 66 attendees in the 2025-2026 grant year.
More than 1,000 contacts on the statewide distribution list, including clinicians from outside Virginia.
Six pioneer health systems, plus Carilion, are adopting the model, with several operating multiple hospitals each, and VCU is also running an ED bridge program.
58 emergency physicians were trained to prescribe buprenorphine at the founding site, a culture shift the ED chair drove by adding it to the department scorecard.
Lessons Learned
Let the data make the case for you. The detailed quality improvement work from 2019 through 2023 is what convinced the state to fund expansion. Build credible measurement into the program from the start, because the outcome numbers do more to recruit new sites than any pitch.
Build on what already exists rather than from scratch. Carilion relied on the California Bridge protocols and Dr. Andrew Herring's manual rather than reinventing them, then curated a trusted toolkit so other hospitals could do the same. Point replicators to vetted resources first.
Make the funding source flexible. Settlement money does not have to come straight from a county. Carilion's expansion drew on federal ARPA, CDC public health funding, and state opioid abatement dollars, often by partnering with organizations that could access funds the program could not. Be willing to work regionally or through a state agency.
Pair clinical change with a trusted messenger. The single most reliable way to overcome staff resistance is for a respected colleague to deliver the message in person. Recruit that champion before scaling the training.
Celebrate the wins with the people who earned them. Emergency staff rarely learn how a patient's story ends. Reporting successes back to clinicians made the work rewarding and kept teams engaged, and that enthusiasm proved contagious.
Spend on the parts that do not pay for themselves. The clinical work sits inside existing skills, but data systems and peer recovery specialists need dedicated funding; direct, limited dollars there rather than toward work the hospital can already do.