Walk in for Recovery

The reality that Columbus, Ohio is the epi-center for the drug overdose epidemic in the state resulted in the leadership of the Addiction Services Division of CPH developing and implementing a model practice of building collaborative relationships with trusted community organizations and agencies to establish coordinated days of service linkage titled, Walk in for Recovery, WIR, and it is tied to the Columbus and Franklin County Addiction Plan, which is led by CPH.  

The primary goal of the WIR was to provide public health care in the community, outside of public health and behavioral health institutions, and to create a walk in service model that operated from mid-afternoon to late evening, not requiring an appointment.  The objectives were to develop rapport with participants through offering a meal and harm reduction resources.

The model of the WIR, asked prevention, harm reduction, treatment and recovery support agencies to commit to meeting with participants in the community at designated sites in which the participant felt safe and supported.  The participant was then linked to services that he/she/they felt comfortable connecting with after a brief motivational interview with a WIR team member.  The costs of services like providing duplicate birth certificates and state identification services, basic wound care, obstetrics and gynecology care, long acting reversible contraception, sexually transmitted infections and HIV testing, health screenings and Covid-19 vaccinations was covered by CPH and the Naloxone and Fentanyl test were covered by CPH and resources from participating agencies.

The drug war being fought in the United States for the past 10 years is one that makes the news for shock value and shames the victims with sensationalized exploitation and crippling stigma.  The opioid epidemic that has plagued our rural, urban and suburban communities since 2011 has become the drug overdose epidemic in the midst of a global pandemic.  In 2019, an estimated 50,000 individuals died from a drug overdose[i].  In 2020, just two years later, that number more than doubled to over 100,000. Ohio has been ground zero competing with its southern neighbor, West Virginia, for the highest number of age-adjusted overdose deaths in the U.S.   

Columbus, Ohio, the state's capital and largest city, is located within Franklin County.  Franklin County had an estimated population of 1,323,807 in April 2020, of which 23.8% were of Black or African American origin alone, 5.8% of Hispanic race/ethnicity and 5.7% of Asian race/ethnicity.  Just below nine percent of adults under 65 are uninsured[ii] and 13.5% are living below the federal poverty level. Columbus Public Health serves the cities of Columbus and neighboring suburb, Worthington, totaling 920,534 people.

Ohio had the second highest rate of drug overdoses involving opioids in 2020, second only to West Virginia^[1]. In Franklin County, Ohio, from January 1, 2020 to December 31, 2020, overdose deaths increased by 45%, totaling 855[iii] deaths in 2020 (587 in 2019). According to the Franklin County Coroner, while Fentanyl is responsible for 87% of the deaths, the number of deaths that occurred as a result of adulteration of other recreational drugs with Fentanyl is alarming:  Cocaine (42.8%) and Methamphetamine (14.3%).[iv]  Also referenced in the Franklin County Coroner's report were the top zip codes with the most overdoses; 43223, 43204, 43207, and 43211. These zip codes, in addition to the zip code, 43213 and 43222, represent close to 44% of emergency medical service and emergency department runs in Columbus for drug overdoses.[v]

Complicating interventions are the structural drivers of economic poverty, low paying jobs, housing insecurity, political unrest due to inequitable policies and judicial practices regarding drug trafficking and drug abuse.  These factors, while detrimental to building resilience and protective factors to delay the onset of drug use, are ideal for drug trafficking and organized crime. In order to address the drug overdose epidemic, in 2020, Columbus Public Health (CPH) took the helm of the Franklin County Opiate Action Plan (FCOAP). Under the guidance of Columbus Public Health Commissioner Dr. Mysheika Roberts, with the support of Columbus City Mayor Andrew J. Ginther and the Franklin County Board of Commissioners, the FCOAP was evaluated by epidemiologist and community partners and was renamed to address not only opioids, but all substances, and renamed as the Columbus and Franklin County Addiction Plan, (C&FCAP). A collective impact model was used to develop a plan that would maximize resources and build intersystem collaboration.

The C&FCAP, led by CPH and facilitated by the CPH Addiction Services Administrator, focuses on meeting three goals annually: decreasing drug overdose deaths by 15%, decreased drug overdoses by 15% and decreasing Hepatitis C rates by 10%.  These goals are met by providing population, health equity and health system interventions. In order to accomplish these goals, the C&FCAP uses real-time data from the hospital emergency departments, epicenter, data from the Franklin County Coroner and the Ohio Department of Health to determine when surge overdose anomalies occur, and to conduct outreach activities to prevent further overdose anomalies.  And although interventions such as increased Narcan and increased Fentanyl test strip distribution, quick response teams to link individuals to treatment post an overdose and increased medical detoxification beds have helped prevent overdoses and overdose deaths, the numbers continued to rise in Columbus; likely due to Covid-19.

It is well documented that the Covid-19 virus negatively impacted alcohol and other drug use with a surge in use and increased mental health issues. [vi] In addition to addressing the complex issue of substance use disorder, SUD, those who are struggling with SUD, are at increased risk of poor Covid-19 outcomes”, as stated by the National Institute of Drug Abuse website on December 19, 2021. Why are the risks increased for the SUD population?

The messages from the healthcare community since the start of Covid-19 have been clear: socially distance, wear a mask, wash your hands, stay home and if you are feeling the symptoms of Covid-19, seek emergency care.  Healthcare systems also spent the better part of 2020 telling individuals that unless they had a chronic health condition requiring emergency care, to not go to the emergency room as they were, crowded”, and attention needed to be given to those with serious” conditions.  Conversely, we have shamed those who use illegal substances and/or are diagnosed with SUD into creating enclave communities that are inherently isolated and unhealthy. And because our society has treated the disease of addiction as an individual's choice that could potentially progress to death, many who overdosed and were saved by Narcan, refused to go to the hospital and/or medical detoxification to begin treatment.  The conundrum of the individual who had clarity of their condition and fragility of the disease of addiction, was how to justify treatment of their disease over the pandemic of the world.

The CPH mission statement to protect health and improve lives is exercised throughout each division and throughout leadership of the C&FCAP. When collaborating to achieve the goals of the C&FCAP, it is imperative that we focus on health equity by building a scaffolding of services that address accessibility, meeting basic needs and connecting and providing essential services for stability in the community and care coordination.  As such, the impact of Covid-19 on individuals with SUD, the increase in drug overdoses throughout the community, and the need to get individuals linked to treatment as well as vaccinated for Covid-19 necessitated a change in the way we traditionally provided services. Columbus Public Health's Addiction Services Division (ADS) modified their annual, Walk in for Recovery (WIR), to ensure that those communities that are disproportionately impacted by drug overdose deaths and Covid-10 infections and deaths, were given access to resources and services. We needed to remove barriers, real and perceived, that prevented individuals from obtaining life-saving treatment and preventive medication.

The WIR is an event created by CPH to provide walk-in access to medical detoxification services, immediate assessment and treatment linkage services and to distribute harm reduction materials.  Starting in 2019, the WIR sought to address concerns identified by those with lived experience that stated that scheduling an appointment is difficult for a variety of reasons, including acuity of need, no telephone or internet access, and little to no transportation.   Additionally, individuals stated that not having a driver's license or identification often prevented them from even seeking treatment or insurance to cover the costs.  In 2020, despite the impact of Covid-19, we modified our approach to ensure that individuals would obtain free copies of birth certificates and free, state identification cards.  Free transportation was also provided to individuals who completed their assessment at the WIR for follow up services.

Prior to conducting the WIR in the summer of 2021, we went through the Incident Command System to address further potential health equity issues that would prevent individuals from utilizing the WIR. Additionally, we found that providing our medical health van at these community events provided another piece of needed services to this most vulnerable population, including a safe place to discuss wound care, human trafficking disclosures, and covid vaccines. We also used the expertise and insight from our State Opioid Response (SOR) outreach team that was funded by the Ohio Department of Mental Health and Addiction Services.  The SOR outreach team literally and figuratively met people where they were.  For many, being able to receive an assessment in their community, while maintaining confidentiality and CFR42 practices, created trust and rapport with the SOR outreach worker. The unique practice also allowed CPH team members' access to enclave communities in homeless camps and houses where individuals are squatting to provide Hep A and Hep C vaccinations, basic wound care and referral to clinical services.  What was clear from the SOR work was that there were many more services that individuals were in need of but that they did not feel comfortable addressing in a medical setting, including at the Columbus Public Health Department, for fear of judgement, shame and mismanagement of care.

 While the practice of outreach and mobile medical services is not new to providing healthcare, particularly in rural communities, the provision of this services in a large, urban environment, focusing on linking individuals to substance use disorder treatment, is innovative and unique. And although the practice of mobile healthcare services is predicated upon meeting the needs of the rural community that is challenged by environmental factors and invisibility of medical offices and emergency care, the hesitancy of engagement on the side of the patient is also of equal significance as familiarity with medical teams and healthcare conditions can result in patients going undiagnosed and untreated.  This specific dynamic is also one that the urban community is influenced by as social determinants of health are also connected to redlined and gerrymandered districts that create desserts of service and mistrust in systems of care.

A variety of non-medical factors influence how patients interact with the health care system and how well they are able to manage their health. These include education level, income, employment, housing quality and stability, the strength or weakness of social relationships, access to transportation, and availability of nutritious and affordable food. Problems in any of these areas can contribute to increased chronic conditions, substance abuse disorders, and shorter life expectancy in rural areas.

The community response to the WIR has increased each year.  The number of individuals served has tripled since the start of this innovative practice, that runs for 9 weeks, since 2019 with many of those participating referencing, word of mouth” from friends and relatives encouraging them to walk-in to get a meal at a minimum.  From a meal, to Naloxone and Fentanyl test strips training, to a Hepatitis A vaccination, to treating an abscess, to transporting a patient to crisis stabilization and medical detoxification, to administering a Covid-19 vaccine, the WIR is an innovative practice that evolves with the ever changing needs of the community and patients it serves. 

The primary goal of the Walk in for Recovery, WIR, was to provide public health care in the community, outside of the public health and behavioral health institutions, and to create a walk in service model that operated from mid-afternoon to late evening, not requiring an appointment.  The objectives were to develop rapport with participants through offering a meal and harm reduction resources in an effort to help build the linkage to ongoing substance use disorder, SUD, treatment services should the participant wish to do so.  In 2021, we decided to use a model of two consecutive days at each selected and advertised location in an attempt to build community connections and allow the participant to return a second day to seek additional services that they may not have been comfortable with the first day.

In order to achieve the goals of the 2021 Walk in for Recovery, WIR, there were several factors that were considered when determining which service(s) would be offered: medical detoxification and treatment bed access, the impact of Covid-19 on the willingness of service providers to assess and link with patients outside of their office(s), location of the highest rates of overdoses and overdose deaths and the peak hours of such incidents. It was essential to use the knowledge of the different Columbus and Franklin County Addiction Plan, C&FCAP, members in filling the gaps in services needed as well as build upon the success of previous interventions to decrease overdose deaths, decrease overdoses and decrease rates of infectious disease.   

To implement the WIR, Columbus Public Health, CPH, asked for the expertise and insight of the members of each subcommittee to help in developing interventions to address inequity in treatment.  The prevention and education subcommittee developed a spatial map to determine where prevention education desserts exists in the community and overlaid the map with overdose and reported chronic health condition maps.  The public safety committee shared their report on overdose incidents post release from jail and the number of individuals that scored high on the Clinical Opiate Withdrawal Scale, COWS, upon booking into the Franklin County Correction Center.  This data was then used to justify providing those who scored high on the COWS with Narcan at release.  The faith and community subcommittee assisted in identifying locations in the community that had high foot traffic and a history of providing community events with large turnouts.  

During each of the monthly C&FCAP subcommittee meetings, including prevention and education, healthcare and harm reduction, treatment and recovery supports, and data, Columbus Public Health, CPH, shared the overdose surge anomaly advisories to date and the after-action steps that were taken if, based upon the analyses of a team of epidemiologists, law enforcement officers, first responders and data analyzed by the data subcommittee, an overdose surge response protocol needed to be implemented. While there was an increase in surge anomalies reported by either the Franklin County Coroner, a local hospital or the epicenter during Covid-19, the need to hold a call to coordinate a specific community response was minimal. This had much to do with the pop-up Naloxone distribution locations and community partnerships whereby CPH and other Naloxone distribution entities set up weekly to provide the harm reduction materials consistently as an overdose prevention method.  Additionally, many of the anomaly surges occurred like buck shot across a zip code map of 44 different areas with only 5 overdose deaths occurring in a 24 hour period.  And while the loss of any life has a tremendous impact on the family and community, the numbers did not rise above a predetermined baseline.   Although an emergency call for additional response was not held for the majority of incidents, an email with specific action steps was sent to all C&FCAP members, with instructions to share on their listserv with imagery and graphics to post on their websites suggesting people use drugs with caution and to call 9-1-1 in an emergency.

From January 2020 through May 2021, there were 51 overdose surge anomalies reported by the partners of the C&FCAP and of those 51 surge anomalies, there were only four calls to coordinate supplementary outreach events in the community for multiple drug overdoses occurring in a concentrated area.  The C&FCAP partners were contacted by CPH and given specific guidelines to follow when conducting outreach, assessments and providing information to the public in order to allow those with lived experience and opportunity to make an informed decision about their substance use.  What was also indicated by the frequency of reports and their locations, was that the increase in overdoses were occurring within a population and community that had little experience with adulterated recreational drugs and overdose prevention.  The public information officers from several agencies, led by CPH's communication team, developed a marketing plan that would encourage not only people with lived experience of SUD, but also those who use drugs recreationally, to stop by the WIR to receive harm reduction tools like Naloxone and Fentanyl test strips. The materials made sure to note that the services and resources were free, the hours were past 5pm, and that a meal and free copy of a birth certificate were provided. Social media, local news outlets and C&FCAP agencies pushed out the material weekly. 

Starting in March 2021, during each of the monthly C&FCAP subcommittee meetings, CPH provided an outline of the structure for the WIR and asked for an intersystem collaborative process that would result in multiple service providers co-locating at a predetermined location in the communities with the highest incidents of drug overdoses.  This would permit treatment providers to schedule their teams at each location including an assessment clinician, a crisis intervention specialist, harm reduction educator(s), and entitlement benefit coordinator(s).  This fostered collaboration and ownership of the WIR.  CPH leveraged their internal clinics to provided the CPH mobile health clinic in order to offer COVID-19 vaccines, wound care,  obstetric and gynecological services, Hepatitis A vaccinations, pregnancy tests, and health screenings:  services were identified by participants from the two previous years of data collection from the WIR. Because we were operating the WIR as a collaborative effort, we also had two federally qualified health clinics, FQHC, PrimaryOne Health and Lower Lights Health Center as locations for the WIR. Each of these FQHCs were able to provide the full range of healthcare services that are offered during their regularly scheduled hours of operation. Both of the FQHCs are located in communities that represent the highest rates of overdose, overdose deaths, infant mortality and infectious disease.

Because of COVID-19, CPH had to consider our participating staff and their individual roles in ICS, CPH clinics, and their limitations due to existing health conditions.  CPH also used past data to determine the days that were most active during the previous WIR events.  As such, we agreed to offer the WIR at one location per week, for two consecutive days, as historically, word of mouth resulted in more participants on the second day of the WIR.  

   CPH also asked to house the events at locations that ensured we were meeting a diverse population.  CPH also chose dates that did not coincide with C&FCAP outreach events that were scheduled based upon historic increased overdose periods.

The following were the locations and dates of event with zip codes included:

June 15 & 16, Jordan's Crossing Food and Clothing Pantry, 43204

June 29 & 30, Stonewall Columbus LGBTQ Center, 43201

July 13 & 14, PrimaryOne Health Center at John Maloney, 43207

July 27 & 28, True Love Ministries Church, 43211

August 10 & 11, Victory Ministries Food, Clothing and Service Pantry, 43213

August 24 & 25, Lower Lights Health Center, 43222

Funding was set aside from the CPH general budget for the WIR in 2020.  The amount set aside was $6000 to cover the costs of locations for use of their space and security if needed. The State Opioid Response Grant, SOR, that CPH's Addiction Services received to serve African American, LatinX and Urban Appalachin populations, allowed CPH to purchase bags to distribute at the WIR that included hygiene kits, hand sanitizer, face masks, socks, rain ponchos, neck gaiters, first aid kits, condoms, sanitary pads, Narcan and syringe collection boxes if requested. Each location sponsored the meals that were provided to participants.  The estimated costs for items in the bags, minus the Narcan, Fentanyl tests stirps, syringe collection boxes, was $32,294.  This does not include staff time or costs of vaccinations and medical services. The costs of the Narcan and Fentanyl test strips was just over $30,880.

The primary goal of the Walk in for Recovery, coordinated by Columbus Public Health, was to provide health care in the community, outside of the public health and behavioral health institutions, and to create a walk-in service model that operated from mid-afternoon to late evening, not requiring an appointment.  We recognized the need to break down specific, short-term interventions that would potentially have immediate and long-term impact. The immediate impact of distributing Narcan to participants of the WIR, was to decrease overdose deaths in the communities with the highest rate of overdoses.  The short-term result was to build trust and rapport and to provide the symbolic act of, no judgement”, or condemnation of the participant's substance use disorder, SUD, or living situation or health condition. This was measured by the follow through of the participant for other services being offered. The additional short-term objective, with a long-term outcome, was to provide and/or address immediate healthcare needs to those attending including but not limited to, COVID-19 vaccination. The partnerships with C&FCAP agencies and the Columbus Division of Fire quick response team provide immediate transportation to treatment if an individual stated they were ready to engage.  Having the event over two consecutive days also permitted the participants who were resistant to intensive services offered on the first day of the event, to return the second day to receive the same quality services if they wanted.

       From the previous two years of WIR events, data collected helped to drive the service delivery and to focus on what those participating identified as most important to improving their health outcomes and linkage to SUD treatment.  A RedCap survey was developed by the CPH epidemiology division that was formatted from the hard-copy survey that was reviewed with each WIR participant.  Consideration was given to the flow and format of the questions that were asked of participants through a motivational interview process.  The forms were then collected and data input by one person within the CPH Addiction Services Division for consistency. Once complete, the CPH epidemiology department would then provide a summary report of the event.

     The summary of data concluded that four of the six locations were successful with serving more people than the previous year. Two of the locations were new additions, with one serving over 100 participants and the other seeing less than 50 for two days total.  We analyzed the possible reasons for the low show rate and the increased rate at the opposing site to determine if we would continue at both locations next year.  We hypothesized that the low participation rate location had to do with two factors: the site is used consistently by members of the community that do not necessarily have SUD, but more so, economic poverty due to lack of employment. This same location is far removed from the sidewalk, with several parking spots in the front of the building.  The WIR used a large tent to provide screenings in the parking lot and to station the mobile medical unit.  These two things may have made the location seem as though there was a planned event for invited guest only.  While the marketing team canvassed the surrounding community and purchased a billboard for the event less than a quarter of a mile from the location, details of services being provided were not on the billboard.

The turnout at the other five locations, when reviewing the data, suggest there were a few factors that impacted the positive outcome, including the fact that we focused on the communities where outreach events are held several times throughout the year, that the majority of locations were not new to providing SUD services in the community, and that we concentrated our efforts in the zip codes that have the highest rates of overdose.

The success of the program each year is in the total of participants that received services. 

2019: 236

2020: 273

2021: 586

After reviewing the demographic data, we were validated that our intention to focus on health equity and disparate communities was achieved with just over 21% of the participants identifying as homeless, and 38% not answering housing status.  Additionally, 36% identifying as unemployed and 39% not answer employment status.  Close to 40% of those participating in the WIR reported not having medical insurance. There were 501 participants who received a meal. 

Based upon the evaluation of the summary data, we have decided to offer the WIR again in 2022, at the same locations, and are considering extending the event to three days if the COVID-19 virus is at a low to moderate rate of infection. This year's WIR was the most successful since we started the annual event in the summer of 2019.  Each year we have had to modify the format, trying to determine the best way to engage with those most in need. Adjustments were also made because of the Covid-19 pandemic, but we knew that the need for those with substance use disorder were at an even greater risk of overdose death during the pandemic due to required social distancing, isolation and inadequate access to healthcare. The outcomes were successful and encouraging. 

Since the first Walk in for Recovery, WIR, in 2019, the role of community partnerships has been vital to the success of event.  Each agency and organization brings a skillset that is unique to their particular model of service delivery to the substance use disorder, SUD, population. Whether it is peer support services, healthcare enrollment, behavioral healthcare assessment and treatment, human services linkage, medical care treatment or holding a conversation in a sacred space with a person who just needs to be heard, member agencies of the Columbus and Franklin County Addiction Plan, C&FCAP, led by Columbus Public Health, have eagerly signed up to participate in the annual event. 

Using funds received from the State Opioid Response, SOR, grant to purchase items to distribute to those who participated as clients in the WIR, was critical to providing prevention tools and developing trust and rapport with the clients.  It was equally important to have a meal being offered regardless of whether the attendee chose to receive other services.  Each location of the WIR agrees to provide the meals as long as the costs to utilize the building and all of the utilities are covered by funds from CPH's addiction services division. The funds from CPH are covered and included in our yearly budget.  The SOR funds are not being reallocated by the Ohio Department of Mental Health and Addiction Services, (OhioMHAS), as our funds were targeted towards the specific population of African American, LatinX and Urban Appalachian population with substance use disorder, SUD. We have submitted a proposal to our local Franklin County Alcohol, Drug and Mental Health, ADAMH, Board for the SOR 2.0 but have not heard if we will be awarded the funds.  The impact of not receiving the dollars will be felt by the participants as they have come to rely on receiving basic items included in their bags that help address physical needs if homeless, (hygiene kits, socks, rain ponchos, sanitary napkins) or if struggling with SUD, (fentanyl test strips, Narcan, and first aid kits).  Sometimes, these materials are part of engaging resistant participants and provides an opening for them to seek further services.  Thus, when we talk about sustainability, it isn't just regarding funding, but also regarding relationships.  The medical services provided will still be available as will the assessment, transportation and treatment as these are all reimbursable. The Alcohol & Drug Services division of CPH was recently awarded a mentor grant from NACCHO and will be using the funds received to provide the fentanyl test strips for the 2022 WIR.

         A cost benefit analysis of the WIR has been difficult to conduct.  It would require each collaborative partner providing the costs associated with their participating staff member's time, including licensing and credentials as these factors influence reimbursement rates from insurance.  It would also necessitate tracking the clients that are linked to specific agencies at the WIR, that followed through with on-going services with that agency.  The collection of that data would need to be done for one year post linkage to the agency and would include the costs and reimbursement encumbered for the client. There are over 20 agencies that participate in the WIR and well over 70 different individuals from those agencies whose roles range from an outreach worker, community health educator, addiction clinician, peer supporter, social worker, nurse, doctor and mental health counselor.   

  The ADS division will be submitting grants to cover the costs of items provided in the bags that are distributed during the WIR and to cover the costs of outreach workers that are critical to building trust in the community and helping people with lived experience become familiar with the imagery of the WIR and the C&FCAP.  These relationships help with community connectors referring new clients to the WIR and to on-going services provided not only by CPH, but through many of the C&FCAP partner agencies.    For CPH and the C&FCAP, there is no doubt that the WIR for occur each summer.  The only question that has been posed by all participating partner agencies is can we do this more often throughout the year; a question we will only be able to answer, post the COVID-19 pandemic as many healthcare agencies, especially CPH, are in the thick of the work to help protect lives and improve health. .