Kent County Overdose Task Force Report Form

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This form is for members of the Kent County Overdose Task Force to be able to report on the efforts of their agencies in responding to the current opioid epidemic, and easily share that information with the group.

As we begin this process, please report on your agencies efforts from January 1, 2017, through September 30, 2017 by:

December 11, 2017

As we go forward, reports will be requested quarterly, by the following dates:

January 31st, (for the period October 1, 2017 through December 31, 2017)
April 30th, (for the period January 1, 2018 through March 31, 2018)
July 31st, (for the period April 1, 2018 through June 30, 2018)
October 31st, (for the period July 1, 2018 through September 30, 2018)

Thank you for your efforts in the community!

BASIC INFORMATION

Date *

YYYY

Name of person completing form: *

Email:

Telephone Number:

Agency Affiliation: *

Title of Project/Effort:

TASK FORCE OBJECTIVES

Which of the following Task Force objectives does this project/effort address? (Check all that apply) *

Prevention 1: Ensure health care provider awareness of, education on, and use of evidence-based guidelines for prescribing opioids for chronic pain including those from: 1) The American Pain Society, 2) The Institute for Clinical Systems Improvement, . . .

Prevention 2: Ensure health care provider awareness of, education on, and use of evidence-based non-opioid and non-pharmacological strategies for pain management.

Prevention 3: Decrease the supply of opioids in the community through decreased prescribing of opioids, decreased opioid diversion, and implementation of opioid take back initiatives.

Prevention 4: Increase counseling and education of patients on safe use, storage and disposal for every prescribed opioid.

Intervention 1: Increase access to Naloxone rescue kits through engagement of health systems leadership.

Intervention 2: Increase access to Naloxone rescue kits through engagement of health care providers, including those working in primary care and pain management settings.

Intervention 3: Increase access to Naloxone rescue kits through engagement of pharmacies.

Intervention 4: Increase access to Naloxone rescue kits through engagement of payors.

Intervention 5: Increase access to Naloxone rescue kits through community-based outreach strategies.

Aftercare 1: Increase community awareness of effective substance use disorder treatment options for individuals using/addicted to opioids, including those offered by the medical community.

Aftercare 2: Increase availability of effective substance use disorder treatment options for individuals using/addicted to opioids including those offered by the medical community.

Aftercare 3: Ensure health care provider awareness of, education on, and use of/referral to effective treatment options for individuals using/addicted to opioids, including those offered by the medical community.

Aftercare 4: Identify and implement options for engaging law enforcement in strategies designed to increase access to substance use disorder treatment for individuals using/addicted to opioids.

Aftercare 5: Improve access to supportive services for people in situations that are high-risk for overdose. (i.e., recent overdose, discharge from substance use disorder services, release from incarceration.)

Overarching 1: Develop and implement strategies for reducing stigma around opioid use/misuse, substance use disorder and substance use disorder treatment.

Overarching 2: Develop and implement an awareness/social marketing campaign aimed at reducing overdose and overdose fatality.

Overarching 3: Develop and implement strategies for evaluating the impact of overdose prevention efforts in Kent County, identify data needed for evaluation efforts, and name a centralized evaluation lead.

Overarching 4: Develop and implement strategies for shaping and/or supporting legislation designed to decrease opioid availability, opioid addiction, opioid overdose, and opioid overdose fatalities.

Required

TARGET AUDIENCE

Which of the following audiences does this project target? (Check all that apply) *

Healthcare Leadership

Healthcare Providers

Law Enforcement Administrators

Law Enforcement Officers

Family Members of People Who Use Opioids

People Who Use Opioids

General Community

Other:

Required

Please provide more detail on the target audience of this effort if needed...

CURRRENT EFFORT

Description of project/effort to date (since last report): *

Description of next steps:

PRODUCTS/TOOLS

Description of products/tools developed:

Are you willing/able to share any of these products/tools with other task force members? (if so, please email to steve@redproject.org)

TECHNICAL ASSISTANCE

Are you willing to provide technical assistance to agencies wishing to implement a similar project? *

If so, please provide the name and contact info of who should be contacted at your agency for technical assistance requests: Name-

Email-

Telephone Number-

EVALUATION

Describe any strategies to evaluate the effect of the project and/or data to be used:

NALOXONE RESCUE KITS

Does your agency effort include prescribing or dispensing naloxone rescue kits? *

If you prescribe/dispense kits, please report on the number prescribed/dispensed each quarter

In January, please report on prior year data. In April, July, and October, please report for the current year.

Number of naloxone kits prescribed/dispensed in the 1st quarter (January-March):

Number of naloxone kits prescribed/dispensed in the 2nd quarter (April-June):

Number of naloxone kits prescribed/dispensed in the 3rd quarter (July-September):

Number of naloxone kits prescribed/dispensed in the 4th quarter (October-December):

THANK YOU FOR YOUR PARTICIPATION!

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This form was created inside of Grand Rapids Red Project. Report Abuse

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