Utah Naloxone

Utah Naloxone (UN), located in Salt Lake City’s urban center, is a harm reduction program operated through the University of Utah’s academic health care system. Committed to providing and improving basic health services for PWUD, UN runs a drop-in Wellness Center and conducts regular street-based outreach in their community, offering overdose prevention and response resources, safer use and harm reduction education, supply access, and testing for HCV, HIV, and sexually transmitted infections (STIs). Under the program’s medical director, UN also offers wound care and skin/soft tissue infection prevention and treatment. People seeking HCV care and MAT are connected with external partners, including the Martindale Clinic, Project Reality, and the University of Utah’s Bridge Program. Participating in the patient navigation project allowed UN to incorporate more hands-on case management and build out services and approaches responsive to common participant goals. Their involvement in the project was an opportunity to learn from service implementation in a community syringe service program under the umbrella of an academic health care system setting and to share experiences and outcomes with other harm reduction programs in the state, which have been growing since Utah legalized SSPs in 2016.

During the project, UN provided services in-office while also developing a telehealth program to provide low-threshold wound care on a walk-in/as-needed basis. The patient navigator was a trained emergency medical technician and medical assistant and was able to assess and triage participants. Using text messaging and FaceTime video calling, the navigator worked with the medical director to perform virtual examinations. The medical director could then prescribe antibiotics and, through pharmacy partnerships, arrange for UN to pay for the medications of un- or under-insured participants. This approach allowed easier integration of clinical services in outreach settings and enabled more people to receive clinical care during the COVID-19 pandemic.

More than 40% of the people engaged in navigation at UN sought wound care services. UN saw unexpected success with one of their participants, who was engaged in care for four months and had eleven appointments to receive treatment for wounds. The navigator initially provided care and resources through the SSP and then referred the participant to the emergency department (ED) for short-term treatment and a primary care provider for ongoing care. The navigator continued to stay engaged by offering counseling and safer injection education and provided wound care supplies at each SSP encounter. Through this wraparound approach and with ongoing support from the navigator, the participant was able to maintain treatment and his wound ultimately healed.

UN encountered a variety of challenges over the course of the project, including COVID-19, an earthquake, staffing shortages, and civil unrest. Though some of these were intermittent issues, one ongoing problem was the lack of foot traffic to the physical SSP location and patient navigation site. UN responded by leveraging existing funding to expand street-based outreach efforts. UN formalized this approach by hiring a permanent outreach worker and increasing outreach presence to three days per week, filling an identified gap in downtown Salt Lake City service networks. Patient navigation project resources partially supported this effort.

During the project, UN enrolled 152 individuals in patient navigation. Of the identified participants, UN reported 36 referrals to medication for opioid use disorder (MOUD) and 28 connections to HIV and HCV testing and treatment. While UN provided HIV, HCV, and STI testing and wound care on site, patient navigators frequently referred to other organizations for HCV treatment and MAT. Additionally, UN provided wound care to 155 individuals, sexual health care to 65 individuals, OB/GYN referrals to 3 individuals, and 86 adult immunizations.

Utah Naloxone Patient Navigation Encounters (March 2020 - February 2022)

Total Number of Patient Navigation Encounters – 373

In April 2020, a 28-year-old white man with 15 years of injection history came to UN seeking wound care. He received a prescription for antibiotics as well as a dose of injectable medication on-site. After missing a scheduled visit for continued care, he reconnected with UN’s medical provider. At that point, more intensive care was needed, and he received an ED referral and application for Medicaid (Medicaid coverage expanded under the Affordable Care Act went into effect in Utah in January 2020).

In June 2020, the navigator saw the participant at the UN site. His wound had become significantly worse, but he refused to go to the emergency department out of fear of COVID transmission and the possibility that his arm would need to be amputated. He requested oral antibiotics and promised the navigator he would stop injecting into the wound.

A month later, the participant returned to the SSP and the wound was still present. The navigator reminded him of the ED referral and discussed Medicaid enrollment again, in which the participant had expressed interest. He also requested food assistance and was given a $25 Kroger gift card. He returned to the SSP later in the month and received additional wound care supplies. Although he remained hesitant to seek health care elsewhere, he regularly visited the SSP and engaged with UN providers routinely. At the time of reporting, his most recent engagement was a visit in May 2021 to the SSP where he was able to show staff a completely healed wound and update that he had discontinued injecting.

In this case study, medical mistrust and the fear of extreme treatment (an arm amputation) posed a significant barrier to receiving hospital-based care for an injection-related wound.  Many PWUD face fear and uncertainty around engaging with medical providers and the type of care they might provider, based on their own or others’ previous experiences. An additional factor was a well-founded fear of COVID transmission. UN was able to provide essential health services that addressed the participant’s urgent wound care needs, serving as the primary source of medical care throughout his engagement. While the participant was not prepared to receive hospital-based treatment, the navigator maintained an open relationship with him and worked to meet other needs while continuing to encourage him to seek further care, demonstrating the importance of long-term, trusting relationships with low-threshold community-based SSPs.

Through the project, UN was able to evaluate existing programming and reorient internal approaches to be more coordinated and comprehensive. It is a high-volume program and staff were able to incorporate lessons and strategies from the project into general SSP services and engagement, increasing the number of people poised to benefit from this initiative. UN identified goals for program growth that would, with sustained funding, support continued positive outcomes for participants:

• Hiring additional patient navigators with robust harm reduction backgrounds.
• Implementing higher levels of case management able to navigate clients through complex systems of care.
• Developing a comprehensive electronic participant data tracking system.
• Incorporating mail-based naloxone distribution and other innovative outreach and service delivery approaches.

When sharing recommendations for other programs, UN highlighted the importance of hiring “somebody with lived experience or professional experience, or education or just intrinsic personality traits [who] is able to relate with the population, able to communicate with the population, make them feel safe and trusted and be able to provide those services and be able to meet people where they're at, wherever that is and be able to kind of speak that language.” Using these abilities to relate, communicate, and engage, UN leveraged staff’s clinical experience and expertise and their proximity to comprehensive medical services to increase access to effective care and improve health outcomes for program participants.