Alcohol and Other Drug Death Review

State: CA Type: Model Practice Year: 2004

Humboldt County Health and Human Services Public Health Branch established an Alcohol and Other Drug (AOD) Death Review Panel. Humboldt County has had one of the highest AOD-related death rates of all California counties. The goal is to involve community partners in reviewing individual deaths, generating recommendations for improved community collaboration, and initiate new practices. The Panel is based on the Child Death Review model. Leadership from the Public Health, Mental Health/Alcohol and Other Drug Program and the Coroner is essential. The review panel also includes community medical and AOD treatment providers, educators, and representatives from law enforcement. Mental health and AOD providers, in particular, had to agree to confidentiality protocols in order to allow them to contribute clinical information to panel discussions. A statistician needed access to death certificates and coroner’s records for statistical analysis and case finding. All AOD-related deaths are reviewed by the leaders, and aggregate statistics are reported. The AOD Death Review Panel reviews four deaths at each of four sessions per year. Recommendations are recorded to facilitate follow through. After the second year, an outside evaluator, Dennis Rose Associates, surveyed a majority of the regular participants about the process and utility of the project. There was widespread support of and appreciation for the opportunity to network with other disciplines in order to improve effectiveness in treatment and prevention of AOD problems. Although many of the recommendations have been acted upon, it is too early to expect an impact on the AOD death rate. Project coordinators published an implementation guide for counties for developing an AOD mortality review panel. The guide was posted on the Humboldt County Public Health Web site and the national Fetal Infant Mortality Review Web site and was distributed to public health, mental health, AOD, and law enforcement officials in all California counties.
Humboldt County Public Health established an Alcohol and Other Drug (AOD) Death Review Panel based on the Child Death Review model. Humboldt County has consistently been among the worst of California’s 58 health jurisdictions in drug-related deaths. A 1999 report revealed that the number of alcohol and other drug (AOD) related deaths in Humboldt County was very high, compared with similar counties. Although Fetal Infant Mortality Review, Child, and Domestic Violence Death Review panels were established through state legislation and supported with state funds, the health department was unable to confirm the existence of any AOD Death Review in the country. The AOD Death Review was established to help clarify why the death rate is so high and what might be done to prevent such deaths. Looking at deaths carefully fosters strong emotion and is likely to trigger action.
Agency Community RolesThe Health Officer conceived of the project and procured funding from the California County Medical Services Program/California Endowment Wellness and Prevention Program. Through an RFP process, Dan Chandler, PhD, Nancy Young, PhD, and Victor Kogler were selected as collaborators. Dr. Chandler provided statistical expertise. Dr. Young and Mr. Kogler are with the Children and Family Futures Agency and provided expertise in confidentiality issues. The research and evaluation waiver of Federal Law 42 CFR allowed review of relevant record in concert with Mental Health’s Quality Assurance Program. The Review Panel represented relevant county and community agencies. Each panel member signed a confidentiality agreement, and agencies signed a memorandum of understanding. County Mental Health, Alcohol and Drug Programs, the Health Officer, and the Coroner have participated in selection of cases for review. Other regular participants in the quarterly Panel meetings include law enforcement, alcohol and other drug treatment providers, social services, health education, public health nursing, hospitals, the district attorney, probation, and health representatives of the local university. When the case involves other agencies and providers, they are invited by specific invitation. Invitees have included medical providers, highway patrol, homeless agencies, jail medical staff, psychologists, and child welfare staff. A prevention matrix of remedial actions is assembled at each review session including suggestions generated by group discussion of cases. The prevention matrix is circulated quarterly to participants, and, on specific recommendations, the Health Officer also follows up with the responsible parties. An annual statistical summary of cases is prepared and circulated to the involved agencies, to the County Alcohol and Other Drug Advisory Board, and elected officials. Costs and ExpendituresTen thousand dollars per year was awarded for contractual services for assembling data, preparing materials for review meetings and for writing reports. Initial start-up costs included funds for establishing confidentiality procedures consistent with state law and establishing a baseline system for linking AOD risks to ICD-9 cause of death codes. Once the format was established, outlay was $5000 a year for consultant costs, which include data analysis, publication of data summaries, and expenses for conducting meetings, as luncheon meetings help ensure participation. The cost of County staff time has not been evaluated, but involves approximately 10 hours aggregate time per review panel meeting. ImplementationIt took approximately eight months to work out procedures, including case definition and confidentiality procedures. The County Counsel reviewed and approved the final protocol. The program has held three or four meetings a year since 2001. Participation has been excellent. The prevention matrix is updated at each panel review session. Some of the items on the matrix are fairly simple, like promoting communication and cooperation between agencies, while some are considerably more difficult to fully accomplish, for instance, insuring adequate transitional housing is available for people working on recovery. The prevention matrix generated at review panel meetings is posted on the website.
Although it is too early to see an impact on the AOD-related death rate, there has been an increased awareness of the issue in the community and enrichment of the community treatment and prevention network. For example, practices have emerged to close the gap between the criminal justice system and the treatment community, which resulted in lost opportunities to help alcohol and other drug offenders become healthy. Congressman Mike Thompson secured federal funding to establish a residential AOD treatment program for women with children. Jail staff and outreach workers have targeted overdose prevention efforts to those drug users more likely to die after release from jail. The Highway Patrol has focused on reducing drunk driving. The Public Health Branch’s Division of Health Education has conducted drowning prevention programs including admonishing AOD use when boating or swimming. A local non-profit secured funding to evaluate feasibility of establishing a pain clinic. County Mental Health and Humboldt State University Student Health Center have taken steps to integrate mental health and alcohol and other drug treatment services. Pharmacists now cooperate more effectively with medical providers to monitor prescription narcotics. Some medical providers have trained to prescribe buprenorphine, an oral agent for substitution treatment of heroin addictions. The grantor funded Dennis Rose Associates to conduct a formal evaluation. Eighty percent of the participants completed a confidential questionnaire designed by Dennis Rose Associates in conjunction with the Health Officer and the consultants who helped establish the AOD Death Review. The consensus was that the process of AOD death review has been worthwhile and no major difficulties with the process were identified. Participants reported improved interagency cooperation in support of clients in need. An evaluation by the Health Education Division of the Humboldt County Department of Health and Human Services assessed community readiness for AOD prevention services. The community survey indicated widespread understanding that there is a significant problem with AOD abuse in the community. The survey reflected a lack of understanding that action should or could be taken to mitigate the negative impact of AOD. Accordingly, subsequent reporting to the community of the AOD Death Review proceedings has emphasized the action response. The process of an AOD Death Review panel is definitely worth the resources invested in it. Once established, an AOD Death Review panel is relatively inexpensive to continue. Although the AOD-related death rate in Humboldt County has not declined, actions initiated as a result of the review panel could contribute to a reduction in the future. The county now has more accurate data about AOD deaths to monitor trends. Review of cases personalizes the issue of AOD-related deaths, inspires community action and facilitates collaboration between partners who might not otherwise get together.
SustainabilityThe project will be continued in 2005 without grant funding by using the newly hired County Epidemiologist and asking participants to contribute to the cost of lunch. Lessons Learned Leadership from Public Health, Mental Health, the District Attorney’s Office, or AOD is essential.  The review panel must include community providers on an as-needed basis, and law enforcement.  Mental health and AOD providers in particular will need to agree to confidentiality protocols in order to allow them to contribute clinical information to panel discussions.  A statistician will need access to death certificates and coroner’s records for statistical analysis and case finding. The process required up to 100 hours a year of statistician’s time, which included writing summary reports.  Several hours of secretarial time are needed per review session to remind participants, arrange meeting logistics, and take notes.  An implementation guide on how to establish an AOD Death Review has been assembled and has been distributed to health officers, AOD administrators, and mental health administrators throughout the state and posted on Humboldt County’s Website and the national Website for Fetal and Infant Mortality Reviews.  Reviewing AOD-related deaths has helped promote changes in the community to help prevent such deaths. It has become clear that a Pain Clinic is needed to help prevent prescription drug overdoses and that availability of methadone treatment could significantly reduce heroin-related deaths. Practices have emerged to close the gap between the criminal justice system and the treatment community that results in lost opportunities to help drug offenders become healthy. The prevention matrix generated at review panel meetings will be posted on the Website. Key Elements ReplicationAn implementation guide of how to establish an AOD Death Review has been assembled and has been distributed to health officers, AOD administrators and mental health administrators throughout the state and posted on Humboldt County’s Website and the national Website for Fetal and Infant Mortality Reviews.