Cracks present a quandary.
When you are trying to coordinate a health ecosystem comprised of multiple, dedicated but widely different parts with potentially disparate agendas it’s usually not the individual components that are the challenge. It is dealing with the cracks between them.
In recognizing and responding to the cracks, there are several options. You can rail against the lack of a single, synchronized system. You can ignore the cracks and just deal with the separate parts. You can work around the cracks by building a myriad of small bridges with each different entity. These tend to be fragile and dependent on the individuals involved. They also tend to collapse if circumstances change (including transitions of the bridge-building brokers). Alternatively, you can press into the strength of the range of expertise and experience and develop the language and formalized relationships that can unite the different entities into a single system for a singular purpose.
Consider this example. A nurse practitioner who regularly works in a city hospital is attached for 12 months to augment the City Health Department’s street medicine program that is focused on overdose prevention. Her paycheck, paid time off, evaluation process and all administrative aspects of her job remain with the hospital. But the Street Medicine director determines which of the health department’s street teams she is assigned to, when they go into the community and to which geographic area. Negotiations regarding the funding of her position would be conducted between the two entities.
For all intents and purposes, that nurse practitioner is now a part of the health department’s operations, but at the same time still belongs to the hospital that “loaned” her. Her hospital provides continued “administrative control” (ADCON) for her. The health department’s street medicine director provides “operational control” (OPCON) of the practitioner’s time and effort. The City Health Commissioner, who in this hypothetical case is responsible for decreasing deaths from overdose in the city provides strategic oversight; determining how much of her budget is devoted to the street teams as a part of this effort based on the mayor’s guidance and strategic priorities. The nurse practitioner on loan from one of the city’s hospitals is now a vital component of her overarching strategy and provides a direct professional link between the street team and the hospital allowing for improved communication, enhanced referrals and greater understanding of the components by all the elements of the ecosystem.
The military has a long history of working with different agencies and services in settings where one service or organization leader has operational leadership authority. In Baltimore City during the COVID-19 pandemic, we demonstrated that this model could work outside the military. The Baltimore Convention Center Field Hospital (BCCFH) was staffed and run by a combination of nursing staff from University of Maryland Medical System (UMMS), providers from Johns Hopkins Medicine (JHM) and a range of contracted staff (e.g. security, logistics, information technology, convention center staff).
Executive leaders for the BCCFH came from both health systems and worked together as a team. The medical systems and contractors retained ADCON for their assigned staff. The BCCFH Director was a Johns Hopkins faculty member who provided OPCON over the contractors, Hopkins and UMMS staff assigned. The BCCFH Director was accountable to the Maryland Secretary of Health (whose department funded the operation) as well as a board of senior leaders from the state health department, Hopkins and University of Maryland health care systems. The Secretary and this board exercised strategic oversight for all BCCFH operations (e.g. inpatient care, ambulatory infusion, testing, vaccination etc.)
Three blocks to the north during the pandemic, the TRI (“Triage, Respite, Isolation”) Support Center located at the Lord Baltimore Hotel was a Baltimore City operation for individuals with COVID-19 who had no safe place to isolate. Thus, OPCON fell to the City of Baltimore’s designated leaders: the site clinical directors who were Hopkins employees attached to the city for this COVID-19 effort. They had OPCON over individuals working in the hotel including all nursing personnel from UMMS and staff from other city agencies. These leaders set policy and procedures in collaboration and consultation with leaders from the other engaged organizations: UMMS, the Mayor’s Office of Homeless Services (MOHS), the Mayor’s Emergency Operations Center (EOC), and Hotel Management.
The operational leaders were accountable to an executive leadership board that included a representative from UMMS, one from the Mayor’s office and the City Health Commissioner, who served as the board chair. The three executives provided strategic oversight and guidance for the operational leadership. The individual organizations responsible for the staff working in the hotel (e.g. UMMS, MOHS, Mayor’s Office, Hotel Management, and contracted security) retained ADCON of their personnel.
While the specific terms “OPCON” and “ADCON” were not used during the pandemic to delineate these operational relationships, this model of centralized authority, shared resources and clearly defined accountability were key to the city’s remarkable success in the pandemic.
Although state and city lines of authority differed between these two efforts, in this case the City Health Commissioner and the health department coordinated the citywide pandemic response. There were obvious cracks. But to the average residents of our city, they were largely invisible. As an example, the Baltimore Mayor or Health Commissioner was much more likely to get compliments on Twitter or Facebook for the convention center vaccine or testing operation than the governor. Although the lines of authority were not always clear (or consistently followed) the city effort functioned as a crisis-driven system of health, ostensibly under the health commissioner as the strategic leader responsible for developing collaborative coordination and the city’s strategic communication plan.
Between 2018 and 2022, Baltimore became the per capita overdose capital of the Nation, boasting a fatal overdose rate that was nearly double that of other large US cities. However, for decades the city has had numerous dedicated civic and community-based organizations, daily addressing the challenges of this syndemic. For example, ten years ago, Baltimore was the first municipality in Maryland to allow naloxone to be obtained by individuals without a provider’s prescription. More recently, in part supported by the city’s opioid restitution funds, targeted efforts have been taken and the rate of death from overdose continues to decrease and is down 23% compared to last year. But insufficient clarity around operational relationships and the absence of a central coordinating authority remain, resulting in cracks in the efforts to provide a continuum of care for individuals at risk of overdose from OUD. In our city, aggressive efforts are underway to remedy this.
The COVID-19 pandemic was defeated by a city wide coordinated, cooperative and collaborative effort. Nationally, the opioid syndemic has raged for more than a quarter century at the cost of more than a million lives with more than six million adults and adolescents still suffering from OUD including thousands in Baltimore. While laudable efforts are underway, this population still lacks a unified system of health for their care.
The opioid restitution fund is an unparalleled opportunity for our city and for municipalities across the country. An infusion of new money is good. An infusion of new thinking might be even better. As with the pandemic, resources and reorganized health care operations could be coordinated to “close the cracks” in our city’s overdose syndemic response as well.
We have figured this out before.
Chuck Callahan Henry V 4.3 – Lead from the Front https://henryv43.com/
“The views expressed by Dr. Callahan are his own, and do not reflect the official policy or position of the BCORE project leadership, (“Baltimore’s Comprehensive Overdose Response to End the Epidemic”), the University of Maryland School of Medicine, the University of Maryland, Baltimore, or any agency or department of the Baltimore City, Maryland or U.S. Governments.”
On a clear, breezy summer Saturday morning in the Sandtown-Winchester neighborhood of Baltimore,