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Manchester, New : Leveraging Trust in Local Institutions to Link Individuals to Treatment

Manchester, : LEVERAGING TRUST IN LOCAL INSTITUTIONS TO LINK INDIVIDUALS TO TREATMENT

OVERVIEW mental health issues. Upon evaluating the man, firefighters walked him over to a nearby Manchester is a mid-size city in the treatment center. They quickly realized that northeastern and home to many people in the community could benefit approximately eight percent of the state’s from such a service. Overdose call volume 1,2 population. Fifteen percent of individuals in had quadrupled in Manchester following the the city live below the federal poverty level, introduction and popularization of synthetic making Manchester one of the poorest cities opioids in Manchester around 2014. In early 3 in the state. Like many rural states across the 2015, the greater Manchester community country, New Hampshire struggles with illicit began meeting to try and develop a response drug use. Statewide, the overdose death rate to the marked increase of overdoses and is 37 per 100,000 population, the fifth highest deaths. MFD’s firefighter led referral initiative 4 in the nation. appeared to be a promising way forward. To combat the high rate of drug overdoses Accordingly, MFD launched Safe Station in the city, the Manchester Fire Department in 2016. Within the first month of the (MFD) developed the Manchester Safe program’s operation, MFD assisted over 100 Station program, which serves as a “front people seeking help with SUD. door” to substance use treatment by Manchester is home to a number of programs providing referrals in a trusted, stigma-free and facilities that support individuals with environment. The idea for the program came mental health conditions and SUD. This case about in April 2016, after a relative of an MFD study focuses on the Safe Station program firefighter arrived at a fire station seeking and presents key takeaways for other cities help for substance use disorder (SUD) and and considering a similar approach.

NATIONAL LEAGUE OF CITIES 1 Manchester, New Hampshire: Leveraging Trust in Local Institutions to Link Individuals to Treatment

PROGRAM DESCRIPTION RESULTS Safe Station To date, more than 5,700 individuals have As part of the Safe Station program, accessed the Safe Station program in firefighters in Manchester’s ten fire stations Manchester, with an average of three to are trained to arrange for or directly provide six walk-ins per day related to substance 5 medical assessments for individuals seeking use. Utilization of the Safe Station program help with SUD. Medical assessments include increased by 30 percent in the first three checking vital signs as well as screening for months of 2019, compared to the previous 6 physical and mental health issues, and recent year. A 2018 Dartmouth study attributed drug use. If the individual is experiencing a the appeal of the Safe Station program medical emergency, they are transported to its immediacy, low-threshold access, to a hospital by ambulance or emergency centralized locations and the respectful and transport. Once these initial assessments non-judgmental attitudes of the firefighters 7 are completed, firefighters provide referrals in the program. According to a recent to local hospitals or to Pathways, epidemiological analysis, Manchester Safe an organization that provides evaluations, Station participants 53 percent less assessments, casework, and referrals to the likely to experience a non-fatal overdose and appropriate level of service. For after-hours 86 percent less likely to experience a fatal 8 referrals (between 11 pm and 8 am), clients are overdose after accessing a Safe Station. transported after triage to Farnum Center, the Cities throughout the country have replicated states’ largest addiction treatment facility, for the Safe Station model, including Nashua, short term stabilization or inpatient treatment. New Hampshire; Providence, Rhode ; and Annapolis, . Firefighters either walk the client to a nearby facility (if within walking distance) or arrange transportation through a partnership with FINANCING AND the ride-sharing app, Lyft. In either case, the SUSTAINABILITY fire department will call local SUD service Safe Station is funded entirely through private providers in advance to alert them to a walk- donations and grants and receives no funds in or hospital dispatch. from the state or from federal agencies. The Upon initial referral, individuals may be program does not have a budget and calls are subsequently connected to mental health handled like medical walk-ins (which already services and/or medication-assisted treatment occurred before the Safe Station program (MAT) providers. Safe Station partners like began). Additional costs associated with the Granite Pathways follow up with clients to program are funded through donations. help them stay connected to treatment after referral and transportation from the fire department. The city chose to leverage the fact that fire departments are open 24 hours a day, 7 days a week, to expand access to SUD services.

NATIONAL LEAGUE OF CITIES 2 Manchester, New Hampshire: Leveraging Trust in Local Institutions to Link Individuals to Treatment

COLLABORATION ACROSS provides treatment navigation, recovery support, housing support, employment SYSTEMS support, health/wellness support, DCYF case The Safe Station program collaborates with navigation support, court support, and other a number of programs and services across services to children and parents affected various systems to support the individuals by SUD.13 Recently, Granite Pathways began they serve: offering screening, needs assessments, referrals and care coordination through the Farnum Center state’s Doorway program, discussed further Manchester Safe Station firefighters refer under “Lessons Learned.” individuals in need of affordable treatment for SUD to the Farnum Center, which The Mental Health Center of Greater provides comprehensive treatment and Manchester recovery services for people affected by Another referral site for people experiencing SUD across five state-of-the-art facilities.9 SUD or mental health issues is the Mental Primary services offered at the center include Health Center of Greater Manchester, which detoxification; outpatient and intensive has provided mental health services for outpatient treatment; inpatient treatment; adults, adolescents, and children since 1960. partial hospitalization; medication-assisted The center offers outpatient treatment, treatment; family services; and transitional SUD counseling, crisis stabilization, living. In 2018, the center opened a 16-bed assertive community treatment, supported Stabilization Unit in conjunction with the employment, and physical health and wellness Manchester Fire Department.10,11 If an individual programs to all individuals, regardless of is placed on a waitlist for SUD treatment, the ability to pay. Its Community Connections Farnum Center provides them with a safe program serves to divert individuals with transitional environment while they await mental illness from the criminal justice treatment. system by engaging them in appropriate treatment services.14 Working with community Granite Pathways organizations including the Farnum Center Individuals in need of SUD or mental health and the Manchester Fire Department, the treatment may also be referred to Granite Mental Health Center of Greater Manchester Pathways, a statewide organization that has sustained itself as a leader in improving provides outpatient services for people mental wellbeing. coping with SUD and mental health issues.12 Founded in 2009, Granite Pathways The Adverse Childhood Experiences promotes an evidence-based, self-help and Response Team (ACERT) peer recovery community to recover from ACERT is a collaboration between Amoskeag mental illness. Its programs have expanded Health’s Project LAUNCH (Linking Action to include peer recovery coaching, 12-step for Unmet Needs in Children’s Health), the programs, SMART recovery programs, Manchester Police Department, and YWCA support groups for family members and New Hampshire.15,16 ACERT consists of a a youth treatment center. In collaboration police officer, a crisis services advocate, and a with Division of Children behavioral health professional who responds Youth and Families (DCYF), Granite Pathways to incidents in which children have been

NATIONAL LEAGUE OF CITIES 3 Manchester, New Hampshire: Leveraging Trust in Local Institutions to Link Individuals to Treatment

exposed to violence. Teams assess children In its first six months, The Doorway-NH and may refer them to support groups, served more than 3,200 individuals and made mental health counseling, early childhood 579 referrals state-wide, but in Manchester, education, or child-parent psychotherapy. the program poses a potential threat to the MFD firefighters can also refer clients directly sustainability of Safe Station.20 Despite Safe to ACERT program managers. MFD recently Station’s successes, the state chose Granite completed training with ACERT and expects Pathways as Manchester’s single intake to roll out additional education modules for point for SUD and allocated $9 million of firefighters in the near future. the SAMHSA grant to help the organization become a “hub.”21 This effort has resulted in two “front doors” to SUD treatment in ROLE OF CITY Manchester. LEADERSHIP Despite state funding and support for Granite The Mayor of Manchester was an early Pathways, Safe Station remains a popular supporter of Safe Station, and his successor intake site. From January through June 2019, has consistently supported and advocated Granite Pathways-Manchester assisted nearly for the program. Other city leaders like 200 individuals through The Doorway-NH, the Manchester Fire Chief, the Director of while more than 700 individuals accessed the Manchester Health Department, and the MFD Safe Station during the same time the Manchester Chief of Police have been period.22 While Safe Station and Granite instrumental in ensuring the operation of Safe Pathways compete as intake centers, the Station as well as representing the city in talks organizations continue to work together to with the state which has developed its own address SUD and mental illness in greater state-level response to SUD. Manchester, and Safe Station continues to refer individuals to Granite Pathways for LESSONS LEARNED treatment services. Responding to Challenges Historically, Manchester city leaders have had Conflicting city/state approaches. In 2018, little influence over state SUD programming. New Hampshire However, city leaders have been persistent announced a new hub-and-spoke treatment in ensuring the state hears their voices and model for opioid use disorder (OUD), based acknowledges the experience and success of on a similar program in .17 The the city of Manchester and its Safe Station program, called “The Doorway-NH”, created program. This persistence has paid dividends. nine “hubs” through health care providers Safe Station leaders like the Manchester across the state, which are responsible for Fire Chief, the Director of the Manchester providing screening, evaluation, closed-loop Health Department, the Manchester Chief referrals to primary care providers and SUD of Police, and the Mayor are now in ongoing services (spokes), and care coordination for talks with representatives from the State people with OUD.18 The Doorway-NH initiative Department of Health and Human Services is supported by a $45.8 million State Opioid to better align their programming and work Response grant from the Substance Abuse together. Negotiations include Doorway-NH and Mental Health Services Administration expanding to 24-hour availability, a reduction (SAMHSA).19 of Doorways so resources are spread less

NATIONAL LEAGUE OF CITIES 4 Manchester, New Hampshire: Leveraging Trust in Local Institutions to Link Individuals to Treatment

thinly and establishing stabilization beds KEY TAKEAWAYS FOR CITY in Doorways. Many of these elements are already present in Safe Station. The LEADERS Manchester Fire Chief has offered the state For city leaders considering similar technical assistance for expanding Safe approaches to address SUD, homelessness, Station programming to fire departments in and mental health issues, there are several key other cities within the state. Ultimately, city lessons that can be learned from Manchester’s leaders do not see the Safe Station model as Safe Station program and its collaboration competing with the state’s hub and spoke with other stakeholders and programs: model. They believe the two can, and should, coexist and are hopeful that continued talks Advocate for local programs. City leaders with the state will lead to better collaboration. can play a vital role in garnering support at the state level for innovative city-led Limited regional resources. Recent initiatives. Although the MFD received early epidemiological data demonstrate that support from the Mayor of Manchester, less than half of Safe Station clients are a lack of consistent communication and Manchester residents.23 Because Manchester collaboration with state leaders may have led has numerous SUD treatment programs, to challenges down the road. Utilizing the many individuals come to the city from other media to amplify city voices so that the state parts of New Hampshire or nearby states to will listen is critical. When state leaders are seek help, putting a strain on local treatment ready to listen, having a team of city leaders facilities and social services.24 ready to advocate for their city can help state leaders understand and better support city Much of the federal Inflexible federal funding. programming. funding for SUD is earmarked for OUD, meaning that providers are paid more to treat Facilitate cross-systems partnerships. City people with OUD and may end up prioritizing leaders can help connect new, cross-systems these patients. As a result, it can be more programs with a broad network of service difficult to find supportive services, such as providers. Initially, Safe Station partnered with transportation, for people with other forms of just one local SUD treatment provider, which SUD, such as alcoholism or methamphetamine dissolved in 2017 due to financial insolvency. addiction. The program has adapted by building new partnerships with several SUD treatment facilities in greater Manchester.

NATIONAL LEAGUE OF CITIES 5 Manchester, New Hampshire: Leveraging Trust in Local Institutions to Link Individuals to Treatment

Leverage the reputations of trusted Use storytelling to combat stigma and institutions. While it may be tempting to political opposition. In 2019, a city aldermen create new organizations to coordinate said on social media that he would work to cross-systems approaches, city leaders shut down Safe Station, claiming that people should first consider which local institutions with SUD are taking advantage of Safe Station have already established a high level of trust and its partners to obtain free transportation within the community. The MFD has served and housing.25 In response to this opposition, the Manchester community for 150 years, MFD invited Manchester residents who had and community members know and trust been through the Safe Station program to local firefighters. The MFD “brand” likely share their stories.26 helped Manchester residents feel comfortable seeking help through a new program.

Track qualitative and quantitative outcomes. Not only should city leaders aim to demonstrate that a new program works, but they should also be able to demonstrate why that program works. The 2018 Dartmouth study of Safe Station provided valuable insight into the unique appeal of the program, which other cities can use to determine how this model might work within their local context.

UNLESS OTHERWISE NOTED, ALL INFORMATION IS BASED ON AN INTERVIEW WITH THE MANCHESTER FIRE DEPARTMENT.

NATIONAL LEAGUE OF CITIES 6 ENDNOTES

1 United States Census Bureau. “2013-2017 American 9 Farnum Center. About Us. https://farnumcenter.org/ Community Survey 5-Year Estimates. ACS about-farnum/. Demographic and Housing Estimates: Sonoma , 10 Farnum Center. https://farnumcenter.org/. CA; Fort Collins, CO; Huntington, WV; , IN; Manchester, NH; , PA; Raleigh, NC; 11 Our History. Farnum Center. https://farnumcenter.org/ Rapid City, SD; San Antonio, TX; Wichita, KS.” https:// history/ factfinder.census.gov/bkmk/table/1.0/en/ACS/17_5YR/ 12 Granite Pathways. https://granitepathwaysnh.org/. DP05/0500000US06097|312M300US22660082742 5|312M300US265805439460|312M300US26900183 13 Id. 6003|312M300US317003345140|312M300US37980 14 The Mental Health Center of Greater Manchester. 4260000|312M300US395803755000|312M300US3 https://www.mhcgm.org/. 96604652980|312M300US417004865000|312M300 US486202079000. 15 Amoskeag Health. Adverse Childhood Experiences Response Team (ACERT). https://www.mchc-nh.org/ 2 United States Census Bureau. “2013-2017 American adverse-childhood-experiences-response-team-acert/. Community Survey 5-Year Estimates. ACS Demographic and Housing Estimates: , 16 Robidoux, C. (2016). New program focuses on , , , New Hampshire, North intervention for children exposed to violence. Carolina, , , , West Manchester Ink Link. https://manchesterinklink.com/ .” https://factfinder.census.gov/bkmk/table/1.0/ new-program-focuses-intervention-children-exposed- en/ACS/17_5YR/DP05/0400000US06|0400000US0 violence/. 8|0400000US18|0400000US20|0400000US33|040 17 . “New Hampshire announces hub- 0000US37|0400000US42|0400000US46|0400000 and-spoke drug treatment plan.” (2018). https://www. US48|0400000US54. apnews.com/f28caa70373b4427a4f1700d3fd6acfc. 3 United States Census Bureau. “2013-2017 American 18 New Hampshire Department of Health and Human Community Survey 5-Year Estimates. Selected Services. (2018). State Opioid Response – (SOR), Economic Characteristics: California, Colorado, (FOA) No. TI-18-015, New Hampshire Grant Proposal. Indiana, Kansas, New Hampshire, , https://www.dhhs.nh.gov/dcbcs/bdas/documents/sor- Pennsylvania, South Dakota, Texas, .” grant-proposal.pdf. https://factfinder.census.gov/bkmk/table/1.0/en/ ACS/17_5YR/DP03/0500000US06097|312M300US22 19 New Hampshire Department of Health and Human 6600827425|312M300US265805439460|312M300US2 Services. State Opioid Response Grant. https://www. 69001836003|312M300US317003345140|312M300US3 dhhs.nh.gov/dcbcs/bdas/sor.htm. 79804260000|312M300US395803755000|312M300U 20 New Hampshire Department of Health and Human S396604652980|312M300US417004865000|312M300 Services. (2019). Summary of Doorway Activity as of US486202079000. 6/30/2019. https://www.dhhs.nh.gov/dcbcs/bdas/ 4 National Center for Health Statistics. (2019). Drug documents/doorway-activity-jun-2019.pdf. Overdose Mortality by State. https://www.cdc.gov/ 21 DeWitt, E. (2018). Sununu, state officials unveil nchs/pressroom/sosmap/drug_poisoning_mortality/ ‘hub and spoke’ opioid treatment partnerships. drug_poisoning.htm. . https://www.concordmonitor.com/ 5 American Medical Response. (2019). Manchester Sununu-state-officials-unveil-hub-and-spoke-opioid- Opioid Crisis Summary [Slides]. https://drive.google. partnerships-20916080. com/file/d/1kiy0X0npf3ilL5V4zxSnbbQGEO4OZ3Xh/ 22 American Medical Response. (2019). Manchester view. Opioid Crisis Summary [Slides]. https://drive.google. 6 Gibson, S. (2019). Despite ‘Doorway’ Expansion, com/file/d/1kiy0X0npf3ilL5V4zxSnbbQGEO4OZ3Xh/ Manchester Safe Station Numbers on the Rise. New view. Hampshire Public Radio. https://www.nhpr.org/post/ 23 Id. despite-doorway-expansion-manchester-safe-station- numbers-rise. 24 Id. 7 Center for Technology and Behavioral Health and 25 Feely P. “Fire chief fires back on city’s Safe Station.” the National Drug Abuse Treatment Clinical Trials New Hampshire Union Leader. (2019). https://www. Network-Northeast Node. (2018). Summary of unionleader.com/news/politics/local/fire-chief-fires- Findings: Safe Station: A Systematic Evaluation back-on-city-s-safe-station/article_63a78381-de08- of a Novel Community-based Model to Tackle 5c79-90d2-b64aeb872650.html. the Opioid Crisis. https://drive.google.com/file/ 26 Mackin J. “Manchester mayor, aldermen vote to d/18BYXKLrP6awODMuJZPCG-KEcmOfiwYuG/view. support Safe Station program.” WAMU. (2019). https:// 8 American Medical Response. (2019). Manchester www.wmur.com/article/manchester-mayor-aldermen- Opioid Crisis Summary [Slides]. https://drive.google. vote-to-support-safe-station-program/26876333. com/file/d/1kiy0X0npf3ilL5V4zxSnbbQGEO4OZ3Xh/ view.