Ocean County Overdose Fatality Review Program

State: NJ Type: Model Practice Year: 2019

Ocean County, New Jersey is one of the largest geographic counties in the state, situated directly on the East Coast.Located approximately 60 miles from Philadelphia and New York City, this makes Ocean County a prime tourist attraction in the summer due to its many beaches, and is affectionately nicknamed the Jersey Shore”.U.S. Census data reflects that the racial and ethnic makeup of Ocean County is two percent Asian, 3.5 percent Black or African American, 9.4 percent Hispanic or Latino, and 92.8 percent White; less than one percent is American Indian or Alaska Native, and 1.4 percent is two or more races. Although the median age of residents is around 42.6, the senior population (65 and older) comprises almost 23% of the population. Ocean County is one of the fastest growing counties in New Jersey, offering 33 varying municipalities ranging from beach towns to rural farms. Each municipality has its own personality with some municipalities with a large population of approximately 100,000 and some with a small population of only 257 residents. There are 17 public high schools, vocational schools, and religious schools that provide education to the high school aged youth and approximately 70 elementary schools for the younger children. As a part of Ocean County since 1978, the Ocean County Health Department (OCHD), has worked in partnership with the community and is committed to promoting healthy lifestyles and a clean and safe environment. The OCHD is guided by the following principles: to assess the priority needs and wants of the community we serve through comprehensive health planning; to inform and educate residents about public health issues; to encourage people to take responsibility for their own and their neighbors' health; to utilize a team approach in achieving our mission; to commit to problem solving utilizing a systemic approach; and to promote a work environment which fosters creativity, innovation, respect, sense of caring, commitment, trust, quality and dependability. The OCHD is a leader in the county successfully implementing public health programs reaching greater than 40,000 individuals across Ocean County annually through a myriad of initiatives. OCHD, in close collaboration with community partners and diverse stakeholders, has established a foundation of implementing strong programs delivering the clinical, technical, and financial management expertise required to successfully ensure grant compliance. The public health issue is that compared to other counties in New Jersey, Ocean County has experienced an unprecedented number of overdose deaths over the past several years. The overdose death rate per 100,000 population for Ocean County is 35.8 surpassing New Jersey, 24.8, and the United States,19.7. The overdose death rate in Ocean County is one of the highest in NJ, being second for overdose death from 2012-2016, with marginal improvement in 2017, being ranked fourth in NJ. In response to the significant numbers of overdoses, the OCHD became the lead agency in a fatality review program introduced by the High Intensity Drug Trafficking Area of NY/NJ (HIDTA) and Drug Enforcement Administration (DEA). A fatality review program brings together county partners to review the cause of overdose deaths identifying trends in both the decedents' life and in their engagement with the system of care. Ultimately, the goal of the Ocean County Overdose Fatality Review Program (OC-OFRPP) is to use the aggregate decedent data to strengthen or build a county capacity to provide data-driven, best practice or evidence-based prevention education, treatment and recovery supports focused on reducing overdose deaths through the identification of specific local issues found in the decedent review or social autopsy.” The OCHD is meeting all of the objectives for decedent's reviews as county wide affiliated partners come to the table every month to review decedent cases.The program has brought together non-traditional partners to work together and identify the reasons for substance use disorder and overdose death.These partnerships have provided opportunity for an assessment of our continuum of care, how resident's access different points in our community from criminal charges to federally qualified health care centers to hospitals and how the different providers can break down silo's, de-conflict relationships, and improve treatment and referrals. This social autopsy” process uncovers the unique and county specific reasons residents are overdosing.By identifying these root causes, community specific programming, environmental changes, and policy changes can be developed. By implementing change, the countywide public health impact will not only be for residents with substance use disorder, but also influence their family and friends, and the county as a whole.The OCHD website is
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The public health issue is that compared to other counties in New Jersey, Ocean County has experienced an unprecedented number of overdose deaths over the past several years. The overdose death rate per 100,000 population for Ocean County is 35.8 surpassing New Jersey, 24.8, and the United States,19.7. The overdose death rate in Ocean County is one of the highest in NJ, being second for overdose death from 2012-2016, with marginal improvement in 2017, being ranked as fourth in NJ. Based on 548 overdose deaths from 2013-2016, 96 or 18% were under the age of 26, 200 or 36% were between ages 27-39, 121 or 22% were between ages 40-49, 94 or 17% were between ages 50-59, and 37 or 7% were 60 and older. From 2013-2017, Ocean County had the highest proportion of treatment admissions out of all the counties in New Jersey. According to the 2009 Household Survey, these numbers do not take into account the estimated 35.3% Ocean County residents who need substance abuse treatment but were not able to access services. From 2010-2016, residents age 25-29 made up the largest percentage of admissions into treatment, that changed in 2017 with ages 35-44 becoming number one for admissions. In 2017, male made up 63% of admissions with females at 37%. In 2013, Ocean County experienced 112 overdose deaths, in 2014, there were 106 overdose deaths, in 2015, there were 119 overdose deaths and in 2016, there were 211 overdose deaths. In 2017, there were 173 overdose deaths. Regardless of the numerous efforts to combat the opioid epidemic in Ocean County, the number of overdose deaths and narcan reversals were not changing. The concept of the fatality review was an attractive option as it drilled down to the root causes of addiction and overarching systemic issues that are experienced across the county. The data retrieved in the fatality review process will highlight the common denominator of an Ocean County overdose decedent. The decedents may all be different but they all had the commonality of being an overdose decedent and resident of Ocean County. For this to be a success, the partners in this project think beyond their own agency, de-conflict, and try to identify causes of overdose to begin to implement local level changes. By identifying trends and causes of overdose death, programming, policy and procedures could be developed or revised to truly meet the needs of Ocean County's most vulnerable population – the residents living with addiction. To date, there are over 36 agencies, with 58 people represented on the OC-OFRPP. From January 1, 2018- December 31, 2018, 58 cases have been reviewed: 38 or 66% were reported to have fair to poor health 33 or 57% had been linked to substance use treatment 32 or 55% were known IV users 33 or 57% had a known criminal history 30 or 52% had been diagnosed or linked to mental health treatment 13 or 22% had been convicted of a DUI 8 or 14% had been diagnosed and known to have Hep C As stated before, because substance abuse has complex biological and social determinants, multiple initiatives have been launched over the years, as the amount of residents seeking treatment and having difficulty securing placement, combined with the lethal effect of fentanyl were making little changes with overdose death rates. As stated previously, some of these efforts include a countywide opiate taskforce to look at local systemic issues, increased access to medication assisted therapy via state funds, state-funded opiate overdose case management, and the expansion of recovery support services into the continuum of care. In addition, Ocean County is home to 20-drug drop off locations and hosts mobile take back events to reduce the availability of prescription drugs. County specific prevention education efforts have been developed to reach the community, specifically youth, to bring awareness and education to opioids and substance use. Additionally, OCHD has facilitated and participated in county planning efforts to identify the reasons for the increasing number of overdose deaths and develop programs to reach residents in need. Other county providers have become active in the opioid epidemic with programs launched through the Ocean County Prosecutor's Office in collaboration with local police departments and behavioral health agencies. There has been state funded programs introduced into the county over the years along with multiple grassroots efforts coming from the family and friends of those that overdosed. The multiple programs and initiatives have success helping the thousands of residents and families that need assistance but have yet to truly impact the number of overdose deaths in the county. Therefore, although the current numbers for the OC-OFRPP are small, the information reviewed in the monthly decedent meetings has led to dialogues about our residents with substance use disorder and how living in Ocean County impact use and the ability to obtain successful recovery. The Ocean County Overdose Fatality Review Pilot Program (OC-OFRPP) is an innovative program that began implementation in 2016, when the OCHD was introduced to the fatality review model by the High Intensity Drug Trafficking Area (HIDTA) of NY/NJ and the Drug Enforcement Administration (DEA). The OC-OFRPP was developed based off a similar model in Maryland. Ocean County was able to reference the materials and expertise of Maryland to create a practice that was specific to our county. Using ideas from Mobilizing Action through Planning and Partnerships (MAPP) during 2016, the OCHD was able to meet with traditional and non-traditional partners to create buy-in for this project. Although this project is not evidence based at this time, it has the potential to become a data driven best practice for counties looking to combat overdose death from a local perspective. At its core, the OC-OFRPP is an adaption MAPP with a specific focus on overdose death. This model brings local partners, agencies, and stakeholders together to conduct a social autopsy on an overdose decedent's life to identify potential reasons for use, gaps and barriers in the system of care, and possible intercepts that could have reduced the chance of overdose if programming existed. In 2017, the OCHD worked on development the infrastructure to a fatality review that would bring together partners, yield data, and be sustainable. This translates to Phase 1 of MAPP in organizing and bringing together partners. Many meetings with potential partners for the project were held in the planning year to generate interest in the project. The OCHD had to dedicate the time to establish buy in and recognition of the project as New Jersey did not have state legislation mandating or supporting the project like other states. It truly had to be a grassroots effort to generate interest and buy in for OC-OFRPP to be successful. Concurrently to Phase 1, Phase 2 of visioning was taking place with an executive committee that was meeting monthly to ensure the fatality review process would be seamless upon official launch. The executive committee also had to identify the goals, vision and objectives for the OC-OFRPP. In January 2018, the OCHD launched the decedent review meetings of the Ocean County Overdose Fatality Review Pilot Program (OC-ORFPP) which translates to Phase 3 of collecting and analyzing data. Phase 3 was crucial, as the data collected would indicate whether to continue the project beyond a pilot year. By keeping the goal of the program, which was to address the opiate epidemic as a serious public health emergency in an attempt to identify social factors to reduce overdose deaths of residents in the forefront of each meeting, the collection of quantitative and qualitative date became seamless over the monthly meeting. The procedures for the program developed in Phase 2, which were to review overdose decedents with county partners performing the social autopsy” identifying behaviors, system barriers, and county specific trends that led to overdose served as the guidance for the meeting content. By identifying the various factors that result in overdose death, Ocean County could begin to make decisions and drive solutions to remove obstacles, develop programming and change policy to keep residents alive and healthy. During 2018, the OCHD saw opportunities for additional and complimentary data to be collected and reviewed which aligns with Phase 4 of MAPP, identifying and prioritizing strategic issues. As the decedent reviews were being done, the OCHD saw these opportunities to dive deeper into the data we had collected or to start additional data collection processes. There were gaps in our data due to agencies that could not participate in confidentiality concerns. For example, the OC-OFRPP does not have school representation due to their inability to share student information. It was continuously discussed in the decedent review meetings that the lack of school based information was hindering the holistic view of the decedent's life, the information about their youth was imperative to help build prevention and early intervention programming. The fatality review members had to brainstorm ideas to work with this specific community sector to get data for a comprehensive report on Ocean County decedents. Therefore, in order to work with the schools, the OCHD will host a focus group to get qualitative information thus eliminating the need for schools to identify students. This information collected in the overdose fatality review combined with other data collection efforts will be used to create an annual report that will guide change in the community similar to Phase 5 of MAPP, developing goals, actions and an action plan. The annual report will encompass the data, recommendations, observations and programming ideas from the decedent review meeting and the additional data collection. This report will be disseminated to the county charging partners to begin making changes or developing programming for residents. At this time the OC-OFRPP is scheduled to continue into 2019-2020 with annual outcome documents thus resulting in Phase 6 of MAPP, taking and sustaining action.
The goal of the overdose fatality review is to reduce overdose deaths. This is achieved through the data collection efforts that will drive programming and policy change, therefore to achieve the goal; the fatality review must be successful. In order for the fatality review to be successful, the OCHD had to develop an implementation strategy. The first objective was to garner interest and participation in the fatality review in which the OCHD projected that it would take 6-12 months. In 2017, the OCHD began to meet with local hospitals, federally qualified health care centers, behavioral health agencies, state governmental agencies and other identified partners to request their partnership in the project. Unlike decedent review models in other states, New Jersey did not have any legislation or state government funding to initiate this process locally. Therefore, all of the momentum to get the project started had to begin at the local level by tapping into existing professional relationships and trying to garner excitement and buy-in for the project. Multiple one-on-one meetings held to achieve the goal including a large kick-off event held in April of 2017 to bring more awareness to the project. There were almost 70 partners that attended the meeting including the NJ Commissioner of Health, the Drug Enforcement Administration, and the NY/NJ High Intensity Drug Trafficking Area. The kick off was such a success that it was recognized in the state publication of the NJ Health Matters” for March-April 2017. The second objective was building a successful infrastructure. Ocean County was able to utilize our partnership with HIDTA and DEA to brainstorm how the project could be a success. Ocean County was able to discuss the development process of a fatality review by connecting with other states that had the project established. An OC-OFRPP Executive Team was developed in order to ensure the sustainability of the project with HIDTA and DEA as members. This accomplishment is integral because many times, federal, state, and local government do not work together in identifying the root cause of an issue. Initiatives are often started at different levels with little to no communication. The overdose fatality review fosters collaboration and sharing with different partners. The third objective was developing a strategy for maintaining partners, promoting the project, and ensuring sustainability to have a reliable data set at the completion of the decedent review project.Therefore, affiliation and confidentiality agreements were developed for partnership to show the legitimacy of the project and provide protection when sharing information.The agreements were followed up by technical assistance phone call reinforcing the importance of the project and the criteria to be an affiliated partner.Additional promotion of the project occurred at county and state meetings, in which the varied Ocean County agencies were able to learn about the project.The OCHD dedicated a small budget to the project, approximately $6,000, which was used to fund the kickoff event, copying and printing, and the purchase of a laptop specific to the data collection for the project.
The OC-OFRPP is currently in its pilot year of decedent review with 2018 serving as a baseline for the project. Throughout the development of the fatality review infrastructure in 2017 with the executive committee and community partners, it was a priority to have a way to collect data, assess data and share data. The success of the OC-OFRPP relies on the partnerships and in order to maintain partnerships and have affiliated partners invested in the project required full transparency of the information being shared. Therefore, the OC-OFRPP had to develop a way to collect the decedent data and trends at each meeting and then be able to report it back quarterly to membership. The OC-OFRPP developed a county specific data sheet that used a Likert scale with option for brief narrative for affiliated partners to use when reviewing decedent cases. As an agency confirmed their engagement with the decedent, they would check all clinical, health, and administrative records cross-referencing the data sheet to detail the decedent's life at the time of their engagement with that particular agency. Internally, the OCHD developed an excel spreadsheet so each decedent's score can be entered and then analyzed as a whole. During the first year it was found that the data sheet did not capture all the information needed and became an optional tool for affiliated agencies to use. The best practice has been having affiliated partners check their internal records and then provide a verbal report during the decedent review meetings. As the facilitator, the OCHD sets up large post its and captures all the shared information so affiliated partners can have a visual on the decedent specific items. Additionally, during the decedent review process; the affiliated partners identify overarching trends and observations that are noted as well. The fatality review not only captures decedent specific trends, but also overall systemic issues that needed to be addressed. The OCHD wanted to develop a way to take the overdose decedent information, organize it, and bring it back in the form of a report to the agencies that affiliated. The hope was that the creation of a quarterly report would incentivize partners to continue participating in the meeting. The quarterly report would outline the overall statistics from the decedent review, as well as encapsulate observations and recommendations made by the partners. The goal of the fatality review is to reduce overdose death and since its start, the project has identified so many things that could be done to improve the system of care. Disseminating a quarterly review document allows the partners to think about ways to improve their respective agencies, methods of enhancing client care, and the potential to apply for funding opportunities to bring additional services to Ocean County. Although qualitative reports are not new to the field of public health, bringing together community partners to perform a social autopsy” on an overdose decedent is a creative way to get local trends and data. It is the goal to continue the promotion of the fatality review to the rest if the state in order to expand into every county. By having state-wide involvement in the project, the data gathered can be using to make sustainable change for residents with substance use disorder by identifying trends seen at a micro level. The participation of the valuable partners has the potential to create conditions in which new and innovative partnerships and programming can drive solutions. Harnessing the power and information from the diverse partners combined reported at the fatality review data can begin to create local, state and federal level change to measure and share future progress. The OC-OFRPP produced quarterly documents that highlighted the number of cases reviewed and the percentage of cases that had similar issues such as criminal issues, driving under the influence, narcan deployment and others. The document also reported on any programming or policy suggestions were made in the quarter as well as captured trending observations from the cases discussed by membership. Lastly, the quarterly report serves to bring additional information or data sets to the affiliated partners. As discussed earlier, the success of the OC-OFRPP is because of the partnerships and for their continued investment and subsequent sustainability, the quarterly document serves to provide as much information and answer their questions from the decedent meetings. For example, in the first quarter of 2018, affiliated partners discussed if there was a link between day of death and receipt of social service monies. An anaylsis was done on the amount of deaths in the first third of the month, second third of the month and the last third of the month and if there was any significant increase. There was nothing substantial found. Yet, by having the OCHD take the time to provide a response to a hypothesis shows the value in participation. The initial process evaluation for the OC-OFRPP was done in 2017 before the decedent review meetings began, as an initiative of this magnitude with the need for numerous affiliations had to be streamlined before any social autopsy could be conducted. In 2017, the OCHD reviewed the decedent review of Maryland looking at their documents and process to see how it could be implemented in Ocean County. As stated before, New Jersey does not have the same legislation as Maryland which allowed partners to come together to share decedent information. The OCHD had to develop a process for the social autopsy that protected the affiliated partners and the OCHD as the facilitator of the program. In order to gauge the community response, the OCHD spent the first quarter of 2017 meeting with community partners to introduce the program and how it would work. The OCHD would take the concerns and potential barriers reported in each meeting and then discuss internally how to overcome them to have the affiliations for the decedent review. In April 2017, the OCHD hosted a kick off meeting with potential affiliated partners to continue marketing and branding the project. In September 2017, an official Board of Health resolution was passed recognizing the project. That resolution then allowed the affiliation and confidentiality agreements to be sent to potential partners for a January 2018 start date. Throughout the pilot year, a continuous quality improvement (CQI) approach was implemented with the fatality review meetings. Initially, OCHD focused on a streamlined and successful process to affiliate partners and review overdose deaths. As the months continued, the gaps in data collection became more apparent and through discussion with OCHD leadership and the executive committee, additional collection of data and an expansion on the scope of the initial project was approved. In the first year of the project, 58 cases were reviewed 38 or 66% were reported to have fair to poor health, 33 or 57% had been linked to substance use treatment, 32 or 55% were known IV users, 33 or 57% had a known criminal history, 30 or 52% had been diagnosed or linked to mental health treatment, 13 or 22% had been convicted of a DUI, and 8 or 14% had been diagnosed and known to have Hep C. In addition to the quantitative data from the year, the qualitative conversation among the affiliated partners proved to be just as valuable. Some of the overarching themes found were that many decedents had a primary support system that also used substances, evidence of benzodiazepines on many decedent toxicology reports, chronic pain, and lack of family, friends and community supports are a huge barrier to successful recovery. There were also recommendations on how to improve the system of care and how to improve overall logistic of information in each meeting. Some of topics discussed were the needs for standardization of documents, flexibility in record sharing, and breakdown of silos in treatment and care.
The drug overdose epidemic is a public health issue that is being discussed at the local, county and federal government levels to try to find successful interventions and implement change to reduce overdose deaths. Many times, there are silos in health w