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The Linkage to Hope Project

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The Linkage to Hope Project

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Content 1
The Linkage to Hope Project
Assignment #3: Capstone Project
Barbara Marsh
Capstone Project Presented in Partial Fulfillment
for the Degree Doctor of Social Work
University of Southern California Suzanne Dworak-Peck School of Social
Work SOWK 722
Dr. Juan Araque, PhD
March 19, 2021
May 2021
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Executive Summary
In 2013, the American Academy of Social Work and Social Welfare presented the Grand
Challenges for Social Work (Bent-Goodley, 2019). These Grand Challenges aim to harness
science, knowledge, and collaboration of cross-sector efforts to solve some of the most complex
and severe social problems while eliminating health disparities (Grand Challenges Canada,
2011). This Capstone Project addresses the Grand Challenge Close the Health Gap, focusing on
the drug epidemic.
The drug epidemic continues to plague the United States and is one of the wicked
complex problems that has increased health disparities. Unintentional drug overdose deaths have
persisted in an upward trend in the United States and have devastated the lives of so many
American citizens. Over 750,000 people have lost their lives due to an unintentional drug
overdose from 1999 to 2018 (Centers for Disease Control and Prevention, 2020a). The COVID-
19 pandemic has only compounded the issue as drug overdose deaths have soared at a time when
the systems that support individuals with substance use disorders have been significantly
disrupted (Centers for Disease Control and Prevention 2020b). The drug epidemic remains a
public health emergency, and at the same time, these deaths are preventable.
Many policies and system changes have taken place to support evidence-based strategies
to increase data collection and improve healthcare systems, but there is still much to accomplish.
A targeted population that disproportionately experiences barriers and stigma is those who suffer
from substance abuse disorders. One of the largest gaps in services is in the emergency
departments across the nation. Individuals who have suffered a drug overdose have flooded the
emergency departments and leave with little to no follow-up care plan. Individuals are medically
stabilized and released. This leaves these individuals at a higher likelihood for repeated overdose
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emergency department visits, increased chance for criminal justice involvement, and ultimately
an increased probability of death. This Capstone, entitled The Linkage to Hope Project, is an
innovative solution that addresses the Grand Challenge, Close the Health Gap, by harnessing
technology and developing a real-time referral and linkage system to connect individuals in an
emergency department to a Certified Peer Recovery Supporter (CPRS). The CPRS is a person
who has lived experience and provides guidance and connection that medical personnel cannot
provide. The Linkage to Hope Project is an innovative solution that will change the system of
care for drug overdose survivors and decrease mortality.
The purpose of the Linkage to Hope Project is to enhance the current healthcare system
by filling a gap in the continuum of care for those who are in active addiction. Modifications in
hospital systems and protocols will create a warm handoff to a CPRS. The Linkage to Hope
Project will develop a system of care that increases engagement for those in active addiction. It
will also provide the much-needed support and direct connection to additional resources that will
decrease future hospitalizations and increase individuals’ likelihood of moving towards recovery.
The Linkage to Hope Project may face two problems, the lack of engagement from
hospital systems and a lack of funding for expansion. The Linkage to Hope Project is an
innovative solution developed with local community task force involvement. The collaboration
and relationships that have been built through the task force have initiated sharing of data sets
between governmental agencies and the hospital systems. While there are many hospital
employees engaged in the project design, there is still a lack of hospital executive engagement.
Hospital employees are now championing the project within each of their systems and are
conveying the need for project implementation. Additionally, the Linkage to Hope Project will
be funded by federal grants and local human services levy dollars. Still, long-term sustainability
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will need to be addressed to expand past the pilot project. The Linkage to Hope Project partners
are committed and will work together to secure funding that will be used for expansion and
sustainability.
The Linkage to Hope Project has engaged in several design phases outlined in the
prototype, Linkage to Hope Project Implementation Guide. The guide aims to provide further
information on the steps taken by the project partners and the technological and clinical solutions
that were developed to address the problem. The Linkage to Hope Project uses a care
coordination platform directly connected to the Health Information Exchange (HIE) system.
This connection allows a direct feed to alert the CPRS when an individual enters an emergency
department on a drug overdose. The CPRS will respond to the alert through a mobile or laptop
device and contact the emergency department to offer intervention. The emergency department
will be responsible for obtaining patient consent. The CPRS will then connect with the patient
via face-to-face in the emergency department or through telehealth. The patient will be offered
services and community resources before discharge. The CPRS will then follow up with the
patient within 48 hours post-discharge and continue engagement until CPRS services are no
longer needed.
The Linkage to Hope Project will be piloted in one emergency department in
Montgomery County, Ohio and will then expand to nine separate emergency departments across
two large hospital systems. The project will hire additional personnel to meet the needs of a 24/7
response and the software platform will be tested and validated. Several process and outcome
measures will be collected and analyzed to support project implementation and further
expansion.
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Large complex systems face many challenges to integrate physical and behavioral health
services. Creating robust data sharing hubs will provide a more holistic approach to care and
allow the patient to be linked to vital community resources. This will decrease duplication of
services and at the same time ensure patient needs are met. While the Linkage to Hope Project
will not fully integrate behavioral and physical care, the care coordination platform will
revolutionize the system. The Linkage to Hope Project has created a robust data-sharing platform
that can also be replicated across other healthcare and behavioral health systems. Its use can be
expanded to respond to other chronic health conditions and support data sharing across other
system partners.
Conceptual Framework
Problem Statement
The Grand Challenge addressed is Close the Health Gap (Fong et al., 2018), focusing on
the drug overdose epidemic in the United States. Unintentional drug overdoses have had
devastating effects on the lives of many Americans. From 1999 to 2018, over 750,000 people
have lost their lives due to an unintentional drug overdose (Centers for Disease Control and
Prevention, 2020a). In 2018, approximately 185 people died every day, and it has remained the
leading cause of injury-related death in the United States since 2008 (Hedegaard et al., 2020).
More people are dying of unintentional drug overdoses than motor vehicle accidents. It has now
been identified as a primary contributor to a decline in the life expectancy rates in the United
States (Centers for Disease Control and Prevention, 2018).
Americans have endured numerous drug abuse crises, but no other crisis has been
responsible for the death rate experienced in the past two decades. Prescription painkillers have
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been identified as the leading cause of overdose deaths, and the White population has been
disproportionately affected by high overprescribing rates (Salmond & Allread, 2019).
In the 1990s, pharmaceutical companies began to use effective targeted marketing
strategies to increase prescription opioids and convince prescribers that there were no addictive
qualities to these medications (Hadland, 2018). The American Pain Society also campaigned to
categorize pain as the fifth vital sign, and the Joint Commission joined this movement. The Joint
Commission began to require prescribers to assess patients' pain through self-reporting and
supported the treatment of pain symptoms with opioids (Mandell, 2016). By 2012, it was
estimated that 4 out of 5 residents in the United States received a prescription opioid, and by
2015 it was estimated that over 2 million Americans were addicted to prescription opioids
(Substance Abuse and Mental Health Services Administration, 2018). While the United States is
only 5% of the world's population, it was consuming over 80% of the opioids manufactured
(Knaggs & Stannard, 2017).
The rise of opioid deaths in the late 1990s and early 2000s spurred the emergence of
more research and evidence that prescription opioids were addictive. In 2012, the Centers for
Disease Control and Prevention published guidelines for opioid prescribing for chronic pain
(Dowell et al., 2016). Additionally, physicians began to be held legally accountable for
overprescribing opioids and other narcotics as the Drug Enforcement Agency started to prosecute
prescribers for operating "pill mills" (Kennedy-Hendricks, 2016). Consequently, as prescription
opioids became less available in the United States, the percentage of citizens that were already
addicted to opioids did not change. Individuals who suffered from addiction began to buy
opioids illegally. As the prescription opioid death rate began to trend downward, the rate of
heroin and illicit fentanyl use started to trend upward (Centers for Disease Control and
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Prevention, 2019). Between 2012 and 2017, the rate of heroin and illegal fentanyl-related deaths
quadrupled, and fentanyl was named as the deadliest substance of 2017 (Centers for Disease
Control and Prevention, 2018). Past misuse of prescription opioids became a strong risk factor
for future heroin use (Hedegaard et al., 2020).
The United States remains at the height of this public health crisis, and the impact of the
COVID-19 pandemic has only accelerated the issue. The COVID-19 pandemic has caused a
disruption in public health, healthcare, treatment, and other social services. This, coupled with an
increase in the drug supply, has contributed to the rise in death (Centers for Disease Control and
Prevention 2020b). From May 2019 to May 2020, provisional data shows the highest number of
drug overdose deaths ever recorded in a 12-month period, and synthetic opioids have been the
primary contributor to these deaths (Centers for Disease Control and Prevention, 2020b).
Presently, the continued impact of COVID-19’s long-term consequences is unknown.
Assessment of What is Known
In 2017, the federal government implemented a coordinated response to the opioid
epidemic by declaring it a national public health emergency (Gostin et al., 2017). In 2019, over
$1.8 billion was allocated to fund states to enhance research, expand harm reduction measures,
and expand prevention and treatment programs (U.S. Department of Health and Human Services,
2019). Although there has been an expansion in funding, behavioral health organizations still
rely on block grants that are time-limited to develop and operate interventions (Kaiser, 2017).
Research supports the need to establish collaborative partnerships between primary and
behavioral healthcare organizations to sustain programming and offer additional services that
could not otherwise be provided in traditional settings (Young, 2000).
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While there has been a wide range of research in response to the growing trend of opioid-
related deaths, the Centers for Disease Control and Prevention (CDC) is one of the primary
sources for morbidity and mortality data (Krisberg, 2018). With additional funding, CDC has
expanded its efforts to include supporting evidence-based strategies, improving data collection,
supporting healthcare systems, and providing education on the misuse of prescription opioids
(CDC, 2019). CDC has provided a wealth of information to aid in response. Still, CDC and other
research entities lack a coordinated effort to combine data sets from other sources, including
hospital admissions, treatment episodes, and criminal justice information that would provide a
deeper dive into the root causes of the issue. The combination of data would provide a more
holistic view of the problem and assist in developing innovative interventions (Schmidt et al.,
2015).
Although some progress was made to reduce substance misuse and abuse rates in the
United States, it remains a major complex public health issue. Substance misuse and abuse are
associated with destructive behaviors, isolation, financial problems, low productivity, loss of
employment, crime, child abuse, domestic violence, and educational failure. It is estimated that
substance misuse and abuse cost the country over $700 billion annually in loss of productivity,
healthcare, and criminal justice involvement (NIDA, 2019). The person suffering from the
disease of addiction and their family members and friends are directly affected and suffer from
significant loss emotionally and financially (Schä fer, 2011).
Significance of the Problem
According to the 2018 National Survey on Drug Use and Health, 7.8% of the population
needed addiction treatment, but only 1.4% received treatment (Substance Abuse and Mental
Health Services Administration, 2019). Lack of access to resources, the high cost of treatment
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services, the stigma of addiction, the lack of knowledge of available resources, the denial of the
addiction, and the lack of willingness to stop using drugs or alcohol are all barriers to individuals
seeking help (Substance Abuse and Mental Health Services Administration, 2018).
One system that the epidemic has dramatically impacted is hospital emergency
departments. Drug addicted individuals who cannot access resources or treatment services are at
higher risk of a drug overdose or an injury related to drug abuse. Drug-related emergency
department visits have created a significant strain on the healthcare system, with a 148% increase
in substance use disorder emergency department visits from 2004 to 2017 (Agency for
Healthcare Research and Quality, 2018). The rise in substance use disorder patients has created
many challenges for emergency departments. Emergency personnel are not equipped to provide
appropriate care coordination after the patient is medically stabilized, nor are staff adequately
trained in addiction. Some hospitals in the United States have begun to implement strategies to
address patient needs, such as prescribing naloxone or offering medication-assisted treatment,
but many patients are still left without intervention (Mcguire et al., 2020). Not providing a
linkage to resources leaves patients at higher risk of suffering from repeated overdoses and a
higher risk of multiple emergency department visits, which can ultimately lead to death (Vivolo-
Kantor et al., 2019).
Patients who are entering into emergency departments may not be ready or able to access
treatment resources. However, these patients still need proper support and effective linkage to
additional community resources. The continuum of care must include intervention for those in
active addiction, and emergency departments play a critical role in preventing repeated
unintentional drug overdose.
Conceptual Framework and Theory of Change
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Biopsychosocial Theory. There have been many theories and models that have
attempted to explain drug addiction. Some of the addiction theories focus on social learning or
conditioning to impact reinforcement of positive behaviors. While influencing individual
outcome behavior, these theories support negative societal beliefs that drug addiction is a choice
controlled by changing one’s actions. These theories have also supported social views that drug
addiction is a moral failure and consequence of a character flaw. This has increased stigma and
discrimination for those who suffer from substance misuse and abuse (See, 2013).
The biopsychosocial disease model has provided a framework for biological,
psychological, and social factors when determining a course of treatment for diseases. All three
factors are considered in treatment, and all are equally relevant (Engel, 1977). Recent research
has found that addiction is a chronic brain disease that alters brain function, creates chemical
imbalances, and can ultimately lead to permanent brain impairment. Environmental factors,
including early exposure to drugs, traumatic events, or social stressors, can also impact the risk
of misuse or abuse of substances. Drug addiction is divided into stages: binge drinking and
intoxication, withdrawal and negative affect, and preoccupation or craving. Although each stage
exhibits distinct behaviors and actions, each stage is also associated with the activation of
specific brain chemicals and circuits (Longo et al., 2016).
Theory of Change. Theory of Change is an active method that introduces a new concept
that, over time, will establish a new desired result. The Theory of Change uses innovative
strategies to address complex community interventions (Dawson & Andriopoulos, 2017). While
many interventions may result in individual change, changes in institutions, service practices,
community norms, and policies are needed to positively impact population health (Annie E.
Casey Foundation, 2004). The Linkage to Hope Project, is a sustaining innovation that enhances
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the current healthcare system for hospitalized individuals due to substance misuse and abuse
(Satell, 2017).
The Linkage to Hope Project will develop and implement a real-time referral and linkage
system to connect drug-addicted patients in an emergency department to a Certified Peer
Recovery Supporter (CPRS). Emergency department providers will be responsible for offering
patients with substance use disorders the opportunity to engage with a CPRS during the
emergency department stay. CPRS will respond, in-person, to emergency departments within 30
minutes of the referral. If the distance is a concern or visitation restrictions are in place in the
emergency department, a telehealth option will be embedded in the platform to connect to the
patient directly. The Linkage to Hope Project will not provide clinical services. Still, it will offer
intervention with someone who has lived experience and provide guidance and connection that
medical personnel cannot provide. CPRS can engage those in active addiction and assist with the
linkage of resources upon hospital discharge. CPRS will also offer ongoing outreach and follow-
up post-hospitalization that will improve the likelihood of a reduction in future admissions due to
drug abuse (Richardson & Rosenberg, 2016).
The primary behavior that will need to change is hospital system protocols and processes.
Currently, drug-addicted patients are medically stabilized and released with no follow-up care
plan. Emergency department personnel must invest in the Linkage to Hope Project and view
CPRS services as beneficial and not hindering medical care. Additionally, CPRS must obtain a
thorough understanding of emergency department processes so as not to impede medical care.
The Linkage to Hope Project will identify individuals who will assist in championing change
within the hospital system.
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Logic Model. The resources necessary for the Linkage to Hope Project are a web-based
care coordination platform, administrative and clinical staff, clinical supervisors, CPRS training,
hospital personnel education, funding, and business associate agreements (BAA) signed.
Activities include developing and implementing the web-based platform, increasing capacity to
provide 24/7 service delivery, serving 1500 individuals in active addiction, providing supervision
and consultation, education sessions for CPRS and emergency department employees,
exploration of funding options, and legal consultation for BAA. Outputs include CPRS services
availability within 30 minutes of referral, hiring 10 full time CPRS, all CPRS will be trained,
50% of the hospital staff will receive training, funding sources are identified, and BAA executed.
Short-term outcomes include the development and implementation of the web-based care
coordination platform, all staff are hired, supervision and consultation are provided weekly,
CPRS and hospital staff gain knowledge about the project, CPRS services are utilized in
emergency departments and legal counsel will be sought. Proposed intermediate results will
include utilization of the web-based platform to triage and manger patient flow, patients are
linked and are engaged with the services, CPRS continue to increase knowledge and expertise in
service delivery, and semi-annual reports will be completed. Services will be fully utilized, and
funding is secured through a blended payor model. Long-term outcomes include an increase in
the engagement of patients, increase the linkage of community resources for patients, a decrease
in hospitalizations, semi-annual and annual reports are completed, funding is secured for
sustainability and all BAA executed (See Appendix A).
Problem(s) of Practice and Innovative Solution
Proposed Innovative Solution
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The Linkage to Hope Project is a web-based care coordination platform designed to link
individuals in active drug addiction who access emergency departments with a Certified Peer
Recovery Supporter. The care coordination platform has been designed to integrate the data feed
from the hospital emergency department Health Information Exchange to the care coordination
platform. The care coordination platform dashboard is utilized by the CPRS to identify
individuals who have entered the emergency department due to a drug overdose. The CPRS will
respond to the alert by contacting the emergency department charge nurse by phone. The
emergency department personnel will obtain consent from the patient. Once patient permission is
received, the CPRS will travel to the emergency department for a face-to-face visit within 30
minutes or will immediately connect with the patient through telehealth. The CPRS will provide
support and linkage to services to the patient. The CPRS will continue to provide outreach and
support to the patient after hospital discharge for as long as the patient needs the service. The
CPRS will also have access to language translators through telecommunication to ensure proper
care is given to all patients, including those who are deaf or hard of hearing and those that are not
English proficient.
Solution/Innovation Contributions to Improvement to the Grand Challenge
The social work field must continue to focus on solutions and innovations to address
vulnerable populations’ inequities and disparities by identifying and addressing the health gaps
in service delivery (Rine, 2016). The Linkage to Hope Project addresses the Grand Challenge,
Close the Health Gap, by expanding the current continuum of care to provide service delivery to
those who may not be able or are not ready to access treatment resources. The web-based care
coordination platform will provide a rich dataset by interfacing the hospital records and criminal
justice data to create a patient’s descriptive and predictive profile. A priority score will be
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assigned to the patient to assist the CPRS in providing intervention strategies specific to the
patient. The data captured and analyzed from the Linkage to Hope Project will advance the
analytics, trends, and opportunities to improve pathways to care. Legal opinions will also be
obtained for project implementation and sharing of personal health information (PHI). All
organizations will also sign business associate’s agreements to assure compliance with HIPAA
and HITECH laws.
Stakeholder Perspectives
The Linkage to Hope Project will be implemented in Montgomery County, Ohio. The
primary stakeholders include Public Health - Dayton & Montgomery County (PHDMC) (local
health department), Montgomery County Alcohol, Drug Addiction and Mental Health Services
(ADAMHS), Kettering Health Network, Goodwill Easterseals, Ascend Innovations, Cordata
Healthcare Innovations (Cordata), CPRS, and those in active addiction. PHDMC will lead the
project. PHDMC provides population health data analysis specific to the drug epidemic, leads
the Overdose Fatality Review Committee (OFR), and co-leads the Community Overdose Action
Team (COAT) (local task force) with ADAMHS. PHDMC will dedicate its current Outreach
Team (2 full-time CPRS, 1 full-time social worker, and 1 full-time supervisor) to the project.
Ascend Innovations is a member of the OFR and COAT. All other stakeholders serve as
members of the COAT. Data reports are published annually to drive decision-making. While the
county has implemented quick response teams to provide outreach to those interacting with the
criminal justice system, the county has not implemented a strategy to intervene with those in
contact with the emergency departments. The OFR and the COAT members perceive a gap in
outreach to those in active addiction. Members have verbally agreed to support the project, and
contracts have been signed with ADAMHS, Ascend, and Cordata.
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PHDMC has partnered with Ascend Innovations and Cordata to build the platform for the
project. Ascend Innovations is a life science data analytics company owned by the three major
hospital networks in the Dayton, Ohio region. With this ownership, Ascend Innovations has
access to all the historical and real-time health information data throughout the hospital systems.
Ascend Innovations’ Hospital Board is supportive of the project and has agreed to allow the
hospital records to be shared for the project purpose. Cordata is a health science company that
has directly partnered with Ascend Innovations and PHDMC to enhance its current care
coordination platform that was designed for chronic disease management.
Ascend Innovations and Cordata will work directly together to implement the care
coordination platform. Cordata has already launched the platform in other counties in Ohio
through a state grant, but no county has the direct hospital data feed or alerts coming to the
outreach teams. Ascend Innovations has already dedicated personal time to the project design
and has implemented the first phase, a hospital overdose alert system. Ascend Innovations and
Cordata perceive the project as a value to the community and will be able to scale the project to
address other chronic health needs.
Emergency department personnel at Kettering Health Network perceive a need to have
additional resources available and admit that they do not provide any discharge plan or follow-up
care for patients with substance use disorders. They view CPRS as a benefit and state that they
would utilize the resources if they were available.
Goodwill Easterseals will provide peer recovery supporter training. This training is
funded through ADAMHS and will lead to Ohio certification for the CPRS. The staff perceive
the project as the next step for expanding current peer recovery support services and have
dedicated resources to assist with implementation.
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CPRS and individuals in active addiction serve as members of the COAT and have
provided project feedback through involvement and direct interviews. They view the problem as
tragic. Many have witnessed friends die of a drug overdose, and many have almost died
themselves. Individuals in active addiction feel hopeless and helpless. Both CPRS and those in
active addiction have experienced or witnessed much stigma and discrimination due to their own
addiction or the addiction of others. They perceive emergency rooms as cold and procedural, and
those who have accessed emergency departments have not received proper linkage to resources.
Those in active addiction support having CPRS services available in the emergency department
and would utilize these services. There are no other intervention options for those still in active
use.
Existing Evidence Regarding the Broader Landscape
Although peer recovery support is just now gaining recognition in the healthcare sector, it
has a long history of success that dates back to the 18
th
century when a psychiatric hospital saw
the value of employing former patients to offer more humane intervention (Davidson et al.,
2012). Since then, peer recovery supports have emerged in mental health services and various
settings, including the addiction field. Peer recovery supporters can play a crucial role in service
delivery by assisting individuals in their journey to recovery and use of a peer recovery supporter
has been shown to increase abstinence, reduce overdoses, increase engagement in treatment and
decrease future hospitalizations (Bagley et al., 2019). Individuals who enter emergency
departments due to drug overdoses are medically stabilized and are released with little to no
intervention. Adding peer recovery support services to emergency departments can increase
patients’ compliance and improve linkage to additional community resources (Ti et al., 2015).
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The Centers for Medicare and Medicaid (CMS) approved reimbursement for peer
recovery support services in 2013, and peer recovery support services have increased in several
settings (CMS, 2020). Implementation of peer recovery support services is new to emergency
departments, and research is just now emerging to document the effectiveness (Stein, 2013).
Although evidence demonstrates the importance of peer recovery support services, further
emphasis on the cost-benefit of the services is needed to convince hospitals to invest in adding
peer recovery supporters to service delivery (Chinman et al., 2014).
Montgomery County, Ohio, has suffered significant challenges related to the drug crisis,
and the county has been broadly publicized in national and international media as the epicenter
of the opioid epidemic (MSNBC, 2017). The current substance use disorder service delivery
system in Montgomery County, Ohio, is fragmented and siloed. Over 50 behavioral healthcare
organizations provide services, but they are not linked, and little care coordination is conducted
for clients outside of their system. None of the current behavioral healthcare organizations
receive direct referrals from hospitals for individuals with substance use disorders (Crescendo,
2018). Peer recovery support services can assist in linking individuals to treatment and other
needed services.
In 2016, Ohio Mental Health and Addiction Services (OMHAS) began to offer
certification for peer recovery supporters. In an attempt to build capacity, Goodwill Easterseals
conducts local Certified Peer Recovery Support training. This has increased the number of
certified peers in the county from 20 in 2017 to 316 by 2019 (Community Overdose Action
Team, 2019). Goodwill Easterseals also provides a Peer Support Collaborative to offer ongoing
training and consultation for CPRS and operates a Warmline call center staffed by CPRS
(Goodwill, 2020).
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Considerations for Existing Opportunities for Innovation
The Linkage to Hope Project is a sustaining innovation that enhances the current service
delivery by addressing the identified gaps (Satell, 2017). The web-based care coordination
software platform provides the opportunity to increase the existing healthcare services’
capabilities by providing immediate linkage of services. The platform will embed real-time
hospital data that will alert CPRS of active overdoses entering the emergency department. The
platform will provide more effective care for those in active addiction by providing health
history and criminal justice information, and it will include priority scoring. The Linkage to
Hope Project will also provide a warm handoff from the emergency department to a CPRS who
will assist with active engagement, remove barriers to other resources and services, and provide
long-term connections. The platform will develop standard processes and workflows for the
CPRS. This will also include historical patient records and response activities, as well as
treatment plans. Data will be collected and analyzed by Ascend Innovations in partnership with
PHDMC.
Connections with the Logic Model and Theory of Change
Inputs. The care coordination platform will be initially funded by PHDMC and
developed by Ascend Innovations and Cordata. The CPRS will be employed by PHDMC and
will enhance current service delivery. PHDMC will also provide supervision and program
implementation, and oversight. The hospital will provide a referral source and support the project
development and implementation. The Department of Justice (DOJ) and the National
Association of County and City Health Officials (NACCHO), and the local human services levy
have provided funding for the project. PHDMC will act as the fiscal agent.
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Activities. The Linkage to Hope Project will build capacity to provide CPRS services 24
hours per day, seven days a week to meet the needs of the emergency departments. Supervision
and support for the CPRS will be available 24/7 through PHDMC. The stakeholders will work
together to develop educational and training resources. Education and training will strengthen the
collaboration between all partners and will increase appreciation for roles and responsibilities.
Additionally, contracts and business associate agreements will be signed to assure that
organizations can ethically and legally share personal health information. PHDMC will work
with stakeholders to seek funding opportunities to address sustainability.
Outputs. The Linkage to Hope Project will provide patient contact with a CPRS within
30 minutes of the emergency department alert. By linking individuals quickly to a CPRS, the
CPRS will have the ability to increase engagement with patients, offer linkage of services, and
support discharge planning after the hospital stay. By hiring ten full-time CPRS, it will increase
capacity from day hours to a 24/7 service. This will allow the CPRS to serve, at a minimum,
1500 patients from 9 hospitals.
Outcomes. The short-term outcomes include the implementation of the care coordination
platform. The CPRS and hospital staff will receive additional training and consultation.
Implementation trials will be conducted, and modifications will be made as needed.
Intermediate outcome results will measure the linkage of at least 1500 patients in 9 hospitals to
CPRS, and funding will be secured to address long-term sustainability. Input will be obtained
from hospital staff and the CPRS throughout the project design to measure the service’s
perceived value and modify any design flaws. Long-term results will include tracking patients
who have received CPRS services to measure whether the service has increased patients’
engagement, decreased hospitalizations, and increased linkage to other resources.
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Project ’s Likelihood of Success
The current environment in Montgomery County, Ohio, will support the Linkage to Hope
Project’s likelihood of success. The COAT and OFR continue to identify the need to expand
CPRS services. Through these collaborations, the formal organizations work alongside
individuals in active addiction and those in recovery. The community sees the value of this
crucial intervention for those who continue to struggle with substance abuse. The community
partners view addiction as a disease and recognize the need to treat it with a biopsychosocial
approach.
PHDMC has secured funding to increase data sharing among the county organizations
and will finance the CPRS positions. The Linkage to Hope Project uses a blended funding
model, but capacity will need to increase to meet service demand. Although State of Ohio
Medicaid allows for reimbursement of CPRS services, the payment is only available when the
services are offered as a component of a substance abuse or mental health treatment service plan.
Outreach to hospitals is not billable to Medicaid or private insurance. Sustainability planning has
begun. Hospitals, a managed care company and a nonprofit agency are interested in investing in
the project. Additional grant funding will be sought to assist with implementation, and additional
Montgomery County human services levy funding will be requested to provide long-term
sustainability.
Project Structure, Methodology, and Action Components
Prototype
A prototype is defined as a final product model that includes phases for implementation
(Arnowitz, 2007). The Linkage to Hope Project prototype is an implementation guide that
outlines the history, the gaps in intervention, and the developed data and technological solutions
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that address gaps. The prototype’s purpose is to offer the reader a summary of how one
community worked together to harness technology to address the drug epidemic. The guide will
provide information on the steps and actions taken that need to be considered when
implementing a similar solution while providing the reader with examples of data collected and
shared among community partners. The guide provides wireframe models of the developed
software design and outlines the direct clinical intervention used by the project to meet the
ongoing needs of those who experience a drug overdose. The prototype will provide
stakeholders, funders, and other community leaders detailed information on the program. Other
communities will use the prototype for replication consideration.
The COAT has fostered positive working relationships between stakeholders and citizens
in Montgomery County, Ohio. Because these relationships have been built, the stakeholders have
agreed to develop shared data sets to drive decision-making. The stakeholders have been meeting
for over a year to develop software solutions.
Market Analysis
A review of the peer recovery support services literature found that these services are not
widely used in ED’s and research is just now emerging (Ashford et al., 2019). In Montgomery
County, Ohio, there are currently four agencies providing peer recovery support services. Still,
none of these agencies offer services in the ED, which continues to be a gap in service delivery.
A literature review of care coordination and risk stratification systems found that many
care coordination platforms have been implemented within healthcare systems (Olivia et al.,
2017). These platforms allow coordination between multiple healthcare providers involved in a
patient’s care to assure the proper healthcare service delivery (PointClickCare, 2019). While
there is a benefit to these platforms within healthcare, the market analysis shows that the
22

platforms have only been developed among healthcare provider networks and have not included
behavioral healthcare systems.
Risk stratification systems have also been implemented within the healthcare industry,
and machine learning algorithms have been developed to predict disease risk, diagnosis,
prognosis, and determine the appropriate patient treatment (Ngiam & Khor, 2019). Risk
stratification systems have also been developed to assess the level of patient risk of prescription
opioid misuse or abuse (Koyyalagunta et al., 2013). These systems are only using electronic
healthcare records from their own healthcare network system or through a prescription
monitoring program data (Lo-Ciganic, 2019). The Linkage to Hope Project risk stratification
system will integrate data sets from the hospital system network, the criminal justice system,
including jail data, and behavioral health treatment data that will be used to develop a priority
risk score. The priority risk score will then be available in the care coordination platform and
used by the CPRS to provide a more holistic view of the patient's needs. It will also assist the
CPRS to provide the most effective interventions to mitigate future risk of hospitalization and
prevent death. Although there are many clinical care coordination platforms and risk
stratification systems in the market, no solution includes the robust data sharing available
through the Linkage to Hope Project used to drive service delivery.
Implementation Strategy
The Linkage to Hope Project has already gone through several phases of development
and is now ready to be piloted within one hospital system. The implementation guide will
provide further information on the steps that were followed and the technological and clinical
solutions that have been developed or are still in the process of development (See Appendix C).
23

The project partners began by engaging in the first phase of the project, a discovery
phase. Through this phase, several stakeholder meetings were held, and interviews were
conducted with those in active addiction and organizations that have implemented similar
projects. The interviews, data review, and research on software solutions moved the project into
phase two, initiation phase. In this phase a logic model was developed, and project goals were
identified. The project then moved into phase three, project planning. Ideas for implementation
were developed and Ascend Innovations and PHDMC worked together to research and identify a
software vendor that could provide the care coordination platform. Software development began
on the risk stratification system and the Health Level 7 (HL7) link. An HL7 is a standard
protocol for exchanging information between different medical record systems (Al-Enazi & El-
Masri, 2013). A clinical interface will be developed between the Health Information Exchange
and criminal justice records and sent to the care coordination platform.
Additionally, Kettering Health Network has agreed to pilot the project, and local funding
has been secured to hire four additional CPRS. The Linkage to Hope Project is still in Phase
Three. The project is validating the software, and the project will be piloted within the next two
months. Once piloted, the project will gather data on software system implementation and CPRS
response.
The Linkage to Hope Project has assured that there is leadership on several levels. The
Community Overdose Action Team provides leadership support to help determine the project's
strategic direction. The project lead is employed at PHDMC and has garnered additional agency
and community resources, and funding for the project. Additionally, the CPRS and those in
active addiction hold leadership roles in the COAT and will have continued input in
implementation.
24

The Linkage to Hope Project has several obstacles to overcome. The COVID-19
pandemic has delayed the implementation of the pilot due to visitation restrictions in the
hospitals. Hospital staff have also been unavailable to meet due to surges of COVID-19 patients
entering the emergency department. Additionally, PHDMC is directly responding to the COVID-
19 pandemic. Many staff have been reassigned to work in vaccine clinics and other duties
required for emergency response. While COVID-19 has taken precedence over other
responsibilities, the project implementation is still a priority as drug overdoses have increased
again in the community. The hospitals and PHDMC have reconvened meetings, and the project
implementation continues to move forward.
An additional obstacle that the Linkage to Hope Project will need to overcome by 2023 is
securing ongoing funding to sustain the project. Grant funding will terminate at this time, and the
partners will need to secure additional funding for the project to continue. The partners are
committed to the project, and there is interest from the local county administration to assure
continuation. The partners will continue to seek additional federal and state funding and
approach the county human services levy committee to increase local funding allocation to
support sustainability.
Financial Plan
Financial budgets for the Linkage to Hope Project are a component of the larger overall
budget for PHDMC. The Health Commissioner is responsible for the organization’s budget, and
the Board Health will ultimately approve the budget, all contracts, and the implementation of the
Linkage to Hope Project. The Linkage to Hope Project will implement a blended funding model
that includes a public provider approach. The public provider model provides essential services
by outsourcing service delivery through contractual agreements between governmental agencies
25

and nonprofit or for-profit entities (Foster et al., 2009). PHDMC does not have the internal
capacity or capability to develop the care coordination platform. PHDMC is contracting these
services through public/private partnerships. Additional local human services levy dollars are
used to fund PHDMC personnel and other operating costs in both Start-Up and Full Fiscal Year
of Operation (FFYO) budgets. Patient billing for service delivery will provide revenue for the
project (See Appendix B).
The project is an enhancement and expansion of a current PHDMC Outreach Program.
The project has already secured funding for start-up and FFYO. The Linkage to Hope Project
will start operations with $641,394 in revenue generated from a federal grant and local levy
funding sources. The Start-Up Budget expenses include personnel costs and benefits for two
positions at $30,612. These positions are current employees at PHDMC who will dedicate a
percentage of time to the project. Other operating costs total $610,782. The operating costs
include supplies and contracts with primary project stakeholders to build the care coordination
platform and upgrade software systems to develop the HL7 connection. Legal fees were also
included in the Start-Up Budget. PHDMC has sought outside legal counsel to assure all laws and
rules are followed in project development and implementation.
In the FFYO, the Linkage to Hope budget includes $865,209 in revenue from federal and
local levy funding and revenue generated from service delivery reimbursement. The FFYO
budget expenses consist of salary and benefits at $320,091. There is an increase in personnel
costs in the FFYO as four new CPRS positions will be created and a part-time Outcomes
Specialist position for data collection. The FFYO operating costs are $545,118, which is a
decrease of $65,276 from the start-up costs. The contractual agreements funded through federal
grants continue in the FFYO, but contractual allocations are less as software upgrades were
26

purchased in the start-up. Legal fees are continued in FFYO operation for consultation during
implementation. Other costs include training PHDMC employees, hospital staff, and contractors
on the benefit of CPRS and hospital protocols and processes.
Additionally, costs include the purchase of Narcan. The CPRS will be furnishing Narcan
to patients. Narcan is an opioid antagonist that has proven to reverse the effects of an opioid-
induced, life-threatening emergency (Mell et al., 2017).
Assessment of Impact
The Linkage to Hope Project’s impact will be assessed by collecting data on process and
outcome measures. The Linkage to Hope Project process measures will include the following:
the number of individuals who enter into the emergency department and the number of
successful contacts; the number of successful follow-ups after discharge; the number and types
of resource referrals; the percentage referred to treatment; the number of drug-related arrests; the
number of overdose hospital visits; the percentage of clients who received a Narcan kit and the
number of overdose deaths post-intervention. Additionally, the care coordination platform
application crash rates and the number of endpoint incidences will be tracked. Ascend
Innovations will provide analytics to test the efficiency of the care coordination platform.
The Linkage to Hope Program outcome measures will include increase the proportion of
clients who receive Narcan kits; increase the number of clients referred to treatment; increase the
proportion of clients’ linkage of resources; increase the number of clients who successfully
engage in treatment; decrease the number of clients who experience a hospital visit due to
repeated overdose; decrease the number of drug overdose deaths.
Data for the Linkage to Hope Project will be collected through the developed care
coordination platform. An epidemiologist at PHDMC will analyze the data in partnership with a
27

data analyst at Ascend Innovations. Reports will be generated quarterly, bi-annually, and a
cumulative yearly report will be published.
Plan for Relevant Stakeholder Involvement
In addition to the partner organizations, the Linkage to Hope Project has identified the
COAT members and the public as additional stakeholders. The COAT is the local task force that
includes over 200 individuals and over 60 organizations. Members include state and local
officials, individuals from nonprofit, government, grassroots organizations, business leaders,
faith-based leaders, healthcare professionals, recovery groups, criminal justice, law enforcement,
fire/EMS, universities, media, managed care companies, and those in active addiction. The
COAT has adopted a Collective Impact Framework as its guiding principles to align all work
under a common agenda and shared measurements (Collective Impact Forum, 2020). It is
structured under an Incident Command System Framework, used in emergency response
nationally (Alperen, 2017). Through this extensive collaboration, all work related to the drug
epidemic must be supported by the COAT members. The COAT will assist in driving the
strategic direction of the Linkage to Hope Project and support implementation.
The Linkage to Hope Project is structured under PHDMC. As a governmental agency,
PHDMC must follow and uphold the government code of ethics (Ohio Ethics Commission,
2020). PHDMC recognizes that a high standard for ethical behavior is essential for good
government. PHDMC ensures public trust by engaging the public in many aspects of decision-
making and holds high standards to transparency and accountability to the community citizens.
Communication Strategy
While the media coverage has created public awareness and has fueled policy changes, it
supports negative attitudes and discrimination towards those suffering from addiction. The
28

stigma of addiction runs deep and is embedded in our social values, attitudes, and beliefs
(Volkow, 2020). Society needs to begin to normalize recovery and expand anti-stigma
campaigns highlighting people in recovery (Botticelli & Koh, 2016).
The Linkage to Hope campaign will appeal to the target groups by crafting heartfelt
messages and stories that promote recovery while educating the community on the drug
epidemic. The messages will seek to inspire others to change their beliefs around addiction. The
Linkage to Hope campaign will use subject matter experts in the field, including physicians, to
engage the public and the healthcare community in addressing stigma within these systems. Peer
supporters will also be used to deliver messages of hope and share diverse perspectives and ideas
that support individuals in obtaining recovery.
The Linkage to Hope campaign will use several media channels to promote the messages.
News briefings will be utilized to continue to educate the public on the problem. Additionally,
videos and social media posts will be developed to promote anti-stigma messaging and promote
available resources in the community. Peer supporters will also create short videos and use
storytelling to share their journey to recovery and promote messages of hope to the public. An
internet website for the local coalition will also be used to promote messages. The Linkage to
Hope campaign will effectively address the need to change the landscape from focusing on death
and despair to focusing on messages of recovery, hope, healing, and innovation.
Problems in Practice
Two of the most considerable problems that the Linkage to Hope Project could face are a
lack of engagement in project implementation from the hospital systems and a lack of continued
funding to support expansion to a 24/7 operation. The COAT members have expressed ongoing
promotion and collaboration for project implementation. Still, it has been challenging to engage
29

top hospital executives who have the power to determine the outcome of the project.
Additionally, business associate agreements will need to be signed with the hospital systems, and
hospital legal counsel will need to be engaged. The Linkage to Hope Project has identified key
healthcare providers in the hospitals that will assist in leveraging support within their respected
systems and will assist in marketing the project benefits to hospital executives. Additionally,
PHDMC has sought legal counsel to execute the business associate agreements with the hospital
systems.
Lack of continued funding to support a 24/7 response may become a problem after the
pilot is complete. The current funding structure supports four CPRS that will respond to five
Kettering Health Network emergency departments. Four additional emergency departments
would be added as a component of expansion. The CPRS staffing would need to expand to 10
CPRS to deploy a 24/7 response to meet all emergency department services in the county. The
Linkage to Hope Project partners are continuing to work together to address expansion efforts
and leverage other community organizations to partner in the care coordination platform system
to increase response efforts.
Project Narrative
The Linkage to Hope Project has contributed to the Grand Challenge, Close the Health
Gap, by providing an innovative solution to the drug overdose epidemic. The Linkage to Hope
Project is a sustaining innovation that will enhance the current service delivery for patients in an
emergency department that have experienced a drug overdose.
The Linkage to Hope Project has been able to integrate multiple data sets into a ground-
breaking software solution that will help drive immediate intervention for emergency department
patients and assist in assuring the most appropriate resources are delivered. An operational
30

implementation plan has been developed, and it is supported monetarily and through stakeholder
involvement. The Linkage to Hope Project can also scale and be implemented to other social
issues, such as patients who attempt suicide.
Ethical Concerns
Individuals in active addiction are a vulnerable population. The Linkage Hope Project
must hold high values, ethical principles, and standards to protect these individuals from any
harm. The Linkage to Hope Project will be challenged with several ethical dilemmas throughout
the project. The primary ethical issues that require particular attention is to confirm that the
Linkage to Hope Project has taken steps to protect patient’s rights to consent to services. It must
also ensure the project has taken the necessary steps to adhere to the Health Insurance Portability
and Accountability Act (HIPAA) and the Health Information Technology for Economic and
Clinical Health (HITECH) Act (U.S. Department of Health and Human Services, 2020a).
HIPAA allows for the provision of coordination or management of healthcare and related
services for an individual by one or more healthcare providers who are covered entities,
including consultation between providers to assure referral of a patient from one provider to
another (U.S. Department of Health and Human Services, 2020b). The Linkage to Hope Project
partners are all covered entities and must comply with all federal and state laws and rules related
to Protected Health Information and agree to share the minimum necessary information to
coordinate care. Additionally, the Linkage to Hope Project CPRS will uphold a patient’s right to
self-determination by obtaining consent to services before engagement. Written authorization
will also be obtained from the emergency department and the CPRS at time-of-service delivery.
The right to refuse services at any time will also be discussed with the patient. All CPRS that are
providing direct intervention are also required to uphold the Ohio Governmental Code of Ethics
31

(Ohio Ethics Commission, 2020), the National Association of Social Workers Code of Ethics
(NASW, 2008), and the Ohio Mental Health and Addiction Services Peer Recovery Support
Code of Ethics (OMHAS, 2017).
The Linkage to Hope Project is developing HIPAA and HITECH-compliant software
systems using the Amazon Web Systems (AWS) Manager. AWS enables covered entities and
their business associates to process, store securely, and transmit PHI while safeguarding and
protecting individual patient rights (Amazon Web Services, 2020). All partner agencies will
enter into business associate agreements that will allow for PHI transmission to support care
coordination.
Conclusions, Actions, and Implications
Conclusions
The Grand Challenge Close the Health Gap addresses the disparities and inequities
experienced by disadvantaged populations in the healthcare system (Browne et al., 2017). The
Linkage to Hope Project is based on the following facts. One, stereotypes about people who may
suffer from substance use disorders support negative attitudes within the healthcare industry
(Tsai, 2019). Two, those who may suffer from substance use disorders disproportionately
experience barriers to healthcare access (Berstein et al., 1997). Three, emergency departments
have been severely impacted by the drug epidemic. Patients are often medically stabilized and
discharged with no follow-up care plan, which increases the likelihood of drug overdose death
(Weiner et al., 2020).
Lastly, peer support services are not widely used in emergency departments (Ashford et
al., 2019). Still, these services have been shown to significantly increase abstinence and increase
the probability of long-term recovery among participants (Pettersen et al., 2019). Peer support
32

services have also led to a reduction in overdoses, increased treatment engagement, and a
decrease in future hospitalizations (Samuels, 2018). The Linkage to Hope Project innovation will
contribute to solving the Grand Challenge by addressing inequities and disparities in the
healthcare system while implementing a community-based intervention that will focus on
vulnerable populations, those that are suffering from drug addiction.
The Linkage to Hope Project engaged in discovery, initiation, and planning phases in
Year One and has moved into an implementation phase in Year Two. In Year Two, the project
will be piloted in one hospital and expand across the healthcare system to include four additional
emergency departments. By Year Three, the project would extend to the second major healthcare
system, and implementation would take place in an additional four emergency departments. The
Linkage to Hope Project would also expand its coordination with other agency partners to
provide CPRS services in collaboration with PHDMC and have access to the care coordination
platform.
The Linkage to Hope Project can be replicated in other communities. The project
provides an innovative solution to integrative care for patients in an emergency department
without requiring it to embed services within their delivery system. The project offers a way to
bridge collaboration and communication with traditional healthcare and behavioral health
services and provides a roadmap for crisis service delivery. These crisis services expand the
current continuum of care for those who are most at risk for death. The Linkage to Hope Project
could also be replicated for other vulnerable populations entering an emergency department,
including those experiencing a mental health crisis.
Implications
33

The Mental Health Parity and Addiction and Equity Act and Affordable Care Act support
the integration of physical and behavioral healthcare (Palmer & Rossier 2020). However, the
integration of these services has been challenging. Physical and behavioral healthcare
organizations have been slow to implement integrated care models (Goodell et al., 2011). The
bulk of behavioral health services are funded through carve-out models where physical and
behavioral health services are funded separately or grant-funded. Separate funding streams have
caused difficulty in supporting integrated services within hospital systems (Friedman et al.,
2018).
Because of the many challenges these large complex systems face with the integration of
service delivery, the systems must increase collaboration and cooperation among local entities
that can work together to develop a robust continuum of care for patients who otherwise are left
without services. One of the largest gaps in integrating a successful continuum of care for
patients is the lack of patient information shared across systems to coordinate effective and
appropriate care. The biggest strength of creating central hubs for patient information can ensure
that patients receive a holistic care approach while ensuring that patient care is integrated and
well-coordinated (Palmer & Rossier 2020).
The Linkage to Hope Project is not a completely integrated healthcare model, but it does
foster integration of physical and behavioral healthcare data. The care coordination platform that
Ascend Innovations and Cordata have developed could revolutionize the system. Integrating the
health information and criminal justice data into one database supports a universal system of care
that assures the proper comprehensive treatment and support needed for patients whose care is
complex. It will also complement the emergency department’s service delivery and decrease
34

duplication of services once a patient is discharged. The project will guarantee that patients will
be linked with the appropriate resources, reduce healthcare costs, and ultimately save lives.
Ethical, Legal and/or Financial Limitations and Risks
The Department of Health and Human Services has proposed rule changes to HIPAA.
These changes will improve care coordination for patients across covered entities by allowing
providers to disclose patient information based on professional judgment if the provider believes
it is in the patient’s best interest. Changes in HIPAA also allow for covered entities to share
patient information if there is a reasonably foreseeable serious, or imminent threat to harm to the
patient’s health and safety (U.S. Department of Health & Human Services, 2020a). These
changes in the laws will improve coordination of care in the drug and COVID-19 public health
emergencies. Additionally, the Substance Abuse and Mental Health Services Administration has
recently made changes to 42CFR Part 2 that protect substance use disorder treatment records’
confidentiality. These changes will more closely align the rule to the HIPAA Privacy Rule
changes and support treatment coordination for those with substance use disorders (U.S.
Department of Health & Human Services, 2020b).
While the integration of physical and behavioral healthcare yields better results for
patients, the sharing of patient information among healthcare providers still poses many legal and
ethical challenges. There remains a lot of confusion over the many laws, statutes, and regulations
that govern confidential information sharing, especially when sharing substance abuse disorder
treatment records. There is also a significant reluctance among healthcare and behavioral
healthcare providers to share records, even when it is legal to do so.
Additionally, technological advances have expanded the use of patient information by
increasing the number of individuals and organizations who have access. Accessing patient
35

records for care coordination purposes has helped support a holistic approach to care, decrease
duplication of service delivery, and decrease the need for a patient to repeat their history and
needs to multiple providers (Agency for Healthcare and Quality, 2014). While there are many
benefits to sharing patient information across systems, ethical dilemmas emerge. Most
professions, including the National Association of Social Workers (NASW), support informed
patient consent and question whether sharing patient health information is in the patient’s best
interest (NASW, 2008). Codes of ethics and privacy laws have not stayed current with the
changes in technology. Future work needs to continue to address sharing of protected health
information. The different laws and rules need to align to decrease confusion among providers,
which impedes patient care. Future work needs to better address the ethical and possible
unintended consequences of sharing data.
Sharing the Prototype
The prototype is ready to be shared with relevant stakeholders, practitioners, and external
constituencies. The prototype has been shared with the COAT members and local elected
officials to assist in continued implementation support. COAT members and elected officials
have provided feedback as the project moves through the pilot and full implementation to all
nine local emergency departments. Additional updates will also be provided to hospital
executives to assure continued engagement and support of the Linkage to Hope Project to drive
coordination efforts.
The Linkage to Hope Project evaluation results will also be shared in a written report.
The report will be developed by a data analyst at Ascend Innovations and an epidemiologist at
PHDMC. The evaluation report will be shared with all the COAT members, elected officials, and
it will be available for public view on the COAT website.
36

Next Steps
After the Linkage to Hope Project is fully implemented within all of the local emergency
departments and data is collected and analyzed for the project, the next step is to publish the
results. Publication of the project will support the advancement of research in data sharing areas.
It will also help elevate peer recovery support services to be viewed as a vital service that should
be integrated into the continuum of care for patients in an emergency department.
Additionally, the next steps will include accessing the care coordination platform’s
scalability to include patients experiencing suicidal ideations in the emergency department and
expanding the platform to address other chronic health conditions. Scaling the system will
require broader coordination, commitment, and investment from additional stakeholders,
including primary care providers, health plans, mental health providers and substance use
disorder providers. It will also include a strong collaboration across agencies as clinical
operations will change within medical and behavioral health agencies.
The Linkage to Hope Project is an innovative solution that has promoted data sharing
across agencies to support care coordination for patients experiencing a drug overdose and
accessing emergency department services. The project will provide other communities with steps
taken to implement a care coordination model and a roadmap for replication. The Linkage to
Hope Project partners have the confidence and the expectation that this model will be used in
other healthcare areas to change service delivery systems and increase collaboration and support
for the most vulnerable populations served.

37

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Appendix A: Logic Model
Program: Linkage to Hope Project

Goal: Implement a care coordination platform that will link individuals with substance use disorders, who are entering into emergency
departments with a Certified Peer Recovery Supporter (CPRS)
INPUTS ACTIVITIES OUTPUTS OUTCOMES - Impact
What Is Reached What is Done Who is Reached

Short-Term results Intermediate Results Long-Term Results
HIPAA compliant care
coordination software
system with telehealth
capability
Develop and
implement care
coordination platform
Ability to provide
CPRS outreach in
person or via
telehealth to patients
CPRS available
within 30 minutes
of referral

Care coordination
platform is developed
and implemented

Utilization of the
platform to triage
referrals and manage
patient flow
Increase in patient
engagement who
receive CPS services
10 CPRS staff to
provide 24/7 outreach
response

Provide 24/7 linkage
to CPRS outreach in
hospitals

Link 1500 individuals
in active addiction to
CPRS services

Hire 10 FT CPRS
staff

10 CPRS hired and
services implemented in
9 emergency
departments – face-to-
face or via telehealth
Patients are linked and
are engaged with CPRS
services

Increase linkage to
community resources
and decrease in future
hospitalization of
CPRS patients
2 FT Supervisors
provide program
oversight and 1 FT
Outcome Specialist for
data collection and
evaluation

Provide 24/7
consultation and
supervision CPRS
staff

Collect and evaluate
project data at least
semi-annually
Supervision will be
available to CPRS
24/7 and to Outcome
Specialist

Supervision and
consultation
available 24/7

Supervision and
consultation provided
weekly and as needed
through face-to-face
sessions, direct
observation, and
Motivational
Interviewing model
fidelity measurement
CPRS will increase
knowledge and expertise
in service delivery and
Outcome Specialist will
produce semi-annual and
annual reports

CPRS will receive at
least weekly feedback
on clinical skill and
adherence to practice.
Semi-annual and
annual evaluation
reports disseminated
and used to drive
decision-making
CPRS training
curriculum topics

Provide hospital
protocol training as
well as other required
topics to 10 CPRS

CPRS training on
emergency department
protocols and other
related topics
All CPRS trained

CPRS increase in
knowledge of hospital
processes and protocols
and increase education
on knowledge, skills
and abilities needed for
CPRS services
CPRS are embedded in
hospital processes and
protocols

Increase in CPRS
service utilization in 9
hospitals

Hospital personnel
education video

Introduction to CPRS
services to hospital
staff

Hospital staff training
on CPRS services

50% of hospital
staff trained

Hospital staff will gain
knowledge about how
to utilize peer support
services in patient care

Hospital staff will
perceive value in CPRS
services and utilize CPRS
in patient service delivery

Increase in CPRS
service utilization in 9
hospitals

Funding (start up and
annual budget)

Seek funding and
develop sustainability
plan.
Federal, state, and
local funding sources
Funding sources
identified
Funding applications
completed
Funding is secured for
start-up and
implementation through a
mixed payor model that
includes federal, state,
and local funding streams
Secure ongoing
funding to sustain
program
implementation.
Business associate
agreements signed
Develop business
associate agreements
through legal
consultation

All stakeholder
partners who have
access to the care
coordination platform
and personal health
information
Business associate
agreements are
executed between
all project partners
Legal counsel hired and
business associate
agreements developed
Business associate
agreements negotiated
All business associate
agreements signed and
executed
Assumptions
• Care coordination platform will be built to provide referral, triage, and
track patient interaction. The platform will also track outcomes.
• CPRS will increase linkage to services for those in active addiction.
• Care coordination platform will increase the use of telehealth and other
technology functions to triage services and track outcomes.
• There is no other 24 hour/7day per week peer recovery support services
offered in the community.
• Stakeholders are motivated, willing, and able to implement the model
and are willing to sign business associate agreements to share
information and data.
• Some of the peer support service delivery will be reimbursed by
Medicaid and/or private insurance.
• The program will be sustainable through a blended funding model that
includes federal, state, and local funding sources, and insurance payment
reimbursement.
• If the model is successful, referral sources could be expanded to include
patients with suicidal ideations and/or threats.
• The care coordination platform, if successful, could be adapted to other
populations or replicated in other communities.

External Factors
• Ohio Mental Health and Addiction Services has
implemented a certification for peer recovery supporters.
• Goodwill Easterseals provides certified peer support
training in the community.
• Ohio Medicaid allows for reimbursement of some peer
support services, but not outreach.
• Hospital administration will need to approve the
implementation of the program.
• One organization will need to provide management of
the platform.
• COVID-19 has impeded face-to-face service delivery.
Services will have to be implemented through telehealth.

Appendix B: Budget

Problem: Montgomery County Ohio hospitals have the highest percentage of drug overdose emegency department visits in the state.
Solution: Develop and implement a care coordination platform to connect drug-addictied patients from the emergency department to a peer recovery supporter
Category Budget Comments
REVENUE
Department of Justice 586,832 $ Contractor Services
Local Levy Funding 54,562 $ Personal Expenses and Other Operating Costs
Total REVENUE 641,394 $
EXPENSES
Personnel Costs
Wages/Salaries
Assistant Health Commissioner 11,000 $ Project Lead (10% of 1 FTE)
Epidemiologist 11,400 $ Data Collection and Analysis (20% of 1 FTE)
Sub-Total Wages and Salaries 22,400 $
Benefits
Workers Compensation 124 $
Retirement-Regular 3,004 $
FICA(Medicare) 260 $
Health Insurance 4,304 $
Life Insurance 360 $
Dental Plans 160 $
Sub-Total Benefits (@ 38%) 8,212 $
Total Personnel Expenses 30,612 $
Other Operating Costs
Contractor Ascend Innovations 350,000 $ Develop the Care Coordination Platform and Analysis
Contractor Coroner's Office 158,625 $ Software Upgrade for Data Sharing
Contractors Eastway Behavioral Health 19,207 $ Qualitative Interviews to Assist With Project Implementation
Contractor MCADAMHS 39,000 $ Data Sharing
Contractor MC Sheriff's Office 20,000 $ Data Sharing and Software Upgrade
Occupancy/Rent 3,000 $
Employee Parking 300 $
Office Supplies 600 $
Laptops and Software 3,900 $
Cell Phones and Office Phones 600 $
Training/Travel - $
Legal Fees 15,000 $
Liability Insurance 550 $
- $
Total Other Operating Costs 610,782 $
Total EXPENSES 641,394 $
SURPLUS/DEFICIT 0
LINKAGE TO HOPE
Start Up Budget

Appendix B: Budget
Appendix C: Protoype Implementation Guide

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This Page is Intentionally Left Blank

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The Linkage to Hope Project Implementation Guide was developed in coordination with a multi-disciplinary group
that provided strategic guidance regarding the development, planning, and implementation of the project. The group
acknowledges those who continue to struggle with addiction and celebrates those who have overcame many
obstacles to enter into recovery. The Linkage to Hope Project was designed for our family, friends, co-workers, and
community citizens who the drug epidemic has dramatically impacted.

PROJECT PLANNING AND IMPLEMENTATION MEMBERS

Public Health – Dayton & Montgomery County (PHDMC)
Montgomery County Alcohol, Drug Addiction and Mental Health Services
(ADAMHS)
Greater Dayton Area Hospital Association
Kettering Health Network
Premier Health Partners
Ascend Innovations
Cordata Health Sciences
Goodwill Easterseals Miami Valley
Community Overdose Action Team (COAT) members
Individuals in Active Addiction
Individuals in Recovery

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ACKNOWLEGMENTS ................................................................................................................3
OVERVIEW ......................................................................................................................................... 5
Purpose ......................................................................................................................................... 5
BACKGROUND ................................................................................................................................... 6
THE COMMUNITY OVERDOSE ACTION TEAM (COAT) ........................................................................... 7
COAT STRUCTURE .............................................................................................................................. 8
COAT ACCOMPLISHMENTS ................................................................................................................. 9
COAT DATA UNIT ............................................................................................................................. 10
OVERDOSE FATALITY REVIEW ........................................................................................................... 11
ENHANCED DATA SHARING .............................................................................................................. 12
IDENTIFIED GAP IN SERVICE ............................................................................................................. 13
Gap in Current Technology ........................................................................................................... 14
FILLING THE GAP .............................................................................................................................. 15
PHASE 1: DISCOVERY PHASE ............................................................................................................ 16
Planning Team ............................................................................................................................. 16
Data Review and Current Market Research ................................................................................... 17
Interview Stakeholders ................................................................................................................. 17
Develop Solution ......................................................................................................................... 17
PHASE 2: INITIATION PHASE ............................................................................................................ 18
Feasibility..................................................................................................................................... 19
Technology Needs ................................................................................................................ 19
Legal Considerations ............................................................................................................ 19
Financial Considerations ...................................................................................................... 20
PHASE 3: PLANNING PHASE ............................................................................................................. 21
Patient Flow ........................................................................................................................ 22
Technology Solution – Care Coordination Platform ............................................................... 23
Funding ............................................................................................................................... 26
Certified Peer Recovery Supporters ...................................................................................... 26
Peer Supporter Certification in Ohio ..................................................................................... 27
PHASE 4: IMPLEMENTATION PHASE ................................................................................................. 29
PHASE 5: CLOSURE AND EVALUATION PHASE ................................................................................... 30
SUMMARY AND LESSONS LEARNED .................................................................................................. 31

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The American Academy of Social Work and Social Welfare has commissioned The Grand Challenges in Social
Work. The Grand Challenge initiative strives to combine science with social values and represents a call to action to
address 13 urgent social problems.
1

The Grand Challenge, Close the Health Gap, seeks to drive the current healthcare medical model beyond addressing
symptomology of illness and address the root causes of disease by developing a social-oriented model in healthcare.
Close the Health Gap outlines recommendations and activities that will guide research, policy, and practice over the
next 10 years to advance health equity and reduce health disparities
2

The Linkage to Hope Implementation Guide will provide an innovative solution to address the Grand Challenge,
Close the Health Gap, while improving outcomes for those individuals who suffer from substance misuse or abuse.

The drug epidemic facing our country today is the largest recorded in U.S. history for all racial and ethnic groups.
3

From 1999 to 2019, over 830,000 individuals have lost their lives due to an unintentional drug overdose, and 2019
shows an increase of 4.8% in drug overdose deaths compared to 2018.
4
Unintentional drug overdoses have remained
the leading cause of injury-related death in the United States since 2008. It has now been identified as a contributor
to a decline in life expectancy rates.
5

While the drug epidemic has taken so many lives, thousands of individuals survive an overdose and are provided
medical care in emergency departments. From 2006 to 2017, emergency department visits rose 44%
6
and have
continued to grow an additional 30% from 2016 to 2017.
7

The purpose of the Linkage to Hope Implementation Guide is to offer the reader a summary of how one community
worked together to harness technology to address the drug epidemic. The guide will provide information on the
steps and actions taken that need to be considered when implementing a similar solution while providing the reader
with examples of data collected and shared among community partners. It will also provide stakeholders, funders,
and other community leaders detailed information on the program.

1
Sherraden, M., Barth, R., Brekke, J., Fraser, M., Maderscheid, R., Padgett, D., (2014 February). Social is Fundamental: Introduction and
Context for Grand Challenges in Social Work. Working Paper No. 1.
2
Fong, R., Lubben, J., & Barth, R. (2018). Grand Challenges for Social Work and Society (pp. 1–306). Oxford University Press.
3
Substance Abuse and Mental Health Services Administration (2020). The Opioid Crisis and the Black/African American Population: An Urgent
Issue. Publication No. PEP20-05-02-001. Office of Behavioral Health Equity.
4
Ahmad F, Rossen L., Spencer M., Warner M., & Sutton P. (2020). Provisional drug overdose death counts. Vital Statistics Rapid Release.
National Center for Health Statistics. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.
5
Hedegaard H., Miniño A., & Warner M. (2020). Drug overdose deaths in the United States, 1999–2018. NCHS Data Brief, no 356. National
Center for Health Statistics.
6
Jaeger, S., & Fuehrlein, B. (2020). Buprenorphine initiation to treat opioid use disorder in emergency rooms. Journal of the Neurological
Sciences, 411, 116716–116716. https://doi.org/10.1016/j.jns.2020.116716.
7
Centers for Disease Control and Prevention (2018b). Opioid Overdoses Treated in Emergency Departments Identify opportunities for action.
https://www.cdc.gov/vitalsigns/opioid-overdoses/index.html.

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The Linkage to Hope Project is an innovative solution to respond to the drug epidemic. The project has expanded
and enhanced data sharing and care coordination among governmental systems and nonprofit hospitals to respond to
individuals in active addiction more effectively. The project has developed and improved public safety, behavioral
health, and public health information-sharing partnerships that leverage key public health and public safety data sets.
The project will also develop and implement strategies for those individuals who are considered high risk for drug
overdose deaths and will use Certified Peer Recovery Supporters who will provide lived experience as an effective
intervention response.
The Linkage to Hope Project has been implemented in Montgomery County, Ohio. Montgomery County ranks fifth
in population in the state compared to all other 88 counties with 28 jurisdictions and an estimated population of
533,000. The city of Dayton is the county seat, and common to other urban areas its size, Dayton has a
disproportionate share of its residents living at or below the federal poverty level, are unemployed, uninsured, and
have not graduated high school.
8

The drug epidemic has significantly impacted Montgomery County, Ohio. From 2013 to 2018, Ohio ranked as
having the second-highest unintentional drug overdose rate in the nation. Montgomery County, Ohio had the highest
overdose death rate in the state at 61.0 per 100,000 residents.
9

Figure 1: Average Age-Adjusted Rate of Unintentional Drug Overdose Deaths by County, Ohio, 2013-2018

8
United States Census (2019). U.S. Census Bureau Quickfacts, Montgomery County Ohio.
https://data.census.gov/cedsci/profile?q=United%20States&g=0100000US
9
Ohio Department of Health (2018). 2018 Drug Overdose Data: General Findings. https://odh.ohio.gov/wps/wcm/connect/gov/d9ee6d3b-bf62-
4b4f-8978-
d7cfcd11348f/2018_OhioDrugOverdoseReport.pdf?MOD=AJPERES&CONVERT_TO=url&CACHEID=ROOTWORKSPACE.Z18
_M1HGGIK0N0JO00QO9DDDDM3000-d9ee6d3b-bf62-4b4f-8978-d7cfcd11348f-mXhFqNO

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As deaths continued to rise, Montgomery County officials came together to develop and support innovative
solutions to combat the problem. Montgomery County officials identified that four separate existing coalitions were
addressing the issue. Unfortunately, the coalitions were not coordinated. The county recognized the need to develop
and align the current coalitions’ work and drive the decision-making under one structured model to obtain a system-
wide response to the drug epidemic and reach the most vulnerable populations at risk of overdose death.
In the fall of 2016, Public Health – Dayton & Montgomery County (PHDMC), Montgomery County Commission,
and Montgomery County Alcohol, Drug Addiction and Mental Health Services (ADAMHS) joined forces to create
the Community Overdose Action Team (COAT).
The COAT adopted the Collective Impact Framework to align coalition efforts under a common agenda, increase
the use of shared measurements, and create an environment of continuous communication between partners.
Collective Impact describes an intentional way of working together and sharing information for solving a complex
problem. It theorizes that meeting five conditions will lead to population-level change.
10

10
Collective Impact Forum (2020). What is Collective Impact? https://www.collectiveimpactforum.org/what-collective-impact

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Although the federal government did not elevate the drug epidemic as a public health emergency until 2017, the
COAT partners structured their response under an emergency structure from the beginning. The COAT adopted the
Incident Command System (ICS) as its operational framework. ICS has been tested for over 30 years and utilized as
an emergency and non-emergency response nationwide. ICS’s goals are clear: communication, accountability, and
efficient use of resources.
11
Although ICS is used nationwide, Montgomery County is unique in choosing this
structure to respond to the drug epidemic.
Over 200 individuals, including those in recovery and family members, and over 60 agencies participate in the
COAT and sit on one of the eight branches. The branches are responsible for creating action items aligned with
national and state strategies, which are produced and reported through Incident Action Plans every 60 days.
The Backbone Support is co-led by PHDMC and ADAMHS and includes county administration, law enforcement,
fire/EMS, emergency management, coroner’s office, and peer support. The Backbone Support guides the overall
vision and strategies and works together to continue to mobilize resources.
12

Figure 2
Community Overdose Action Team Incident Command System Operational Structure

11
U.S. Department of Homeland Security. (2017). National Incident Management System (NIMS) and National Response Framework (NRF).
In Foundations of Homeland Security: Law and Policy.
12
Community Overdose Action Team (2019). Annual Report www.mccoat.org

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The COAT members have accomplished many things since its inception in 2016. The COAT has developed,
expanded, or enhanced over 80 programs and services to meet the branch priority areas’ needs. The COAT structure
has also allowed for collaboration and alignment with organizations to address gaps and reduce duplication in
services. The COAT members have diligently worked together to diversify funding opportunities and increase local,
state, and federal funding. The work of the COAT members has paid off. From 2017 to 2019, overdose emergency
department visits decreased by 57%; law enforcement overdose calls decreased by 53%; naloxone administrations
by emergency services decreased by 50%, and drug overdose deaths decreased by 48%. In 2019, Montgomery
County's unintentional drug overdose death rate decreased from 61.0 per 100,000 to 54.3 per 100,000.
13

While the COAT has experienced much success, there is still much work to do.
Figure 3
Montgomery County Ohio Unintentional Drug Overdose Deaths 2017 - 2020

13
Ohio Department of Health (2019). 2019 Drug Overdose Data: General Findings. https://odh.ohio.gov/wps/wcm/connect/gov/0a7bdcd9-
b8d5-4193-a1af-
e711be4ef541/2019_OhioDrugOverdoseReport_Final_11.06.20.pdf?MOD=AJPERES&CONVERT_TO=url&CACHEID=ROOTWO
RKSPACE.Z18_M1HGGIK0N0JO00QO9DDDDM3000-0a7bdcd9-b8d5-4193-a1af-e711be4ef541-nmv3qSt

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The COAT Data Unit was formed to increase data sharing across systems. The formal county and nonprofit agencies
have access to multiple data sets, but the agencies did not share the data. The Data Unit increased collaboration
among agencies, and a COAT Data Unit report is published every six months to assist in driving the decision-
making among the eight COAT Branches.
14
The data reports include drug overdose death data, emergency
department data, harm reduction initiatives data, drug seizure and forfeitures, prescription opioid data, treatment
data, and trends.
Figure 4
Community Overdose Action Team Data Unit 2019 Annual Report

14
Community Overdose Action Team (2020 June). Community Overdose Action Team Data Unit Six Month Report 2020.
https://www.mccoat.org/

11 | P a g e

PHDMC has evaluated data on unintentional drug overdose deaths since 2010, but COAT members saw the need to
develop and implement an Overdose Fatality Review Team. PHDMC hired a full-time Epidemiologist to provide
the Poisoning Death Review reports, the COAT Data reports, and conduct the Overdose Fatality Review process.
The Poisoning Death Review Reports are published annually, and the Overdose Fatality Review team meets
quarterly.
15
Recommendations are published from the Overdose Fatality Review and used by the COAT to drive
decision-making for the COAT branch prevention and intervention efforts.
Figure 5
Poisoning Death Review Report 2019 Executive Summary

15
Public Health – Dayton & Montgomery County (2019 November). Poisoning Death Review Report Montgomery County 2019.
https://5807d37f-2586-4a6d-bbcb-486dd9e77fca.filesusr.com/ugd/739abe_98f908606f774a4e84a5e607fbf5f04a.pdf

12 | P a g e

To address the need for enhanced data sharing, PHDMC secured a grant from the Department of Justice to create a
comprehensive view of those who are in active addiction. PHDMC partnered with Ascend Innovations to build the
database. Ascend Innovations is a data science company formed in partnership with the Greater Dayton Area
Hospital Association and the three major hospital systems in Dayton, Ohio. Through this partnership, Ascend
Innovations provides management of the Health Information Exchange for the three hospital systems. Ascend
Innovations uses a HIPAA compliant Amazon Web Services environment to store and analyze real-time hospital
data and other data sets. Health Level Seven (HL7) feeds were developed from the following sources:
• Health Information Exchange patient data
through the three major hospitals
• Historical patient data through the 29 member
hospitals in the Dayton region is available
through the Greater Dayton Area Hospital
Association
• Coroner’s Office and PHDMC vital statistics
data for unintentional drug overdoses
• Montgomery County Sheriff's Office jail
booking data
• ADAMHS mental health and addiction treatment
claims data
Dayton Police Department 911 dispatch data.

In addition to the 360 Degree Database, the COAT partners also identified another need to increase communication
among the hospitals and behavioral health providers. Behavioral health providers were not receiving any
information when one of their clients would enter the emergency department on a drug overdose. Ascend
Innovations worked with ADAMHS to develop the Montgomery County Emergency Response Notification System
(MCERON). This system expands the HL7 feeds from the emergency department to ADAMHS. ADAMHS then
intersects hospital records with behavioral health insurance claims data. If a patient who has been hospitalized
identified as open with a behavioral health provider, an email is sent in the morning to the provider. This informs the
agency that their client was hospitalized due to a drug overdose. For those not open with a provider, the email is sent
to the PHDMC Outreach Team. The PHDMC Outreach Team then attempts to contact these patients the next
business day.

13 | P a g e

Montgomery County, Ohio hospitals saw a significant increase in drug overdose emergency department visits, with
a peak in 2015 and 2016. While the hospitals have experienced a substantial decrease in 2018, a 14% increase
occurred in 2019 with 1,195 overdose visits by Montgomery County residents.
16
Through interviews with
Montgomery County emergency department personnel, it was expressed by the majority of the staff that there was
little to no linkage to services for individuals who experience a drug overdose. These patients are medically
stabilized and discharged with no follow-up care plan. Emergency departments play a critical role in preventing
repeated unintentional drug overdose and death by assuring patients’ coordination of resources before discharge.

In 2019, the COAT members engaged in a strategic planning process to outline targeted objectives and implement
strategies in the next two years. One of the gaps that have continued to be identified by COAT members is the lack
of resources available to those who are in active addiction. The COAT members recognized the need to expand
resources through formal and informal systems to provide effective intervention to this population. One of the
formal systems identified was emergency departments and the need to assure real-time intervention to individuals
while they are still in the emergency department.

Figure 6
Drug Overdose Emergency Department Visits by Montgomery County Residents

16
Community Overdose Action Team (2019). 2019 Annual Report. https://www.mccoat.org/

14 | P a g e

15 | P a g e

Once the COAT members identified the gap in services to those in active addiction, PHDMC took a leadership role
and began implementing a project management process to identify innovative solutions to address the issue.

Project management is applying skills, tools, and techniques used to develop and implement a design or plan.
Defining specific project management phases and the distinct actions under each phase have supported the project to
move into implementation.
17

The project followed five phases for implementation: Discovery, Initiation, Plan, Implement and Evaluate. Each one
of these phases will be discussed and more detail.
18

17
Lock, D. (2013). Project management (10th edition.). Gower.
18
HBR guide to project management. (2012). Harvard Business Review Press.

16 | P a g e

The Discovery Phase requires research to be completed and the groundwork to be laid for the project. The Discovery
Phase is the initial stage that requires data collection and review, and it will lead to an increased understanding of the
current landscape. It will identify the problem and the solution to the potential problem while ensuring that
stakeholders’ and users’ needs are addressed. PHDMC took the following steps in the Discovery Phase.
19

1. Define Planning Team
2. Review Data and Research the Current Market
3. Interview Stakeholders
4. Develop Project Solution Idea

The project began by identifying stakeholders who would serve on a Planning Team to create innovative solutions to
fill the gap in services. The Planning Team should be multi-disciplinary, and team members should have varying
levels of expertise in three domains: human factors (someone with a background in behavioral science); technical
factors (someone who has expertise in technology), and business factors (someone who can gauge the viability of
the idea).
20

The following criteria were used when identifying project stakeholders:

1. Selected stakeholders should include a culturally diverse group of individuals from various disciplines.
2. Selected stakeholders should include those who are in active addiction and those in recovery.
3. Selected stakeholders should include those who would directly use the designed solution.
4. Selected stakeholders should be available for meetings and be able to provide feedback.
5. Selected stakeholders should not have a conflict of interest.

It was also essential to keep the Planning Team small. To ensure a high level of engagement, teams should be
between eight and ten members.
21
The Planning Team included eight individuals from the following disciplines:
emergency department physician, emergency department social worker, data scientist, behavioral health provider,
public health official, peer recovery supporter, and healthcare administrator.

The Project Lead researched other programs in the market and gathered all the national and local data needed for the
team to make decisions. The following goal was set for the Planning Team: Identify innovative solutions to fill the
service gap for drug overdose survivors accessing emergency department services.

The following objectives were set for the Planning Team:
• Attend and participate in meetings
• Review all national and local data provided by PHDMC
• Review other programs that are currently in the market nationally and locally
• Identify solutions to the problem
• Prioritize solutions for implementation

19
Horine, G. (2013). Project management absolute beginner’s guide (3rd ed.). Que.
20
Dyer, J., Gregersen, H., & Christensen, C. (2011). The Innovator’s DNA: Mastering the Five Skills of Disruptive Innovators (1st ed.). Harvard
Business Review Press.
21
Aldag, R., & Kuzuhara, L. (2015). Creating high performance teams: applied strategies and tools for managers and team members. Routledge.

17 | P a g e

It is important to gather documents to be reviewed before the meetings, and the Project Lead should provide the
team members copies of the documents in advance.
22

The Planning Team scheduled four meetings. The first two meetings were spent reviewing and discussing the data
and the programs currently implemented in emergency departments. The data revealed that the emergency
departments in Montgomery County, Ohio, averaged 1100 patients per year treated for a drug overdose. They
identified that immediately linking individuals to care from an emergency department was a priority and developing
services to meet this goal was of utmost importance.

While there are no programs locally that respond to the emergency departments, the group reviewed information
from five emergency department programs that have designed interventions that included induction of medication-
assisted treatment during the emergency department visit, prescribing naloxone, and embedding peer support
services within patient care.

•

The Planning Team moved to brainstorming ideas in the third and fourth sessions. Four solutions were identified.
The group then evaluated the strengths and barriers to each solution. The group chose to design a solution that
would link individuals from an emergency department to a peer recovery supporter. The Project Lead presented the
Planning Team a summary of the data, an overview of the brainstorming session, and a summary of the stakeholder
interviews. The Project Lead also presented the Planning Team with a proposed solution. The solution included the
following: Design a system that would link patients from an emergency department to a peer recovery supporter.

22
Aldag, R., & Kuzuhara, L. (2015). Creating high performance teams: applied strategies and tools for managers and team members. Routledge.

18 | P a g e

The Linkage to Hope Project will implement a real-time referral
and linkage system to connect drug overdose patients in an
emergency department to a Certified Peer Recovery Supporter
(CPRS).

The project will use a real-time patient hospital data feed provided by the Health Information Exchange system into
a care coordination software platform. The CPRS will use this platform to identify when a patient has entered the
emergency department on a drug overdose. The CPRS will contact the patient and provide linkage to resources and
follow-up care after the patient is discharged from the emergency department.

Goals:
• Create a more robust multi-disciplinary approach to data sharing to address the factors surrounding the
county’s high rate of unintentional drug overdose deaths, identify high-risk populations, and identify other
substance-related issues
• Decrease future hospitalization of individuals who are entering emergency departments due to drug
overdoses
• Increase access to community resources
• Decrease drug overdose deaths

Considerations:
• Changing the emergency department protocols will be difficult, and the hospitals are not interested at this
time in embedding services in the current service delivery.
• Utilize the current PHDMC Outreach Team members to respond to the emergency departments. The team
already includes Certified Peer Recovery Supporters and social workers. They have some capacity to
respond but would need to expand to offer a 24/7 service. Could a pilot begin with the current team?
• PHDMC, The Greater Dayton Hospital Association, Ascend Innovations, and ADMAMHS have already
begun integrating data sets into the 360 Degree Database. Could the current data set be used to develop a
solution that would provide the PHDMC Outreach Team with information on patients entering the
emergency department?

23
Barron, M. & Barron, A., (1995). Project Management. file:///C:/Users/barbm/Downloads/project-management-
11.6.pdf

19 | P a g e

24
Barron, M. & Barron, A., (1995). Project Management. file:///C:/Users/barbm/Downloads/project-management-11.6.pdf
25
U.S. Health and Human Services (2013). Summary of the HIPPA Privacy Rule. https://www.hhs.gov/hipaa/for-professionals/security/laws-
regulations/index.html
26
U.S. Health and Human Services (2013). Summary of the HIPPA Privacy Rule. https://www.hhs.gov/hipaa/for-professionals/security/laws-
regulations/index.html
27
Office for Civil Rights (2017). How HIPAA1 Allows Doctors to Respond to the Opioid Crisis. https://www.hhs.gov/sites/default/files/hipaa-
opioid-crisis.pdf

20 | P a g e

28
Office for Civil Rights (2017). How HIPAA1 Allows Doctors to Respond to the Opioid Crisis. https://www.hhs.gov/sites/default/files/hipaa-
opioid-crisis.pdf
29
U.S. Health and Human Services (2013). Summary of the HIPPA Privacy Rule. https://www.hhs.gov/hipaa/for-professionals/security/laws-
regulations/index.html Office for Civil Rights (2017).
30
Develop Sustainability Funding Plan and Write Grants for District’s Trauma-informed Care Project. [Tender documents: T433663476]. (2018).
MENA Report.

21 | P a g e

31
Barron, M. & Barron, A., (1995). Project Management. file:///C:/Users/barbm/Downloads/project-management-11.6.pdf
32
Tran, L., (2015 February). The Importance of the Gantt Chart and the Critical Path for Project Management.
https://www.inloox.com/company/blog/articles/the-importance-of-the-gantt-chart-and-the-critical-path-for-project-management/

22 | P a g e

When an individual experiences a drug overdose, the individual will enter the emergency department by ambulance
or walk-in. The patient information is entered into the electronic health record, and the Health Information Exchange
will send information directly to the care coordination platform through the HL7 feed. An alert will be sent to the
peer supporter, and the peer supporter will contact the emergency department charge nurse. Patient consent will be
obtained, and the peer supporter will contact the patient either by face-to-face interaction or by telehealth. The peer
supporter will provide intervention and link the patient with the appropriate resources before discharge. The peer
supporter will then follow up with the patient within 48 hours post-discharge. All interactions will be immediately
documented in the care coordination platform.

Figure 8
Linkage to Hope Patient Flow

23 | P a g e

PHDMC developed a partnership with Ascend Innovations and Cordata Healthcare Innovation (Cordata) to create
the Linkage to Hope Project’s care coordination software. Cordata has developed a comprehensive care coordination
platform currently in use in 80 of the 88 counties throughout Ohio and in the neighboring state of West Virginia.
The enhancement of the current care coordination system will provide an HL7 feed to allow medical data to be
transmitted directly into the care coordination platform.

When an individual enters the emergency department due to a drug overdose, the individual is registered by front
desk staff and triaged by a Registered Nurse. Once the patient screening is complete, “drug overdose” is documented
as the chief complaint in the electronic health record. The HL7 feed has been developed to trigger a data pull when
certain words, for example, drug overdose, overdose, or drug poisoning, are entered into the electronic health record.
Figure 9
Hospital electronic health record ICD-10 Code entered for drug poisoning.

The HL7 feed will also trigger the data pull when a series of identified drug overdose ICD-10 codes are entered into
the patient record. The following data is transmitted from the electronic health record to the care coordination
platform in real-time:
• Patient Name
• Date of Birth
• Gender
• Race
• Address
• Phone Number
• Event Code which documents the date and time of the emergency department visit and whether the patient
was admitted to the hospital
• ICD10 Diagnosis codes
• Emergency Department Facility

24 | P a g e

Ascend Innovations and Cordata will also develop a mobile application to the system that will alert the Linkage to
Hope Project users when an individual who has suffered an overdose enters the emergency department.
Figure 10
Mobile application and alert system will alert the
Linkage to Hope project CPRS that an individual has
entered into the emergency department.

The Linkage to Hope CPRS will respond to the alert by logging into the HIPAA compliant Cordata system. The
system will display demographic information on the individual and will provide photos from the jail data feed if the
individual has had contact with the judicial system in the past. The emergency department facility location will be
displayed with a direct link to the phone number.
Figure 11
Care coordination platform mobile application
demographic page.

25 | P a g e

The CPRS will also be able to view the dashboard feed to view other drug overdose interactions. The mobile
application will allow the CPRS to click on any names to display the main demographic page.
Figure 12
Drug overdose interaction dashboard

The CPRS will then document the interaction into the Cordata system. The records will be shared by the CPRS
team.
Figure 13
Mobile and desktop versions of the care coordination platform are available.

26 | P a g e

The Linkage to Hope Project has adopted the Substance Abuse and Mental Health Services Core Competencies for
Workers in Behavioral Health Services.
33
These core competencies serve as a foundation for developing the
knowledge, skills, and abilities for the Certified Peer Recovery Supporters will need for the project. It also serves as
a foundation for the development of the position roles and responsibilities. Position postings, job descriptions,
resume screening, and interview questions will be tailored to identify and select candidates who meet the
competencies needed for successful performance in the position.

Knowledge, skills, and abilities include:
• Ability to communicate and convey lived experience to support others in recovery
• Serve as a role model for individual patients and the community
• Promote the use of recovery language
• Display effective communication skills
• Display effective conflict resolution skills
• Display skill in using Motivational Interview techniques
• Ability to advocate for others and promote a person-centered approach
• Display the foundational elements of cultural competency and can tailor services to different cultural
groups
• Display effective problem-solving skills
• Ability to effectively navigate through formal systems to assure direct linkage and coordination of
resources
• Display the ability to collaborate with system partners and stakeholders effectively
• Recognized the importance of a holistic approach to care
• Ability to adhere to confidentiality and follows all laws and rules that address disclosure of protected health
information
• Ability to recognize and maintain professional and personal boundaries with patients
• Ability to recognize crisis and emergency situations and have the knowledge and skills to address these
situations
• Knowledge of the biopsychosocial theory of addiction
• Knowledge of the impact of trauma
• Recognize the importance of self-care
• Recognize when there is a need to consult with others

Roles and Responsibilities include:
• Conduct community outreach to consumers, families, and support systems
• Mentor and develop meaningful and trusting relationships with consumers and their families
• Coordinate consumer arrival and departure for services
• Work closely with the emergency department and various other governmental and social service agencies
• Arrange and provide transportation, manage follow-up appointments
• Work with agency staff members to coordinate services
• Use own’s unique, life-altering experience to guide and support others
• Conduct outreach to patients who are in active addiction and who are seeking recovery
• Perform individual, group, community, and family education

33
Substance Abuse and Mental Health Services Administration (2015). Core Competencies for Peer Workers in Behavioral Health Services.
https://www.samhsa.gov/sites/default/files/programs_campaigns/brss_tacs/core-competencies_508_12_13_18.pdf

27 | P a g e

• Provide crisis intervention and de-escalation with consumers
• Refers and links patients to community programs/services and conducts follow-up, as necessary
• Compile consumer records and maintains documentation according to program and accreditation standards
and protocols
• Maintain confidentiality, respect consumer’s privacy, routine, and independence as much as possible

The Linkage to Hope Project requires all Peer Recovery Supporters to be certified through the state of Ohio within
their first six months of employment. Certification is valid for two years, and recertification is required before the
two-year lapse. To become certified, individuals must complete 40 hours of required training as outlined by
OHMHAS or have at least three years of work or volunteer experience as a peer navigator, peer coach, peer
specialist, or peer supporter.
34

Ohio certification requirements are as follows:
• Complete 16 hours of online training in the following topics:
o Introduction to Peer Recovery Support
o History of Addiction for Peer Recovery Supporters
o Ethics and Boundaries for Peer Recovery Supporters
o History of Peer Recovery Supporters
o Helpful Tips for Peer Recovery Supporters Entering the Workforce
o Health and Wellness in Peer Recovery Support
o Cultural Competence in Mental Health and Addiction Recovery
o Human Trafficking
o Supervision for Peer Recovery Supporters
o Trauma-Informed Care
o Ohio S-BIRT: An Introduction to S-BIRT and Motivational Interviewing

• Pass the Peer Recovery Supporter exam
• Submit the signed code of ethics statement
• Submit a Bureau of Criminal Investigations background check that is conducted within 30 days of
application submission

34
Ohio Mental Health and Addiction Services (2020). Ohio Peer Recovery Supporter Training and Professional Development
https://mha.ohio.gov/Health-Professionals/About-Mental-Health-and-Addiction-Treatment/Peer-Support/Peer-Supporter-Training-
and-Professional-Development

28 | P a g e

In addition to the training topics required for the Ohio Peer Recovery Supporter Certification, the following training
is required for all CPRS to complete within the first three months of employment.

TRAINING TITLE TRAINING DESCRIPTION TRAINER WEBSITE
OHIO SBIRT 102:
Foundational Skills of MI
This course focuses on the foundational
skills of the evidence-based practice of
Motivational Interviewing through the
scope of Screening Brief Intervention and
Referral to Treatment. The course
focuses on the skills proven efficient in
helping people change health behaviors
including open-ended questions,
affirmations, reflections, and summaries.
The course will illustrate examples of MI
adherent patient interactions to
demonstrate the various ways the skills
can be utilized.
E-Base Academy http://www.ebasedacademy.org/learn
Ohio SBIRT 103: Reinforcing
Change with Motivational
Interviewing
Building upon foundational Motivational
Interviewing spirit and skills, this course
focuses on enhancing behavior change by
reinforcing Change Talk and navigating
Discord. Participants are provided
opportunities to observe Change Talk
and Sustain Talk as well as practice
responding to common discord
statements.
E-Base Academy http://www.ebasedacademy.org/learn
Question, Persuade, and Refer
(QPR) Suicide Prevention
QPR is a nationally recognized and
evidence-based suicide prevention model
where organizations, businesses and
everyday individuals can learn the
needed skills to recognize and intervene
when someone is showing signs of a
suicidal crisis.
Montgoemry County
ADAMHS
https://www.mcadamhs.org/
Mental Health First Aid
Mental Health First Aid teaches you how
to identify, understand and respond to
signs of mental illnesses and substance
use disorders. Learn the skills you need
to reach out and provide initial support to
someone who may be developing a
mental health or substance use problem
and help connect them to appropriate
care.
Montgomery County
ADAMHS
https://www.mcadamhs.org/
Safety in the Workplace
Educates participants on safety
guidelines that should be followed to
reduce the risk of harm. Trianing is
based on the National Association of
Safety in the Workplace Guidelines
(2003).
Public Health - Dayotn &
Motngomery County
Virtual or In PersonTraining
Crisis Prevention Institute -
Nonviolent Crisis Intervention
Teaches de-escalation techniques as well
as restrictive and nonrestrictive crisis
interventions.
Public Health - Dayotn &
Montgoemry County
Certified CPI trainer
https://www.crisisprevention.com/Our-
Programs?campaign=cpih-b
Implicit Bias: Understanding
Multicultural Diversity
This training will explore paths we have
taken and the personal experiences that
have shaped our biases.
Montgomery County
ADAMHS
https://www.mcadamhs.org/

29 | P a g e

The Implementation Phase is where the project is executed and finalized. These tasks include:
• Developing an implementation team
• Securing resources
• Executing the project work plan
• Defining measures
• Modify project plans as needed
35

PROCESS MEASURES
• Number of individuals who enter into the
emergency department and the number of
successful contacts
• Number of successful follow-ups after
discharge
• Number and types of resource referrals
• percentage referred to treatment
• Number of drug-related arrests
• Number of overdose hospital visits
• percentage of clients who received a Narcan
kit
• Number of overdose deaths post-
intervention

OUTCOME MEASURES
• Increase in the proportion of clients who
receive Narcan kits
• Increase in the number of clients referred to
treatment
• Increase the proportion of clients linked to
resources
• Increase in the number of clients who
successfully engage in treatment
• Decrease the number of clients who
experience a hospital visit due to repeated
overdose
• Decrease the number of drug overdose
deaths

35
HBR guide to project management. (2012). Harvard Business Review Press.

26 | P a g e

The project will move into the last phase, Closure and Evaluation. In this phase, the project will conclude all
development activities and will continue ongoing activities. The project will also assess outcomes and evaluate
lasting performance.
36
The project will conclude when the Linkage to Hope Project is implemented in all nine
emergency departments in Montgomery County, Ohio, and it is operating 24 hours per day, seven days per week.
The project will scale to include other agencies that offer peer support services, and these agencies will be included
in the care coordination platform. Additionally, the technology used for this project can also be scaled to other areas
of disease management within the healthcare industry.

A quarterly and annual report will be generated shared with all partners and the COAT members, and the public.

Figure 15
Evaluation report example pages:

Summary

36
HBR guide to project management. (2012). Harvard Business Review Press.

27 | P a g e

The Linkage to Hope Project has taken an innovative approach to assure that individuals who have experienced a
drug overdose in the emergency department are provided appropriate and effective care upon hospital discharge.
The project has brought together partners from public and private entities to develop a software solution that can and
will be scaled past the implementation of this project to other areas of healthcare. The partners are committed to the
project's success and will further advance solutions that will continue to benefit vulnerable populations that
otherwise face healthcare system disparities.

There are many lessons learned from the Linkage to Hope Project. Here are some that the project partners have
identified:

• Define the project team members upfront and assure those with the expertise needed are involved. New
team members can also be added as required.
• Begin establishing partnerships BEFORE you plan a project. Relationships and partnerships are essential to
project success. If project team members change, take the time to develop a working relationship with the
new members.
• Assure that there is a long-term commitment from partners before planning takes place.
• Take time to fully understand the roles, responsibilities, and limitations of each agency.
• Never engage in a project without including individuals who will be directly impacted or using the product.
• Take the time to do the market research. Know what is already out there.
• Develop and plan the project BEFORE funding is secured. Do not modify a project’s vision to adhere to
grant requirements. Secure funding that aligns with the vision.
• Understand the software development takes time, and solutions cannot be developed overnight.
• Take the time to test the intervention before it is scaled. Start small.

ALWAYS CHALLENGE THE STATUS QUO!

Abstract (if available)

Abstract In 2013, the American Academy of Social Work and Social Welfare presented the Grand Challenges for Social Work (Bent-Goodley, 2019). These Grand Challenges aim to harness science, knowledge, and collaboration of cross-sector efforts to solve some of the most complex and severe social problems while eliminating health disparities (Grand Challenges Canada, 2011). This Capstone Project addresses the Grand Challenge Close the Health Gap, focusing on the drug epidemic. ❧ The drug epidemic continues to plague the United States and is one of the wicked complex problems that has increased health disparities. Unintentional drug overdose deaths have persisted in an upward trend in the United States and have devastated the lives of so many American citizens. Over 750,000 people have lost their lives due to an unintentional drug overdose from 1999 to 2018 (Centers for Disease Control and Prevention, 2020a). The COVID-19 pandemic has only compounded the issue as drug overdose deaths have soared at a time when the systems that support individuals with substance use disorders have been significantly disrupted (Centers for Disease Control and Prevention 2020b). The drug epidemic remains a public health emergency, and at the same time, these deaths are preventable. ❧ Many policies and system changes have taken place to support evidence-based strategies to increase data collection and improve healthcare systems, but there is still much to accomplish. A targeted population that disproportionately experiences barriers and stigma is those who suffer from substance abuse disorders. One of the largest gaps in services is in the emergency departments across the nation. Individuals who have suffered a drug overdose have flooded the emergency departments and leave with little to no follow-up care plan. Individuals are medically stabilized and released. This leaves these individuals at a higher likelihood for repeated overdose emergency department visits, increased chance for criminal justice involvement, and ultimately an increased probability of death. This Capstone, entitled The Linkage to Hope Project, is an innovative solution that addresses the Grand Challenge, Close the Health Gap, by harnessing technology and developing a real-time referral and linkage system to connect individuals in an emergency department to a Certified Peer Recovery Supporter (CPRS). The CPRS is a person who has lived experience and provides guidance and connection that medical personnel cannot provide. The Linkage to Hope Project is an innovative solution that will change the system of care for drug overdose survivors and decrease mortality. ❧ The purpose of the Linkage to Hope Project is to enhance the current healthcare system by filling a gap in the continuum of care for those who are in active addiction. Modifications in hospital systems and protocols will create a warm handoff to a CPRS. The Linkage to Hope Project will develop a system of care that increases engagement for those in active addiction. It will also provide the much-needed support and direct connection to additional resources that will decrease future hospitalizations and increase individuals’ likelihood of moving towards recovery. The Linkage to Hope Project has engaged in several design phases outlined in the prototype, Linkage to Hope Project Implementation Guide. The guide aims to provide further information on the steps taken by the project partners and the technological and clinical solutions that were developed to address the problem.

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Asset Metadata

Creator Marsh, Barbara Lynn (author)

Core Title The Linkage to Hope Project

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Degree Conferral Date 2021-05

Publication Date 05/24/2021

Defense Date 04/16/2021

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag active addiction,addiction outreach,care coordination,close the health gap,data sharing,drug overdose,healthcare,healthcare technology,Linkage to Hope Project,opioid addiction,peer recovery support,peer support,substance abuse,substance misuse

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Araque, Juan (committee member), Rice, Eric (committee member), Weiss, Eugenia (committee member)

Creator Email barbmarsh27@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC13012637

Unique identifier UC13012637

Identifier etd-MarshBarba-9639.pdf (filename)

Legacy Identifier etd-MarshBarba-9639

Document Type Capstone project

Format theses (aat)

Rights Marsh, Barbara Lynn

Internet Media Type application/pdf

Type texts

Source 20210611-usctheses-batch-839 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu