In California’s Alameda County, across the bay from San Francisco, roughly two-thirds of people experiencing homelessness live unsheltered, with nearly 29 percent reporting having a substance use disorder (SUD). In recent years, synthetic opioids and stimulants are among the leading causes of fatal overdoses in Alameda County. Recognizing the critical need for opioid treatment and the limited medications and programs available to help people who use stimulants, several organizations decided to partner to provide these needed services in a more coordinated way.

Collectively referred to as the Alameda team, these organizations included: Alameda County Health Care for the Homeless (ACHCH), a federally funded health center within the Alameda County Health Care Services Agency; The Henry Robinson Center (The Henry), a transitional housing site that is part of Bay Area Community Services (BACS), a homeless services provider; Cardea Health, a nonprofit health care organization; and Alameda Health System Highland Hospital’s Bridge Clinic (AHS Bridge), a drop-in clinic that offers low-barrier access to substance use treatment. This profile explores lessons from the Alameda team’s efforts to leverage their trusted relationships within the community to pilot a comprehensive set of integrated services to people residing in interim housing. As described in the profile, the pilot sought to reduce drug overdose deaths and increase access to harm reduction and SUD services at The Henry. The Alameda team was a participant in Partnerships for Action: California Health Care & Homelessness Learning Collaborative, funded by the California Health Care Foundation and led by the Center for Health Care Strategies.

Partnership Intervention

The Alameda team developed three goals for their partnership:

1. Increase access to and knowledge of naloxone, a medication used to reverse the effects of opioids, and harm reduction strategies among transitional housing staff and The Henry residents;
2. Provide low-barrier access to medications for addiction treatment (MAT) for people residing at The Henry; and
3. Pilot contingency management for residents.

To best reach their shared goals, the Alameda team: (1) centered the voices of residents to support effective program design and (2) offered pilot services based on community needs, including by hiring peer support specialists to engage residents and help run the program.

Centering the Voices of Residents

The Alameda team hosted a series of focus groups with residents at The Henry to better understand how to build and design their harm reduction and SUD services. The focus groups offered an opportunity for residents to connect with one another and provide input on available services at The Henry. During the pilot program, five focus groups were hosted once a week for a month. Initially, these groups were led by The Henry and ACHCH staff, but later, peer support specialists hired through the pilot program took over facilitating the focus groups. Food and refreshments were provided, and approximately six to 10 people participated in each session. Each focus group addressed on a specific topic, including: (1) integrating peer support specialists; (2) piloting MAT and contingency management; (3) using naloxone and preventing drug overdose deaths; (4) principles of harm reduction; and (5) comfort with harm reduction materials on-site versus treatment and/or abstinence approaches. Residents with lived experience helped the staff find the most effective words to describe harm reduction, helping to minimize stigma and judgment. Focus groups helped build relationships with residents and generate buy-in for the piloted services at The Henry. The focus groups also helped build trust and camaraderie among residents at The Henry, as they encouraged people to leave their rooms and engage with each other — something that had become less frequent since the COVID-19 pandemic. Participants in the focus group noted feelings of loneliness and isolation and expressed appreciation for opportunities to connect with one another.

Offering Pilot Services Based on Community Needs

Based on focus group feedback, lessons from the field, and best practices in evidence-based SUD treatment, the Alameda team designed a set of pilot services that leveraged each partner’s unique skills and capabilities to meet community needs. Exhibit 1 describes four services offered through the pilot and the role of each partner. While not explicitly part of the pilot, The Henry residents who expressed interest in health care services were referred to ACHCH for those clinical services. Additional details on services are available on the following page.

Exhibit 1. Pilot Services and Partnership Roles

Hiring Peer Support Specialists

To support the pilot services at The Henry, Cardea Health hired peer support specialists. The Alameda team highlighted the benefit of including peers, not just as volunteers, but as hired staff members. The peers were a source of continuity across pilot services. Peers received extensive training prior to starting, in partnership with the organizations on the Alameda team and other community-based organizations. They first received training at BACS to familiarize themselves with the interim housing operations and how their role could support individuals in the pilot. They also spent three weeks at AHS Bridge shadowing substance use navigators, who support patients in identifying and accessing SUD treatment, like MAT, as well as follow-up appointments. Finally, they received training from the HIV Education and Prevention Project of Alameda County, which included overdose prevention and education on naloxone and how it can be safely administered.

Peers played a key role in increasing access to and knowledge of naloxone and harm reduction strategies by staffing the drop-in center, where they provided naloxone training and facilitated MAT induction in private spaces with a case manager and a nurse. At the drop-in center, The Henry residents were able to receive harm reduction education and supplies focused on overdose prevention and safer use, including fentanyl and xylazine testing strips. Wound care was also available as needed. Peer support specialists also led a weekly contingency management clinic and focus groups at the Henry once they had been onboarded.

Increasing Access to Harm Reduction

The Henry staff ensured that harm reduction supplies were available throughout the residential center. Harm reduction kits are available at the end of the hall on every floor, including fentanyl test strips, naloxone, and safer use-kits, among other resources. These harm reduction supplies are also available at the drop-in center. During the pilot, peers along with the supervising nurse offered training for The Henry residents on how to use harm reduction supplies. To ensure a consistent level of understanding and uniform use of terminology, all staff on the project team at The Henry received training from ACHCH. The training covered harm reduction, MAT, substance use identification, and contingency management.

Integrating Medications for Addiction Treatment

The Henry follows a “no wrong door” approach to SUD treatment enrollment. In partnership with AHS Bridge, medical residents provided MAT for substances including opioids and alcohol, one day per week to The Henry residents. Given the success of the MAT pilot at The Henry, the pilot expanded their on-site service to Cardea Health’s other housing facilities. AHS Bridge residents saw a total of 30 unique Henry residents during the pilot at The Henry.

Piloting Contingency Management

The peers and a nurse supervisor, who was also employed by Cardea Health, led the day-to-day management of the contingency management pilot, with support from onsite BACS staff as needed. The pilot, which lasted four months, included 10-12 participants who screened positive for one or more of the stimulants of focus (methamphetamine, cocaine, crack). Pilot participants met with the nurse manager and peers two to three times per week, where they were assessed with a urine drug screen. Participants who tested positive for substances beyond stimulants were not excluded from contingency management. The pilot used a fish-bowl style incentive structure for negative urine screens, offering e-gift cards ranging in value (i.e., $1, $5, $20, and $100) and notes with positive affirmations, for example, “I am worthy of love and respect.” They had the option to meet more frequently if participants had questions or wanted to talk more about their goals.

Notable insights from the contingency management pilot included the importance of carefully defining contingency management inclusion and exclusion criteria, as well as the incentives. While meeting attendance was not incentivized directly, increased touch points with individuals led to greater rapport and engagement for participants. The team found that overly specific inclusion criteria (e.g., use of only stimulants) could create variability and/or limitations in recruitment and funding sustainability, while increasing the barrier to individuals accessing the service. Aligning priorities was also important, as clients’ priorities may differ from those of the providers, and it was important for clients to develop and work toward their own goals. The team emphasized the importance of getting staff feedback for the pilot, which fostered greater buy-in, especially critical for a new service with few external examples. Implementation-focused insights included ensuring the reloadable gift cards were correctly loaded with funds and easily accessible.

Lessons in Effective Partnership

Below are early lessons from the Alameda team’s pilot, which can inform other health care and homeless systems on the partnering process to improve outcomes for people experiencing homelessness.

• Align across goals and responsibilities. The team recognized the importance of establishing cross-agency alignment from the outset of the pilot program. This included aligning programmatic goals, dividing responsibilities, and clarifying specific roles. Each organization brought unique skills and resources to the collaboration, making it essential to match those skillsets to corresponding responsibilities.
• Aim for patient-centered processes. The team also highlighted that partnerships involving multiple organizations can lead to bureaucratic redundancies for clients, such as paperwork and retelling of their story or histories. While maintaining organizational policies, the partners developed workflows to streamline intake processes and avoid redundancies, where possible.

Looking Forward

The Alameda team leveraged their pilot learnings to inform the development of a program within ACHCH, funded by a Substance Abuse and Mental Health Services Administration Grant for the Benefit of Homeless People to provide medications for opioid use disorders treatment and SUD recovery services in shelters setting, including BACS and Cardea shelter and medical respite locations.

 In addition, the drop-in center and focus groups continue at The Henry. Cardea Health continues to contract with ACHCH to provide harm reduction services and MAT through AHS Bridge. They are able to provide a warm hand-off and enhanced follow-up after referrals. While the Alameda team is no longer providing contingency management, they are reviewing the possibility of partnering with other organizations that they could refer individuals for outpatient services.