Since 2003, the National Association of County and City Health Officials (NACCHO) has administered the Model Practice Award Program to commemorate the outstanding work of local health departments that have demonstrated creative and dynamic action in addressing identified public health needs. This nationally recognized award has been bestowed to more than 3000 local health departments since its inception and provides local health departments with a shared database of hundreds of health departments and more than 850 best practices that are immediately replicable in their communities without having to "reinvent the wheel."
In 2022, 5 outstanding local health department programs were recognized as Model Practices and 16 programs were recognized as Promising Practices. The following article highlights one of those Model Practices that was submitted by the Florida Department of Health in Duval County and highlights what they were able to achieve within their community when it comes to overdose intervention.
For additional information about the Model Practices Program or to search Model Practices Database, visithttps://www.naccho.org/membership/awards/model-practices.
The Florida Department of Health in Duval County (DOH-Duval) serves a population of 999 935 (48.7% male and 51.3% female), where 60% identify as White, 31.1% as Black, 5.1% as Asian, and 3.2% as 2 or more races (11.3% having Hispanic ethnicity).1 In Duval County, 15% of residents live below the federal poverty level compared with 13.1% for Florida.1 Based on Florida Health CHARTS, Duval County saw a 234% increase in overdose deaths (from 171 to 571) from 2015 to 2020, with an overdose death rate of 58.1 compared with 36 (per 100 000 population) for Florida in 2020.2
In response to the overdose epidemic, the Jacksonville City Council held a public workshop in 2017 to identify priority gaps. The community voiced concerns about treatment facility wait-lists, an underfunded health care system, and stigma surrounding addiction and mental illness. In collaboration with the City of Jacksonville (COJ), Gateway Community Services Inc, and Jacksonville Fire Rescue Department (JFRD), Project Save Lives (PSL) was established to address substance use disorder and co-occurring conditions by developing a seamless collaborative stabilization and treatment solution to reduce overdoses, recidivism, and mortality. PSL adds a layer of compassion by having Certified Recovery Peer Specialists (CRPS), with lived experience, engage and connect with overdose survivors in the hospital setting in ways health care professionals often cannot.
While initially funded by COJ, PSL expanded with additional funding from DOH-Duval. Duval County was awarded funds from the Centers for Disease Control and Prevention and the US Department of Health and Human Services Overdose Data to Action (OD2A) grant in 2019 to address the overdose crisis through 10 interdisciplinary surveillance and prevention strategies. The collaborative efforts of this program targets 4 of these strategies: strategy 3, utilizing data to support and guide prevention interventions; strategy 6, using the eTransX Opioid Care Community, a community-based health record system that facilitates linkage to care and tracks available treatment beds; strategy 7, supporting health providers through learning sessions; and strategy 9, empowering individuals to make safer choices by providing continuing support to PSL enrollees and to CRPS.
PSL partnered with Ascension St Vincent's Riverside in 2017, which at the time had the highest number of drug-related encounters in Duval County, to pilot the program in its emergency department (ED). Prior to the implementation of PSL, EDs in Duval County had limited policies to intervene during drug-related encounters beyond acute medical stabilization. Standard urinalysis tests utilized were not testing for fentanyl or fentanyl analogues. In response, OD2A partnered with Premier Biotech Labs (PBL) in 2020 to test urine samples voluntarily provided by PSL enrollees-greatly increasing understanding of the illicit drug supply and current overdose trends.
Providers expressed experiencing burnout and compassion fatigue for being unable to effectively engage overdose survivors. CRPS reduce this burden, using techniques such as motivational interviewing to counsel patients on harm-reduction strategies and linking patients to resources supporting recovery. Overdose survivors enrolling in PSL have the option to be linked to treatment, to receive peer support only, or both. CRPS help individuals with self-management, recovery, and work alongside participants to help them actively engage in services.
Since inception, the PSL program has expanded into 7 total area hospitals, with at least one additional hospital currently negotiating an agreement to bring PSL to its ED. Besides the EDs, peers are now embedded in inpatient and maternity areas of the hospital. An analysis of death records data from November 2017 through November 2020 compared PSL enrollees with overdose survivors who declined all PSL services. The analysis showed that since 2017, a total of 8212 ED patients were eligible to enroll in PSL. Of those, 837 (10%) had no program contact and 3340 (41%) declined services. Of the 4035 patients who consented to PSL, 3443 (85%) elected to receive peer support services only and 583 (14%) elected to receive peer support services and treatment. During this time, 9 (0.2%) patients enrolled in PSL died because of an overdose; still, the overdose rate of those who participated in PSL was statistically lower than those who did not (P = .02). In addition, toxicology testing found that the top 6 drugs with the highest overall percent positivity were alcohol (53%), fentanyl and fentanyl analogues (49%), marijuana (43%), cocaine (35%), amphetamine (34%), and benzodiazepines (28%). A cost-benefit analysis also showed participating hospitals saved approximately $3 million in a 12-month period as 80% of overdose survivors who consented to PSL did not have an overdose-related ED visit after discharge from PSL. Data also suggests participation is associated with a reduction in future EMS responses for program participants. Moreover, peers and patients have been able to share their lived experience of withdrawal with clinical providers, allowing for the introduction of comfort medications following opioid antagonist treatment as well as induction of medication-assisted treatment in the ED, which has increased engagement with the PSL program.
DOH-Duval proudly continues collaboration with Gateway and PBL to ensure the continuance of PSL. Effective partnerships between community-based recovery centers, hospitals, COJ, and DOH-Duval have been critical to overall success and ensures the long-term sustainability of PSL. A benefit of implementing this peer recovery model is that overdose survivors can themselves become CRPS after undergoing treatment and rehabilitation. Not only do these CRPS increase sustainability of staffing for the program but they also embody hope for recovery. Furthermore, this hospital-based approach has become a model for developing a community-based addiction stabilization paramedicine program in collaboration with Gateway and a federally qualified health center to ensure access to care.
Applying a continuous quality improvement approach has resulted in insightful input from partners, patients, peers, and providers. Ongoing meetings between PSL, PBL, and hospital staff are needed to improve collection and processing of urinalysis samples to reduce burden, increase sample volume, and ensure integrity of specimens. DOH-Duval being at the forefront through networking has been indispensable in raising awareness, breaking down interagency and interdisciplinary silos, and maintaining an updated list of community resources for the eTransX system, thereby increasing the community's overdose prevention capacity.
For more information, visit https://duval.floridahealth.gov/programs-and-services/preventoverdoseduval/index.
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