Peer Overdose Interventions in the Hospital Setting

The Florida Department of Health in Duval County (DOH-Duval) is the local health department in Jacksonville, FL. Duval County comprises 928 square miles located on the northeastern coast of Florida. According to the 2020 U.S. Census, Duval County has a population of 995,567 (48.5% male and 51.5% female). The median household income is $55,807. In addition, Duval County's population is 60.6% White, 30.8% Black, 5.0% Asian, and 3.6% other races, with approximately 10.5% having Hispanic ethnicity. In Duval County, 15.2% of residents live below the federal poverty level, compared to 12.4% for Florida, and 11.4% nationally. In 2018, 27% of households earned more than the Federal Poverty Level, but less than the basic cost of living for the county.

According to CDC, the increase in overdose deaths nationwide has involved three distinct, but interrelated waves: a 15-year increase in overdose deaths involving prescription opioid pain relievers, a surge in heroin deaths starting in 2010, and an increase in deaths involving illicitly manufactured fentanyl and fentanyl analogs since 2013. Additionally, from 2015 to 2016, there was an increase in incidence of stimulant-related deaths. From 2017 to 2018, deaths involving illicitly manufactured fentanyl increased 11%, while deaths involving prescription opioids and other illicit synthetic opioids decreased 5%. In 63% of these opioid deaths several additional substances were present. 

Based on Florida Health CHARTS, Duval County has seen a 276% increase in deaths from drug overdose (136 to 511) from 2015 to 2020. In 2020, Duval County had the third highest number of overdose deaths in the state of Florida. Moreover, the overdose death rate in Duval County was 52.8 compared to 34.6 (per 100,000 population) for Florida. While the opioid overdose epidemic worsens in scope and magnitude, it is also becoming more complex with the introduction of novel synthetic substances. 

In response to this public health crisis, Duval County was one of 17 counties nationwide eligible to apply and was awarded funds in 2018 by the Centers for Disease Control and Prevention (CDC) and the U.S. Department of Health and Human Services (HHS) three-year collaborative Overdose Data to Action (OD2A) grant. 

Due to the growing overdose epidemic and the strain on emergency medical services, in 2017 the City of Jacksonville (COJ) with support from Mayor Lenny Curry, Gateway Community Services Inc., Jacksonville Fire Rescue Department (JFRD), and Jacksonville City Council launched a pilot program called Project Save Lives (PSL). PSL initially partnered with one local hospital in 2017 to pilot the program in their emergency department (ED; Ascension St. Vincent's Riverside). Since inception, PSL program has expanded into six additional area hospitals (Baptist Medical Center Downtown, Baptist North, Memorial Hospital, Park West ER, Ascension St. Vincent's Southside, and UF Health Jacksonville), with at least one additional hospital currently negotiating an agreement to bring PSL to its ED (Baptist South).

The goal of PSL is to develop a seamless, collaborative, stabilization, and treatment solution to reduce opioid-related overdoses, recidivism, and mortality. The program is grounded on the concept of engaging opioid overdose survivors while they are recovering in the ED to consider immediately entering substance use treatment. A critical component of PSL is the use of Certified Recovery Peer Specialists (CRPS) who engage overdose survivors in the ED while they are recovering. While CRPS are not clinical professionals, they have lived experience with addiction recovery, as well as substance use and mental health disorders. This lived experience allows CRPS to connect with overdose survivors in ways health care professionals are often not able to. Overdose survivors that enroll in PSL have the option to receive peer support only or to receive peer support and linkage to treatment, including inpatient or outpatient programs. Patients who consent to participate in PSL can enter inpatient treatment immediately following ED discharge and are provided transportation directly to Gateway Community Services Inc. or other local treatment providers with an available bed. PSL utilizes eTransX Opioid Care Community (OCC) software services, which allows CRPS to connect overdose survivors with available treatment beds within participating treatment centers in the community. The majority of PSL enrollees choose peer services only, however continued follow-up and connection by CRPS encourages survivors to enter treatment when they are ready. In addition to CRPS, PSL utilizes Peer Navigators that assist with treatment, care coordination, and linkage to community referrals to address the social determinants of health (e.g., employment assistance, housing needs). The COVID-19 pandemic has greatly impacted persons with substance use disorder (SUD) and has exacerbated health and social inequities among vulnerable and underserved populations. CRPS assist in addressing these inequities by ensuring seamless referral coordination to address the social determinants of health to support long term recovery of program participants. 

Currently, standard urinalysis tests utilized in the ED do not test for fentanyl or fentanyl analogs. To fill this gap, the OD2A and PSL programs formed a partnership with Premier Biotech Labs (PBL) to provide comprehensive liquid chromatography mass spectrometry toxicology testing on submitted urinalysis samples of PSL enrollees. The urinalysis samples are collected when the PSL patients are in the ED recovering from an overdose. Toxicology information has increased our community's understanding of the composition of the illicit drug supply and current overdose trends in Duval County. 

Several factors have contributed to the success of the PSL. The dynamic partnership between Gateway Community Services Inc.'s PSL, COJ, JFRD, DOH-Duval, LSF Health Systems, and participating hospitals has played a critical role in ensuring linkage to care for overdose survivors in EDs in Duval County. The peer recovery model is key to the program's success. The CRPS bring lived experience of recovery, combined with training and supervision, to assist overdose survivors in initiating and maintaining recovery. OD2A funding has allowed PSL to build staffing and community capacity to address the overdose epidemic in Duval County. In addition, OD2A funding allowed for the expansion of PSL, an existing peer recovery program in Duval County, and the addition of the eTransX OCC to facilitate linkage to substance use treatment centers.

Website: http://duval.floridahealth.gov/programs-and-services/preventoverdoseduval/index.html 

Public Health Issue and Target Population

The overdose epidemic in the US is a complex crisis involving poly-substance use, which continues to impact in our country. Between 1999-2019, nearly 841,000 people died from drug overdose. Provisional data from the CDC's National Center for Health Statistics indicates that over 100,000 overdose deaths occurred in the US during the 12-months period ending April 2021. In 2020, Florida recorded 6,953 drug poisoning deaths of unintentional or unknown intent with 511 of these deaths occurring in Duval County. This is a 34% increase from 2019 and a 275% increase from 2015. 

Overdose disparities exist based on sex, age, race, and ethnicity. According to 2021 data from Duval County available in ESSENCE-FL, the highest number of drug-related ED visits was among those aged 35-54. When comparing data from January to October 2019 to the same time in 2021, females aged 55-74 saw a 188% increase in opioid-related ED visits and males experienced a 213% increase. However, females aged 75+ experienced the most significant increase (361%) in the number of opioid-related ED visits. Unlike other drug types, females experienced a higher number of benzodiazepine-related ED visits compared the males. Although Whites experienced the highest number of drug-related ED visits, the percent increase is higher among Black populations. Blacks aged 35-54 experienced a 368% increase in the number of opioid-related ED visits, while Whites saw a 77% increase from 2019 to 2021. Unlike other drug types, Black and White populations experience an equal distribution of stimulant-related ED visits, but only 31% of Duval County residents are Black and 61% are White. These findings highlight the importance of understanding the impact of overdose prevention efforts on health disparities and how to better address the differences in overdose vulnerability among the population. 

As we have come to understand the impact of COVID-19 on this vulnerable population and the potential for connections with overdose survivors through PSL, January 1 to December 31, 2020 represented a unique juncture. During this time, there were 7,822 overdose-related ED visits in Duval County (ESSENCE-FL). During this time, 3,486 individuals eligible for PSL visited participating EDs, of which 1,529 (44%) consented to PSL services. Of those patients who consented to PSL, 1,369 participated in peer services and 160 entered treatment. Eligibility includes being at least 18 years of age and having a substance use and/or mental health disorder. Data from ESSENCE-FL is not unduplicated, meaning that one patient could present to the ED several times and each visit would be recorded independently. PSL data is unduplicated, meaning after the initial overdose ED visit, any subsequent visits are matched to the patient record. This allows PSL to track overdose recidivism. Despite this limitation, it is estimated that during 2020 PSL reached approximately 20% of overdose survivors that presented to the ED in Duval County.

Model Practice and Innovation

DOH-Duval works with community partners to address the overdose crisis with funding from the CDC's Overdose Data to Action (OD2A) cooperative agreement. Through DOH-Duval, these funds are made available to community programs to expand their overdose prevention efforts. With OD2A funds, PSL hired 10 additional CRPS. This has allowed PSL to build capacity for expansion to additional local EDs, as well as to connect patients to treatment using the eTransX OCC system. In addition, PSL is an integral component of Duval County's Community Health Improvement Plan and is a key aspect of our community's efforts to prevent future overdose deaths in Duval County.

In March 2017, COJ held a public workshop with local leaders, public health officials, health care and substance use treatment providers, and concerned citizens to discuss the health crisis. Attendees raised concerns about waitlists for treatment facilities, stigma surrounding addiction and mental illness, and an underfunded, siloed healthcare system. In response, PSL was developed as a peer-based linkage to care pilot program based on recommendations to address opioid overdoses from the CDC, Substance Abuse and Mental Health Services Administration (SAMHSA), as well as Rhode Island's Anchor ED program. 

The goal of PSL is to develop a seamless, collaborative, stabilization, and treatment solution to reduce opioid-related overdoses, recidivism, and mortality. The program is grounded on the concept of engaging opioid overdose survivors while they are recovering in the ED to consider immediately entering treatment. A critical component of PSL is the use of CRPS who engage overdose survivors in the ED. PSL also utilizes Peer Navigators that assist with treatment, care coordination, and linkage to community referrals to address the social determinants of health (e.g., employment assistance, housing needs). Overdose survivors that enroll in PSL have the option to receive peer support only or to receive peer support and linkage to treatment. Patients who consent to inpatient treatment immediately following ED discharge are provided transportation directly to Gateway Community Services Inc. or other local treatment providers. PSL utilizes eTransX OCC software services, a non-clinical community-based electronic health record system used by interdisciplinary organizations, which allows CRPS to identify available treatment slots within participating treatment centers. In addition, PSL establishes a Plan of Safe Care (POSC) for pregnant women who are enrolled in the program and the POSC is entered into the eTransX system. This allows providers to coordinate care as a team to best meet the needs of the mom and her infant. 

DOH-Duval also provides OD2A funding to PBL to provide comprehensive toxicology testing of urinalysis samples collected when the PSL enrollees are in the ED. Toxicology analysis has increased our community's understanding of the composition of the illicit drug supply. As PSL builds capacity and CRPS services expand to additional EDs in Duval County, data collected by PBL is used to monitor overdose trends. Interestingly, the urinalysis results and presence of combination of substances varies greatly among participating hospitals, based on geographic location. Ongoing surveillance of drug overdose trends has strengthened our community's capacity to advocate for additional resources to address the overdose epidemic in high-priority areas. 

Prior to the implementation of PSL, EDs in Duval County had limited policies or procedures to intervene during drug-related encounters beyond acute medical stabilization. In addition, many clinical providers in the ED expressed feelings of burnout and compassion fatigue because they were unable to effectively engage overdose survivors to consider treatment options. The COVID-19 pandemic exacerbated these feelings. To address these challenges, PSL utilizes CRPS to engage overdose survivors in the ED to consider options to immediately enter substance use treatment. While CRPS are not clinical professionals, they have lived experience with addiction recovery, as well as substance use and mental health disorders, allowing them to connect with overdose survivors in ways health care professionals are unable to. The placement of CRPS in EDs has increased capacity of EDs to better care for overdose survivors and created opportunities to educate providers on substance use disorders and recovery. This has helped to reduce stigma around addiction among hospital staff. Although the idea of peer support is not new, embedding peer support programs in EDs has only recently gained traction and more evidence is needed to determine the efficacy of this model.

Addressing Health Inequities

Since inception, PSL was mindful of health inequities that impact persons with SUD. The National Institute on Drug Abuse (NIDA) recommends a comprehensive approach for individuals with SUD to address unmet needs. Wraparound services such as childcare, education, employment, housing, transportation, clothing, financial, food, and legal needs are recommended to support individuals with OUD/SUD. Oftentimes health improvement efforts aimed at creating a wraparound system of care are slow-moving and results are not always immediately evident. However, PSL created a robust partnership between substance use treatment providers, local hospitals, city council, local department of health, first responders, people with lived experience, and community-based organizations, which has increased Duval County's capacity to better support individuals in recovery. The COVID-19 pandemic has greatly impacted persons with substance use disorder and has exacerbated health and social inequities among vulnerable and underserved populations. PSL works to address these inequities by ensuring seamless and culturally competent referral coordination to support long term recovery of program enrollees.

PSL's engagement with overdose survivors in the ED provides a unique opportunity to address health inequities during a crucial touchpoint within the healthcare system. The program was initially implemented in the hospital experiencing the highest number of drug-related encounters in Duval County (Ascension St. Vincent's Riverside) and has since expanded to include 6 additional hospitals (Baptist Medical Center Downtown, Baptist North, Memorial Hospital, Park West ER, Ascension St. Vincent's Southside, and UF Health Jacksonville) in other high-risk areas of the county. Additionally, having CRPS integrated as hospital personnel has lessened the burden on clinical staff by increasing their capacity to holistically treat a patient following an overdose. For example, peers use motivational interviewing techniques to counsel patients on harm reduction strategies and link patients to necessary resources to support the recovery process. Using OD2A funding, Gateway Community Services Inc. purchased eTransX OCC software, which allows CRPS and Peer Navigators to link PSL enrollees to resources that address the social determinants of health (e.g., housing, employment) and available detoxification facilities in Duval County. One way that the eTransX system has been used is to refer to Operation New Hope an organization that helps people with housing, and education, and training within their first year of release from jail or prison. Using their lived experience, CRPS meet the patient where they are in their readiness for change by providing tailored and empathetic support. Gateway Community Services Inc's works to ensure equitable access to substance use treatment options by offering services on a sliding fee scale and will not deny any patient based on their ability to pay. 

Access to appropriate withdrawal symptom management influences a person's substance use and recovery. Improvements in clinical treatment approaches have resulted from lessons learned though PSL. For example, procedures and protocols have been tailored to improve the patient's experience of withdrawal, which is a consequence of utilizing naloxone to reverse an overdose. Quality improvement not only helped patients experience less severe withdrawal symptoms, but it also increased the opportunity for the CRPS to have meaningful discussions with the patient regarding treatment options. 

Data on health disparities is used to inform the expansion of the PSL program in Duval County. In 2020, the number of infant deaths per 1,000 live births was higher in Duval County (7.8) compared to the state of Florida (5.8). Additionally, the infant mortality rate in Duval County was 2.9 times higher for Black babies compared to White babies. Results from Northeast Florida's Fetal and Infant Mortality Review found that: 1) substance use is a leading factor contributing to infant mortality in Duval County and 2) health services and social services in Duval County are fragmented and uncoordinated, resulting in a fragmented system of care for women. Based on these findings, PSL set out to support pregnant women and mothers who give birth to a substance exposed newborn. Although there have been challenges with accessing the labor and delivery unit due to COVID-19, peers are now supporting parents of substance exposed babies enrolled in PSL to develop a POSC. The POSC assists with ensuring the safety and wellness of the child by addressing the health and substance use treatment needs of the child and affected caregiver to advance personal and family recovery and resiliency. Gateway Community Services Inc. provides guidance by mentoring OD2A funded community partners (i.e., Northeast Florida Healthy Start Coalition), and holds regular Extension of Community Health Outcomes (ECHO) learning sessions to expand knowledge in the community. 

Finally, advocacy efforts among PSL partners, such as LSF Health Systems, and stakeholders statewide led to legislature changes which improved CRPS credentialling requirements by removing barriers to employment such as background screening requirements. People with lived experience of addiction are disproportionately represented in the criminal justice system and, as such, there were many people who would not be able to work in a hospital setting due to a prior felony conviction. This reform increases employment access and reduces inequality. 

Goals and Objectives

The goal of PSL is to establish a program in Duval County that provides specialized, coordinated, and seamless services for the treatment of substance misuse among overdose survivors, thereby reducing future overdose and other drug-related deaths. The targeted medical services are provided by ED healthcare providers and include but are not limited to stabilization and treatment for withdrawal, medication assisted treatment. After connection to a CRPS, the overdose survivor is provided information about PSL and given the option to enroll in the program. The overdose survivor is given the option to receive peer support services only or peer support services and treatment. If peer support and treatment is chosen, the CRPS ensures seamless transfer to residential and/or outpatient services. 

Implementation

Gateway Community Services Inc. proposed the PSL program to Bill Gulliford who was a Jacksonville City Councilman and Chair of the Special Committee on Opioid Epidemic, Vaping & Mental Health Resources in 2017. Councilman Gulliford proposed Ordinance 2017-426-E to appropriate emergency funding to fund the PSL pilot program and this request was approved in the amount of $1.5 million. More specifically, the initial proposed budget outlined $648,000 for residential treatment services, $300,000 for outpatient services, and $80,000 for medication costs. Other costs included staffing and training.  

The initial PSL pilot program was set to last six months with JFRD overseeing the program with the assistance from Gateway Community Services Inc., River Region Human Services, UF Health Jacksonville, Ascension St. Vincent's Hospital, and DOH-Duval. The mayor's office assisted with developing agreements needed to execute the program. Additionally, the PSL pilot program was supported by the General Counsel and the City's Risk Management Division. As the program expanded, so did the collaborative consortium of interdisciplinary partners. For example, Drug Free Duval, a local nonprofit, donated a web-based version of SBIRT to use in the ED. LSFHS, incorporated in 1979 by a consortium of churches and Jacksonville community leaders, is one of Florida's largest networks of behavioral healthcare providers. They are now helping to close the gap by assisting in the expansion of PSL in other counties and are also developing CRPS training programs throughout Florida. One of the methods that helped the PSL program gain buy-in has been through community meetings. For example, after an opioid symposium in 2018, 10 treatment centers pledged their support by contributing 10 percent charitable services to this effort. Treatment partners include Gateway Community Services Inc., Lakeview Health, Stepping Stone, and Wekiva Springs. Other partners like the Florida Alcohol and Drug Abuse Association, a subsidiary of the Florida Behavioral Health Association, and the State of Florida, Department of Children and Families have been supportive of the PSL program.

The PSL program has utilized surveillance data provided by DOH-Duval and other local partners to strategically implement the program in the community. During the first six months of the PSL pilot program, CRPS were only available in one ED (Ascension St. Vincent's). Peers were strategically scheduled at the time with the highest number of overdose-related ED visits and/or EMS pre-hospital transports for suspected overdose which was between Thursday and Sunday from 8:00 am - midnight. Within the six-month period, the PSL pilot program was able to expand services to include additional staffing hours and an additional hospital facility, Ascension St. Vincent's Southside. At the conclusion of the six months, there was leftover funding that allowed for PSL's expansion to two more hospitals. Dr. Raymond Pomm, chief medical officer of Gateway Community Services Inc., said the program is turning out to be cheaper because patients are choosing to get sober with the help of peer recovery specialists and not always choosing in-patent treatment.” According to PSL cost analysis data, on average participating EDs save $3,078,843 in 12-months period as 79% of overdose survivors who consent to PSL do not have an overdose-related visit to the ED after discharge from the program. Since inception, PSL has expanded to six local hospitals with one more facility in the process of onboarding which is set to take place in 2022. Hospital systems implementing PSL include Ascension St. Vincent's, UF Health Jacksonville, Baptist Health, Orange Park Medical Center Park West ER, and Memorial Hospital. 

Program Cost

Currently, the total cost of the program is split between the COJ, JFRD, participating hospitals, DOH-Duval's OD2A funding, LSFHS, Duval and First Coast Delegation, Florida Blue, and other federal grants. For fiscal year 2020/21 the COJ budget included $1,160,999.00 for PSL. For the fiscal year 2021/22 the COJ has appropriated $1,128,348 to Gateway Community Services Inc. Additionally, the participating hospitals contributed funding toward their CRPS positions. The program also receives $1,004,470.25 from the CDC's OD2A cooperative agreement via DOH-Duval to fund ten CRPS positions and the eTransX OCC system. The community continues to benefit from PSL program through the reduction in drug-related deaths among PSL enrollees and decrease in recidivism.  

Role of the Local Health Department

In addition to providing a portion of the funding for PSL, DOH-Duval provides surveillance data to assist with the planning and implementation of PSL. For example, data may include, but is not limited to, the hour and day of the week with the highest number of pre-hospital transports, which informs scheduling of CRPS in the ED. DOH-Duval also increases awareness of services provided by partners through marketing campaigns, health fair outreach, and strategic partnership development. To build community partnerships, DOH-Duval schedules introduction meetings with local organizations to learn more about their strategies for overdose prevention in Duval County. In these meetings DOH-Duval shares information about the OD2A program and the integral partners, such Gateway's Community Services Inc's PSL program. These meetings assist with breaking down silos by encouraging interdisciplinary partnerships in Duval County, which is essential to finding solutions for overdose prevention. In addition, PSL is an integral component of Duval County's Community Health Improvement Plan and is a key to reaching our community's goal to prevent future overdose deaths in Duval County. Duval County CHIP meetings are used to share updates on PSL, as well as other OD2A funded overdose prevent efforts in the community, and to identify opportunities for collaboration with Duval County's diverse CHIP partnership. 

Collaboration with Target Population

Approaches have been tailored to incorporate feedback from CRPS, hospital and laboratory staff, and community partners. An example of this is the improvements that were made to the requisition process for obtaining urine samples from PSL enrollees. More specifically, it was noted that the number of urine samples collected from PSL enrollees had declined. To address this issue, PSL program staff consulted peers and hospital staff to determine the barriers that they were facing. CRPS noted that they were spending a considerable amount of time filling out the requisition forms since a form had to be filled out for each sample. To eliminate these challenges, PSL and PBL changed the process to eliminate the need for requisitions. All samples are now de-identified when sent to PBL which reduces the workload for the CRPS and will hopefully increase the number of samples being sent to PBL. While deidentified data does not allow for the tracking of demographics or matching samples to the patient, it does allow for toxicological trends to be examined geographically by hospital facility. This data is shared with community partners and assists in planning targeted prevention strategies addressing specific drugs and drug combinations contributing to overdose. 

Additionally, community members with substance use and mental health challenges have been a part of the quality improvement of OD2A marketing materials. For example, during an outreach event in a high-risk area of Duval County, the OD2A brochure was distributed to attendees. This brochure directed people to the OD2A website for additional information. Several individuals mentioned that they had limited access to technology and/or the internet which prevented them from being able to take the next step. As such, the flyer was revised to include phone numbers and addresses of partner agencies to ensure equitable access to resources.

The overall goal of PSL is to reduce overdoses, recidivism, and deaths in Duval County that are related to opioid-related use disorder (OUD), other substance use disorder (SUD), or co-occurring substance use disorder (CSUD) and mental health disorder (MHD). 

Data collection and evaluation approach

The approach developed to evaluate OD2A followed the guidelines, steps, and standards of the CDC Evaluation Framework. Process measures were collected to measure and track grant activities, while data for outcome measures were collected to assess whether the program had its desired impact. DOH-Duval worked collaboratively with internal and external stakeholders to evaluate PSL. Prior to finalizing the evaluation plan, DOH-Duval met with stakeholders to discuss the evaluation plan, address any barriers or concerns, and receive feedback on the evaluation plan and preferred methods of disseminating findings. The evaluation plan was regularly assessed via feedback from OD2A partners and improvements were implemented based on recommendations. Data was reviewed with stakeholders to determine how it can be used for continuous quality improvement purposes.

To monitor process measures, a Microsoft Office Excel data collection tool was created with input from the PSL director. Monthly process indicators reported via the data collection tool included the following:

1.       Total number of overdose survivors eligible to enroll in PSL

2.       Number of overdose survivors with no program contact (e.g., expired, left against medical advice AMA, CRPS not available)

3.       Number of overdose survivors that consented to PSL

4.       Number of PSL enrollees that selected peer support services plus treatment for substance use disorder and the number of PSL enrollees that selected peer support services only

5.       Number of PSL enrollees actively engaged in PSL

6.       Number of PSL enrollees that completed PSL

7.       Number of PSL enrollees that died from an overdose

8.       Number of PSL enrollees placed in a treatment slot in the eTransX OCC system and that were linked to care

9.       Number of PSL enrollees serviced by a CRPS at each participating ED and the number of PSL enrollees served by an OD2A funded CRPS

10.   DOH-Duval also collects data related to the number of pregnant women enrolled in PSL that have a POSC and that are linked to care.

In addition to the process measures reported to DOH-Duval, data was also collected through surveys and interviews. This data is used to evaluate the effectiveness of PSL and for program improvement purposes. To date, the following surveys and interviews have been conducted:

1.       Annual CRPS survey. CRPS staff are asked to provide their feedback regarding the following topics: 

a.       Needs of program enrollees (e.g., housing, employment, food, access to care, transportation) 

b.       Organizations PSL enrollees are most frequently linked to (e.g., housing support, food banks, mental health treatment facilities, clothing, employment services, additional services) 

c.       Perceived barriers that PSL enrollees experience to seeking treatment for OUD/SUD 

d.       Instruments and strategies utilized during interactions with PSL enrollees (e.g., SBIRT, URICA, link to NARCAN resources, motivational interviewing, sharing personal experiences) 

f.        Modes of communication that are most effective in reaching PSL enrollees  

g.       Perception of PSL's effectiveness and the care coordination provided

i.         Beliefs about the effectiveness of the eTransX OCC system, as well information on barriers, opportunities for improvement, and the most utilized features

j.         Barriers to implementing linkage to care activities

k.       Challenges faced due to COVID-19

2.       Quarterly Professional Quality of Life Scale Survey (ProQOL) of CRPS 

a.       Measure levels of compassion satisfaction and compassion fatigue, which consists of burnout and secondary traumatic stress 

3.       Annual interview with Director of PSL 

a.       Interview includes questions concerning the functionality of PSL, successes, barriers, lessons learned, suggestions for improvement, program sustainability, and specific challenges faced due to the COVID-19 pandemic

4.       Annual Stakeholder Meeting Survey 

a.       Frequency that stakeholders attend various community meetings (i.e., North Florida Poly-Drug Task Force quarterly meeting, OD2A Monthly Grant Partner meeting with DOH-Duval, Drug Epidemiology Network (DENS) meeting, etc.) 

b.       Usefulness of data presented at each meeting in informing overdose prevention efforts

c.       Data sources most frequently utilized (e.g., JFRD Transport/EMS data, ED visits (ESSENCE-FL), PSL data, Medical Examiner, Vital Statistics Death data, Premier BioTech laboratory reports) 

d.       COVID-19's impact on ability to conduct prevention and response work in the community 

Program Reach and Outcomes

University of Florida's Center for Health Equity and Engagement Research completed an analysis of death records from the Florida Department of Health's Vital Statistics Office from November 2017 through November 2020 for the five-county area of Northeast Florida (Baker, Clay, Duval, Nassau, and St. Johns). Overdose death records during this time were compared between overdose survivors that consented to participate in PSL and overdose survivors that were approached by a CRPS but declined all PSL services. Primary and secondary causes of death were examined, the number of days the death occurred after the initial overdose visit to the ED, and whether the deceased participated in substance use treatment. The results of the analysis showed that since inception of PSL in 2017, 8,212 ED patients have been eligible to enroll in PSL. Of those, 837 (10%) did not have any program contact and 3,340 (41%) declined all PSL services. Of the 4,035 patients that consented to PSL, 3,443 (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 due to an overdose. Analysis showed that the overdose rate of those who participated in PSL was statistically lower than those who did not participate in PSL (p = 0.02). 

Data also suggests that participation in PSL is associated with a reduction in future JFRD response calls for program participants. Analysis conducted in 2018, reported a 52% decrease in JFRD overdose response calls to PSL enrollees. This analysis was performed by comparing the number of JFRD overdose response calls to each participant for the 12-months prior to enrolling in PSL and the 12-months post PSL program completion.

Premier BioTech Laboratory Testing

As part of this work, PBL tests urine samples of overdose survivors who consent to the PSL program. PBL tests for Opiates, Oxycodone, Cocaine, Amphetamine/Methamphetamine, Marijuana, Buprenorphine, Benzodiazepines, Tramadol, Heroin, Gabapentin, Dextromethorphan, Alcohol, and 13 different variations of Fentanyl. Between November 1, 2020, and June 30, 2021, a total of 222 samples from six different EDs were accepted for testing. The top five drugs with the highest overall positivity percent were alcohol (53%), fentanyl and fentanyl Analogs (49%), marijuana (43%), cocaine (35%), amphetamine (34%), and benzodiazepines (28%). PBL also conducts a detailed breakdown of fentanyl and analogs and opiates. In Duval County, fentanyl is found in 98% of the specimens, followed by the analog norfentanyl (97%), acetyl norfentanyl (19%), acetyl fentanyl (19%). Furanyl fentanyl was not found in any sample within this period. Morphine (67%) was the most common opiate followed by norhydrocodone (33%), hydrocodone (29%), hydromorphone (24%), dihydrocodeine (20%), codeine (7%), heroin (7%). Finally, an analysis of drug combinations shows that synthetic fentanyl was found with two or more substances in a total of 80 specimens, and with three or more substances in 54 specimens. When synthetic fentanyl was found with only one other substance, the most common substance was amphetamine (N = 56) or cocaine (N = 52). 

The toxicology reports of PSL enrollees provided by PBL have increased our understanding of the illicit drug supply in Duval County and the geographic differences that exist based on hospital location. All test results are aggregated, analyzed, and presented at stakeholder meetings to inform future overdose prevention efforts.

Linkage to Care

PSL enrollees are linked to a variety of services and programs, both internal and external to Gateway Community Services Inc. The data below represent the percent of PSL enrollees that were linked to each service during the time frame of September 1, 2019, through August 31, 2020. The linkages are tracked in the eTransX OCC. 

1.       Substance use treatment 68%

2.       Mental health services 77%  

3.       Support systems 34%

4.       Housing 90%

5.       Hygiene/food 15%              

6.       Clothing 34%

7.       ID/legal 8%

8.       Medical needs 34%

9.       Medical insurance 3%

10.   Employment 16%

11.   Education 3%

12.   Life Skills 92%

Sharing Results with Stakeholders

DOH-Duval disseminates surveillance data through a variety of mechanisms including data requests, brief reports, presentations, stakeholder meetings, and other publications and has built relationships with community partners that can immediately use surveillance data to prevent overdoses.  The intended target audience for dissemination included the public, stakeholders, and policy makers working to prevent overdoses. DOH-Duval worked with stakeholders to identify additional target audiences for evaluation data and ensure that data is disseminated in a way that is clear, concise, useful, and practical. In addition to sharing evaluation results, communication materials included information that stakeholders may need to implement evaluation findings. Stakeholder meetings, community meetings, and briefs will continue be used as a mechanism to share timely data, communicate what is working well, what needs to be adjusted, and to share recommendations for using evaluation findings to improve overdose interventions. Success stories and reports are utilized to share accomplishments, demonstrate value and impact, and communicate how data can be used to improve overdose interventions. As part of this work, an evaluation reporting tool has been developed to track data dissemination and how evaluation data was used to inform overdose prevention efforts. A marketing specialist at DOH-Duval supports OD2A dissemination efforts, including the development of a DOH-Duval OD2A website and other marketing materials to share evaluation findings. PSL data is also presented by Gateway during the City of Jacksonville City Council Special Committee on Opioid Epidemic, Vaping & Mental Health committee meetings, which is free and open to the public. 

PSL was envisioned in 2017 to be a program that would address the lack of wraparound care and resources available to overdose survivors in the ED. Since the initial pilot program, PSL has expanded to six additional EDs in Duval County. Effective partnerships between community-based recovery centers, hospitals, COJ, and DOH-Duval have been critical to the overall success of PSL and will ensure the long-term sustainability of PSL.

Lessons Learned Related to the Practice. 

The groundwork laid by Gateway Community Services Inc. administrators, clinical experts, programmatic staff, and others to implement this hospital-based peer recovery program showcases how collaboration can lead to program sustainability. In a short period of time, the strong partnerships that are the foundation of PSL let to its quick expansion from one hospital in Duval County to six additional hospitals. Lessons learned from implementation include: the benefit of embedding CRPS in the ED, flexibility around criminal history in the hiring process, cost benefits of peer support services versus traditional staffing models, and changes to the PSL process.

Staffing CRPS in the ED resulted in a person-centered approach to the delivery of linkage to treatment and care services provided to overdose survivors. Based on conversations between peers and patients, we learned that overdose survivors often experienced shame in their interactions with clinicians and this resulted in a general distrust and disengagement from seeking treatment. Now that people with lived experience are embedded in the ED, peers use the emotional connection to deliver a message of hope for recovery based on their own personal journey. Peers and patients have also been able to share their lived experience of withdrawal with clinical providers which allowed for introduction of comfort medications, like buprenorphine, following opioid antagonist treatment. This insight gained from CRPS has improved patient-doctor interactions and resulted in higher engagement with the PSL program. 

Another benefit of implementing this peer recovery model, is that overdose survivors can themselves become a CRPS after undergoing treatment and rehabilitation, which increases the sustainability of staffing for the program. For many, serving a CRPS has strengthened their recovery. Moreover, having a stable job helps individuals in recovery and reduces their chances of relapse to substance use. We have also learned that the impact of peers on the community transcends PSL. An example of this is that CRPS have reported moving on to other jobs and applying their lived experiences to helping other vulnerable populations, such as mothers and substance-exposed infants.

A continuous quality improvement approach has been taken to the implementation of PSL. Lessons learned and opportunities for improvement have been gathered from partners, patients, peers, and providers. Collaboration on the process of continuous quality improvement has been an integral part of PSL implementation. For example, PSL, PBL, and participating hospital staff worked together improve the process of collecting and processing urinalysis samples to reduce burden on CRPS, increase the number of samples tested, and ensure integrity of the samples. Finally, challenges learned related to linkage to care included a lack of male beds and peer-patient communication during COVID-19. 

Lessons Learned Related to Partner collaboration

Strong community partnerships have been integral to the success of PSL. In the first phase of PSL, Gateway Community Services Inc.'s leadership team engaged implementation partners around their proposed treatment and stabilization peer recovery model. Gaining buy-in and cultivating the partnership with JFRD was critical to engaging and educating first responders on PSL. Meeting first responders where they are, not only in their level of understanding of addiction but also in their workplace environment, helped to increase knowledge of SUD and awareness of PSL and other support services. Partner collaboration was also essential to addressing the social determinants of health. Because individuals with SUD often experience health and social inequities, effectively linking PSL enrollees to resources and care coordination proved important in supporting program participants in their long term recovery. Lessons learned from collaboration have been the importance of maintaining diverse/cross sector partnerships and the importance of receiving feedback to improve the effectiveness of the services provided. 

Lessons-community engagement

Community engagement in a variety of forums was important to heighten awareness and involvement in PSL. The Special Committee on Opioid Epidemic, Vaping & Mental Health Resources is a venue where PSL updates are provided to Jacksonville City Council meetings. Meetings of OD2A Partners, the North Florida Poly Drug Task Force, the Duval Drug Epidemiology Network, and CHIP meetings are other avenues for partners to lean about PSL and identify opportunities for collaborating. Presenting in community meetings has led to networking opportunities which has increased awareness among a broader array of stakeholders, such as the business and faith communities. Community engagement has been essential to breaking down interagency and interdisciplinary silos which has helped to increase capacity of the PSL program to serve overdose survivors. Additionally, attending these meetings helps all agencies involved in overdose prevention remain aware of community resources, such as the eTransX OCC system, and ultimately increases our community's overdose prevention capacity. Awareness of the benefit of these life-saving support systems implemented though PSL has resulted in greater buy-in from area hospitals, allowing the expansion of PSL which in turn increased the program's capacity to reach more overdose survivors. Furthermore, timely surveillance data presented by DOH-Duval OD2A increases awareness of the scope of the overdose epidemic locally which assists with developing a sense of urgency to implement prevention programs like PSL. Sharing PSL data has also resulted in neighboring counties implementing similar peer recovery models in their local ED's. 

Implementing the PSL program within the hospital provided an opportunity for engagement with clinicians and led to the reduction of stigma among staff. Based on the results of the Annual CRPS Survey, most CRPS reported that hospital staff to be very (71%) or extremely (24%) supportive, and none reported hospital staff not being supportive. 

Outreach and education are sustainable ways of increasing program awareness at the hospital and community level. Additionally, partnerships with DOH-Duval, other hospitals, and relevant community groups established the credibility of the program and this in turn increased buy-in from other key stakeholders. Another early lesson from program implementation was the usefulness of establishing credibility within the community through partnerships with community-based organizations including law enforcement and emergency medical services.

Lessons-available funding or funding mechanisms

Since November 2017, PSL continues to be funded by the COJ, Councilman Bill Gulliford, Councilman Ron Salem, JFRD, LSFHS, the State of Florida, Duval and First Coast Delegation, and Florida Blue. The expansion of the project with funding from DOH–Duval's CDC OD2A cooperative agreement allowed for increased capacity by the funding of additional peer navigators, supervisory support, a cloud-based case management system, and data support. Interagency collaboration has strengthened the community's capacity to advocate for additional resources and funding to address the overdose epidemic in Duval County. For example, with OD2A funding the PSL program has been able to hire additional CRPS, implement the eTransX system, and onboard additional hospital facilities which has increased its capacity to engage overdose survivors in recovery. COVID-19 precautions related to limiting each room to have one occupant resulted in challenges related to treatment bed availability. To address the challenge, PSL approached treatment providers who typically only accept private insurance and asked them if they could offer scholarships to indigent program enrollees. Having a diverse stream of funding sources not only allows PSL to continue to expand its services to new locations and additional patients, but it also ensures the sustainability of the program beyond the OD2A funding period. 

A major barrier to care coordination was the lack of interoperability between electronic medical records systems. With the help of OD2A funding, PSL established the eTransX system which allows the peers and the treatment team to coordinate linkage to treatment and resources to address the social determinants of health. Being able to document referrals, interactions, and conversations between agencies such as EMS, law enforcement, clinical providers, and peers improved care coordination for the patient. 

Cost/benefit analysis

Our community continues to benefit from PSL through the reduction in drug-related deaths among PSL enrollees. In addition, participating hospitals have seen a decrease in recidivism, as 79% of PSL enrollees discharged from the program did not have repeat overdose ED visit during the 12 months after program discharge. An initial cost/benefit analysis of PSL found that since inception, implementation of the PSL program has resulted in a total cost savings of $3,078,843 for JFRD and local hospital systems.

Sufficient stakeholder commitment to sustain the practice

Community engagement is a pillar of the PSL program, this allows the program and partners to identify ways to build community capacity which is a more sustainable approach to address the overdose epidemic in Duval County compared to investing in new public health interventions. PSL has commitment from a diverse group of stakeholders and funding sources which will facilitate sustainability of the program. Although the program has only recently begun conducting cost/benefit analyses, evidence suggest PSL has resulted in substantial monetary savings. Cost savings, coupled with improved health outcomes for people living with SUD has reaffirmed our community's commitment to continuing the PSL program and has also generated interest in further expansion of the program. Likewise, as awareness of the benefits of an implementing peer recovery models in hospital settings grows, other counties in Florida have looked to PSL for technical assistance. 

Another component of sustaining the PSL program is ensuring the wellness of the CPRS. DOH-Duval partners with Gateway Community Services Inc. to conduct quarterly assessments of compassion satisfaction, burnout, and secondary trauma among CRPS working on PSL. Resources and coaching are provided to CRPS experiencing low levels of job satisfaction and high levels of burnout or secondary trauma to better support them in their roles and personal recovery.

Sustainability plans

Since implementation of the PSL pilot program, gaining buy-in from hospital leaders and clinical providers has been a primary focus to ensure sustainability. Implementing strategies to integrate peers in hospital settings creates sustainability in these positions beyond any grant-based program that is contingent upon the continuation of funding. Moreover, the multiple funding streams provided by cross-sector partners increases the likelihood that there will continue to be funds to support implementation of PSL after OD2A funding ends.