Improving on Excellence: Expanding Existing Overdose Prevention Approaches in New York City

As New York City pulled itself out of the worst pandemic in a century, its leaders faced the urgent challenge of getting life back on track. From the economy to education, restoring and strengthening pandemic-era losses would be no small feat. For public health officials, a pressing priority was crafting a strategic and equitable plan to reclaim the years of life expectancy lost due to the impact of the COVID-19 pandemic.

The answer was HealthyNYC – the city’s population health agenda – which sets a clear goal of reaching at least 83 years of life expectancy by 2030 and reducing mortality across seven leading causes of death: drug overdose, suicide, cardiovascular disease and diabetes, screenable cancers, COVID-19, violence, and maternal mortality. These represent about 70 percent of the leading causes of mortality in the city, and progress on each is measurable with NYC Vital Statistics Data.

Within HealthyNYC, overdose deaths remain one of the most persistent and inequitable challenges. Despite 2023 and provisional 2024 data showing the first decrease in overall overdose mortality in New York City since 2016, disparities have widened in many communities most impacted by decades of punitive drug policy and the subsequent overdose crisis. In particular, older Black New Yorkers (55–84 years old) and residents of high-poverty neighborhoods continue to experience the highest rates of overdose in New York City.

The city works to prevent these deaths in a multitude of ways, including through the distribution of naloxone kits, facilitation of overdose reversal trainings for community-based organizations, and peer support for individuals experiencing non-fatal overdoses to prevent subsequent overdoses. Despite these interventions, the scope and scale of the overdose crisis requires innovative solutions. One such effort is the NYC Health Department’s use of quality improvement methods to accelerate and strengthen its overdose prevention response to priority communities and neighborhoods. 

IHI and the NYC Health Department co-designed the Overdose Prevention Collaborative to meet the needs of those individuals who remain at the highest risk of overdose deaths. Two key themes emerged as opportunities for improvement: 1) the importance of placed-based strategies to prioritize neighborhoods in New York City continuing to disproportionately experience high rates of fatal overdose; and 2) the depth and breadth of expertise in overdose prevention found amongst frontline staff in the Overdose Education and Naloxone Distribution Unit (OENDU) and the Relay Program at the NYC Department of Health. This Collaborative integrated both key themes in developing the design and the implementation strategy for improvement projects tailored to the internal activities within the agency.

Expanding on Place-Based Strategies

New York City has a unique geography, with five distinct boroughs and a population of nearly 8.5 million people. New York City’s Department of Health often uses a more granular system of United Hospital Fund Areas (UHF-42) to define 42 distinct communities and implement health-related strategies to meet their specific needs. In reviewing overdose data by UHF-42 neighborhoods, several “hot spots” emerged as priorities for using improvement science to enhance and expand naloxone dispensing, along with other harm reduction services tailored to the unique characteristics of these neighborhoods. 

This place-based approach is at the heart of the improvement projects developed by the OENDU teams. Two improvement teams are focusing on: 1) increasing naloxone dispensing in neighborhoods with high rates of overdose death, using the existing network of Opioid Overdose Prevention Program (OOPP) organizations; and 2) proactively engaging new potential OOPPs in areas with less programmatic saturation. A study found that 97 percent of people who received naloxone kits through OOPPs were at high risk of overdosing or witnessing an overdose, attesting to the ability of OOPPs to reach those most impacted by the overdose epidemic. During the first learning session of the Collaborative, the two teams mapped their current processes, developed aim statements, established theories of change, and created measures. Both teams are now testing their theories of change to determine whether increasing engagement with existing OOPPs, and intentional outreach to expand the OOPP network, will increase naloxone distribution in neighborhoods and, as a result, reduce overdose deaths in these UHF-42 neighborhoods with a persistent rate of high overdose deaths.

Leveraging Frontline Staff Expertise

Launched in 2017, the Relay Program is an initiative led by peer Wellness Advocates, working in collaboration with 15 NYC emergency departments. Relay provides timely outreach and engagement for individuals who have experienced a near-fatal overdose, and up to 90 days of ongoing support to connect participants to appropriate services. With the wealth of experience and knowledge gained by eight years in operation, the Overdose Prevention Collaborative included the participation of Wellness Advocates on two improvement teams to create their teams’ process maps, aim statements, theories of change, and measures. This approach allowed both teams to surface their own change ideas and customized theories of change, rather than implementing an externally created change package. The two Relay Program-focused improvement teams are now testing their initial change ideas to: 1) improve their outreach methods through dedicated outreach time for Wellness Advocates to reach older Black men and those participants experiencing homelessness; and 2) revise their follow-up model to create stronger engagement with participants during the critical 24–48 hours following an emergency department visit. By including frontline staff expertise in the first learning session, both teams were able to test their internally developed change ideas with greater confidence in the likelihood of improved outcomes for participants.

Conclusion

The HealthyNYC agenda sets forth an ambitious, equity-focused framework to address the decline in life expectancy for all New Yorkers. In collaboration with IHI, which is providing the Collaborative model, extensive training in the Model for Improvement, and team-level support through improvement coaching, the NYC Health Department is leveraging quality improvement methodologies to extend and expand overdose prevention neighborhoods and populations at highest risk. By using place-based strategies to target high-priority neighborhoods and integrating the vital expertise of frontline staff, this initiative is developing more effective, tailored interventions to reduce overdose deaths. This strategic, community-centered model is integral to addressing the systemic causes of health disparities and extending public health advancements to the city’s most vulnerable populations.

Georgia Kinsley, MPH, is the HealthyNYC Program Director at the NYC Department of Health.

Winnie Ho, MPH, is a Special Projects Manager for the Bureau of Alcohol and Drug Use in the New York City Department of Health.

Brian Youngblood, LCSW, is an IHI Project Director on the HealthyNYC team.

Photo by Frolicsome Fairy on Unsplash

You might also be interested in:

• Epi Data Brief: Unintentional Drug Poisoning (Overdose) Deaths in New York City in 2024
• HealthyNYC: New York City’s Campaign for Healthier, Longer Lives
• A Guide for Health Systems to Save Lives from “Deaths of Despair” and Improve Community Well-Being
• IHI Open School course: PFC 104: Confronting the Stigma of Substance Use Disorders