Implementing Overdose Prevention Strategies at the Local Level

Seminole County is located in east Central Florida just north of Orlando. With an estimated population of 473,408 (as of July 1, 2019), according to the U.S. Census Bureau. Seminole County is also the most densely populated county in Central Florida with a total land area of 309.5 square miles. The county is comprised of seven cities and six unincorporated areas represented by 26 zip codes and 86 census tracts as of the 2010 Decennial Census. 52% of the population is female, 80% Caucasian and 78% non-Hispanic.

The Florida Department of Health in Seminole County (DOH-Seminole) serves the community with a mission to protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts. DOH-Seminole, and its community partners, have worked collaboratively to address the needs of county residents who are most impacted by the COVID-19 pandemic.

According to the Centers for Disease Control (CDC), more than 100,000 Americans died from overdoses in the last 12 months, which is a 28% increase from the prior 12-month period.  Most of these deaths were linked to synthetic opioids, like fentanyl. Florida ranks 2nd in the nation for overdose deaths. As of November 2021, 794 overdose incidents were reports in Seminole County, Florida. This is 46 more overdoses than were reported at the same time in 2020. COVID-19 has introduced large and unprecedented challenges for overdose response efforts in Seminole County. Anxiety, grief, isolation, and financial worries can threaten people with a substance use disorder. The increase in substance use continues to climb in Seminole County as the COVID-19 pandemic persists.

Due to this unprecedented rise in opioid and other substance related activity in the community, DOH-Seminole sought strategies to proactively address the growing community concern. Instead of relying on traditional Substance Use Disorder (SUD) services in office and institutional settings, DOH-Seminole utilized a community paramedicine approach to deliver services and intervention in the community and in individual homes.  Understanding that limited State funding exists to address this concern, DOH-Seminole sought funding sources capable of supporting this innovative service delivery approach. Working in partnership with local law enforcement, hospital systems and community SUD providers, DOH-Seminole community paramedics respond to non-lethal overdoses to offer in-home services that address social, behavioral, and medical issues that may exacerbate substance use. By engaging the individual in the home, in a non-threatening manner, the community paramedic is able to complete a medical screening and assessment to provide an individualized service plan that addresses the needs of the individual. Additionally, outreach activities offer a larger scale means to increase knowledge of services available in the community to encourage the individual to begin their recovery journey. Finally, marketing activities including billboards and bus wraps, enhanced community awareness of available resources to seek help.

In this project, DOH-Seminole was able to hire staff capable of responding to non-fatal overdose referrals. This included the DOH-Seminole community paramedic, project coordinator, project evaluator, and epidemiologist. Each week the DOH-Seminole team met with members of the SCSO and SCORE Team, AdventHealth's Hope and Healing Center, and other community partners. Together, a list of area providers, that work with individuals with SUDs, was compiled and the team was able to develop inter-agency protocols on responses to non-fatal overdoses. The team created templates, data project records, and home visit logs to document responses to the referrals provided from the SCORE Team. Additionally, bus wraps and billboard signs for the local media campaign were created using the Opioid Prescription campaign from the CDC.

The key or main factor that led to the project's success was ongoing and comprehensive program evaluation. Adjustments were made to find the most effective means of meeting the needs of the community. This led to expanding the reach for individuals with SUDs to include, not only the referrals from the SCORE Team, but creating community outreaches in the areas known to be frequented by people in need. The team approach and ongoing communication through weekly team meetings helped solidify the partnership between DOH-Seminole, the Seminole County Sheriff's Office (SCSO), the Seminole Collaborative Opioid Response Efforts (SCORE) Team, and AdventHealth's Hope and Healing Center. The weekly meetings were also expanded to include peer counselors and key Seminole County medical personnel.

The project increased and improved coordination among organizations that provide care for individuals struggling with SUD. Outreach activities improved community awareness of available SUD services and delivered services directly to community neighborhoods. The project strengthened programmatic partnerships to leverage the resources and expertise of public safety and first responder organizations. It also enhanced the local response to non-lethal overdose calls to law enforcement by providing community paramedic overlay services in the field. By delivering services directly in the community, and targeting locations known to have high prevalence of illegal drug use, a greater societal impact was made. By offering health equitable services in the community and intervening to reduce or eliminate serious illness or death due to overdose, the program positively impacted the lives of individuals medically and behaviorally.

In 2019, 385 overdose incidents were reported from January to October; as of October 31, 2020, Seminole County reported 608 overdose incidents which represent a 63% increase from overdoses reported in 2019. The number of overdoses reported in 2020 among males was 65%, and 35% among females. Out of these 608 overdose incidents, 63% occurred among Whites, 9% among Hispanics, 7% among Blacks and 21% Other. The program's target population was people who use drugs (PWUD) and experience a non-fatal overdose. These individuals experience significant barriers when it comes to accessing medical care, treatment, and other services. With the community paramedicine model, and partnership with local law enforcement agencies and health agencies, DOH-Seminole was able to connect PWUDs with resources in the community.

In less than a year, 95 individuals who had non-fatal overdoses were referred to DOH-Seminole's community paramedic. Of those 95 individuals, the DOH-Seminole Community Paramedic was able to reach 57 of them: offering referrals, services, medical screenings, vaccinations, food boxes to address food insecurity issues, socks, hygiene kits, and raincoats (primarily for unhoused individuals). DOH-Seminole has been working with several community partners as an active member of the Seminole County Opioid Task Force since 2017. The initial goal of the task force was to develop an action plan to address the reduction of opioid addiction, prevent overdose deaths, and improve the quality of life in Seminole County.

As stated previously, PWUD experience significant barriers when it comes to accessing medical care, treatment, and other services. With this program, DOH-Seminole was able to meet the needs of these individuals by connecting them with resources in the community. This would allow for all individuals, regardless of income or circumstance, to receive medical and behavioral interventions. In addition, efforts to educate the broader Seminole County community on mental wellness and addressing stigma associated with PWUD was critical to ensuring that those who need treatment, and other services, feel comfortable enough to seek it out. This was accomplished through the local media campaigns and community outreach events.

Activities were established under two main categories, Establishing Linkages to Care and Establishing Partnerships with Public Safety and First Responders. The activities for establishing linkages to care include: providing critical personnel to respond to non-fatal overdoses; coordinating team meetings with DOH-Seminole, Seminole County Sheriff's Office (SCSO), and AdventHealth's Hope and Healing Center; defining a list of preferred SUD providers for coordination and service referrals, and developing interagency protocol for DOH-Seminole Community Paramedic response to referrals from SCSO involving non-fatal overdoses.

The activities for establishing partnerships with public safety and first responders include: provide training to DOH-Seminole and AdventHealth's Hope and Healing Center on the SCSO Seminole Collaborative Opioid Response Effort (SCORE) Team's protocols for response to non-fatal overdoses; develop inter-agency protocols with AdventHealth's Hope and Healing Center and DOH-Seminole for access to AdventHealth's overdose dashboard; develop a reporting tool to track the number of non-fatal overdose referrals to DOH-Seminole, response actions, and total number of overdose deaths in Seminole County. DOH-Seminole also created a media campaign to utilize graphics for bus wraps for the local transit system, create messaging for local billboards, develop materials for community outreach events, and enhance DOH-Seminole's public facing website (http://seminole.floridahealth.gov/locations/sanford.html) utilizing Mysidewalk to incorporate information and data about this project.

DOH-Seminole's community paramedicine program is unique in its design and implementation. By delivering services directly in the community, and targeting locations known to have high prevalence of illegal drug use, a greater societal impact can be made. By offering health equitable services in the community and intervening to reduce or eliminate serious illness or death due to overdose, the fiscal benefits to the taxpayer are significant and rapidly growing. Delivering services through a health equitable lens was a key component to the program's success. DOH-Seminole sought service provider partners who were able to provide services at little to no cost. Enlisting the services and expertise of individuals with lived experience enabled DOH-Seminole to understand the most appropriate manner to approach and communicate with participants of the program. Peer Counselors and DOH-Seminole staff with lived experience were essential members of the team who guided practice and protocols to ensure every program participant was afforded the opportunity to attain his or her full health potential. When health inequities were identified, the team sought viable solutions to address them immediately. In addition, outreach events were targeted to areas of the community where health inequities were known to be more prevalent.

In this program, DOH-Seminole established two main goals, each with three objectives:

1.       Establish Linkages to Care

a.       Implement support care linkages to improve delivery of substance use prevention and intervention services and improve awareness of, and coordinate community resources, by providing critical personnel to respond to non-fatal drug overdose cases.

b.       Increase and improve coordination among organizations that provide care or enable linkages to care for individuals that have an SUD.

c.       Improve community awareness of available SUD services through marketing and data sharing efforts and integrate collection in a public facing website which allows partner and public access to data related to substance use.

2.       Partnerships with Public Safety and First Responders

a.       Strengthen programmatic partnerships and protocols to leverage the resources and expertise of public safety and first responder organizations.

b.       Enhance the local response to non-fatal overdose calls to law enforcement by providing community paramedic and substance use disorder therapeutic overlay services in the field.

c.       Evaluate program impact in Seminole County by comprehensive data collection and analysis related to substance use disorder prevalence and service effectiveness.

Activities were established under two main categories, Establishing Linkages to Care and Establishing Partnerships with Public Safety and First Responders. The activities for establishing linkages to care include: providing critical personnel to respond to non-fatal overdoses; coordinating team meetings with DOH-Seminole, Seminole County Sheriff's Office (SCSO), and AdventHealth's Hope and Healing Center; defining a list of preferred SUD providers for coordination and service referrals, and develop the interagency protocol for DOH-Seminole Community Paramedic response to referrals from SCSO involving non-fatal overdoses.

The activities for establishing partnerships with public safety and first responders include: provide training to DOH-Seminole and AdventHealth's Hope and Healing Center on the SCSO Seminole Collaborative Opioid Response Effort (SCORE) Team's protocols for response to non-fatal overdoses; develop inter-agency protocols with AdventHealth's Hope and Healing Center and DOH-Seminole for access to AdventHealth's overdose dashboard; develop a reporting tool to track the number of non-fatal overdose referrals to DOH-Seminole, response actions, and total number of overdose deaths in Seminole County. The team also created a media campaign to utilize graphics for bus wraps for the local transit system, create messaging for local billboards, develop materials for community outreach events, and enhance DOH-Seminole's public facing website (http://seminole.floridahealth.gov/locations/sanford.html) utilizing Mysidewalk to incorporate information and data about this project.

In this project, DOH-Seminole was able to hire staff capable of responding to non-fatal overdose referrals. This included a community paramedic, project coordinator, project evaluator, and epidemiologist. Each week the team met with members of the SCSO and SCORE Team, AdventHealth's Hope and Healing Center, and other community partners. Together, the team created a list of area providers, that work with individuals with SUDs, and develop agency appropriate protocols on responses to non-fatal overdoses. The team created templates, data project records, and home visit logs to document responses to the referrals given to us from the SCORE Team. The team was also successfully able to create bus wraps and billboard signs for the local media campaign using the Opioid Prescription campaign from the CDC.

The program started in January 2020 and will be completed in July 2022. Throughout the development of the program, DOH-Seminole consulted with the SCSO and AdventHealth. There were numerous meetings held to discuss the program, how it would look, how it would work, and what the intended outcomes would be. Once funding was established, it was DOH-Seminole's role to plan and implement the program. Early activities included hiring personnel, establishing meetings, creating protocols, integrating data collection in DOH-Seminole's public facing website, creating graphics for bus wraps and billboards, and working with SCSO and AdventHealth to develop and acquire marketing materials. Utilizing the Community Mobile Health Unit and the Community Paramedic, outreach events were held, in coordination with community stakeholders. DOH-Seminole established monthly events in the community to provide education, medical screenings, vaccinations, food boxes, socks, hygiene kits, and raincoats.

While working through collaboration in this program, DOH-Seminole was able to expand outreach to local faith organizations, sober living houses, and recovery centers that serve the homeless population and PWUD. This further established DOH-Seminole as a valuable resource for the community. To ensure the program was targeting the population that needed resources, the team reviewed overdose data and created hotspot maps based on the data. This allowed DOH-Seminole to focus on specific areas of Seminole County that needed the most assistance.

This program was made possible through a grant from CDC and NACCHO. The Implementing Overdose Prevention Strategies at the Local Level (IOPSLL) cost reimbursement grant provided funding for key personnel, supplies and equipment.  The following is a summary of funds spent for the IOPSLL program:

In creating the budget, we ensured that all expenditures were related to our established activities. Our initial activity was to put together our team. For our Program Coordinator, Community Paramedic, Epidemiologist, and Program Evaluator we budgeted $244,995. As of November 15, 2021, we have requested reimbursement for $103,203. We also had to factor in Fringe Benefits. Thus far, we have requested reimbursement for $25,025. For equipment, office supplies, medical supplies, printing of marketing materials, public facing website (Mysidewalk), bus wraps, and billboards we budgeted for $118,037. As of November 15, 2021, we have requested $57,916 for reimbursement. We also budgeted for cell phones ($2,196) and trainings ($3,250). Our partnership with AdventHealth's Hope and Healing Center included assistance with funding for an additional Substance Use Disorder licensed mental health therapist. For this, we budgeted $88,233. Please see attachment for further breakdown of costs associated with this program.

DOH-Seminole and program partners were able to achieve all established objectives.

Initially, the primary source of data was the reports provided from the SCSO. From there, the DOH-Seminole epidemiologist researched medical examiner data and Emergency Medical Services (EMS) data. DOH-Seminole also created an internal data spreadsheet to track referrals, visits, medical referrals, and success stories. This data was utilized to ensure the team targeted appropriate areas for community outreaches, meeting the needs of the individuals who were referred to the program, and tracking the progress of the program participants. Please see attachment for an example of the data DOH-Seminole collected.

In reviewing the program from the point of inception to the present day, the lessons learned are simple but profound and important to remember for future work. The most important lesson learned, and sometimes the most humbling, is that working with PWUDs is difficult and the need to establish trust is critical to ensure successful outcomes for each program participant. The premise of the community paramedic is to establish a trusting relationship with each program participant, identify the individual needs of each participant and focus on manageable steps to achieve participant goals.

Another lesson learned was that the community is open and willing to help people who have a substance use disorder. Community leaders and key stakeholders recognize the overdose epidemic and are willing to try a plethora of activities to curb this crisis. Finally, we learned that relationships with our partners is the most vital component to success of an initiative of this magnitude. Once weekly meetings with the SCSO SCORE Team, AdventHealth's Hope and Healing Center, peer counselors, and key medical personnel were established, communication increased, the sharing of information increased, and joint response to individuals who needed our help was stronger.

Multiple studies indicate that every dollar spent on substance abuse prevention results in long-term savings to the community as a whole. DOH-Seminole's Community Paramedicine program represents a long-term investment rather than an on-going expenditure. Governments are spending nearly 16% of their budgets addressing the negative consequences of substance abuse and addiction. Nearly all the money (95.6%) is used to respond to what is referred to as the burden of substance abuse and addiction.” The per capita cost is about $500 annually. This represents costs that are spread across the social fabric including, hospitals, the juvenile justice system, schools, and health care. ¹ Aos, S., P. Phipps, R. Barnoski, and A. Lieb. (2001).  According to the United States Census Bureau, the population of Seminole County is over 471,000. 

DOH-Seminole's Community Paramedicine program has allowed us to collaborate and engage partners outside of the health care system to work as a team – physicians, pharmacists, social workers, mental health professionals, health educators, and community health workers to address root causes of opioid abuse and addiction at the community level.

The program involves community outreach events, marketing campaigns to increase knowledge of community resources and where to seek help, home visitation and individualized support and weekly collaborative team meetings.

The cost savings detail is as follows:

Estimated Per Capita Cost = $500

Seminole County Population = 471,000

Total Annual Cost without Intervention = $235,500,000

Total Intervention Anticipated (Marketing, Outreach and Home Visitation Program) = $2,500

Total Estimated Annual Cost Savings = $1,250,000

DOH-Seminole and partner agencies are committed to continuing to address the increase in substance use disorders in the community. Through the efforts and lessons learned of this program, community sustainability is anticipated. Fiscal sustainability is dependent on securing additional funding sources and sustaining existing partnerships with a continued focus on robust communication, information sharing and collaborative service provision to the community.