Understanding engagement with an emergency department-based peer navigator intervention for opioid overdose prevention for a subset of patients experiencing homelessness

The leading cause of death among people experiencing homelessness is overdose. New York City operates the Relay initiative, which sends trained peer "Wellness Advocates" (WAs) to meet patients in the emergency department (ED) who have presented with an opioid-involved overdose. A high proportion of Relay patients experience homelessness. We conducted in-depth, one-on-one qualitative interviews with patient recipients of Relay services, Relay peer Wellness Advocates (WA), and emergency department providers. Interview transcripts were analyzed using iterative line-by-line coding to identify themes related to experiences of homelessness among Relay patients, including barriers and facilitators to engagement with Relay. Twenty-three participant interviews were included in this study. The results were organized into three overarching themes: (1) Multi-level barriers to engagement in services for patients experiencing homelessness; (2) Wellness Advocates as facilitators to participation and follow-up in Relay and other necessary services; and (3) Frustrations experienced by ED providers and stigma experienced by patients in the ED setting. This qualitative study illustrated that peers provided an important resource for overcoming some immediate barriers to service delivery presented by patient homelessness. However, policy interventions are needed to address the multi-level structural barriers to overdose prevention for people experiencing homelessness.