The activity will assist the COE healthcare team in understanding what proactive outreach involves, the key principles, and how it can benefit the COE.

Agenda:

1.    Introduction 

a.    Definition of Proactive Outreach 

i.    There is no single definition of proactive outreach.
ii.    Traditional treatment methods are reactive.
iii.    Proactive outreach evolved out of the Assertive Community Treatment (ACT) approach.

b.    Proactive Outreach and COEs

i.    The COEs were designed to help clients with opioid use disorder (OUD) achieve optimal health, well-being, recovery, and choice by minimizing the treatment gaps, providing intensive physical and behavioral health care coordination, expanding access to MOUD, helping engage and retain clients at high risk for ODD in the community, and ensuring access to high-quality, evidence-based OUD treatment. 
ii.    Some COE requirements that play a key role in proactive outreach are:

1.    A community-based care management (CBCM) team that includes a certified recovery specialist (CRS) 
2.    Ability to provide or refer to services such as primary care, mental health, and family planning 
3.    Ability to accept referrals 24 hours a day, seven days a week 

iii.    Legacy COEs included proactive outreach as a strategy for retention.
iv.    The evaluation of these original COEs showed 

1.    The COE-client engagement rate for the initial 90 days was 76.9 percent and 55.5 percent for the first 12 months, whereas standard non-COE OUD treatment client retention for 12 months was 44.1 percent. 
2.    Clients who were engaged in COE care had a 29 percent decrease in the number of inpatient and emergency department visits related to opioid overdose (11.1 to 7.9 per 1,000 member months). 
3.    Hospitalizations related to opioid overdose also decreased by 33 percent, from 1.8 to 1.2 hospitalizations per 1,000 member months.

c.    Need for Proactive Outreach

2.    Benefits of Proactive Outreach 

a.    Reduction in hospitalization rates
b.    Enhanced medication adherence 
c.    Decreased rates of homelessness 
d.    Improved quality of life and functioning 
e.    Decreased criminal justice involvement
f.    Lower cost to the system

3.    Key Principles of Proactive Outreach  

a.    Proactive engagement and persistent outreach 
b.    Tailoring services to individual needs and preferences 
c.    Multidisciplinary team approach 
d.    Collaborative and flexible service delivery 

4.     Indicators of Successful Proactive Outreach

a.    Building trust and rapport with clients 
b.    Engaging family and social networks 
c.    Providing proactive and continuous support
d.    Coordinating care and integrating services 
e.    Evaluation of how they’re doing and how they are living

i.    SDOH needs

f.    If you start the relationship in the community if someone disengages it isn’t odd for you to come to them

5.    Challenges and Limitations

a.    Limited resources and funding 
b.    Staff turnover and burnout 

i.    More telehealth if it’s a client fit
ii.    Burnout can be mitigated by client success- Know you did everything you could
iii.    Family support of efforts

c.    Resistance from clients and families 
d.    Stigma and societal barriers
e.    Confidentiality- Get information don’t give information

6.    Trauma-Informed Intervention

a.    Safety
b.    Trust- Transparency 

i.    What we can do
ii.    What we can’t do
iii.    Follow through with what you say you’re going to do
iv.    Up-front explanations
v.    Let folks know that staff was there (leave cards)

7.    Outreach

a.    Target areas with high overdose rates

i.    Leave cards in doors
ii.    Grocery Store
iii.    Laundry mats

b.    Social media
c.    Community organizations
d.    SU providers that aren’t COEs

i.    Methadone providers

e.    Narcan distribution
f.    After hours
g.    Celebrate successes!

8.    Intake

a.    Client choice
b.    Orientation to the services provided.
c.    Client Locator Form
d.    Imbedded into the intake

9.    Process

a.    Defined process
b.    First 2 weeks of the month
c.    After 2 months
d.    Phone and mobile 
e.    Have some staff onsite 
f.    Missed appointments

10.    Helpful Tips

a.    Check jail list (Vinelink) 
b.    Emergency contact can provide more information. 
c.    Try different times of day (after hours and weekends)
d.    Let the team know when someone is disengaged. 
e.    Look in the PDMP for alternate addresses 
f.    Use information that is collected to find people. 
g.    Social media 
h.    Celebrate successes!

11.    Discussion
12.    Questions