The New York City Department of Health and Mental Hygiene (NYC DOHMH) is one of the world's largest public health agencies, serving over 8 million New Yorkers. NYC DOHMH's Bureau of Alcohol and Drug Use Prevention Care and Treatment (BADUPCT) works to reduce morbidity and mortality related to alcohol and substance use among New Yorkers through contracting and oversight of prevention, treatment, harm reduction, and recover and support services; policy analysis and development; epidemiology, surveillance, and evaluation; development and dissemination of treatment and management guidelines; harm reduction initiatives; public and provider outreach and education; and community involvement and interagency collaboration. Within BADUPCT is the Center for Disease Control Technical Assistance (CDC-TA) team that supports local health departments (LHDs) across the country to implement successful programs and strategies to tackle the opioid overdose crisis in their communities. Based on evidence-based initiatives developed by BADUPCT, this programming was adapted by the CDC-TA team to fit the unique needs of the partner LHDs and their respective communities. The CDC-TA team collaborates closely with the National Association for County and City Health Officials (NACCHO), the funding partner, to support the partner sites in meeting their grant funded deliverables and objectives. 

Like the other partner communities, NYC was impacted by the COVID-19 pandemic, which quickly changed how the CDC-TA team could provide substance use focused technical assistance. The CDC-TA team could not provide in-person support to the LHDs, and LHDs capacity changed significantly as LHD staff were activated to do COVID-19 related work. In light of this, the CDC-TA team quickly shifted gears and began developing an online learning content series that would maintain the goal of supporting the LHDs. This asynchronous module series was developed so that LHDs would have access to a suite of evidence-based programs based on NYC DOHMH's existing opioid prevention and response initiatives. Creating this new technical assistance style would not have been possible without the support from both pre-existing and newly developed partnerships. With the help of subject matter experts and the LHD partners, the modules could be innovated so that the CDC-TA team's new partners, PRYCO Solutions, could design and develop the series to be hosted online on NACCHO University.

Typically, technical assistance work is time-limited, and with staff's schedules changing due to COVID-19, the modules allow for flexibility and sustainability without losing content. Additionally, technical assistance can be limited or inequitable in its standard form as it is usually only provided to a specific subset of people and organizations. Providing technical assistance through a free to access online learning series aids in making the practice more equitable— people and organizations who did not qualify for the technical assistance programming initially (due to lack of funding, staffing, or other resources) could now access the entire suite of technical services offered by NYC DOHMH. The provision of this innovative way of providing TA allows for a broader reach that will only further help organizations provide the best possible care to people who use drugs (PWUD).

The United States is in the midst of a crisis, with an average of 130 Americans dying every day from an opioid-involved overdose. From 1999 to 2017, more than 700,000 people died from a drug overdose. In 2017, the number of overdose deaths involving opioids (including prescription opioids and illicit opioids, such as heroin and illicitly manufactured fentanyl) was six times higher than in 1999.

Nationwide, local health departments (LHDs) have struggled to address this growing crisis. In 2019, the Centers for Disease Control and Prevention (CDC) awarded emergency funding to the National Association of City and County Health Organizations (NACCHO) to help LHDs develop and improve their response. Using these funds, the New York City Department of Health and Mental Hygiene (DOHMH) created the Opioid Crisis Response Technical Assistance (TA) Project. The team provides our partners LHDs with information and assistance for a suite of evidence-based programs so they could develop and enhance their capacity to launch such programs.

The NYC community was hit extremely hard by COVID-19. This presented unique challenges to the already vulnerable populations BADUPCT and our partners at the LHDs serve—people who use drugs (PWUDs). Even with the COVID-19 pandemic ongoing, the opioid crisis persists and presents challenges communities previously did not face. To name a few: COVID-19 restrictions on group sizes impacted encampments, closings, and changes to regularly scheduled hours affected how people could access care and treatment programs, and disruptions to the drug supply have led folks to seek out substances from unfamiliar sources. 

LHDs, in addition to PWUDs, face unique challenges amidst a national emergency.  LHDs staff have been reassigned from their usual scope of work to focus solely on COVID-19 related jobs. But unlike many partner LHDs, the CDC-TA team was exempt from being reassigned, which allowed the team to continue and adapt the TA programming to fit the site's needs. With LHD staff limited in their capacity to continue their substance use programming as initially planned, the CDC-TA team created a new goal to fill in the gap.

The CDC-TA team quickly pivoted and innovated an online learning series that would cover the entire menu of NYC DOHMH's programming, the first of which would focus on public health emergencies. Online learning, or "e-learning" is an evidence-based practice focused on delivering education, "using a wide variety of instructional designs, including synchronous and asynchronous formats." This learning style can be just as effective as face-to-face learning and expands access to learners with the addition of flexible scheduling (Lawn et al., 2017). Before the onset of the COVID-19 pandemic, the CDC-TA planned on eventually creating modules that would focus on various TA objectives. However, the CDC-TA team had to quickly innovate new content to fit the partner LHDs and a larger audience's needs. 

By innovating these modules, the TA team ensured that partner sites would have access to crucial substance use programming that could be completed on their own time. The modules also provided flexibility for NYC DOHMH staff focused on the emergency response, who were no longer readily available as a subject matter expert. The innovation of the first module, in particular, was useful and timely as it provided: concepts related to public health emergencies, LHDs roles and responsibilities, information about locating resources in an emergency setting, and a description of evidence-based practices as well as specific NYC DOHMH programs that adapted with the onset of the pandemic.

Typically, the provision of technical assistance is time-limited and selective to whom can receive the TA. In the past, technical assistance was only provided through direct site to site contacts (including site visits, scheduled calls, and conferences) and available only to six LHDs during work hours. The online learning series innovation increases access to evidence-programming in a flexible manner, which is particularly useful during a time of crisis. 

To provide this innovative form of TA, the project budget and staff responsibilities needed to be re-worked. Instead, the unused travel expenses were reallocated to hire a professional instructional design company, PRYCO solutions, to develop the modules that would later be hosted online by NACCHO University. Additionally, the NYC DOHMH TA team re-worked their previous job responsibilities to include the development of design documents based on existing NYC DOHMH evidence-based programs. Overall, the TA team was able to develop, with the assistance of PRYCO solutions, seven asynchronous modules:

1. Public Health Emergencies: Opioid Crisis & Covid-19
2. PDMP & Mortality Surveillance
3. MOUD: Low-threshold Buprenorphine, Naloxone, and Overdose Education
4. Syndromic Surveillance & RAR
5. The Relay Program and Evaluation
6. Anti-stigma
7. Communications (Knowledge Translation and Dissemination)

As an innovative form of technical assistance, these modules will be freely available online through NACCHO University— not limited to the partner LHDs included in this specific CDC-TA project. These modules highlight multiple topics as well as being a composite of resources, including relevant links (e.g. evidence-based programs outside of NYC). This will allow health departments across the country to access and learn from our programming, broadening our reach and ability to disseminate successful NYC DOHMH strategies to tackle the opioid overdose crisis.

Lawn, S., Zhi, X., & Morello, A. (2017). An integrative review of e-learning in the delivery of self-management support training for health professionals. BMC Medical Education, 17(1). doi:10.1186/s12909-017-1022-0

Evidence Based Practices

Allen, B., Harocopos, A., & Chernick, R. (2019). Substance Use Stigma, Primary Care, and the New York State Prescription Drug Monitoring Program. Behavioral Medicine, 46(1), 52-62. doi:10.1080/08964289.2018.1555129

Nolan, M. L., Ehntholt, A., Merrill, T., Weiss, D., Lall, R., & Paone, D. (2019). Novel use of syndromic surveillance to monitor the impact of synthetic cannabinoid control measures on morbidity. Injury Epidemiology, 6(1). doi:10.1186/s40621-019-0210-2

Nolan, M. L., Kunins, H. V., Lall, R., & Paone, D. (2017). Developing Syndromic Surveillance to Monitor and Respond to Adverse Health Events Related to Psychoactive Substance Use: Methods and Applications. Public Health Reports, 132(1_suppl). doi:10.1177/0033354917718074

Welch, A. E., Jeffers, A., Allen, B., Paone, D., & Kunins, H. V. (2019). Relay: A Peer-Delivered Emergency Department–Based Response to Nonfatal Opioid Overdose. American Journal of Public Health, 109(10), 1392-1395. doi:10.2105/ajph.2019.305202

The NYC DOHMH technical assistance project's objective was to support LHDs in enhancing their capacity to launch programs and initiatives. These programs included hospital-based non-fatal overdose response (Relay), prescription drug monitoring (PDMP), syndromic and mortality surveillance, medications for opioid use disorder (MOUD), anti-stigma and media campaigns, and rapid assessment and community engagement using BADUPCT's Rapid Assessment and Response (RAR) model.

When adapting to the current pandemic, the CDC-TA team created a new goal: develop seven educational, online learning modules (courses) that explain the various initiatives in NYC that respond to the opioid overdose crisis. Since community partners were unable to engage in the TA, the modules are a resource that could be accessed in the future when LHDs have the capacity to refocus on the opioid overdose crisis. 

To do this, NYC DOHMH, with the help of subject matter experts, community partners, and extensive research, developed HLDDs and PowerPoints for each course that PRYCO utilized to then create the modules to be hosted on NACCHO University's BlueSky Learning Management System. 

The CDC-TA team worked with various stakeholders, including NYC DOHMH staff, subject matter experts, the partner sites staff, PRYCO solutions, and NACCHO University to foster collaboration and confirm this specific newer type of technical assistance would meet the needs of the partner LHDs and other people/organizations not initially included in this TA program. The community partners were crucial in editing and developing the modules' content, as they provided specific subject matter knowledge and experiences. While creating the modules, the team continued to grow further relationships with sites allowing for a more trusting environment and more effective translation of NYC DOHMH evidence-based programs. Thus, meeting the objectives of the technical assistance project.

When developing the modules with PRYCO solutions, the CDC-TA team utilized various subject matter experts to provide specific subject-matter knowledge focusing on health equity. These experts included Dr. Larry Yang, a leading expert in the emerging field of anti-stigma work, and various NYC DOHMH Race to Justice staff. In 2016, Race to Justice was launched at NYC DOHMH to advance racial equity and social justice across all programs, policies, and practices. This work is done throughout the agency and engages staff to incorporate a health equity approach in all facets of their work. Our partnerships with these staff and subject matter experts, in addition to some newly formed partnerships, allowed for the CDC-TA program, including the online learning modules, to promote health equity. 

However, not all partnerships were pre-existing. New, innovative partnerships were needed to both develop and disseminate the online learning series. To create the online learning modules, the CDC-TA team re-allocated resources from the travel budget to hire a professional instructional design company and ended up selecting PRYCO solutions. This relationship was imperative as PRYCO solutions had the knowledge and extensive experiences developing and designing online learning experiences for adults through education and learning theories (allowing for our modules' easy-understanding). The CDC-TA also innovated a new partnership with NACCHO University to disseminate the modules to a broader audience. These new partnerships allowed TA to be provided innovatively at no charge and no time-limit for accessing the modules. Additionally, by translating and sharing this information to both the partner sites and other settings (including potentially under-resourced communities and municipalities), the practice of providing technical assistance is more equitable and far-reaching.

The CDC-TA program quickly needed to adapt and respond to meet the partner LHDs and their communities' needs since most LHD staff was reassigned to work on COVID-19 related activities. Because the partner LHDs substance use staff was often already limited pre-covid, this had profound implications for the CDC-TA program's execution. To meet the needs of the CDC-TA teams' target population, the selected LHDs, and more broadly, people who use substances, the technical assistance program had to adapt. The CDC-TA team innovated a new type of virtual technical assistance that ensures LHDs still receive the entire NYC DOHMH programming as initially promised while also reaching previously excluded communities.

This new style of technical assistance provides a more equitable form of research translation and dissemination. Before developing the modules, the technical assistance was only offered to six select sites that met specific criteria (i.e., capacity, funding limitations, unintentional overdose rate, and disease burden). The technical assistance program's adaptations allowed anyone who chooses to visit NACCHO university access to the entirety of the NYC DOHMH substance use programming developed for the CDC-TA program, reaching a broader population than the initial six LHDs. 

The CDC-TA team, to increase efficiency, staggered module development so that content for one module was created while the developers designed the layout, graphics, audio, and video segments of another module. Additionally, the CDC-TA team had SME's and other community partners review content early on in the development process. This increased partnership buy-in and reduced the need to edit the content at a later stage as it is much more cumbersome to edit once the developers have built it into the online learning platform. 

The modules will be maintained both by NACCHO & NYC DOHMH even after the grant expires, making it sustainable and long-term in a way that it was not originally. The technical assistance that was once time-limited is now a long-term, free resource that can be accessed on NACCHO University by a broader population than previously anticipated. There is room to grow this online learning series as more substance use programs and practices become evaluated. 

Formatting and packaging technical assistance as an online learning series has not been done before and is truly an innovative way to translate and disseminate knowledge and resources. Designing and disseminating content in this resourceful way has been incredibly valuable and may be incorporated into future projects unrelated to this CDC-TA program. Additionally, this may have larger-scale impacts on how NYC DOHMH provides technical assistance in the future.

This new technical assistance style allows the practice of providing TA to be more equitable— reaching a more extensive network and spreading information to people and organizations that would not have access to these resources. Amid a pandemic, having these resources housed on an online platform, NACCHO University, allows people to access these resources on their own time.

Although the online learning series's initial intent was to ensure our partner LHDs had access to the promised technical assistance, the actual impact extends much further. Health departments across the country will have access to these free learning modules, allowing for evidence-based substance use programming to be replicated across the country to provide the best possible stigma-free care to people who use drugs in the United States.