introduction: what is - overdosefreepa · web viewmanual janice l. pringle, phd university of...

Technical Assistance Center (TAC) Manual

Janice L. Pringle, PhD

University of Pittsburgh School of Pharmacy

Program Evaluation and Research Unit (PERU)

In collaboration withThe Pennsylvania Commission on Crime and Delinquency

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Table of Contents

Introduction: What is the Technical Assistance Center and How Can It Help Your Community Fight Overdose?.............................................................................................................................................................. 3

A. How to Use This Manual.............................................................................................................................................5

B. Why a Coalition?.............................................................................................................................................................7

C. Describing Your Community...................................................................................................................................8

D. Obtaining Your Data.....................................................................................................................................................8

E. Determining Your Community’s Readiness to Have an Impact on Overdose Deaths............9

F. Selecting Your Coalition Members....................................................................................................................10

G. Developing Your Coalition Vision Statement..............................................................................................10

H. Selecting Your Coalition Leadership................................................................................................................11

I. Conducting Productive Meetings.......................................................................................................................11

J. Assessing Your Coalition’s Health.....................................................................................................................11

K. County Overdose Elimination Framework...................................................................................................12

L. Selecting Your Evidence-Based Interventional Strategies..................................................................12

M. Building an Impact Model......................................................................................................................................13

N. Developing and Using a Strategic Plan...........................................................................................................15

O. Developing an Evaluation Plan...........................................................................................................................16

P. Finding Evaluation Assistance.............................................................................................................................16

Q. Current Situation Assessment.............................................................................................................................16

R. County Dashboard Framework...........................................................................................................................17

S. Sustainability: Developing a Grant Application........................................................................................17

Glossary...................................................................................................................................................................................... 21

References.................................................................................................................................................................................25

Appendices................................................................................................................................................................................26

Appendix I: County Overdose Elimination Framework..................................................................................27

Appendix II: Current Situation Assessment...........................................................................................................29

Appendix III: County Dashboard Framework.......................................................................................................46

Appendix IV: Assessment Worksheets.....................................................................................................................48

A.1. Describing Your Community and Community Factors Checklist.....................................................49

A.2. Data Available to Your Community...................................................................................................................53

A.2.1. Potential Sources of Data....................................................................................................................................54

A.2.2. A Guide For Analyzing Community Data....................................................................................................57

A.3. Community Readiness Assessment...................................................................................................................601

Copyright 2016. University of Pittsburgh. All Rights Reserved.

Appendix V: Capacity Worksheets..............................................................................................................................62

C.1. Potential Coalition Members and Roles..........................................................................................................63

C.2. Creating a Vision Statement (And a Greater Purpose)...........................................................................65

C.3. Leadership Questionnaire......................................................................................................................................67

C.4. Coalition Health Assessment.................................................................................................................................69

C.5. Ascertain Available Resources and Support................................................................................................79

C.6. Determine Community Activation Level........................................................................................................80

Appendix VI: Planning Worksheets............................................................................................................................81

P.1. Identify Potential Evidence-Based Intervention Strategies................................................................82

P.2. Develop Impact Model..............................................................................................................................................90

P.3. Develop a Strategic Plan..........................................................................................................................................91

Appendix VII: Implementation Worksheets..........................................................................................................95

I.1. Determine Relevant Community Connections.............................................................................................96

I.2. Develop an Effective Communication Plan....................................................................................................97

I.3. Implement Strategies Supporting Continuous Quality and Fidelity...............................................99

Appendix VIII: Evaluation Worksheets..................................................................................................................101

E.1. Develop an Evaluation Plan.................................................................................................................................102

E.2. Measure Progress......................................................................................................................................................104

Appendix IX: Sustainability Worksheets..............................................................................................................105

S.1. Secure Funding Resources...................................................................................................................................106

S.2. Develop a Sustainability Plan.............................................................................................................................107

S.3. Obtain Continued Community Support.........................................................................................................108

2Copyright 2016. University of Pittsburgh. All Rights Reserved.

Introduction: What is the Technical Assistance Center and How Can It Help Your Community Fight Overdose?

Mission: The Pennsylvania Heroin Overdose Prevention Technical Assistance Center (TAC) will be the first ever resource and technical assistance hub for all counties within the Commonwealth of Pennsylvania. Based out of the Program Evaluation and Research Unit (PERU) at the University of Pittsburgh School of Pharmacy, the TAC will assist counties and communities in planning, developing, implementing, and sustaining community-based initiatives for reducing overdose throughout Pennsylvania.

Activities: Through the TAC, PERU will continue to develop and expand the OverdoseFreePA.org website, which contains a wealth of information regarding overdose prevention strategies, interventions, data, and resources. The website includes a growing database of overdose death data within Pennsylvania, which will expand to cover all 67 counties in Pennsylvania. This data provides insight into the causes and populations affected by overdose and is sortable to provide relevant information to interested audiences.

The TAC staff will coordinate with county and community representatives to conduct assessments of current strengths and liabilities for addressing overdose in each community using a systems focused framework they have developed and tested. Results of this assessment will guide the development of a customized evidence-based strategic plan to address the community’s current state of overdose and overdose deaths. Technical assistance will continue to each community as they implement and sustain their efforts to reduce overdose deaths.

Finally, TAC staff will assist the PCCD with developing Requests for Proposals (RFPs) and evaluating applicants for funding awards to support the above efforts toward reducing overdoses and overdose deaths.

For more information or to request technical assistance, please complete the TAC Request Form available at http://overdosefreepa.org, use the form on the next page, or contact us at:

PA Heroin Overdose Prevention TACUniversity of Pittsburgh School of Pharmacy

5607 Baum Boulevard, 432Pittsburgh, PA 15206

[email protected]


http://overdosefreepa.org/

The Pennsylvania Heroin Overdose Prevention Technical Assistance Center

County Overdose Prevention CoalitionRegional Training Participation Interest Form

Please complete and return this form to the TAC along with a copy of a signed Memorandum of Understanding (MOU) or other organizational documents.

Organization Name: _______________________________________________________ __

Primary Contact: _____________________________________________ ________________

County: __________________________________________________________________ ______

Address: _______________________________________________________ ________________

City/State/Zip: ______________________________________________________ ___________

Phone: ___________________________ Email: ______________________________

Preferred Training Month: (circle) June July August September

Preferred Training Region: (circle) NW SW NC SC NE SE

Coalition Vision: __________________________________________________________________________________________________________________________________________________________________________________________________________________

Note – the vision should be an ideal vision which will inform all of the coalition’s activities. Ex. “We will work to eliminate overdoses in _______________ County.”

Coalition Mission: (Preliminary):

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please verify that your coalition presently has participation/representation from the following domains (4 at minimum):

_____ SCA_____ CJAB_____ County Coroner/Medical Examiner_____ County Health Department (if applicable)_____ Law Enforcement/Criminal Justice_____ EMS/First Responders_____ County Medical Society_____ MOU/Organizational Document Copies Attached


A. How to Use This Manual

This manual has two functions. First, it provides background information regarding what is known about how to prevent overdoses and how to organize that knowledge. Second, it provides questionnaires, worksheets, checklists, and guiding principles that can be used to apply this knowledge towards the development of a community-specific strategic plan that could effectively guide a community towards reducing overdoses and overdose deaths.

Please note that the TAC staff will provide your community with ongoing technical assistance regarding how to use the information in this manual.

This manual will guide your group to develop or enhance a coalition to reduce overdose deaths within your community. Because each community has unique characteristics, no single coalition will look the same. The resources in this manual will help your group to understand the current overdose phenomena in your community and the most effective people, resources, and strategies to enlist in the fight against overdose deaths. Worksheets and resource links will assist you as you assess your community, use available data resources to identify the scope of the overdose issue, form or develop your coalition and leadership, select your evidence-based strategy or strategies, and evaluate your coalition’s effectiveness.

The processes for guiding your community towards reducing overdose deaths is based both on SAMHSA’s Strategic Prevention Framework, shown in Figure 1 (SAMHSA, n.d.) and a Framework for Guiding System Transformation, Figure 2, (Diamond, 2015) developed at the Program Evaluation and Research Unit (PERU). The System Transformation Framework is used to develop and enhance the effectiveness of an organization in order to maximize its ability to achieve its selected purpose. The Framework is intended to provide a guide to system transformation around one domain: the vision or greater purpose of the organization. This domain influences four other domains regarding the function of the organization: (1) culture or employee/members’ values, beliefs and assumptions about their work; (2) behavior or how employees/members’ handle relationships, power, decision-making, conflict, and learning; (3) structure or how the organization is designed so lines of communication in the organization can facilitate decisions and innovations; and (4) the use of performance measurements for system improvement. Ultimately, these domains are continually managed by the facility leadership and are influenced by external learning (methods to provide learning and skills development to the workforce) and internal learning (systematic processes used to improve organizational functioning), which can continuously transform the organization toward its intended vision.


Figure 1. SAMHSA Strategic Prevention Framework

Figure 2. System Transformation Framework

This manual walks your community through how to apply both of these processes and includes worksheets to assess your community, obtain data to guide your selection of evidence-based practices (EBPs) which are best matched to the data, select and implement strategies to address overdose deaths, and maintain a healthy coalition.

Table 1: Appendices and WorksheetsStage Resources and Worksheets Appendix

Supplemental County Overdose Elimination FrameworkCurrent Situation AssessmentCounty Dashboard Framework

Appendix IAppendix IIAppendix III

Assessment Describing Your Community and Community Factors Checklist

Data Available to Your CommunityCommunity Readiness Assessment

Appendix IV: A.1.

Appendix IV: A.2.Appendix IV: A.3.

Capacity Potential Coalition Members and RolesCreating a Vision Statement (and a Greater Purpose)Leadership QuestionnaireCoalition Health AssessmentAscertain Available Resources and SupportDetermine Community Activation Level

Appendix V: C.1.Appendix V: C.2.Appendix V: C.3.Appendix V: C.4.Appendix V: C.5.Appendix V: C.6.

Planning Identify Potential Evidence-Based Intervention StrategiesDevelop Impact ModelDevelop a Strategic Plan

Appendix VI: P.1.Appendix VI: P.2.Appendix VI: P.3.

Implementation Determine Relevant Community ConnectionsDevelop an Effective Communication PlanImplement Strategies Supporting Continuous Quality and Fidelity

Appendix VII: I.1.Appendix VII: I.2.Appendix VII: I.3.

Evaluation Develop an Evaluation Plan Appendix VIII: E.1.


Stage Resources and Worksheets Appendix

Measure Progress Appendix VIII: E.2.

Sustainability Secure Funding ResourcesDevelop a Sustainability PlanObtain Continued Community Support

Appendix IX: S.1.Appendix IX: S.2.Appendix IX: S.3.

Figure 3. TAC Implementation Diagram

B. Why a Coalition?

A coalition is a group of individuals or organizations who work together to address a problem in the community (Center for Prevention Research and Development, 2006). The coalition may include existing organizations such as social service agencies, government agencies, or community groups, or may be formed by individuals who share a common concern. Research on overdose prevention strategies shows that community coalitions can be very effective at implementing changes that promote health in the community (Albert et al., 2011). One of the strongest effects of a coalition approach is the ability to change the environment in the community by increasing awareness of overdose-related issues that also result in changes in the community’s attitudes and beliefs


regarding overdose. This evolution then yields targeted changes in community systems that are needed to support the application of specific evidence-based practices to reduce overdose. In summary, coalitions help to form links between organizations and individuals at various levels in the community to leverage their resources toward reducing overdose deaths (University of Kansas Work Group for Community Health and Development, 2015).

C. Describing Your Community

Identifying characteristics of your community helps you to understand factors which will influence your ability to affect change within your community. The composition of your coalition, strategy selection, collaboration opportunities, and selection of evidence-based practices are enhanced when you choose them with the overall character of the community in mind.

Your coalition should represent views of the various stakeholders affected by overdose issues and provide opportunities for participation to as broad a section of your population as possible. Consider demographic, cultural, economic, and social factors in your community to ensure that your strategy is inclusive and represents the community as a whole. Size, population, urban or rural location, and resource availability are factors which will influence your approach. Also, consider any specific subpopulations within your community (age, gender, race and ethnicity, religion, veteran status, etc.) You will need to identify where, when, and in which population segments overdose is more of a risk.

Use the Describing Your Community and Community Factors Checklist to characterize your community (see Appendix IV: A.1.)

D. Obtaining Your Data

Data about the incidence and prevalence of drug use, overdose, and overdose deaths in your community will help you understand the scope of the problem and identify possible solutions.

The PA Heroin Overdose Prevention TAC collects data on overdose deaths in Pennsylvania through the OverdoseFreePA.org Overdose Death Data registry. County coroners or medical examiners submit case information through a secure access website to provide an almost real time picture of overdose deaths by county. Information includes age group, race, gender, type(s) of drug(s) contributing to death, and zip codes of incidence and residence (if available). This information helps community members to know who is affected by overdose in their community. Single County Authorities (SCAs), coroners, and medical examiners should contact the TAC for guidance on how to submit overdose data.

Other data sources for information on the scope of overdose deaths include national and state data sets and local data sources such as law enforcement agencies, healthcare facilities, or emergency medical services (EMS) agencies. Identifying the types of healthcare practitioners, hospitals and clinics, human service agencies, substance use disorder (SUD) treatment facilities, recovery support groups, education resources, and criminal justice facilities in your community will help you to obtain information about available resources and identify gaps in existing services or unmet needs.

Data on non-fatal overdoses can help you identify risk factors or intervening variables for overdose, but it is not always easy to obtain. You may be able to acquire this information from local law enforcement, healthcare, or EMS agencies to help provide a total picture of overdose risk in your community, but standard data collection methods remain a challenge.


Use the Data Available to Your Community and Potential Sources of Data worksheets to identify what data on overdoses is currently available for your community and potential sources for this data. Utilize resources such as contact lists for state or county organizations or individuals which can help provide additional data or sources for your coalition. (See Appendix IV: A.2. for worksheets.)

E. Determining Your Community’s Readiness to Have an Impact on Overdose Deaths

“Readiness” refers to your community’s capacity to initiate and implement change. Some groups or segments of your community may not be aware that overdose is an issue. Other groups may deny that this problem exists or that it doesn’t need to be solved (because it is not severe enough, or because they believe time and resources could be better spent elsewhere). Even if the community is aware and wants to take action, views about the appropriate interventions and solutions to your overdose problem will also vary (University of Kansas Work Group for Community Health and Development, 2015).

Conducting a readiness assessment helps you to determine how likely it is for a social change initiative to be successful based on your community’s current status (Substance Abuse and Mental Health Services Administration, 2015). If your community is not ready to effectively conduct overdose prevention and intervention efforts, you may need to complete preparatory work to enhance awareness and receptiveness in your community before you attempt to develop your prevention and intervention plan. When preparing to implement overdose reduction efforts, it is always best to consider roadblocks which may interfere with your efforts and try to plan ways to remove these obstacles before you begin implementation (Substance Abuse and Mental Health Services Administration, 2015).

Complete the Community Readiness Assessment worksheet to assess your community readiness (see Appendix IV: A.3.), then compare your community’s readiness to the stages below in Table 2.

If your Community Readiness Assessment indicates that your community has little to no awareness of its overdose death risk, you may need to conduct awareness enhancement efforts in your community before you begin to choose intervention strategies. There are many evidence-based strategies for increasing community awareness regarding public health threats such as overdose. The TAC can provide you with some of these strategies and guide you in their implementation.

If you find your levels in one readiness area (see table below) are much lower than another area, you will want to focus on increasing capability in that area. Again, the TAC can provide you with support on how to apply effective strategies to increase readiness in specific areas. All readiness areas should be fairly consistent before you begin your work. If they are not, work on those with the lowest readiness levels first.

After you complete the Community Readiness Assessment worksheet, compare your community’s stage in each domain to the levels shown in Table 2 to determine where your coalition should start its efforts.

Table 2: Stages of Community Readiness

Stage Goal

No awareness Increase awareness about the issue of overdose


Stage Goal

Denial Increase awareness that the problem exists in your community

Vague awareness Increase awareness that the community can do something

Pre-planning Increase awareness with ideas to address the problem

Preparation Gather information and begin to plan

Initiation Identify and implement evidence-based programs

Stabilization Evaluate and improve programs

Confirmation Expand services

Professionalization Maintain momentum and continue growth

F. Selecting Your Coalition Members

As you build your coalition, carefully think about who should be involved and what viewpoints these individuals represent. Questions to consider include: which potential coalition members represent the composition of your community; and which potential members advocate for people with SUDs? Your first step should be to contact your county’s SCA for Drug and Alcohol Programs for assistance if they are not already involved with your coalition. If there is an existing coalition working to address overdoses, it is preferable that you don’t duplicate the efforts made by this coalition or compete against it. Instead, you may be able to enhance the existing coalition’s efforts rather than starting a new group.

Carefully consider those who hold positions of influence within your community or its various subgroups. These individuals can make systems and resources accessible that are otherwise unavailable. These individuals and their resources may be required to implement strategies that can effectively reduce overdoses. Social service providers, healthcare providers, SUD treatment professionals, law enforcement officers, EMS providers, school leaders, religious leaders, government officials, and media personnel are all examples of possible coalition members.

Also consider members who more completely represent your community and permit inclusion of people from different backgrounds and viewpoints. Refer to the Describing Your Community worksheet (Appendix IV: A.1.) to ensure that your coalition is as inclusive and diverse as possible. Consider the technical skills your coalition will need such as administrative, fiscal, public relations, and management skills. Try to identify potential members or volunteers with expertise in as many of these areas as possible as you get started. Begin with a smaller, core group of individuals (typically no more than ten) committed to reducing overdose and expand your membership as you develop and implement your strategy.

Complete the Potential Coalition Members and Roles worksheet to identify potential coalition participants in your community (see Appendix V: C.1.)

G. Developing Your Coalition Vision Statement

Your coalition leadership will need to develop a Vision and Greater Purpose to guide your group as you proceed. The Vision and Greater Purpose are extremely important to your Coalition’s work and guide the activities and priorities of all members. The Vision should be short, clear, inspirational, and inarguable and should set a goal that is ambitious and idealized. Refer to the Creating a Vision


Statement worksheet (see Appendix V: C.2.) to develop a Vision Statement and Greater Purpose for your coalition.

H. Selecting Your Coalition Leadership

When selecting coalition leadership, consider the background and experience of potential leaders. Choose a leader who has experience leading community-based efforts to improve health. Good coalition leaders are respected in the community, have access to community leaders, and have some understanding of overdose and evidence-based prevention, intervention, and treatment strategies.

Complete the Leadership Questionnaire to evaluate potential leaders for your coalition (see Appendix V: C.3.)

I. Conducting Productive Meetings

As your coalition forms, you will need to hold meetings to discuss issues and determine strategies and action steps. Your coalition leadership will need to identify someone to facilitate meetings, both of the entire group or any subgroups. You may be able to access a meeting room through one of your coalition groups, a local library, community center, coffee shop or restaurant. Good meeting facilitation requires confidence and interpersonal skills. It is important to provide a forum for all stakeholders to be heard in a constructive manner. Below are some tips for conducting a good meeting:

1. Have a written agenda with enough copies for attendees;

2. Have a sign-in sheet to document participants/update contact info;

3. Have a plan for what to accomplish;

4. Begin and end on time;

5. Make people feel welcome and introduce selves;

6. Agree as a group on the rules of meetings;

7. Encourage and allow participation;

8. Treat all participants with respect;

9. Keep routine reports brief;

10. Provide more time for planning of new activities/initiatives;

11. Assign responsibility and a timeframe for all action items and document in minutes;

12. Defer an item if necessary; and

13. Summarize key points to ensure accurate understanding.

J. Assessing Your Coalition’s Health

If your coalition is already established, you should conduct an evaluation of your organization health to understand where your coalition currently stands. If your coalition is new, you should conduct an evaluation of your organizational health within one month of beginning your coalition. All coalitions should conduct annual coalition health assessments to make sure they are operating as efficiently and effectively as possible. The TAC will provide you with a method for conducting this assessment. Analyzing the relationships between your coalition’s mission, vision, objectives,


and organizational culture and behavior can help you to optimize performance towards reducing overdose.

Complete the Coalition Health Assessment worksheet (see Appendix V: C.4.)

K. County Overdose Elimination Framework

Refer to the County Overdose Elimination Framework (see Appendix I) to see how a county or community coalition can implement strategies to prevent overdose deaths. The framework uses a population health approach to target interventions based on the risk level of SUDs or overdoses for various populations. The framework illustrates the importance of a comprehensive strategy to prevent overdoses which incorporates health promotion and supply reduction strategies, consideration of risk and protective factors involved in prevention, intervention strategies at the point of overdose, and treatment and aftercare availability. To be effective in preventing deaths, coalitions need to adopt a comprehensive view of their community and of where to direct their efforts.

L. Selecting Your Evidence-Based Interventional Strategies

Based on the circumstances and resources in your community, you should select your interventional strategies from the following four EBPs to reduce overdoses (US Department of Health and Human Services ASPE, 2015). Be sure to consider conceptual fit (does the strategy address the problem you identified) and practical fit (is the strategy a good match for your community’s characteristics). Some subsidiary strategies fit under these main areas.

1. Naloxone Availability:

Naloxone (also known as Narcan™) is a medication that reverses opioid and opioid overdose effects and can be administered by healthcare professionals, emergency responders, family members, friends, or bystanders. Naloxone is available in several forms with the most common being an auto-injector (Ev-Zio™) or a nasal spray. Pennsylvania has a standing order which permits individuals to purchase naloxone without a prescription and administer it to someone they suspect is having an overdose. Naloxone is safe and effective and will not harm the person in the event that the individual is not actually experiencing an opioid overdose.

Common placements for naloxone include: those prescribed an opioid medication, first responders such as EMS and law enforcement, jail or correctional facilities, or family and friends of people at high risk of overdose. Pharmacies that stock and dispense naloxone are increasing, but many are unaware of the need. Your coalition may choose strategies to increase awareness and availability of naloxone in your community, particularly at intervention points where people are at high risk of overdose.

2. Medication Assisted Treatment (MAT):

Medication Assisted Treatment (MAT) uses FDA-approved medications as part of an overall treatment program, which includes counseling and behavioral therapy, to treat SUDs and prevent overdose. Prescribed medication helps to normalize brain chemistry, block the euphoric effects of alcohol or opioid drugs, relieve physiological cravings, and normalize body functions without the harmful effects of the drug.


Medications used for MAT of opioid dependence include methadone, buprenorphine, and naltrexone. All of these require medical oversight and must be used in conjunction with counseling and behavioral therapy. MAT may be safely used for long periods of time, even months or years, under appropriate medical supervision and as part of a holistic treatment program that includes psychosocial counseling. Many people achieve full and sustained recovery using MAT (National Institute on Drug Abuse, January 2016). Possible treatment settings include hospitals, clinics, or physician offices. Access to treatment is a significant component of the recovery process.

3. Opioid Prescribing Practices:

Pennsylvania is among the many states with disproportionately high opioid prescribing rates. Educating prescribers on the correct indications for opioid painkillers and the risks of overprescribing can reduce the risk of overdose deaths. The Pennsylvania Medical Society has recently developed Prescribing Guidelines for several specialty areas (Pennsylvania Department of Health, 2016) and some physicians have begun to implement screening methods such as SBIRT (Screening, Brief Intervention and Referral to Treatment) to identify people at risk of overdose from prescription opioids. Your coalition may choose to work with physicians in your community to make sure they are aware of and follow these Prescribing Guidelines and use these screening methods (PA Medical Society, 2014b). Your coalition may also work with pharmacists to make sure they are following appropriate dispensing guidelines for opioid medications (PA Medical Society, 2014a).

4. Prescription Drug Monitoring Programs (PDMP):

Pennsylvania is in the process of implementing a prescription drug monitoring program, ABC-MAP. This program will allow doctors and pharmacists to check the prescribing history of patients to ensure that they are not seeking multiple opioid prescriptions or are at risk of diverting medications. Practitioners will be able to check records from over 30 participating states to reduce inappropriate opioid prescriptions. Your coalition may choose strategies to increase awareness of the PDMP program in your community, especially among medical professionals such as physicians and pharmacists.

Use the Selecting Your Evidence-Based Strategies worksheet (Appendix VI: P.1.) to identify strategies appropriate for your community.

M. Building an Impact Model

An impact model (sometimes called a logic model) will guide you and your group in your efforts to reduce overdose deaths. It outlines the course of action you will take in your initiatives and helps you with strategic planning and evaluating your progress. The impact model provides a visual map of the work you plan to do and how you expect it to affect your community. This model can help you to think through the process and evaluate how well a particular intervention fits your community and coalition.

First, you must consider the problem you are trying to address (the Situation). Next, Part One of your Impact Model (Inputs and Activities) are the planned work of your coalition. Finally, Part Two (Outputs, Outcomes, and Impacts) are the intended results of your coalition’s work in your community.


Impact Model: Situation

Part One: Work of Coalition Part Two: Results Within CommunityInputs Activities Outputs Outcomes Impact

Figure 4. Impact Model

The Situation refers to the current condition that you are trying to address in your community, in this case overdose deaths.

1. Inputs include the people and resources available to your coalition and the characteristics of your community. You need to consider what strategies will fit your community and capabilities, what resources are available to you, and what barriers may stand in the way of a particular initiative. Some strategies may not be right for your community now and would be frustrating to attempt.

2. Activities are the actions and tools you use to implement your program. Products, services and activities you have or can obtain to use in your efforts would be included here.

3. Outputs are the products of your coalition efforts, such as types, levels, and targets for your activities. Examples include number of treatment centers available, people who participated in program activities, hours of programming, etc.

4. Outcomes are the specific, measurable behavior changes in knowledge, skills, or attitudes of the people whom your program affects. These can be changes in awareness, practices, knowledge, or relationships. Outcomes can be measured on a short-term, medium-term, or long-term basis.

5. Impact is the longer-term change (usually over several years or more) that occurs in your community as a result of your coalition’s efforts. Examples would be policy changes or improved conditions which reduce overdose.


Sample Impact Model:

Situation: Overdose deaths from heroin among adults ages 18-34 are increasing in our community

Inputs Activities OutputsOutcomes

(Short/Medium/Long-Term)

Impact

Limited knowledge or ability by community members to respond to overdoses

Training of community members on overdose rates, recognition, and how to effectively respond

People trained in various sectors

Short – number of people who completed training

Medium – the people trained demonstrate improved knowledge of risk factors and appropriate response

Long – diffusion of knowledge into the broader community

Reduced overdose death rates among adults age 18-34 in our community

Use the Develop Impact Model worksheet (Appendix VI: P.2.) to develop your own impact models for the problems you want to address in your community. Use a separate sheet for each Situation you want to address.

N. Developing and Using a Strategic Plan

The goal of the PA Heroin Overdose Prevention TAC is to reduce or eliminate overdose deaths in Pennsylvania. How your coalition will address this goal will vary based on your community’s profile and needs. You will need to select interventions which are realistically possible to be successfully implemented in your community.

Using data on overdoses for your community, you should identify who is affected, which substances contribute most to overdoses, when and where overdose deaths are occurring, and what strategies will reduce deaths based on this information. The strategies you select need to be evidence-based as well as good conceptual and practical fits for your community.

Based on the work you have done so far, you are now ready to develop your strategic plan. You will create objectives to address overdose in your community. You will want to record the current conditions, so you can measure your progress when you conduct evaluations. Develop objectives to reduce overdose by using the “SMART” framework:

1. Specific – how much of a change you expect (%, number, etc.) based upon your community readiness, resources, and coalition influence;


2. Measurable - data is available and will show effects;

3. Achievable – objectives are possible and your coalition can accomplish them;

4. Relevant – objectives fit your group, community and the issue you are targeting; and

5. Time-oriented – you have a timeline for when objectives will be achieved.

Example: We intend to provide training and supply naloxone to all officers from 6 police departments in our county within the next year.

Use the Develop a Strategic Plan worksheet to begin developing your goals, objectives and action steps (see Appendix VI: P.3.)

O. Developing an Evaluation Plan

An evaluation plan is important to your project because it helps you assess your efforts and identify gaps between goals and accomplishments, and actual versus expected outcomes. You may need to adjust your program, goals, or methods based upon evaluation results. Evaluations can be conducted while the project is ongoing or at the completion of a project period. Many funding agencies focus on results or outcomes and will require you to report evaluations of your progress against the goals you set.

Evaluation should be done on both a short-term and long-term basis. You will measure your accomplishments against the objectives, milestones and goals you established in your Impact Model and your Strategic Plan.

Use the Develop an Evaluation Plan worksheet to build an evaluation plan for your coalition (see Appendix VIII: E.1.)

P. Finding Evaluation Assistance

Your project may need to have an outside evaluator because the funder requires it. You may also need an outside evaluator because you do not have the current staff or resources available to conduct specialized analyses in-house. Evaluators may be available from local colleges or universities (faculty members or graduate students), hospitals, government agencies, or private companies, which provide these services. Graduate students in public health or social science programs might be available to provide evaluation services as part of a course project or internship at little to no cost to your coalition. One potential resource for evaluators is the American Evaluation Association Evaluator Finder available online at:

http://tools.eval.org/find_an_evaluator/evaluator_search.asp.

Q. Current Situation Assessment

Both your strategic plan and evaluation plan will be more effective if you have a baseline measure of the current conditions influencing overdoses in your community. Your coalition will be better able to identify issues and gaps in treatment as well as measure progress toward reducing overdose deaths. The Current Situation Assessment Survey (see Appendix II) provides a mechanism to obtain a full-circle view of conditions in your community. Your coalition can complete the assessment with assistance from local agencies, particularly your county SCA, as well as TAC staff.


http://tools.eval.org/find_an_evaluator/evaluator_search.asp

Understanding the current conditions and resources available will enhance your ability to select and implement effective overdose reduction strategies.

R. County Dashboard Framework

The County Dashboard Framework (see Appendix III) provides a mechanism to highlight important results from your Current Situation Assessment. You may change the indicators shown in the model, but you should use the template to illustrate how your community ranks for important interventions against overdose or exceptionally high or low capacities. TAC staff can assist in compiling the dashboard indicators and interpreting results from your survey.

S. Sustainability: Developing a Grant Application

You will need to secure adequate financial resources to develop and sustain your coalition. One of the more common ways coalitions obtain funding is through grants awarded by organizations such as government agencies (federal, state or local), corporate or business donations, or foundation sponsors. There may be varying levels of complexity in the application process for these funders, with some requiring only a simple letter or application and others requiring a complex proposal with a specific format and requirements.

The background work in obtaining grants is to make sure you have a well-defined understanding of the issue(s) you are trying to address, a well thought out plan to intervene, and a plan to measure or evaluate your success. Look for a good match between the project you are planning and potential funders. Look at previous projects they have funded to see if yours is similar in focus, scope, and target audience.

Plan plenty of time ahead of any deadlines – some grant applications require support letters or documentation that will take time to acquire. Read the requirements for the application carefully and completely – particularly page limits, format requirements, what types of organizations are eligible, and deadlines. Also, consider whether your organization has the capacity to complete the project you describe in your grant application.

Make sure your application is written with proper grammar and follows a logical path. Use plain language and define any acronyms or “jargon”, so the reviewers understand them. If you have multiple people contribute to the writing, make sure the application sounds consistent in style and tone when these sections are compiled. Using spell check, proofreaders, and reading the application out loud can help find errors and inconsistencies. Make sure to address every item identified in the proposal and include all information requested as specified by the funding entity, so your application is not rejected for technical issues. Assume the funding agency doesn’t know anything about your issue – don’t leave out information because you assume they know something.

Most grants will require some form of the following sections:

1. Narrative :a. Introduce your organization. Include your history, participant organizations or

individuals, mission, purpose, and guiding principles. Discuss current programs, activities, or services your organization conducts. How is your organization unique?

b. State the problem to be addressed, the causes, and solutions that have been attempted. Use “who, what, when, where, why, how, and how much” descriptions of the problem and your plan to address it. Use credible data and sources to support your position.


c. Identify your target population. What geographic area, groups, individuals, or populations do you serve or plan to serve? What is the incidence of the issue in this population? How will your project impact this issue?

d. Describe why the problem should be addressed. Include information on severity, number of people affected, costs to the community, what will happen if it is not addressed, etc. Reference relevant literature or similar projects that have been successful.

e. Describe why your organization is the right one to address the problem. What specific strengths or capabilities does your organization have? How are you different (better) than other organizations or initiatives?

2. Goals and Objectives :a. Use or adapt the goals that you developed in your impact model. Describe what you

want to accomplish and how it will impact your target population.

b. Use the SMART objectives you developed as part of your strategic plan to describe the steps you will take toward achieving your goals. Be realistic or even conservative in describing your objectives – these will be used later to evaluate your progress.

3. Methods :a. What activities, services, or programs will you provide? How do these relate to your

goals and objectives?

b. Who will do the work? Describe the type of staff, volunteers, or consultants you have. If you need staff, describe how you will acquire them – hire new staff, volunteers, sub-contract an outside organization, etc.

c. Who will administer and monitor the project? You may need to choose a lead organization or individual from your member agencies.

d. What other resources, equipment or supplies will be used? How will you obtain these?

e. What is the project timeline? Include milestones and checkpoints to measure progress.

4. Evaluation Plan :Use or adapt the evaluation items you identified in the evaluation component of your plan. Evaluate both products (items tied to your objectives) and processes (items tied to methods and activities). You can then develop metrics which relate to the evaluation questions you formed.

Some funders and applications will require you to evaluate and report on specific metrics. Make sure you know what these metrics are and that you specify how and when you will collect, analyze, and report the data for each of these metrics. These funders will typically also allow you to supplement the required metrics with your own. This is a good way to include those product and process measures that may only be relevant to your particular initiative.

If your project, or its evaluation, requires working with and collecting personal, private, or medical data from patients or “human subjects”, you will most likely be required to outline how you will protect the privacy and confidentiality of the individuals who participate in


your project and their information. You may be required to adhere to strict guidelines for obtaining participant consent and maintaining confidentiality of data provided. You may need to have secure servers or special software to protect participant data stored on computers. Your staff may need to complete special certifications for working with human subjects and human subjects data. If your project is funded, it may need to undergo Institutional Review Board approval to ensure that your evaluation plan adheres to ethical guidelines.

Typically, if you partner with an outside organization or evaluator that regularly works on projects that involve human subjects, the organization will already have the appropriate staff, certifications, resources, and familiarity with these procedures. Your partnering organization can help clarify and expedite this process. While this level of security may not be required for every initiative you implement, it is important that you know and understand the security measures your funding agency requires. Failure to show that you understand these processes and can fulfil these requirements can damage your opportunity to get funded. The TAC has familiarity conducting projects with human subjects and will be able to provide support and clarify these processes if needed.

Reasons Applicants Do Not Get Funded:

Understanding reasons that applicants do not get funded can help you avoid problems when writing a grant. Here are some of the more common pitfalls in grant writing:

1. Not following directions. This could be logistics such as page limits, missing required sections, or applicant eligibility. Your application could also be missing relevant data, program descriptions, or letters of support.

2. Proposal is too vague. Your application doesn’t fit the funder’s objectives, or doesn’t clearly tie the proposed activities to the expected outcomes.

3. Proposal is too narrow. It may not be inclusive enough or may have too narrow a focus for the funding organization to support.

4. Proposal is too broad. Your goals may be too unrealistic or poorly linked to your activity plan.

5. Your organization is not well established. Your coalition may need to have some structure, and credibility or track record to demonstrate your capability to achieve your stated goals.

6. Your evaluation plan isn’t clear. Your evaluation plan needs to show that you have objectives and methods to measure your progress in achieving your goals. You need to have a tracking plan to document your progress and accountability measures for the funds you receive.

7. Circumstances beyond your control. Funders may change their priorities, a state budget may be delayed, or other such circumstances could change the availability of expected funds.

Potential Sources of Grant Funding:

Here are some possible sources of grant funding for your coalition:

1. PA Commission on Crime & Delinquency http://pccd.pa.gov

2. Federal Government Grants http://grants.gov

3. Foundation Center Find Funders http://foundationcenter.org/findfunders/


http://foundationcenter.org/findfunders/

http://grants.gov/

http://pccd.pa.gov/

4. Council on Foundations http://www.cof.org/

5. Local Human Service Agencies Specific to your county

6. Local corporations and organizations Specific to your county

How the TAC Can Help:

Staff from the TAC can assist you as you form your coalition, develop your effort, and implement strategies to address overdose deaths in your community. We provide training and technical assistance at all points throughout the process, including grant assistance. Please contact us as early as possible in the grant process using the form in the front of this manual.


http://www.cof.org/

GlossaryAbstinence: Nonuse of alcohol or any illicit drugs, as well as non-illicit of medications normally obtained by prescription or over the counter.

Addiction: A chronic, relapsing disease characterized by compulsive drug seeking and use, despite serious adverse consequences, and by long-lasting changes in the brain.

Agonist: A chemical entity that binds to a receptor and activates it, mimicking the action of the natural substance that binds there.

Antagonist: A chemical entity that binds to a receptor and blocks its activation. Antagonists prevent the natural substance from activating its receptor.

Benzodiazepines: Group of medications having a common molecular structure and similar pharmacological activity, including anti-anxiety sedative, hypnotic, amnestic, anticonvulsant and muscle-relaxing effects. Benzodiazepines are among the most widely prescribed medications (e.g. diazepam, clonazepam, alprazolam, lorazepam, etc.)

Buprenorphine: Partial opioid agonist approved by FDA for use in detoxification or maintenance treatment of opioid addiction and marketed under the trade names Subutex and Suboxone (the latter also containing naloxone).

Criminal Justice Advisory Board (CJAB): Local (usually county-level) planning and problem solving groups which collaborate on criminal justice issues within Pennsylvania.

Cold turkey: Term used when quitting drugs on one’s own with no medical help. Abruptly discontinuing drug use in an effort to quit long-term.

Comorbidity: The occurrence of two disorders or illnesses in the same person, also referred to as co-occurring conditions or dual diagnosis.

Compulsive: The type of behavior a person exhibits that is overpowering, repeated, and often irrational.

Counseling: In Medication Assisted Treatment, behavioral therapy which is provided by a trained counselor along with medication to treat substance use disorders.

Craving: Powerful desire for a substance that cannot be ignored. Unnaturally strong desire/urge for a substance. An overpowering urge that people are ill-equipped to control through will.

CSAT: The Center for Substance Abuse Treatment (CSAT) of SAMHSA, within the U.S. Department of Health and Human Services (HHS), promotes the quality and availability of community-based substance use disorder treatment services for individuals and families who need them

Department of Drug & Alcohol Programs (DDAP): The state agency which leads efforts to reduce drug, alcohol, and gambling addiction and promote recovery in Pennsylvania.

D.E.A.: Drug Enforcement Administration. Website: www.dea.gov

D.O.C. (DOC): Drug of Choice. A favored illicit substance for an individual or group at a specific point in time; can also refer to the pharmaceutical that is favored among healthcare professionals to treat a particular condition or disease.


Denial: A common reaction of people with substance use disorders who, when confronted with the existence of those disorders, deny that they have a substance use problem and/or have lost control of it.

Dependence: State of physical adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, and/or administration of an antagonist.

Detoxification: A process in which the body rids itself of a drug (or its metabolites). During this period, withdrawal symptoms can emerge that may require medical treatment. This is often the first step in substance use treatment.

Disease: A condition that results in medically significant symptoms in a human; a disorder with recognizable signs and often having a known cause. In the context of addiction, some people reject the fact that addiction is a disease, despite corroboration from top medical organizations.

Dopamine: A brain chemical, classified as a neurotransmitter, found in regions that regulate movement, emotion, motivation, and pleasure.

Drug Collection Box/Take-Back Event: Mechanisms to remove unused medications from the community through a secure collection location or event.

DSM-IV: The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), published by the American Psychiatric Association, is the handbook used most often in diagnosing mental disorders in the United States.

Enabling: As it applies to the disease of addiction, can be defined as doing for someone, in an attempt to help, those things they could or should be doing for themselves, thus actually making it easier for them to continue in the progression of the disease.

Evidence-Based Practices (EBPs): Scientifically validated approaches.

FDA: Food and Drug Administration. Website: www.FDA.gov.

Harm Reduction: Refers to policies, programs and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption.

Heroin: Heroin (diacetylmorphine) is an opioid drug that is synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. Heroin is a full opioid agonist.

HIPAA: Health Insurance Portability and Accountability Act. Website: www.HIPAA.gov.

Medication Assisted Treatment (MAT): The use of medications, combined with other forms of therapy such as counseling, in order to provide an inclusive approach to the treatment of SUDs.

Methadone: A long-acting synthetic opioid medication that is used in maintenance therapy for those individuals dependent on opioids.

Naloxone: Also known as Narcan™. An opioid antagonist that blocks opioid receptors in the brain, thereby blocking the effects of opioid agonists (e.g., heroin, morphine). Naloxone is a life-saving drug that can immediately reverse an opioid overdose. In Pennsylvania, anyone can get a prescription for naloxone from their healthcare provider or through a standing order.

Naltrexone: Also known as Vivitrol™. A medication used in MAT for opioid addiction.

Off-label use: When a drug is used in a way that is different from that described in the FDA-approved drug label.


Office-based opioid treatment (OBOT): OBOT is the treatment of opiate addiction with a medication in a physicians' office and outside of the clinic system. Each medication has specific requirements and regulations to be dispensed.

Opioid: A compound or drug that binds to receptors in the brain involved in the control of pain and other functions (e.g., morphine, heroin, hydrocodone, oxycodone).

Opioid Treatment Program (OTP): OTPs provide MAT for people diagnosed with an opioid-use disorder. MAT patients also must receive counseling, which can include different forms of behavioral therapy.

Overdose Education and Naloxone Distribution (OEND): A program providing naloxone kits and training on recognition and response to suspected overdose (administering naloxone).

Patient Review & Restriction Programs (PRRs): Strategy to reduce prescription drug use by those at high-risk by limiting the pharmacies or physicians through which they can obtain controlled substances.

Painkillers: Analgesic substances that relieve pain. Painkillers come in two classes: opioid and non-opioid. The non-opioid analgesics come in over the counter and prescription forms, while opioid analgesics are only available through prescription and are potentially addictive.

Peer Support: Structured relationship in which people meet in order to provide or exchange emotional support with others facing similar challenges. The group does not necessarily need to have healthcare providers among its members. Alcoholic Anonymous (AA) is an example of a peer support group.

Pennsylvania Commission on Crime and Delinquency (PCCD): Entity which supports programs, practices, and collaboration to enhance the effectiveness of the criminal justice system components in Pennsylvania.

Polysubstance Use: The use of two or more drugs at the same time, such as CNS depressants and alcohol or opioids and benzodiazepines.

Prescription Drug Nonmedical Use: The use of a medication without a prescription, in a way other than as prescribed, or for the experience of feeling elicited.

Relapse: Breakdown or setback in a person’s attempt to change or modify a particular behavior; an unfolding process in which the resumption of compulsive substance use is the last event in a series of maladaptive responses to internal or external stressors or stimuli.

Remission: A period of time in which the signs and symptoms of the addiction have disappeared.

Respiratory Depression: Slowing of respiration (breathing) that results in the reduced availability of oxygen to vital organs. A common symptom of overdose that can lead to death.

SBIRT: Screening, Brief Intervention, and Referral to Treatment. A method to identify, reduce, and prevent problematic use and dependence on alcohol and illicit drugs.

Single County Authority (SCA): The entity which administers drug and alcohol treatment programs in each county in Pennsylvania.

Screening: Process of identifying whether a prospective patient may have a substance use disorder before admission to treatment. Screening usually involves use of one or more standardized techniques, most of which include a questionnaire or a structured interview.

Side effect: Consequence (especially an adverse result) other than that for which a drug is used—especially the result produced on a tissue or organ system other than that being targeted.


Standing Order: A written prescription by an authorized prescriber to make a medication available to those who meet pre-described conditions. In Pennsylvania, there is a standing order signed by the Physician General to make naloxone available to first responders and general public.

Stigma: Negative association attached to an activity or condition; a cause of shame or embarrassment. Stigma is commonly associated with opioid addiction and MAT.

Substance Abuse and Mental Health Services Administration (SAMHSA): A division of the US Department of Health & Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of harmful substance use and mental illness on America's communities. Website: http://www.samhsa.gov.

Substance Use disorder (SUD): A broad term that includes dependence on drugs and/or alcohol or using drugs in ways outside of their intended purpose.

Suboxone®: FDA approved in October 2002, Suboxone is a medication for the treatment of opiate dependence (addiction). Contains the active ingredient, buprenorphine hydrochloride, which works to reduce the symptoms of opiate dependence.

Supply reduction: A general term used to refer to policies aiming to interdict the production and distribution of drugs, particularly law enforcement strategies for reducing the supply of illicit drugs.

Tapering Phase: Phase of MAT in which patients receiving medication maintenance attempt to gradually eliminate their treatment medication (e.g., methadone) while remaining abstinent from illicit substances.

Tolerance: A condition in which higher doses of a drug are required to produce the same effect achieved during initial use; often associated with physical dependence.

Withdrawal: Symptoms that occur after chronic use of a drug is reduced abruptly or stopped.


http://www.samhsa.gov/

References

Albert, S., Brason, I., Fred, W., Sanford, C. K., Dasgupta, N., Graham, J., & Lovette, B. (2011). Project Lazarus: community based overdose prevention in rural North Carolina. ‐ Pain Medicine, 12(s2), S77-S85.

National Institute on Drug Abuse. (January 2016). DrugFacts: Treatment Approaches for Drug Addiction

PA Medical Society. (2014a). Guidelines for ED Opioid. Retrieved from https://www.pamedsoc.org/PAMED_Downloads/PA%20ED%20Guidelines%20Opioids.pdf

PA Medical Society. (2014b). PA Guidelines on The Use of Opiods to Treat Chronic Noncancer Pain. Pennsylvania Department of Health. (2016). Opiod Dispensing Guidelines. Retrieved from

http://www.health.pa.gov/My%20Health/Diseases%20and%20Conditions/A-D/Documents/PA%20Guidelines,%20on%20the%20Dispensing%20of%20Opioids.pdf

Substance Abuse and Mental Health Services Administration. (2015, 9/24/15). Stages of Community Readiness. Retrieved from http://www.samhsa.gov/capt/tools-learning-resources/stages-community-readiness

University of Kansas Work Group for Community Health and Development. (2015). The Community Tool Box. Retrieved from http://ctb.ku.edu/en/toolkits

US Department of Health and Human Services ASPE. (2015). Issue Brief: Opioid abuse in the US and HHS actions to address opioid drug-related overdoses and deaths. Retrieved from https://aspe.hhs.gov/sites/default/files/pdf/107956/ib_OpioidInitiative.pdf


https://aspe.hhs.gov/sites/default/files/pdf/107956/ib_OpioidInitiative.pdf

http://ctb.ku.edu/en/toolkits

http://www.samhsa.gov/capt/tools-learning-resources/stages-community-readiness

http://www.samhsa.gov/capt/tools-learning-resources/stages-community-readiness



https://www.pamedsoc.org/PAMED_Downloads/PA%20ED%20Guidelines%20Opioids.pdf

Appendices


Appendix I: County Overdose Elimination Framework


Appendix II: Current Situation Assessment


Current Situation Assessment

Survey of County Overdose Prevention Efforts

Please complete this questionnaire about overdose prevention efforts that are underway in your county and save the questionnaire with your responses.

County:

Completed by:

Job Title:

Contact email:

Contact phone:

30

Section A. Scope of the Overdose Problem in Your County

1. What is the MOST CURRENT overdose death rate in your county (for which you have data)?

Year Number of Deaths Source of Data

2. What has been the trend in overdose deaths in your county for the past five (5) years of which you have available data? Please complete the table below.

Year Number of OD

Deaths

Top Five Drugs Involved Source of Drug Information

1.

2.

3.

4.

5.

3. Do you have access to CURRENT, RELIABLE, and VALID data from which you can determine the distribution of overdose deaths by age, gender, ethnicity, etc. over the past three years?

☐ YES☐ NO☐ Don’t Know

4. Where do MOST overdose deaths occur in your county?Check No More Than Two (2) Reponses.

☐ Areas of Economic Challenge;☐ Areas of Economic Privilege;☐ Isolated Rural Areas;


☐ Urban Areas or Towns;☐ Suburban Areas; ☐ Other: _______________________________________________☐ Don’t Know.

5. In what types of settings are overdose deaths TYPICALLY occurring in your county?Check ALL that are True.

☐ Streets;☐ Parks;☐ Abandoned Building and Homes;☐ Homes with Occupants;☐ Parked Cars; ☐ Other: ☐ Don’t Know.

Section B. Availability of Naloxone

1. Who TYPICALLY responds to overdose emergencies in your county?Check ALL that are true.

☐ EMS;☐ Fire Department;☐ Police Department;☐ Sheriffs;☐ Other: ☐ Don’t Know.

2. Please complete the following table regarding the status of these “first responders” having naloxone and having received training in naloxone.

Responder Type Has Naloxone YES/NO

Trained to Use YES/NO

If NO – Why Not?

EMS

Fire Department


Responder Type Has Naloxone YES/NO

Trained to Use YES/NO

If NO – Why Not?

Police Department

Sheriffs

Other:

3. If first responders do have naloxone and have received training in its use are there still problems with first responders USING naloxone in the case of an overdose?

☐ NO☐ YES (If Yes, Please Explain Briefly.)

4. Is naloxone CURRENTLY provided at the below intercept points within your county to those at higher risk of overdose?

High Risk Intercept YES/NO

Emergency Department Discharge

Release from Jail/Correctional Facility

Mental Health Treatment

SUD (Substance Use Disorder) Treatment Facility

Physicians when Prescribing Opioid Medications

Other (Please Describe):


5. Is naloxone CURRENTLY available in the county for those likely to be present when an overdose occurs?

Groups Likely to be Present at OD Naloxone Available YES/NO

People who use Drugs

Family/Friends

Police

EMS/First Responders

Criminal Justice Personnel

SUD Treatment Personnel

Mental Health Treatment Personnel

Other (Please Describe):

6. Are there other educational efforts within your county aimed at increasing overdose awareness and naloxone education?

☐ YES☐ NO☐ Don’t Know If YES, please indicate the type of activity and how frequently the activity occurs:

Activity How Frequently Activity Occurs


Activity How Frequently Activity Occurs

7. Do local pharmacies within your county TYPICALLY have naloxone in any form available to customers?


8. Do MOST local pharmacies within your county recognize the PA Standing Order for naloxone (no prescription needed)?


9. Do MOST local pharmacies within your county maintain naloxone in stock?


Section C. Changing Opioid Prescribing and Community Availability

1. Please describe the availability of the following strategies to remove opioids in your county.

Activity

YES/NO(Circle One)

How Many

Was a Public Awareness

Campaign Used to Support?

(Circle One)

Drop Off Boxes YES/NO/DON’T KNOWYES/NO/DON’T KNOW

Take Back Programs YES/NO/DON’T KNOWYES/NO/DON’T KNOW


Section D. Availability of Substance Use Disorder (SUD) Treatment

1. Please indicate the number of SUD treatment programs you have in your county by PCPC (Pennsylvania’s Client Placement Criteria) Level of Care.

Type of ProgramPA

PCPC Level

Number of Programs

Capacity (Greatest Number of Persons Who Can Receive Treatment At Any Given Point in Time

Across ALL Programs)

Intensive Intervention .5

Outpatient 1A

Intensive Outpatient 1B

Partial Hospitalization 2A

Halfway House 2B

Medically Monitored Inpatient Detox

3A

Medically Monitored Short Term Residential

3B

Medically Monitored Long Term Residential

3C

Medically Managed Inpatient Detox

4A

Medically Managed Inpatient Residential

4B

2. Please indicate the top three levels of care you MOST need to address SUD in your county?

1.

2.


3.

3. How many Medication Assisted Treatment (MAT) programs do you have in your county by the following services?

MAT Program Type Number AvailableNumber of physicians who can prescribe pharmacotherapy (buprenorphine, suboxone, etc.) but whose patients are not referred or actively linked to counseling. (HARM REDUCTION)Number of programs that involve physician prescribing pharmacotherapy and referring patients to psychosocial counseling.Number of programs that involve physician prescribing pharmacotherapy, ensuring patients access psychosocial counseling and intensive care management.

4. What recovery support organizations exist in your county?

Briefly Describe the Number and Type of Organizations:

5. What is the usual wait time to access any level of care in your county?

Days

Weeks


6. Please rank the major barriers to providing access to SUD treatment in your county (1 Most Significant – 6 Lease Significant).

Barrier Rank (in order of significance)

Transportation

Funding

Level(s) of Care Needed Are Not Available

Childcare Needed

Recovery Support

Other (Please Specify):

7. Within your county, how are connections TYPICALLY made from the following intercept points to SUD treatment? To what degree is SBIRT (Screening, Brief Intervention, and Referral to Treatment) provided in these intercept locations?

Intercept Point How are connections to treatment facilitated?

To what degree is SBIRT provided in these

intercept locations?

Primary Care

☐ Embedded Behavioral Health Program/Staff;☐ Full “Warm Hand Off”;☐ Partial “Warm Hand Off”;☐ Referral with Number and/or Contact;☐ Referral without Number and/or Contact;☐ Other: ☐ Don’t Know

☐ Fully Implemented Across ALL Programs;☐ Implemented in Some Programs;☐ Not Implemented at All;☐ Don’t Know

Emergency Department ☐ Embedded Behavioral Health Program/Staff;☐ Full “Warm Hand Off”;☐ Partial “Warm Hand Off”;☐ Referral with Number and/or Contact;☐ Referral without Number and/or Contact;



Intercept PointHow are connections to treatment facilitated?


intercept locations?☐ Other: ☐ Don’t Know

Jail/Prison



Probation/Parole



Law Enforcement



Drug Courts



Faith-Based Organizations ☐ Embedded Behavioral Health Program/Staff;☐ Full “Warm Hand Off”;☐ Partial “Warm Hand Off”;

☐ Fully Implemented Across ALL Programs;☐ Implemented in Some Programs;


Intercept PointHow are connections to treatment facilitated?


intercept locations?☐ Referral with Number and/or Contact;☐ Referral without Number and/or Contact;☐ Other: ☐ Don’t Know

☐ Not Implemented at All;☐ Don’t Know

Other (Please Specify): ☐ Embedded Behavioral Health Program/Staff;☐ Full “Warm Hand Off”;☐ Partial “Warm Hand Off”;☐ Referral with Number and/or Contact;☐ Referral without Number and/or Contact;☐ Other: ☐ Don’t Know


Section E. Prescribing Practices

1. In your opinion, are most prescribers and pharmacists within your county aware of the Prescription Drug Monitoring Programs (PDMP) expected in PA in August 2016 to reduce drug diversion and “doctor shopping”?


2. In your opinion, are most prescribers in your county aware of the risks of prescribing opioids?


3. To your knowledge, do most prescribers in your county follow PA Medical Society or Centers for Disease Control (CDC) Prescribing Guidelines for use of opioid pain relievers?


4. Have any prescribers in your county completed a training program on Opioid Prescribing Guidelines?



5. If some prescribers have completed an Opioid Prescribing Guideline training, what estimated percent of the TOTAL number prescribers have completed this training?

☐ 100 – 75%☐ 74 – 50%☐ 49 – 25% ☐ < 25%☐ Don’t Know

Section F. Community Resources

8. On a scale of 1 – 10, how would you rank the level of community awareness about overdose in your county?

1 Unaware 5 Moderately Aware 10 Extremely Aware

Rank

9. On a scale of 1 – 10, how much do members of your county support overdose prevention efforts?

1 Don’t Support 5 Moderately Supportive 10 Extremely Supportive

Rank

10. On a scale of 1 – 10, how much do members of the county support overdose intervention efforts (e.g. Naloxone Provision)?

1 Don’t Support 5 Moderately Supportive 10 Extremely Supportive

Rank


11. Does your county have an organized response to the overdose issue (e.g. Task Force, Coalition, etc.?)


If Yes, in what year what is established?

12. What community segments are currently involved in your overdose response (Coalition/Task Force, etc.)?Please check all involved.

☐ Single County Authority (SCA) for Drug and Alcohol Treatment;☐ Criminal Justice Advisory Board (CJAB);☐ Coroner/Medical Examiner;☐ SUD Treatment Provider(s);☐ Law Enforcement/Criminal Justice;☐ EMS/First Responders;☐ County Medical Society/Physician Representation;☐ Hospitals/Health Systems;☐ Other (Please Specify):

13. What community segments are NOT currently involved in your overdose response, but you think should be in your overdose efforts?Please check all involved.

☐ Single County Authority (SCA) for Drug and Alcohol Treatment;☐ Criminal Justice Advisory Board (CJAB);☐ Coroner/Medical Examiner;☐ SUD Treatment Provider(s);☐ Law Enforcement/Criminal Justice;☐ EMS/First Responders;☐ County Medical Society/Physician Representation;☐ Hospitals/Health Systems;☐ Other (Please Specify):

14. Which community leaders are involved in your county’s overdose response efforts?


Check all Leaders involved.

☐ Political/Elected;☐ Business;☐ Philanthropic/Foundations;☐ Health Systems/Insurers;☐ Criminal Justice/US Attorneys/District Attorney;☐ Probation/Parole;☐ Judiciary/Judges;☐ Community Leaders at Large.

15. What community resources are available to address overdoses in your county?Check ALL that are True and Please Explain in the space provided.

☐ County Funds/Resources

☐ States Funds/Resources

☐ Grant Funds/Resources


☐ Other Funds/Resources

☐ Don’t Know

16. What additional funding and resources would your county ideally wish to have to address the overdose problem?

Please explain:

17. Are any initiatives underway in your county that were not referenced in this questionnaire?

Please explain:


18. Do you have any additional comments?

Thank you.


Appendix III: County Dashboard Framework


County Dashboard Framework

Number of Overdose

Deaths (most

recent, complete

year available)

Overdose Death Rate(deaths per

100,000 population)

Top Five Drugs in Overdose

Deaths (most recent,

complete year available)

Naloxone Availability

Treatment Resources

Barriers to Accessing

Treatment (in order of

importance)

Prescribing Practices

(including use of

Prescription Drug

Monitoring Programs)

SBIRT Use

Community Response to

Overdose


Appendix IV: Assessment Worksheets


A.1. Describing Your Community and Community Factors ChecklistThe following are a list of possible ways you can characterize your community. Discuss each factor with your team and start to decide how you might describe your community based upon the possibilities provided. In the last column you will note how this factor might affect your

choice of leadership, coalition members, evidence-based practices, and strategic plan.

Community Factor Definition Potential Way You Might

Describe Your Community For This FactorHow This Factor

May Affect Your Work

Culture The manner in which the community tends to come together (or not) to express its values, beliefs and traditions.

Political Culture Tends to be more traditional; Tends to be more progressive; Tends to be a mixture of both traditional and

progressive.Arts Culture Tends to highly value it’s arts; Tends to not value its arts; Tends to be a mixture of both those who value

and do not value arts.Acceptance Tends to practice acceptance of all persons of

different ethnic groups, sexual orientation, races, etc.;

Tends to not practice acceptance of all persons of different ethnic groups, sexual orientation, races, etc.;

Tends to be a mixture of practices that both accept and do not accept persons of different ethnic groups, sexual orientation, rates, etc.

Work Ethic Tends to value a strong work ethic among its

members; Tends to not value a strong work ethic among

its members; Tends to be a mixture of a culture that both

values and doesn’t value a strong work ethic.

1. Affects who you will include in your coalition;

2. Affects how you will approach and apply language to educational efforts;

3. Affects where you will apply your interventions within the community;

4. Affects how you will implement selected interventions;

5. Helps point out where culture may be different within your community.


Community Factor Definition Potential Way You Might

Describe Your Community For This FactorHow This Factor

May Affect Your Work

Religion/Spirituality Tends to value religion/spirituality in

everyday life; Tends to not value religion/spirituality in

everyday life; Tends to be a mixture of both strong and weak

religious/spiritual values in everyday life.

Economic Conditions

The prevailing economic indicators that affect the quality of life within the community.

Per Capita Income Average per capita income over the federal

poverty level;Guidelines for Assessing Per Capita Income:

Greater than $11,770 for individuals Greater than $15,930 for a family of 2 Greater than $20,090 for a family of 3 Greater than $24,250 for a family of 4

Average per capita income below the federal poverty level.Guidelines for Assessing Per Capita Income:

Less than $11,770 for individuals Less than $15,930 for a family of 2 Less than $20,090 for a family of 3 Less than $24,250 for a family of 4

Income Disparity Significant income disparity across the

community; Income tends to be more similar than

different across the community;Unemployment Rate Unemployment rate is above the state

average of 5.0%; Unemployment rate is below the state

average of 5.0%.




4. Affects how you will implement selected interventions;

5. Helps point out where culture may be different within your community.


Social Networks

Manner in which community members socialize AND use social network applications.

Socialization Patterns Community members tend to socialize well

between different groups of different ethnic backgrounds, races, sexual orientations, etc.;

Community members tend to only socialize based upon the group they identify with most (e.g., ethnic group, race, sexual orientation, etc.).

Social Network Penetration Most community members tend to use social

network applications (e.g., Facebook, Instagram, Snap Chat, Twitter, etc.);

Only community members of specific demographic groups tend to use social network applications.

Power Structures

How community power is distributed at the local level.

Power Distribution Power over the community health as a whole

is distributed traditionally mostly to one group of people and the other community groups are often not included in decision making;

Power over the community health as a whole is distributed into subgroups of people who do not tend to work collaboratively;

Power over the community health as a whole tends to be equally distributed throughout all group members who work well together towards a common aim.


2. Affects how you will engage community leadership;


4. Affects how you will implement selected interventions.

Demographic Trends

The community’s demographic characteristics and trends.

Demographic Characteristics Predominant ethnic/racial groups are:

White; Black or African American; Asian; Hispanic or Latino; American Indian or Alaskan Native; Native Hawaiian & Other Pacific Islander; Other Race, not listed.



3. Affects what interventions you will select;

4. Affects where you will apply your interventions within the


Predominant age distribution is: 0 – 19 years; 20 – 34 years; 35 – 54 years; 55 – 74 years; 75 or older.

Demographic Trends How is this ethnic/racial group distribution

anticipated to change over the next 5 years?Comment:

How is this age distribution anticipated to change over the next 5 years?Comment:

community;5. Affects how you will implement

selected interventions;6. Helps point out where culture may

be different within your community.

Prior Experience with Groups Addressing Overdose Reduction

Prior experience the community has had with groups inside or outside of itself in addressing overdose reduction.

Prior Experience with Overdose Reduction Efforts Prior experience with efforts (inside or

outside) have primarily been GOOD; Prior experience with efforts (inside or

outside) have primarily been POOR; The community has had NO prior experience

with efforts to reduce overdoses.


2. Helps you learn from the community’s positive or negative experiences to improve your present efforts.


A.2. Data Available to Your CommunityPlease review the following potential data indicators and determine your community’s availability for

each type of data.

Data Source Availability/Amount

1. Data regarding persons who have died from overdose:a. Real time (as close as possible);b. Accurate metabolic Profile;c. >5 Years Data Available;d. Demographic info (age, gender, race);e. Substance(s);f. Location;g. Decedent’s involvement with mental health services; andh. Decedent’s involvement with drug and alcohol treatment.

2. Number of physicians and healthcare providers:a. Primary care; andb. Specialty.

3. Types of SUD treatment programs by type of program (level of care), number of persons who can be served at any time.

4. Number of MAT programs operating.5. Number of programs that may not be evidence-based.6. Number of health profession schools (medical, nursing, pharmacy,

physician assistant, social work, dental).7. Availability of naloxone (number of pharmacies that stock;

number of police, firefighters, EMTs and paramedics who carry).

8. Number of emergency departments or urgent care centers.a. Current number of educational programs that address: b. Addiction;c. Overdose prevention strategies;d. SUD treatment approaches;e. Prescribing practices that can reduce overdoses;f. Naloxone use; and g. Other relevant topics.

9. Number of recovery support groups that facilitate patient access, engagement, and retention in SUD treatment of any kind.

10. Number and names of family support groups that address overdoses.

11. Trends in arrests associated with drug-related crimes.12. Trends in children referred to child welfare because of drug-

related issues.13. Number of drug courts (adult and juvenile).14. Availability of educational programs within jail aimed at reducing

overdose risk upon release.

15. Indications of gaps in obtaining reimbursement for SUD treatment.


A.2.1. Potential Sources of DataThese resources can help you to obtain data about your community, overdose risk and deaths in your local area,

and will act as helpful resources as you build your coalition.

Title Website

US Census Bureauhttp://www.census.gov/data.html

http://www.census.gov/quickfacts/table/PST045215/00http://www.census.gov/programs-surveys/acs/

CONTENT: Information on population and economy in the US

National Survey on Drug Use and Health http://www.samhsa.gov/data/population-data-nsduh

CONTENT: Survey on alcohol, tobacco and illegal drug use in US population age 12 and older

Monitoring the Future Survey http://www.monitoringthefuture.org/

CONTENT: Survey of American secondary school, college, and young adult population

Trust for America's Health Key Health Data http://healthyamericans.org/states/?stateid=PA

CONTENT: Health Data for PA

CDC Youth Risk Behavior Surveillance System http://www.cdc.gov/healthyyouth/data/yrbs/index.htm

CONTENT: Monitors 6 types of health-risk behaviors

CDC Prescription Drug Overdose http://www.cdc.gov/drugoverdose/

CONTENT: Information on prescription drug overdose

TEDS Treatment Episode Data Sethttp://www.samhsa.gov/data/sites/default/files/TEDS2011St_Web/

TEDS2011St_Web/TEDS2011St_Web.pdf

CONTENT: State admissions to substance use disorder treatment centers (usually several years prior)

SAMHSA Behavioral Health Services Treatment Locator https://findtreatment.samhsa.gov/

CONTENT: Locator to find behavioral health treatment service providers by zip code

DEA 360 Strategy http://www.dea.gov/divisions/hq/2015/hq111015.shtml


http://www.dea.gov/divisions/hq/2015/hq111015.shtml

https://findtreatment.samhsa.gov/

http://www.samhsa.gov/data/sites/default/files/TEDS2011St_Web/TEDS2011St_Web/TEDS2011St_Web.pdf

http://www.samhsa.gov/data/sites/default/files/TEDS2011St_Web/TEDS2011St_Web/TEDS2011St_Web.pdf

http://www.cdc.gov/drugoverdose/

http://www.cdc.gov/healthyyouth/data/yrbs/index.htm

http://healthyamericans.org/states/?stateid=PA

http://www.monitoringthefuture.org/

http://www.samhsa.gov/data/population-data-nsduh

http://www.census.gov/programs-surveys/acs/

http://www.census.gov/quickfacts/table/PST045215/00

http://www.census.gov/data.html

Title Website

CONTENT: DEA website outlining 360 strategies against drug use

FDA Drug Disposal Informationhttp://www.fda.gov/Drugs/ResourcesForYou/Consumers/

BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm

CONTENT: FDA website with information on how to safely dispose of unused medications

PA Department of Drug and Alcohol Programs (DDAP) http://www.ddap.pa.gov/pages/default.aspx#.Vtb49_krKHs

CONTENT: PA DDAP website; Includes Rx Guidelines, treatment and drug-collection box locators and other resources

PA Youth Survey (PAYS)http://www.pccd.pa.gov/Juvenile-Justice/Pages/Pennsylvania-Youth-

Survey-(PAYS).aspx#.VscvBPkrKHs

CONTENT: Survey of 6th, 8th, 10th, and 12th grade students to determine behavior, knowledge and attitudes about alcohol and drug use

PA Regional Planning Commissions http://www.arc.gov/about/localdevelopmentdistrictsinpennsylvania.asp

CONTENT: Regional planning and development districts; Population statistics and community profiles

County Commissioners Association of PA http://www.pacounties.org/Pages/default.aspx

CONTENT: Information for each county in PA including list of contacts for county commissioners

PA DCED Municipal Statistics http://munstats.pa.gov/public/

CONTENT: Searchable data for municipalities; includes contact information for local government officials

PA State Coroners Association http://www.pacoroners.org/coroners_list.php

CONTENT: Listing of PA Coroners

PA DOH County Health Profileshttp://www.statistics.health.pa.gov/HealthStatistics/VitalStatistics/

CountyHealthProfiles/Pages/CountyHealthProfiles.aspx#.Vvvjg-IrKHs

CONTENT: Information on health indicators and resources for each county and PA as a whole

PA 911 Coordinatorshttp://www.pema.pa.gov/about/Daily%20Document%20Updates/

911%20Coordinators.pdf


http://www.pema.pa.gov/about/Daily%20Document%20Updates/911%20Coordinators.pdf

http://www.pema.pa.gov/about/Daily%20Document%20Updates/911%20Coordinators.pdf

http://www.statistics.health.pa.gov/HealthStatistics/VitalStatistics/CountyHealthProfiles/Pages/CountyHealthProfiles.aspx#.Vvvjg-IrKHs

http://www.statistics.health.pa.gov/HealthStatistics/VitalStatistics/CountyHealthProfiles/Pages/CountyHealthProfiles.aspx#.Vvvjg-IrKHs

http://www.pacoroners.org/coroners_list.php

http://munstats.pa.gov/public/

http://www.pacounties.org/Pages/default.aspx

http://www.arc.gov/about/localdevelopmentdistrictsinpennsylvania.asp

http://www.pccd.pa.gov/Juvenile-Justice/Pages/Pennsylvania-Youth-Survey-(PAYS).aspx#.VscvBPkrKHs

http://www.pccd.pa.gov/Juvenile-Justice/Pages/Pennsylvania-Youth-Survey-(PAYS).aspx#.VscvBPkrKHs

http://www.ddap.pa.gov/pages/default.aspx#.Vtb49_krKHs

http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm



Title Website

CONTENT: List of 911 Center Coordinators for each county

PA State Prisonshttp://www.cor.pa.gov/FACILITIES/STATEPRISONS/Pages/

default.aspx#.Vtb4XfkrKHt

CONTENT: List of State Correctional Facilities

PA County Jailshttp://www.cor.pa.gov/Facilities/CountyPrisons/Pages/County-Prison-

Contact-Info.aspx#.Vtb4uvkrKHs

CONTENT: Link to list of PA County Jail contacts

PA Medical Society County Medical Societieshttp://www.pamedsoc.org/MainMenuCategories/PAMED-Community/

County-Medical-Societies.aspx

CONTENT: List of each County Medical Society in PA

Center for Rural Pennsylvania http://www.rural.palegislature.us/index.html

CONTENT: Information and research for rural policy; Reports and public hearings on heroin/opioid issues

OverdoseFreePA http://overdosefreepa.org/

CONTENT: Comprehensive information and resources including overdose death data and link to TAC


http://overdosefreepa.org/

http://www.rural.palegislature.us/index.html

http://www.pamedsoc.org/MainMenuCategories/PAMED-Community/County-Medical-Societies.aspx

http://www.pamedsoc.org/MainMenuCategories/PAMED-Community/County-Medical-Societies.aspx

http://www.cor.pa.gov/Facilities/CountyPrisons/Pages/County-Prison-Contact-Info.aspx#.Vtb4uvkrKHs

http://www.cor.pa.gov/Facilities/CountyPrisons/Pages/County-Prison-Contact-Info.aspx#.Vtb4uvkrKHs

http://www.cor.pa.gov/FACILITIES/STATEPRISONS/Pages/default.aspx#.Vtb4XfkrKHt

http://www.cor.pa.gov/FACILITIES/STATEPRISONS/Pages/default.aspx#.Vtb4XfkrKHt

A.2.2. A Guide For Analyzing Community Data1. If possible, start with accurate and as real time as possible overdose death data and determine

trends in the most recent year and in the previous years for drugs involved and the demographics of persons who died by the drugs involved in their deaths. This information helps determine what types of interventions, treatment, community education, healthcare provider training efforts, etc. should be implemented. Other things like location of the person’s death or residence can be helpful in determining what communities may need to be targeted for interventions;

2. Look for gaps in resources, community member knowledge/awareness, and healthcare provider knowledge/awareness that would need to be addressed in order to implement identified interventions;

3. Look at standardized survey data to determine how the risk for development of use disorders (alcohol or other drug) compares with other communities and how this may indicate whether your community as a whole has more protective or risk factors that would be associated with supporting risk reduction or recovery;

4. Remember that each survey or data source has limitations including:

a. Errors with respect to how the data are defined;

b. Incomplete or missing data;

c. Data only covers one segment of the population;

d. Persons reflected in the data are different from the entire population of eligible persons (usually referred to as bias);

e. Data aren’t really a measurement of what they are supposed to measure.

It is best to understand the limitation of your data set before you report your conclusions from it. The TAC can help you understand the limitations of the data you may use.

5. Develop questions that you use the data to answer and describe your tentative answers to these questions (citing the data you used);

6. Remember that the common intercept points for patients who are at risk for overdose are:

a. Jail (persons are at greatly increased risk for an overdose following release);

b. Emergency departments (most persons who have died from an overdose have visited an ED at least 3 times in the year preceding their death);

c. Substance Use Disorder treatment (persons are at increased risk for an overdose when they leave SUD treatment); and

d. Mental Health treatment (persons who died from an overdose often have been involved with Mental Health treatment within the year prior to their deaths).

These above points present good places to implement interventions in your community to prevent overdose deaths among high risk persons;

7. Patients who are prescribed Suboxone are at increased risk for overdose if they discontinue their use (or are not adherent to how they are supposed to take it);

8. Patients who take methadone and benzodiazepines together are at greatly increased risk for overdoses;

9. Qualitative data (interviews and focus groups) can be a good way to understand how a population feels about an intervention and how it should be implemented;


10. Use your dashboard to help identify areas where you may need to increase the number and type of a particular intervention.


Root Cause Analysis Steps in a Root Cause Analysis:1. Identify the event (overdose) and gather additional information [Columns A & B];2. Identify contributory factors [Column C];3. Describe the contributory factors on a timeline (0 – 12 months pre-death) [Column C];4. Identify root causes by asking 5 “Whys”1; 5. Design changes to eliminate root causes;6. Implement and evaluate change.

A. Identify Substances Directly Contributing to Overdose

B. Identify Additional Information C. Identify Contributory Factors

1. Prescription drug use:a. Medical mishap (Rx

drugs);b. Rx drugs in combination

with other substances (alcohol, benzodiazepines, heroin);

c. Misuse (Rx drugs).

2. Illicit Drug Use:a. Illicit Use of Rx opioids

(diversion); b. Heroin;c. Fentanyl.

3. Combination Use:a. Cocaine;b. Benzodiazepines;c. Alcohol;d. CNS depressants;e. Other substances.

1. Identify the event (overdose) and gather information:a. Demographic Information:

i. Age;ii. Gender;

iii. Race;iv. Marital status;v. Education level;

vi. Employment status;vii. Military/veteran status;

viii. Insurance status (MA, private insurance).b. Location of Death (geography, type);c. Location of residence;d. Circumstances of death (alone, with people,

etc.);e. Did decedent access any of the following one

year prior to death (# of times):i. Mental health treatment;

ii. SUD treatment;iii. CJ system (jail, prison, etc.);iv. ED’s.

f. SUD History;

1. Identify Contributory Factors:a. Lack of education (prescribers, patients, payers, etc.); b. Non-adherence (Rx drugs);c. Dose escalation;d. Polysubstance use;e. Polypharmacy use;f. Pain(physical, psychosocial);g. Desire to get high;h. Desire to avoid withdrawal;i. Medical comorbidities;j. Mental health comorbidities;k. Trauma;l. SUD history;m. Previous overdose (non-fatal);n. Criminal Justice System intercepts;o. Mandatory abstinence (incarceration, treatment

programs);p. Treatment availability (lack or inadequate);q. Naloxone availability (lack).

2. Describe what happened (timelines): a. Material found at scene of death;b. How long decedent was deceased before discovery;

1 The “5 Whys” is a simple and effective way to identify the root cause of a problem while also uncovering the relationship between the different root causes. The “5 Whys” method does not require a lot of resources, and it can be done without having to use statistical analyses. Simply begin by identifying the specific problem, then continue asking “why” until the root cause is discovered. For example, why did the person die? Because they took heroin and Fentanyl… Why did they take heroin and Fentanyl? Because they were addicted… Why did they continue to be addicted? Because they did not receive appropriate SUD treatment, etc.… Why did they not receive appropriate SUD treatment? Because…


A. Identify Substances Directly Contributing to Overdose

B. Identify Additional Information C. Identify Contributory Factors

g. Dual Diagnosis (MH/SUD). c. Was naloxone rescue attempted?


A.3. Community Readiness AssessmentUse this sheet to identify how ready your community is to take on a social change initiative to address

overdose. This helps your coalition to identify steps and actions appropriate for your community’s current state and how to best begin your efforts.

1. Existing community efforts: How knowledgeable are members of your community about the issue of overdose?

☐ NO KNOWLEDGE: No knowledge or awareness of the need for efforts to address overdose.

☐ DENIAL: No efforts addressing overdose.

☐ VAGUE AWARENESS: A few people recognize the issue, but there are no initiatives to do anything.

☐ PRE-PLANNING: Some community members have met and discussed beginning an effort.

☐ PREPARATION: Efforts are being planned.

☐ INITIATION: Efforts have been started.

☐ STABILIZATION: Efforts have been running for several years.

☐ CONFIRMATION/EXPANSION: Several different programs, activities, and policies are in place aimed at a wide range of age groups and people. New efforts are being planned based on evaluation data.

☐ PROFESSIONALIZATION: Evaluation plans are routinely used to test effectiveness of different efforts and guide changes and improvements.

2. Community knowledge of efforts: How knowledgeable are members of your community about current efforts to address overdose?

☐ NO KNOWLEDGE: No knowledge about the need for efforts to address overdose.

☐ DENIAL: No knowledge of efforts to address overdose.

☐ VAGUE AWARENESS: At least some have heard of local efforts, but their knowledge is limited.

☐ PRE-PLANNING: Some community members know about local efforts.

☐ PREPARATION: Members of the community have basic knowledge about local efforts.

☐ INITIATION: An increasing number of community members have knowledge about local efforts and are trying to increase knowledge of the general community.

☐ STABILIZATION: The community has specific knowledge of local efforts.

☐ CONFIRMATION/EXPANSION: There is considerable knowledge about different community efforts and the level of effectiveness.

☐ PROFESSIONALIZATION: Community has knowledge of program evaluation data on how well the different local efforts are working and their benefits/limitations.

3.


4. Leadership: How concerned are leaders of your community toward the issue of overdose?

☐ NO KNOWLEDGE: Leaders have no recognition of the issue.

☐ DENIAL: Leaders do not believe overdose is an issue in our community.

☐ VAGUE AWARENESS: Leaders recognize the need to do something regarding the issue.

☐ PRE-PLANNING: Leaders are trying to do something.

☐ PREPARATION: Leaders are part of a committee or group that addresses the issue.

☐ INITIATION: Leaders are active and support the implementation efforts.

☐ STABILIZATION: Leaders support continuing efforts and are considering resources available for self-sufficiency.

☐ CONFIRMATION/EXPANSION: Leaders support expanding efforts through active participation.

☐ PROFESSIONALIZATION: Leaders continually review evaluation results of the efforts and modify support accordingly.

5. Community climate: What is the climate in your community about the issue of overdose?

☐ NO KNOWLEDGE: Not a concern; overlooked.

☐ DENIAL: There is nothing that can/should be done.

☐ VAGUE AWARENESS: Neutral, disinterested.

☐ PRE-PLANNING: Becoming interested; have to do something but not sure what.

☐ PREPARATION: Concerned; supportive of efforts to address.

☐ INITIATION: Becoming involved in efforts to address.

☐ STABILIZATION: Majority of the community supports programs or efforts.

☐ CONFIRMATION/EXPANSION: Strong support; participation is high.

☐ PROFESSIONALIZATION: Major segments of the community are highly supportive and actively involved.

6. What resources exist in your community to address the issue of overdose?

☐ NO KNOWLEDGE: No awareness of the need for resources.

☐ DENIAL: No resources are available.

☐ VAGUE AWARENESS: Unsure of what resources could be used.

☐ PRE-PLANNING: Some community resources are available.

☐ PREPARATION: Some community members are looking into available resources.

☐ INITIATION: Resources have been obtained and/or allocated.

☐ STABILIZATION: Ongoing support is from local sources, which are expected to continue.

☐ CONFIRMATION/EXPANSION: Diversified resources are secured and efforts are expected to be ongoing. There is additional support for further efforts.

☐ PROFESSIONALIZATION: There is continuous and secure support, routine evaluation, and resources for trying new effort.


Appendix V: Capacity Worksheets


C.1. Potential Coalition Members and RolesThe following are a list of potential coalition members’ domains. Review this list and determine which

members might be best to include in your coalition.

NOTE: You do not need, and in fact it is not recommended, to include individuals who represent every domain in your coalition. Include those that you feel are most important based upon an examination

of your community data and potential evidence-based strategies for reducing overdoses initially. Domains in bold are essential for your coalition.

Domain Member Who Represent Role in Coalition Name(s) of Potential

Member

Single County Authority (SCA)

Assist in improving access to substance use disorder (SUD) treatment and development of treatment models involving medication assisted treatment (MAT).

Criminal Justice Advisory Board (CJAB)

Assist in coordinating state, county and local level criminal justice system entities and facilitate.

Coroner/Medical Examiner

Assist in providing real-time data from which strategies emerge to identify and eliminate new drug forms that appear within the community. Understand how the overdose phenomena is expressing itself within the community, so data-driven strategies for reducing overdoses can be planned and evaluated.

Police/Law Enforcement

Assist in developing strategies for providing naloxone to individuals who have overdosed, strategies for identifying and removing new highly fatal drugs that have entered the community, and facilitating educational efforts with police (among others). Gather information on drug use in the community.

EMS Provide information on non-fatal overdoses and assist with expanded naloxone availability.

County Medical Society Assist in communicating with physicians regarding overdose issues, treatment, and prescribing practices.

General Health Care Provider (e.g., physicians, nurses, pharmacists, physician assistants, etc.)

Assist in identifying persons who are at risk of overdose, assist in implementing programs that affect opioid prescribing practices, assist in referring patients to specialty care, assist in enhancing participation in prescription drug monitoring program (PDMP), assist in enhancing development and participation with MAT program (among others).

Specialty Health Care Provider

Assist in improving access to SUD and mental health treatment and in developing new treatment models involving MAT.


Domain Member Who Represent Role in Coalition Name(s) of Potential

Member

Recovery Support Assist in improving individual access, engagement, and retention to SUD treatment.

Jail

Assist in designing and implementing educational programs and linkages to relevant programs within the community that are designed to reduce overdose risk among inmates. Awareness of decreased tolerance on release.

Family MembersProvide context for the gaps that prevent individuals from obtaining the services they need to prevent overdoses.

AcademiaAssist in identifying evidence-based practices and evaluating the coalition’s ability to reduce overdoses.

Political LeadersInfluence public policy around awareness and strategies to reduce of overdoses. Connect resources available in the community.

SchoolsAssist in developing and implementing programs that are designed to identify and intervene with students at risk for overdoses.

Religious Leaders

Assist in providing educational and interventional services that are endorsed by these leaders and even provided within their facilities that are aimed at reducing overdoses.

Foundation Community

Assist in providing resources and funding for the coalition’s efforts.


C.2. Creating a Vision Statement (And a Greater Purpose)Follow the steps below to develop the Vision Statement and Greater Purpose for your coalition.

Complete your vision statement and write it in the area at the end of this worksheet.

1. Assemble the Right PersonsAssemble the persons who are the engaged and senior leaders for all aspects of the coalition.

2. Determine the Topic and ScopeDetermine and explicitly list the components of the community that you will be including in your Vision/Greater Purpose.

3. Determine the TimeframeDetermine the timeframe for your Vision and Greater Purpose. It may be best for some organizations that are struggling to transform themselves because of severe and life threatening challenges to keep the timeframe moving forward in five year increments (every five years the Vision/Greater Purpose is changed as the organization achieves its Vision for the previous five years). For more stable organizations, one life-long Vision/Greater Purpose will be best (such as a Greater Purpose that each patient receives the right care at the right time every time). However, even these Vision/Greater Purpose statements may need to be changed as new leadership arises or as the environment outside of the coalition dramatically changes.

4. Determine Your IdealA Vision/Greater Purpose should clearly and very succinctly state what you believe is your ideal goal for your coalition. It should be inspirational and inarguable and it should present a condition that (for a short term Vision/Greater Purpose) falls just outside the realm of what can be achieved for the time duration of which it is intended to be active. The Vision/Greater Purpose should be something that is easily recited by each and every one of your coalition members (i.e., SHORT and to the point). It should be prominently displayed throughout and incorporated into your organization/system activities so that each member realizes that it actually does guide the coalition’s work. It should be used as your coalition’s COMPASS to determine its TRUE NORTH for all major actions within your organization/system - especially in times when there are challenges, failures, set-backs, and pivotal decisions.

5. Draft Your Vision/Greater PurposeUse your initial team to draft/redraft and revise your Vision/Greater Purpose until you think you have it right. Use the above suggestions to guide your final draft development.

6. Gain Input from Your System/Organizational MembershipUnveil your Vision/Greater Purpose to your coalition’s members and seek their input to finalize it. Sometimes it is best to carefully craft how this unveiling will occur or to select members that represent all aspects of the organization to review the Vision/Greater Purpose rather than do an organizational wide unveiling. Make sure that you are inclusive in selecting who will represent different member groups within your coalition so you don’t miss an important perspective. This step helps ensure that the larger group accepts your Vision/Greater Purpose as well.

7. Share Your Final Vision/Greater PurposeShare your final Vision/Greater Purpose with your larger group in an “unveiling” process that covers the following points: (1) why the Vision/Greater Purpose is important; (2) the process used in developing the Vision/Greater Purpose; (3) how the Vision/Greater Purpose will be used; (4) how the leaders will ensure that the Vision/Greater Purpose is used as intended; (5) how long the Vision/Greater Purpose is intended to cover the coalition’s activities; and (6) the process that will be used to access (at least annually) the extent to which the Vision/Greater Purpose has been achieved and what will be done to increase the ability of the coalition to better reach its Vision/Greater Purpose.


After working with your team, write your coalition’s vision here:


Coalition Name:

Vision:

C.3. Leadership QuestionnaireThe following are optimal leadership characteristics for your community coalition aimed at reducing

overdoses. Review this list with your community members and determine for any given leader(s) his or her strengths and challenges in meeting each criterion.

NOTE: It is optimal to choose leaders that have the highest level of preferred qualities, but the Technical Assistance Center can also help existing leaders and coalitions use strategies to improve its

leadership.

1. EXPERIENCE in successfully leading community efforts aimed at improving member health:

☐ Strong experience (has successfully led 2 or more community efforts)

☐ Good experience (has successfully led 1 community effort)

☐ No experience (has never led a community effort)

☐ Poor experience (has led unsuccessfully 1 or more community efforts)

2. RESPECTED within all community groups/membership:

☐ High respect by all community groups/members

☐ Respect (even high) by some community groups/members

☐ Neither respect nor disrespect by community groups/members

☐ Low respect by some community groups/members

☐ Very low respect by all community groups/members

3. ACCESS to community leaders who can make important decisions:

☐ Has important access to the most important community leaders who make critical decisions that would affect the coalition’s work and success

☐ Has some access to some community leaders who can make decisions that would affect the coalition’s work and success

☐ Has little access to any community leaders who can make decisions that would affect the coalition’s work and success

☐ Has poor to no access to any community leaders who can make decisions that would affect the coalition’s work and success

4. UNDERSTANDING of issues associated with overdose and overdose prevention, intervention, and treatment:

☐ Strong understanding of all issues associated with overdose and overdose prevention, intervention, and treatment

☐ Some understanding of all issues associated with overdose and overdose prevention, intervention, and treatment

☐ Poor to no understanding of all issues associated with overdose and overdose prevention, intervention, and treatment

5. Seen as a SERVANT LEADER who works to ensure the coalition members and efforts have the resources and tools necessary to succeed:


☐ Strongly exhibits values and behavior that demonstrates he/she sees his/her role to serve the members and community by ensuring the efforts have the resources and tools necessary to succeed

☐ Exhibits some values and behavior that demonstrates he/she sees his/her role to serve the members and community by ensuring the efforts have the resources and tools necessary to succeed

☐ Poorly or does not exhibit values and behavior that demonstrates he/she sees his/her role to serve the members and community by ensuring the efforts have the resources and tools necessary to succeed

6. OPEN-MINDED to learn how to change approaches that may not be working in order to optimize success:

☐ Very open-minded to learning how to change approaches, so they are more likely to succeed

☐ Somewhat open-minded to learn how to change approaches, so they are more likely to succeed,

☐ Poorly or not at all open-minded to learn how to change approaches, so they are more likely to succeed


C.4. Coalition Health AssessmentThe Self-Report Coalition Organizational Behavior Questionnaire

Consider GENERALLY how your organization behaves in five different ways:

RELATIONSHIPS:

Levels1 = Closest to

Undesired10 = Closest to Desired

Consider the relationships between members/staff when they are doing their work. How are the relationships between leaders and staff in your coalition?

Desired There is true collaboration in all we do and mutual respect between the

members of our coalition. The mutual understanding and respect that exists between coalition

members is also replicated in how the leaders treat each other and how the leaders treat members.

Common goals and values that affect how we do our work are openly discussed among all members of the coalition (leadership included). These common goals and values are regularly updated as things change, and these common goals and values are actively used in day-to-day decision-making by all members of our coalition.

Undesired The coalition doesn’t really allocate enough time for really

understanding each other (between members and between leadership and members) and truly working together on things.

Our statements of common goals and values are largely just words on paper.

Many of our joint projects are just coordinating our largely separate things we do at the coalition; we don’t really work together and come up with new ideas that transform things.

DECISION MAKING:



Consider how your coalition makes decisions to change things or do things:

Desired Our coalition ensures that a key person is held accountable for

implementation of each decision we agree on. We take the time to more clearly define the issues before we get deep

into debate on them. The information needed to make decisions is readily available because

the coalition regularly uses a designed and proper system to provide this


information. We actively think about the level of participation that is really needed to

make each decision. Every decision does not need everyone’s input; some things are simple and things are just done!

Undesired Decisions are made quickly with lots of opportunity for everyone to

provide input, but there are problems with follow through. Though some decisions have been made well, there are a few specific

issues where there is much discussion and there is little movement beyond traditional and entrenched positions.

When someone wants to put off a decision, they just ask for more and more information – they never seem satisfied and more data is always requested.

POWER:



Consider how people use their power (ability to influence) in your coalition to make sure that things get done. How do the members or staff use power with the leaders to make sure that things get done? How do the leaders use power with the members or staff to make sure that things get done?

Desired There is little to no use of coercive power (being told you need to do

something or else) in our coalition – and we only use this type of power when absolutely necessary.

When it comes to direct activities or issues, position power (persons in higher positions have to make all of the decisions) is meaningless – expert power (whomever knows the most information or has the greatest expertise) and attractive power (the decision is obvious to the unit’s overall reason for existing) is key.

Undesired Power is generally acquired and used by the coalition in traditional ways

– emphasizing position-power (those with the highest level of authority in the coalition call the shots), rewards and sanctions.

There is little reliance on expert power (the person who knows the most about the situation should be able to have the most power in making the decisions) in our coalition’s work.

Though the coalition members talk like they believe in collective power, when the real issues come to play, coercive power (persons use power to force decisions rather than sitting down and listening to those who may know better about the situation and what is the right thing to do) is what is used to sort things out.


CONFLICT:



Consider how the people within your coalition generally handle conflict between themselves. How does staff handle conflict between themselves? How do leaders handle conflict with staff?

Desired It is mandatory to express opinions and points of view in meetings

(hallway complaining or bitching is completely unacceptable). Our unit uses tools and language to help move through conflict in an

objective, non-personal manner – this is especially the case with financial decisions and other important issues vital to our coalition’s functioning.

Undesired Our coalition tends to avoid conflict and things go nowhere. Differences in basic values drive conflict in our coalition, but are never

discussed openly. Competitive “work around” seems to be the way of dealing with internal

conflict. The “majority” works around the minority to avoid conflict or the minority works around the majority to sabotage change.

LEARNING:



How does your coalition experiment with making things better? Why does your coalition like/not like to experiment so it can learn how to improve what it does?

Desired Our coalition has a formal structure and process for spreading ideas

more rapidly and translating them into action. These include peer-to-peer interactions more than formal processes like large training meetings.

Coalition members understand and respect each other’s natural preferences when it comes to how to acquire new knowledge, and both learn to be like the other (and learn as the other would prefer to learn) when appropriate.

Senior leaders are role models of being learners, rather than critics and judges and clearly demonstrate more risk tolerance so experimenting with new ideas can take place even if it results in setbacks.

Undesired Our coalition may have a tolerance to new ideas, but it doesn’t spread the

ideas and translate them into action. The coalition staff likes to experiment with new ideas, but leaders are the

complete opposite as they don’t like to experiment at all (or the other


way around).

Organizational Structure

For the following section, use the scale below to assign a score to your coalition.

Never Rarely Occasionally Sometimes Frequently Usually Always

1(0% of time)

2(<10% of

time)

3(30% of time)

4(50% of

time)

5(70% of

time)

6(90% of

time)

7(100% of

time)

Consider how work is structured in your coalition. Score(1-7)

To what extent is the way your coalition is structured (how people report to one another, how the leadership interacts with the staff, how staff can communicate with one another) enable it to generate new ideas that can improve its outcomes?

To what extent is the way your coalition is structured enable it to make good decisions so that it can improve its outcomes?

To what extent is the way your coalition is structured enable it to solve problems that come up so it can always achieve its best outcomes?

To what extent is the way your coalition is structured enable it to take action when action is warranted so that it can always achieve its best outcomes?

TOTAL ORGANIZATIONAL STRUCTURE SCORE

COMMENTS:

Performance Measurement




1(0% of time)

2(<10% of

time)

3(30% of time)

4(50% of

time)

5(70% of

time)

6(90% of

time)

7(100% of

time)

These questions are about the extent to which your coalition uses performance measures to guide its work.

Score(1-7)

To what extent do you use performance measures to guide your work in the coalition?

To what extent are your performance measures:

Collected in the course of doing your work;

Used to identify problems in the work in real time (as the problem happens);

Available for all of the coalition members to see and discuss;

Reported in a way that every staff person can identify his/her performance and the performance of the coalition as a whole (against its Vision/Goals);

TOTAL PERFORMANCE MEASURMENT SCORE

COMMENTS:

Internal Learning




1(0% of

2(<10% of

3(30% of time)

4(50% of

5(70% of

6(90% of

7(100% of

This question is about the degree to which coalition uses a system to learn how to improve.

Score(1-7)

To what extent does your coalition use a common way (such as Six Sigma, Lean, etc.) to understand how it can improve its work using information such as performance measures, patient satisfaction feedback, and staff feedback, etc.

NOTE: Name the system that is typically used.

TOTAL INTERNAL LEARNING SCORE

COMMENTS:

External Learning




1(0% of

2(<10% of

3(30% of time)

4(50% of

5(70% of

6(90% of

7(100% of

These questions are about how a coalition develops and implements training programs.

Score(1-7)

To what extent does your coalition regularly assess its members to determine what additional training or support they may need in order to perform their work effectively;

To what extent does your coalition keep track of the type of trainings that your members receive as part of their permanent employee record?

To what extent does your coalition differentiate trainings that are knowledge based from those that are skill based?

TOTAL EXTERNAL LEARNING SCORE

COMMENTS:


System Transformation Framework


C.5. Ascertain Available Resources and SupportThe following are some strategies for ascertaining your community’s available resources and support to implement a comprehensive overdose prevention initiative:

1. Identify ALL of your tested, effective community resources that would address overdose reduction either directly or indirectly;

2. Identify resources that are not either tested or effective that aim to reduced overdoses either directly or indirectly;

3. Then, identify the GAPS in resources for resources that are not available at all or that are available but in a manner that is untested or of poor quality;

4. Then, identify the issues and barriers to expanded the targeted quality services;

5. Finally, identify ways to enhance or expand existing tested, effective resources or develop new tested, effective resources.

C.6. Determine Community Activation LevelCommunity Activation is one step beyond Community Awareness. When communities are activated to work towards solving a problem, they are willing to provide the resources and tools necessary for the problem to be solved.


The following is a brief guide to use with your coalition to determine its level of activation on the scale of 1 – 5 with 5 being the highest activation level. Your community should have an average score that is NO LOWER than a 3 across these components in order for you to be successful in implementing your strategies.

If your community is below a 3, then the TAC team can help you strategize ways of raising your score.

Activation Component Level 12 Level 23 Level 34 Level 45 Level 56

The organizations that pay (SCA, managed care entities, etc.) for the development of new SUD treatment slots or ways of enhancing the quality of current SUD treatment are willing to provide additional resources to increase the quality and/or number of SUD treatment slots.There is a way that will work to provide education to our physicians regarding how to reduce unnecessary opioid prescribing.Providing naloxone to persons at risk or to their family/friends is accepted by a good percentage of physicians, pharmacists, first responders, ED’s and others within our community.Our law enforcement efforts within our community are effective in reducing the availability of illicit drugs.Our faith based community is interested in working with our coalition to reduce overdoses.Our SUD treatment system would work with our EDs and physicians to improve access to care.

2 Not at all true3 True in only a few parts of our community4 True in some of the indicated components of our community5 True in most of the indicated components of our community6 True in all of the indicated components of our community


Appendix VI: Planning Worksheets


P.1. Identify Potential Evidence-Based Intervention StrategiesYour coalition should consider intervention strategies from among these evidence-based practices. Various interventions apply at different prevention points and require different levels of resource to implement. General strategies are listed in bold.

Prevention Stage Strategy Description/Application LiteratureLevel of

Evidence on Effectiveness

Level of Resource Required

Universal(applies to broad populations without considering individual differences in risk)

Increase Awareness

Community knowledge about overdose or risk is low

Association of State and Territorial Health Officials, 2012; Bachhuber, M.A., McGinty, E.E., Kennedy-Hendricks, A., Niederdeppe, J., & Barry, C.L., 2015; Bohnert, A.S., Ilgen, M.A., Ignacio, R.V., McCarthy, J.F., Valenstein, M., & Blow, F.C., 2012; Calcaterra, S., Glanz, J., Binswanger, I.A., 2013; World Health Organization, 2012;

Strong Low

Increase Community Readiness

Community scores low on Community Readiness Assessment domains

Kegler, M. C., & Swan, D. W., 2012; Lasker, R. D., Weiss, E. S., & Miller, R., 2001; World Health Organization, 2012;

Moderate to Strong Low

Drug Collection Boxes

Reduce supply of opioids in the community

Gray, J., Hagemeier, N., Brooks, B. & Alamian, A., 2015; Suggestive Low

Drug Collection Events

Reduce supply of opioids in the community

Fleming, E., Proescholdbell, S., Alexandrisdis, A.A., Margolis, L., & Ransdell, K., 2016; Ma, C.S., Batz, F., Juarez, D.T., & Ladao, L.C., 2014; Welham, G. C., Mount, J. K., & Gilson, A. M., 2015;

Suggestive Low

OEND (Overdose Education and Naloxone Distribution)

Provide training and naloxone to those who may be present when an overdose occurs

American Public Health Association, 2012; Behar, E., Santos, G., Wheeler, E., Rowe, C., Coffin, P. ,2015; Bennett AS, Bell A, Tomedi L, Hulsey EG, Kral AH, 2011; Clark, A., Wilder, C., Winstanley, E., 2014; Doe-Simkins M, Quinn, E., Xuan, Z., Sorenson-Alawad, A., Hackman, H., Ozonoff, A., & Walley, A.Y., 2014; Giglio, R.E., Li, G., & DiMaggio, C.J., 2015; Green, T.C., Heimer, R., Grau, L.E., 2008; Jones, J.D., Roux, P., Stancliff, S., Matthews, W., Comer, S.D., 2013; Leece, P. N., Hopkins,

Moderate Low





S., Marshall, C., Orkin, A., Gassanov, M. A., & Shahin, R. M., 2013; Maldjian, L., Siegler, A., & Kunins, H.V., 2016; Mueller, S.R., Walley, A.Y., Calcaterra, S.L., Glanz, J.M., & Binswanger, I.A., 2015; Roe, S.S., & Banta-Green, C.J., 2016; Tobin, K.E., Sherman, S.G., Beilenson, P., Welsh, C., & Latkin, C.A., 2009; Centers for Disease Control and Prevention, 2012; Wagner, K.D., Valente, T.W., Casanova, M., Partovi, S.M., Mendenhall, B.M., Hundley, J.H.,…Unger, J.B., 2010; Walley, A. Y., Xuan, Z., Hackman, H. H., Quinn, E., Doe-Simkins, M., Sorensen-Alawad, A., … Ozonoff, A., 2013; Wheeler, E., Davidson, P. J., Jones, T. S., & Irwin, K. S., 2012; William, A.V., Marsden, J. & Stang, J., 2014;

Selective (delivered to subpopulations based on membership in a group with higher risk)

Naloxone Persons at higher risk for overdose or their family/friends have naloxone available

Baird, C., 2014; Beheshti, A., Lucas, L., Dunz, T., Haydash, M., Chiodi, H., Edmiston, B., … Horzempa, J., 2015; Bennett AS, Bell A, Tomedi L, Hulsey EG, Kral AH, 2011; Clarke, S.F.J., Dargan, P.I., Jones, A.L., 2005; Coffin, P. O. & Sullivan, S. D., 2013; Centers for Medicare and Medicaid Services, 2016; Kerr, D., Kelly, A.M., Dietze, P., Jolley, D., Barger, B., 2009; Kim, D., Irwin, K. S., & Khoshnood, K., 2009; McDermott, C., Collins, N.C., 2012; McDonald, R., & Strang, J., 2016; National Association of State Drug and Alcohol Abuse Directors, 2014; Office of the Assistant Secretary for Planning and Evaluation., 2015; Rowe, C., Santos, G.M., Vittinghoff, E., Wheeler, E., Davidson, P., & Coffin, P.O., 2016; Straus, , M., Ghitza, U. E., & Tai, B., 2013; U.S. Food and Drug Administration, 2012; Wermeling D., 2013; Wermeling, D.P., 2015; Wermeling, D.P., 2010;

Moderate Low





Pharmacies Carry

Family or friends of those with SUD can obtain naloxone

Bailey, A.M., & Wermeling, D.P., 2014; Beheshti, A., Lucas, L., Dunz, T., Haydash, M., Chiodi, H., Edmiston, B., … Horzempa, J., 2015; Green, T. C., Dauria, E. F., Bratberg, J., Davis, C. S., & Walley, A. Y., 2015; Jones, C.M., Lurie, P.G., & Compton, W.M., 2016;

Moderate Low

High-Risk Populations:Jails/Prisons, SUD Treatment, Mandatory Detox Programs, Previous ODFriends/Family

Staff in high risk intercept locations should have naloxone available; naloxone should be provided to people with SUD or their family/friends upon release/re-entry

Albert, S., Brason, II F.W., Sanford, C.K., Dasgupta, N., Graham, J., Lovette, B, 2011; Baca, C. T. and Grant, K. J., 2005; Barocas, JA., Baker, J., Hull, SJ., Stokes, S., & Westergaard, RP., 2015; Bird, S.M., McAuley, A., Perry, S., & Hunter, C., 2015; Doe-Simkins M, Quinn, E., Xuan, Z., Sorenson-Alawad, A., Hackman, H., Ozonoff, A., & Walley, A.Y., 2014; Doe-Simkins M, Walley AY, Epstein A, Moyer P., 2009; Giglio, R.E., Li, G., & DiMaggio, C.J., 2015; Kerr, D., Kelly, A.M., Dietze, P., Jolley, D., Barger, B., 2009; Lott, D.C., & Rhodes, J., 2016; Merrall E. L. C., Kariminia A., Binswanger I. A., Hobbs M. S., Farrell M., Marsden J.,…Bird, S.M., 2010; Rowe, C., Santos, G.M., Vittinghoff, E., Wheeler, E., Davidson, P., & Coffin, P.O., 2015; Strang, J., Bird, S.M., & Parmar, M.K., 2013; Wakeman, S.E., Bowman, S.E., McKenzie, M., Jeronimo, A., & Rich, J.D., 2009; Wheeler, E. A., Jones, T. S., Gilbert, M. K., Davidson, P. J., 2015; Wilder, C.M., Brason, F.W., Clark, A.K., Galanter, M., Walley, A.Y., & Winstanley, E.L., 2014; William, A.V., Marsden, J. & Stang, J., 2014; World Health Organization, 2014; Zucker, H., Annucci, A. J., Stancliff, S., & Catania, H., 2015;

Moderate Low to Medium

First Responders Advanced Life Support EMS Banta-Green, C.J., Beletsky, L., Schoeppe, Moderate Medium





response is not immediate

J.A., Coffin, P.O., Kuszler, P.C., 2013; Davis, C. S., Ruiz, S., Glynn, P., Picariello, G., Walley, A.Y., 2014; Davis, C. S., Southwell, J. K., Niehaus, V. R., Walley, A. Y., and Dailey, M. W., 2014; Davis, C.S., Carr, D., Southwell, J.K., & Beletsky, L., 2015; Green, T.C., Zaller, N., Palacios, W.R., Bowman, S.E., Ray, M., Heimer, R., Case, P., 2013; Ray, B. O'Donnell, D. and Kahre, K., 2015; Wagner, K.D., Liu, L., Davidson, P.J., Cuevas-Mota, J., Armenta, R.F., & Garfein, R.S., 2015;

Connections to Treatment, a.k.a. “warm hand-offs”ED, Law Enforcement, EMS, CJ System Diversion (drug courts)

Direct connection to treatment when persons with SUD have been identified

Beckett, K., 2014; Davis, C.S., Carr, D., Southwell, J.K., & Beletsky, L., 2015; Dwyer, K., Walley, A. Y., Langlois, B. K., Mitchell, P. M., Nelson, K. P., Cromwell, J., & Bernstein, E., 2015; Faul, M., Dailey, M.W., Sugerman, D.E., Sasser, S.M., Levy, B., Paulozzi, L.J.,2015; Green, T.C., Zaller, N., Palacios, W.R., Bowman, S.E., Ray, M., Heimer, R., Case, P., 2013; Wagner, K.D., Liu, L., Davidson, P.J., Cuevas-Mota, J., Armenta, R.F., & Garfein, R.S., 2015;

Moderate Medium

Prescribing Practices

Prescribers are unaware or don’t follow opioid prescribing guidelines

Agarin, T., Trescot, A.M., Agarin, A., Lesanics, D., & Decastro, C., 2015; Baumblatt JA, Wiedeman C, Dunn J, Schaffner W, Paulozzi L, Jones T., 2014; Cochella, S., & Bateman, K., 2011; Centers for Medicare and Medicaid Services, 2016; Logan J, Liu Y, Paulozzi LJ, Zhang K, Jones C., 2013; Lyapustina, T., Rutkow, L., Chang, H., Daubresse, M., Ramji, A.F., Faul, M.,... Alexander, G.C., 2015; Mack KA, Zhang K, Paulozzi L, Jones C., 2015; McCauley, J.L., Leite, R.S., Melvin, C.L., Fillingim, R.B., & Brady, K.T., 2016; Office of the Assistant Secretary for Planning and Evaluation.,2015;

Moderate Low





Paulozzi, L.J., Kilbourne, E.M., Shah, N.G., Nolte, K.B., Desai, H.A., Landen, M.G.,...Loring, L.D., 2012; Paulozzi, L.J., Zhang, K., Jones, C., & Mack, K., 2014; Paulozzi, L.J., Weisler, R.H., & Patkar, A.A., 2011; Paulozzi, L.J. & Ryan, G.W., 2006; Walley, A.Y., Doe-Simkins, M., Quinn, E., Pierce, C., Xuan, Z., & Ozonoff, A., 2013;

PDMP (Prescription Drug Monitoring Programs)

Prescribers are unaware of or don’t follow opioid prescribing guidelines

Centers for Medicare and Medicaid Services, 2016; Paulozzi, L.J., Kilbourne, E.M., Shah, N.G., Nolte, K.B., Desai, H.A., Landen, M.G.,...Loring, L.D., 2012; Paulozzi, L.J., & Stier, D.D., 2010; Poon, S.J., Greenwood-Ericksen, M.B., Gish, R.E., Neri, P.M., Takhar, S.S., Weiner, S.G.,…Landman, A.B., 2016; Prescription Drug Monitoring Program Center of Excellence at Brandeis., 2015;

Moderate Low

Indicated (designed to address specific risk conditions)

MAT Persons have been identified as having SUD

Connery, H. S., 2015; Centers for Medicare and Medicaid Services, 2016; Hedrich, D., Alves, P., Farrell, M., Stöver, H., Møller, L., & Mayet, S., 2012; Hser, Y.I., Evans, E., Huang, D., Weiss, R., Saxon, A., Carroll, K.M.,…Ling, W., 2016; Jones C, Campopiano M, Baldwin G, McCance-Katz E., 2015; Jones, C.M., Campopiano, M., Baldwin, G., & McCance-Katz, E., 2015; Kimber, J., Larney, S., Hickman, M., Randall, D., & Degenhardt, L., 2015; Lee, J., McDonald, R., Grossman, E., McNeely, J., Laska, E., Rotrosen, J. and Gourevitch, M. N., 2015; Mattick, R.P., Breen, C., Kimber, J., & Davoli, M., 2014; Mattick, R.P., Breen, C., Kimber, J., & Davoli M., 2009; Office of the Assistant Secretary for Planning and Evaluation., 2015; Pierce, M., Bird, S. M., Marsden, J., Dunn,

Strong Medium





G., Jones, A., and Millar, T., 2016; Rich, J.D., McKenzie, M., Larney, S., Wong, J.B., Tran, L.,…Zaller, N., 2015; Volkow, N.D., Frieden, T.R., Hyde, P.S. & Cha, S.S., 2014; Walley, A. Y., Alperen, J.K., Cheng, D.M., Botticelli, M., Castro-Donlan, C., Samet, J. H., Alford, D.P., 2008; World Health Organization, 2009; Lee, J.D., Friedmann, P.D., Kinlock, T.W., Nunes, E.V., Bonet, T.Y., Hoskinson, R.A.,…O'Brien, C.P., 2016;

Prescribing PracticesPhysicians or Prescribers

Prescribers are unaware of or don’t follow opioid prescribing guidelines

Baumblatt JA, Wiedeman C, Dunn J, Schaffner W, Paulozzi L, Jones T., 2014; Cochella, S., & Bateman, K., 2011; Dowell, D., Haegerich, T.M., & Chou, R., 2016; Frieden, T.R., Houry, D., 2016; Larochelle, M.R., Liebschutz, J.M., Zhang, F., Ross-Degnan, D., & Wharam, J.F., 2016; Mack KA, Zhang K, Paulozzi L, Jones C., 2015; McCauley, J.L., Leite, R.S., Melvin, C.L., Fillingim, R.B., & Brady, K.T., 2016; Paulozzi, L.J., Kilbourne, E.M., Shah, N.G., Nolte, K.B., Desai, H.A., Landen, M.G.,...Loring, L.D., 2012; Paulozzi, L.J., Zhang, K., Jones, C., & Mack, K., 2014; Paulozzi, L.J., Logan, J.E., Hall, A.J., McKinstry, E., & Kaplan, J.A., 2009; Paulozzi, L.J., Weisler, R.H., & Patkar, A.A., 2011; Paulozzi, L.J., Zhou, C., Jones, C.M., Xu, L., & Florence, C.S., 2016; Toblin, R., Mack, K., Perveen, G., & Paulozzi, L., 2011; Toblin, R.L., Paulozzi, L.J., Logan, J.E., Hall, A.J., & Kaplan, J.A., 2010;

Moderate Low

Prescribing Guidelines:ED, Dental,Non-Cancer Pain,

Prescribers and dispensers may be unaware of or don’t follow opioid prescribing guidelines

Dowell D., Haegerich, T.M., & Chou, R., 2016; Frieden, T.R., Houry, D., 2016; Paulozzi, L.J., Zhang, K., Jones, C., & Mack, K., 2014;

Moderate Low





Other specialties

NaloxoneWith Opiate Prescription

Prescribers of opioids co-prescribe naloxone with opioid; dispensers of opioids offer naloxone when filling opioid prescription

Albert, S., Brason, II F.W., Sanford, C.K., Dasgupta, N., Graham, J., Lovette, B, 2011; Baca, C. T. and Grant, K. J., 2005; Beletsky, L., Rich, J.D., Walley, A.Y., 2012; Beletsky, L., Ruthazer, R., Macalino, G.E., Rich, J.D., Tan, L., & Burris, S., 2007; Bennett AS, Bell A, Tomedi L, Hulsey EG, Kral AH, 2011; Doe-Simkins M, Quinn, E., Xuan, Z., Sorenson-Alawad, A., Hackman, H., Ozonoff, A., & Walley, A.Y., 2014; Doe-Simkins M, Walley AY, Epstein A, Moyer P., 2009; Enteen, L., Bauer, J., McLean, R., Wheeler, E., Huriaux, E., Kral, A.H., & Bamberger, J.D.,2010; Hawk, , K. F., Vaca, F. E., D'Onofrio, G., 2015; Maxwell S, Bigg D, Stanczykiewicz K, Carlberg-Racich S., 2006; Mueller, S.R., Walley, A.Y., Calcaterra, S.L., Glanz, J.M., & Binswanger, I.A., 2015; Piper, T.M., Stancliff, S., Rudenstine, S., Sherman, S., Nandi, V., Clear, A., & Galea, S., 2008; Rowe, C., Santos, G.M., Vittinghoff, E., Wheeler, E., Davidson, P., & Coffin, P.O., 2015; State Medical Board of Ohio, 2013; Tracy, M., Piper, T.M., Ompad, D., Bucciarelli, A., Coffin, P.O., Vlahov, D., & Galea, S., 2005; Wagner, K.D., Valente, T.W., Casanova, M., Partovi, S.M., Mendenhall, B.M., Hundley, J.H.,…Unger, J.B., 2010; Wermeling, D.P., 2010; World Health Organization, 2014;

Moderate Low

PRRs (Patient Review and Restrictions)

Payers (insurers or managed care organizations) limit those with high opioid use or suspected of “doctor shopping” to particular prescribers or dispensers

Centers for Disease Control and Prevention, 2012; Centers for Medicare and Medicaid Services, 2016;

Moderate Low





Harm Reduction

Minimize negative consequences of drug use such as Hepatitis C or HIV through interventions such as needle exchanges

Hawk, K. F., Vaca, F. E., D'Onofrio, G., 2015; Aspinall, E.J., Nambiar, D., Goldberg, D.J., Hickman, M., Weir, A., Van Velzen, E.,…Hutchinson, S.J., 2014; Abdul-Quader, A.S., Feelemyer, J., Modi, S., Stein, E.S., Briceno, A., Semaan, S.,…Des Jarlais, D.C., 2013; Palmateer, N., Kimber, J., Hickman, M., Hutchinson, S., Rhodes, T., & Goldberg, D., 2010; Department of Health and Human Services, 1998; Wright, N.M., & Tompkins, C.N, 2006; Heimer, R., Khoshnood, K., Bigg, D., Guydish, J., & Junge, B., 1998; Des Jarlais, D.C., Nugent, A., Solberg, A., Feelemyer, J., Mermin, J., & Holtzman, D., 2015; Hedrich, D., 2004;

Suggestive Moderate

Level of effective evidence: Strong: Strategy is represented in literature, is being delivered in community settings, is listed in registries of evidence-based

practices such as NREPP or AHRQ Moderate: Strategy is emerging and may be represented in literature or is being delivered in community settings, but not listed in

registries of evidence-based practices Suggestive: Strategy is emerging but is not well-represented in literature or highly replicated in community settings, but shows

promise to reduce overdose deaths

Level of resource required: Consensus determination made by a panel of prevention experts in consideration of cost, difficulty to implement, receptiveness of

community partners, and supporting infrastructure currently in place

Last update: April 15, 2016

P.2. Develop Impact Model Use this worksheet to create an impact model for each situation you are trying to address to reduce overdose.

Impact Model: Situation


Part One: Work of Coalition Part Two: Results Within CommunityInput Activities Outputs Outcomes Impact


P.3. Develop a Strategic Plan Use this worksheet to develop the goals, objectives, and action steps for each strategy you choose as

part of your plan to reduce overdose deaths in your community.

Strategy:

Local condition addressed by the strategy:

Goal:

SMART Objective:

Action/Tactics Who is Responsible Resources Needed Target Date


Community Considerations for Plan Development

A. Aggregate Potential Community Responses to Overdoses in a Simple 3- Step Fashion

We might view the method for most expeditiously addressing the primarily opioid-related overdoses in three ways:

A comprehensive checklist could be developed that lists the potential strategies within each of these three response types. For example:

1. Reducing the Amount of Opioids That Would be Available within the Community:

a. Interdiction/Law Enforcement Methods;

b. Prescriber Training (Physicians, Dentists);

c. Methods to Reduce Diversion:

Drop Boxes;

Lock Boxes at Home;

Give Back Programs;

Hospice Collection Post Death;

Community Education Programs;

Patient Education Programs;

School Education Programs.

2. Intervening with People Who Have Overdosed or Who are At Increased Risk for Overdose:

a. Naloxone Distribution (Pharmacy Availability) and Training (First Responders, Police, At-Risk Individuals (including anyone receiving an opioid prescription), Family/Friends, Persons Leaving Jail, SUD and MH Treatment Providers, Pharmacists) etc.;

b. SBIRT in ED’s (and other Healthcare Settings) with Viable Linkage to SUD Treatment, Naloxone Distribution, Patient Education;

c. Needle Exchange Programs (and other Harm Reduction Strategies).

3. Providing High Quality and Effective SUD Treatment:


Intervening with People Who Have

Overdosed or Who are At

Increased Risk for Overdose.

2

Providing High Quality and

Effective SUD Treatment.

3

Reducing the Amount of

Opioids That Would be

Available within the Community.

1

a. Assess the Treatment Gap Needed to Address Overdoses and SUD;

b. Develop a Plan to Expand High Quality SUD Treatment Availability;

c. Implement Innovative Solutions that can Extend and Optimize Resources (i.e., Telemedicine, Healthcare IT, Recovery Support/Patient Navigators, Innovative Funding and Incentive Mechanisms).

B. Points to Consider as your Developing your Plan

1. Guiding Questions:

a. How Can the Environmental Supply of Agents Associated with Overdoses be Reduced? (E.g., Increasing Appropriate Interdiction Processes, Decreasing Opioid Prescribing, and Reducing Diversion)

b. How Can We Prevent Initiation of Risk or Increase Protective Factors? (LONG RANGE IMPACT)

c. How Can We Reduce Risk for Persons At-Risk for Overdose?

d. How Can We Prevent Persons from Dying Who Do Overdose?

e. How Can We Increase the Availability of Appropriate and High Quality SUD Treatment Matched to Each Patient’s Needs?

2. Resource Considerations:

a. Real Time and Accurate Data Sources;

b. Activated Community;

c. Engaged Community Leadership;

d. Resources to Support Appropriate Program Development;

e. Effective Guiding Coalition/Oversight Group.

3. Guiding Principles:

a. Training/social marketing alone almost always doesn’t change behavior, but it can improve engagement and increase awareness. Changing awareness in an entire community, however, takes time and multiple messages applied in multiple ways and in multiple locations/settings;

b. Changing prescribing patterns requires multiple approaches applied over time;

c. Acquired SKILLS WILL DECAY without continued monitoring;

d. Communities should operate from a DATE DERIVED STRATEGIC PLAN that is linked to an EVALUATION PLAN (i.e., Note that strategies that are effective at one point in time may not be effective at another point in time);

e. Programs should be applied with FIDELITY (based upon the evidence) and in a CONTINUOUS QUALITY IMPROVEMENT approach;

f. Success is defined more by HOW you do things rather than WHAT you do (Effective leadership/Coalition health);


g. Programs should be of sufficient QUANTITY to significantly drive down SUPPLY AND DEMAND for the agents involved with the overdoses and overdose deaths;

h. Most overdose decedents have touched Emergency Departments, Jails, Mental Health and Substance Use Disorder (SUD) treatment facilities several times in the proximal period before their deaths (usually in this order). Therefore, these locations provide opportunities for effective intervention/treatment efforts.


Appendix VII: Implementation Worksheets


I.1. Determine Relevant Community ConnectionsIt is important that you ensure you have made the appropriate community connections for every intervention you plan to implement. This will help secure the support to implement the intervention as planned.

The following are some ideas regarding how to ensure you have made the appropriate community connections for any targeted intervention:

1. Start with the easiest organizations and individuals to convince and implement with them FIRST. Once you have either obtained their consent or implemented within these organizations, move to more difficult organizations next. Demonstrate the success within the previous implementers to each subsequent implementation group.

However, don’t fail to approach an organization or individual just because they are known to be difficult to convince. Try to have persons known and trusted to that organization or individual help you gain their time and attention.

2. Make sure that all of your connections include organizations that represent persons of different cultures and perspectives.

The TAC can help you with strategies for how to successfully engage organizations representing different cultures.

3. Memorandum of Understandings (MOUs) are an excellent way to formalize and describe the nature of your collaborations with relevant organizations and individuals.

The TAC can help you develop MOU’s within your community.

4. Always be specific regarding what it is you are offering and need when meeting with an organization or individual. Refrain from only approaching collaboration as a way for you to take something. Always find ways you can meet the needs of the organization or individual in your collaboration.

5. Try to engage the entity that has authority over the targeted individuals/organizations for their support of what you are proposing. This leadership buy-in will be very important to securing the buy-in of all involved.

6. On the other hand, don’t ONLY communicate with the leadership of specific entities. Make sure that you also communicate with the specific entities as well to gain their input and buy-in.

7. If you are targeting a specific group within your community, it is sometimes a good idea to obtain the buy-in of a number of entities involved with that group, which that group trusts or sees as its leader(s) before you meet with group.

8. Always follow through with what you say you will do.


I.2. Develop an Effective Communication Plan

A. The following are the mains steps involved in developing a communication strategy:1. Set the communication goal and objectives: In some communications campaigns for

behavior-change, communication goals and objectives may be identical to the overall program goals and objectives (e.g. to reduce overdoses). More commonly, communication goals vary according to different target audiences. This is the norm in most community based communication programs as primary and secondary target audiences need to be reached differently and will likely take different types of action.

2. Develop key messages that effectively speak to target audiences : Messages should be tailored to resonate with the target audience(s) – various versions of the message may need to be prepared to reach different audiences. Behavior-change messages resonate better from peer groups of the target audience, but awareness and advocacy messages might resonate better from community leaders and providers.

3. Identify effective communication channels, techniques and tools: One can distinguish between interpersonal channels (one-on-one contact), community-oriented channels (existing social networks), and media channels (including modern mass media such as radio and TV, “new media” such as the internet and SMS, and “folk media”, e.g. story-telling and traditional cultural performances).

What are the techniques and tools that are most likely to effectively reach the audience(s) through these different channels? Evaluations suggest that behavior change campaigns are most effective when they keep repeating the message (a specific technique) and combine different channels, including person-to-person contact.

4. Outline accessible communication resources: These include, for example, media production skills, access to free air-time or pro bono work by experts, and availability of suitable materials from other (e.g. international and national-level) campaigns.

5. Set and monitor time-lines, milestones and indicators in action plans: A communication action plan helps to specifically guide the strategy’s activities, while monitoring helps to verify, at regular intervals, whether the strategy is progressing as planned, and whether context changes call for adjustments (e.g. different tactics).

6. Write up a communication strategy document: This is essential to clearly define, layout and track all the key steps mentioned above. A written document can also be shared easily with all involved to ensure that everyone is ‘on the same page’, in terms of messaging and how communication activities will be conducted.

B. Issues to bear in mind:1. A communication strategy may need to be adapted during the program to respond to new

challenges and opportunities.

2. For marginalized groups, particularly those experiencing multiple challenges or feeling disconnected from the general system, mass media may not necessarily be the best way to reach them especially if this is not in a language they understand, or via a channel they have access to. Some rural minority communities, for example, may not understand the national, mainstream language, and they may not have proper access to radio, TV or the internet. In this


case, printed materials may be more useful (including pictorials for illiterate communities). In some contexts, specialized media that targets marginalized groups may exist – such as print media in Braille and radio or TV stations that broadcast in minority languages. It is useful to research how effectively these can be utilized in campaign activities. In addition, community-level work (e.g. through trained community educators who are part of or familiar with the target communities) can be an effective way to reach marginalized groups.


I.3. Implement Strategies Supporting Continuous Quality and FidelityThe following are strategies for ensuring that any intervention is implemented with fidelity and using principles of continuous quality improvement.

1. Implementing with Fidelity:

a. Determine if the intervention comes with a fidelity checklist that can be used to ensure it is implemented as intended either via the literature or via the intervention developer;

b. If you can’t find a fidelity checklist for your intervention, please contact the TAC who may have one or may be able to help develop one for you;

c. Fidelity checklists that come from developers typically also come with ways they should be applied. Fidelity checklists developed via the literature or otherwise should have a protocol for application also derived from the literature about the intervention or principles in the published literature related to the intent of the intervention (i.e., provide education/training).

2. Continuous Quality Improvement Principles:

a. The TAC can provide you with support regarding the use of its Systems Transformation Framework in the implementation of any interventions , especially those implemented within healthcare settings;

b. Always conduct workplace reviews to determine how the intervention can be implemented without disrupting typical workflow (again the TAC can help you with this process);

c. Use the Rules of Use in implementing any intervention:

i. Rule 1: All work must be highly specified as to content, sequence, timing, location and expected outcome;

ii. Rule 2: Every customer-supplier connection must be simple and direct, and there must be a binary, yes-or-no, way to send requests and receive responses;

iii. Rule 3: The pathway for every product and service must be predefined, simple and direct with no loops or forks;

iv. Rule 4: Any improvement must be made using the scientific method, under the guidance of a teacher, and close in time, space, and person to the problem and toward the ideal.

All four rules have built-in internal tests that let you know if the activities, connections, pathways and improvements are being done as expected.

d. It is best to assume an “ideal” Vision for any intervention you implement:

i. Example: Every patient receives the right care at the right time by the right provider every time.

e. If you cannot measure it – you cannot improve it;

f. Define the measures you will use to determine that you are implementing an intervention with quality. The TAC can help you determine potential measures given your resources and the specific intervention;

g. Sometimes you may wish to assign “benchmarks” or targeted performance measures for each process/outcome measure;


h. Ensure that the data are collected in as close to real time as possible;

i. Implement a process for using the data to evaluate how well you are moving towards the targeted performance measure;

j. If you are not moving towards the targeted performance measure in the way you would like – then strategize with those involved ways of improving how the intervention is implemented so it can better move towards the performance measure;

k. Keep track of your data and strategies so you can generalize what you have learned and apply it with other sites.


Appendix VIII: Evaluation Worksheets


E.1. Develop an Evaluation Plan

Activity Focus Sample Questions

A. Engage Stakeholders

1. Community stakeholders interested in overdose reduction

2. Funding or partnering agencies

3. Those served by program

4. Coalition members

Who is affected by the issue?

Which groups are involved in dealing with the issue?

Who can contribute resources to the issue?

How do we ensure representation of all stakeholder perspectives?

B. Describe Your Program

1. Need for the program

2. Expected change as a result of the program

3. Resources available

4. Resource gaps

How severe is the problem?

What are the short term goals of the program?

What are the medium-term goals of the program?

What are the long term goals of the program?

What are the expected outcomes of the program?

C. Design Evaluation Questions

1. Activity Reports

2. Surveys of coalition members

3. Surveys of recipients

4. Surveys of community stakeholders

5. Data on overdose rates/deaths

Did activities occur as planned? Why or why not?

Did the program evolve during the process?

How well has the program met its objectives?

What are the strengths of the program?

What are the weaknesses of the program?

What difference has the project made in the community?

How has the project increased collaboration in the community?

How much has the program affected overdose deaths?

D. Gather Evidence 1. Activity Reports

2. Surveys of coalition

How many events/training programs have been held?

Which subpopulations had an opportunity to participate?


Activity Focus Sample Questions

members

3. Surveys of recipients

4. Surveys of community stakeholders

How much has the program affected overdoses and overdose deaths?

E. Justify Conclusions

1. Standards

2. Analysis

3. Interpretation

4. Judgements

5. Recommendations

What are the values held by the stakeholders?

What patterns emerge from the evaluation findings?

What conclusions can be made from the results?

What improvements can be made to the program?

What areas are most or least effective?

F. Disseminate/Apply Lessons Learned 1. Provide feedback

How can we be more effective?

What challenges did we overcome in delivering the program?

How can evaluation results guide program improvements?

How do we translate lessons back to the community?


E.2. Measure ProgressIt is a vital principle to your community’s success that it use its evaluation plan to measure its progress towards reducing overdoses. Sometimes this will involve measuring progress towards meeting intermediate processes associated with overdoses (such as increasing the amount of quality MAT slots).

Here are some principles to consider when evaluating your community’s progress in reducing overdoses:

1. Always base your evaluation upon the program’s aim and impact model;

2. When developing program objectives, make sure they are Specific, Measureable, Achievable, Relevant, and Time Bounded (SMART);

3. Use both quantitative and qualitative data and approaches in understanding your community’s ability to achieve its intended goals;

4. Identify factors that are facilitating or limiting your program from achieving its objectives and whether the program was able to sustain (facilitators) or overcome the limitations and how;

5. Always include some aspect of participant feedback/satisfaction in your evaluation so you can ensure you are understanding whether those involved are satisfied with how things are going and ways you can improve their satisfaction, participation and buy-in;

6. Report evaluation results at least every six months so you can determine whether course corrections are necessary to your program, and continue to engage your stakeholders in program participation and support.

Again, the TAC is available to assist you in either connecting you with an evaluation partner or with developing your evaluation plan.

103Copyright 2016, University of Pittsburgh. All Rights Reserved.

Appendix IX: Sustainability Worksheets


S.1. Secure Funding ResourcesHere are some possible sources of grant funding for your coalition:

1. Pennsylvania Commission on Crime & Delinquency (PCCD)http://pccd.pa.gov

2. Pennsylvania Department of Drug and Alcohol Programs (DDAP) http://www.ddap.pa.gov/pages/default.aspx

3. Federal Government Grantshttp://grants.gov

4. Foundation Center Find Funders http://foundationcenter.org/findfunders/

5. Council on Foundationshttp://www.cof.org/

6. Local Human Service AgenciesSpecific to your county

7. Local corporations and organizations Specific to your county

8. Managed care entities via providing billable services; and

9. Crowd funding strategies (check your organization’s ability to access these).


http://www.cof.org/

http://foundationcenter.org/findfunders/

http://grants.gov/

http://www.ddap.pa.gov/pages/default.aspx

http://pccd.pa.gov/

S.2. Develop a Sustainability PlanA. What is Sustainability?

“Sustainability” refers to the continuation of a project’s goals, principles, and effortsto achieve desired outcomes. Although many programs think that guaranteeing the sustainability of a project means finding the resources to continue it “as is” beyondthe grant period, ensuring sustainability really means making sure that the goals ofthe project continue to be met through activities that are consistent with the current conditions and workforce development needs of the region. Thus, sustainability does not mean simply maintaining the status quo in terms of funding, staffing, and activities.

B. What is a Sustainability Plan?

There is no single formula or answer to the sustainability challenge. However, creating a written sustainability plan will provide a road map to guide you and your partners as you work on sustainability efforts. The process of creating a written sustainability plan can also strengthen your partners’ buy-in and understanding of the efforts needed to keep your project operating and improving. You can use the plan to market your project to potential funders and other possible partners, and as a guide to support the ongoing management of the project.

A sustainability plan can help identify what resources are necessary to sustain your project, encourage the development of partnerships and support collaboration, and help define progress and the necessary action steps needed to ensure long-term success. Engaging in sustainability planning gives you an opportunity to map out how you can maintain valuable projects and innovations in a changing environment.

C. Developing a Sustainability Plan

Thinking about sustainability is not something that should be left until your grant funding is coming to an end. You will need time to conduct an assessment of your current project and determine which activities can and should be continued, whether you want to add or drop any target groups, what the desired scale of activities you want to sustain is, etc. You also will want to develop buy-in among currently participating partners and staff, and market your project, both internally within your organization, and externally to the outside world. Perhaps most importantly, you should plan for sustainability, and choose sustainability strategies that are most appropriate for your situation.

D. Conducting a sustainability planning process involves six key steps.

1. Clarify your Vision;

2. Determine what you want to sustain;

3. Build collaboration;

4. Choose your desired sustainability strategies and methods;

5. Develop action steps for sustainability;

6. Document and communicate your sustainability success.


S.3. Obtain Continued Community Support The most important principles to obtaining continued community support are:

1. Delivering exactly what you said you would do;

2. Demonstrating that you did deliver what you said you would do with objective information/data;

3. Demonstrating that you are making progress towards your goal via data and testimonies;

4. Demonstrating you have increasing support by many stakeholders to continue your program/project.
