Filling the gaps

ONE DAY AT A TIME: Peer support specialist Justin Hall and Emergency Services lead paramedic Claire Hubbard are part of a new team addressing overdoses in Buncombe County. Photo by Jessica Wakeman

It’s a rainy Thursday in West Asheville when the word “overdose” crackles over the radio dispatch. Jamie Judd, emergency medical services division manager for Buncombe County Emergency Services, immediately turns on his siren and increases speed. The late afternoon traffic on Patton Avenue is clogged; vehicles aren’t pulling to the side to let this emergency vehicle pass. It’s the time of day — between noon and 4 p.m. — when the majority of overdose calls come in, and every minute counts.

Judd careens down Interstate 240 toward the shopping center in South Asheville where the overdose was reported. The radio dispatch crackles again; other emergency personnel have already arrived. They found no overdose and are clearing the scene. Judd turns his siren off.

Some afternoons are not as fortunate for Buncombe County’s community paramedicine team, a pilot program started in November 2020 with support from the county’s Emergency Services, Health and Human Services, Justice Services and Sheriff’s Office. The effort, based on the national Post Overdose Response Team model, comes after Buncombe County experienced a 147% increase in overdose deaths between 2015 and 2017, the most recent period for which data is available from the N.C. Department of Health and Human Services. And according to Emergency Services, Buncombe averages six-to-eight deaths monthly from probable overdoses.

The PORT seeks to link care for social determinants of health — including food security, safe housing and substance abuse disorder support  — with the immediate medical care required to reverse a drug overdose. “That’s really what our job is with the community paramedics: to fill the gaps,” says Van Taylor Jones, Buncombe’s director of emergency services.

Not only may the team lead to better health outcomes for clients, Jones says, but it can also prevent health care providers and law enforcement from becoming overburdened with people whose needs they can’t directly meet. Homeless clients comprise 30% of the nearly 1,800 calls the PORT has received since its inception. And over half of PORT calls overlap with behavioral health calls, which include reports of people intoxicated in public, mental health crises and welfare checks.

Prior to the program’s establishment, emergency services had two options for where to take clients after responding to an overdose: the hospital or jail. It was a situation that everyone involved found frustrating, says Claire Hubbard, the program’s lead paramedic and manager.

“If someone is intoxicated and mentally ill and homeless, and we’re sending understaffed police and medics to that call — and we’re not giving them the option to bring people anywhere — how in the world, with even the best people on Earth, can you make a good thing out of that situation?” she asks.

Meeting people where they are  

The six-person team consists of Hubbard, three community paramedics, a mental health counselor and peer support specialist Justin Hall. The paramedics respond to overdose 911 calls 24/7, co-responding with police, fire and EMS. But three days per week, Hall rides along with the PORT as it follows up with previous contacts within 72 hours of their overdose.

Hall has been in recovery for five years from opioid abuse and has struggled with depression, panic attacks and agoraphobia, an anxiety disorder. He says his mental health and drug abuse experiences enable him to connect with clients; people with opioid use disorder often feel isolated and stigmatized and have built up defenses that may not be penetrated by law enforcement or traditional paramedics, he explains.

“As soon as I introduce myself and I mention I’m in recovery, that may be the first time you see them make eye contact,” Hall says of those clients, which PORT sometimes visits directly at shelters and emergency rooms. “You can see them loosen up a little bit — ‘Somebody’s here who might understand a little bit of what I’ve been through.’”

How the PORT responds to calls is also different from a traditional EMS approach. Paramedic Robbie Stanton explains that he arrives in a gray SUV with orange stripes, which intentionally looks different from other emergency services vehicles like ambulances and police cars. He introduces himself to clients by saying, “Hi, I’m your community paramedic.” Instead of the usual EMS uniform of blue dress pants and a golf shirt, he wears a scrub top featuring the community paramedicine logo.

Stanton also says he will frequently ask law enforcement officers who have responded to an overdose to step outside so he can speak to the client alone. People who have substance abuse disorder may decline assistance from public safety departments due to fear of potential incarceration. Putting clients at ease in this way can be crucial for their receptivity to getting further help.

The PORT maintains a database of 414 clients who have signed releases of their information, allowing the team to follow up with them. While PORT works with all of them in some capacity, Hubbard says 90 people are currently active in recovery programs.

“These connections we’ve made have allowed people to feel comfortable enough to call us up, know they’re not going to be judged, and say, ‘I messed up, I need some help getting back in the right direction,’” Hall says. He follows up with clients for up to one year, with the goal of handing clients to an agency that can provide more in-depth support.

Removing barriers

Fundamentally, the PORT addresses gaps in health care accessibility, says Jones. Many people in Buncombe County primarily access basic health care through the 911 system. Additionally, some in the community turn to the ER for shelter, food or a safe option while detoxing; Hubbard says the ER is frequently used as refuge during Code Purple alerts, when the Asheville Homeless Coalition warns of extreme cold.

Judd, the EMS division manager, says one of the PORT’s biggest roles is connecting clients with harm reduction strategies, which are meant to lessen the negative consequences of drug abuse. Dispensing fentanyl test kits and naloxone (an overdose reversal drug commonly known as Narcan)  is especially important because of a rise in contaminated and misrepresented substances that can harm users. “Ultimately, we like to see the person seek recovery in some manner. But we know that some people are just not ready to make that step,” he says.

The team can also connect clients to rehab. The Mountain Area Health Education Center, for example, has set aside a number of beds in its rehab for PORT’s clients. And if those clients must wait for a bed to open, says Hubbard, the team provides medication to bridge the gap. “We find them a slot with a facility or a hospital and then we safely redose them with suboxone for up to several days, even if it’s in their car or under a bridge,” she says.

Buncombe County has a dearth of options for people experiencing mental illness crises, requiring detox and rehab and leaving intimate partner violence, adds Hubbard. And in the aftermath of a crisis, it can be particularly difficult for a person to connect with care. Ultimately, she explains, the PORT hopes to show “that when you give people what they need, and you make it possible for them, they are more willing to comply for recovery and treatment.”

Into the future

Currently, the team’s personnel expenses of $500,000 are funded entirely through the Dogwood Health Trust. Some of the cost of equipment and the mental health response is partially covered by a Comprehensive Opioid Abuse Site-based Program grant, awarded by the U.S. Department of Justice.

Once those grants expire, Jones is hopeful that funding can come through the federal American Rescue Plan Act, which will send nearly $51 million in COVID-19 relief to Buncombe County. Money could also come from the roughly $21 million settlement Buncombe is set to receive from litigation against pharmaceutical companies for their role in the opioid crisis.

The PORT is the area’s first community paramedicine pilot program. But Jones says he and Asheville Police Department Chief David Zack frequently discuss the possibility of broadening the work. While Jones emphasizes that those talks are preliminary, the wish list would expand the linkage of care with sober living facilities, behavioral health emergency treatment shelters and low-barrier shelters. But Jones says the program can’t expand until the county has additional capacity in those types of places.

“There’s a lot of weight on the shoulders of my community paramedics, and all my paramedics, for what they do out here,” says Jones. He wants the community to know “that people taking care of them care about them, and we’re working every day to find better solutions.”

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