Carol Gregory*,†, Scott Allen†, Mike Botieri†, Daniel Meloy†
ABSTRACT
The opioid overdose crisis in the United States has given rise to innovative solutions to address behavioural health problems in communities. These complex initiatives vary greatly, making it difficult to understand what makes them successful and where their gaps and needs are, which impairs the ability to know how to best apply resources. This article examines Cordata’s Operation to Save Lives (O2SL) and Quick Response Team (QRT) National’s use of the Project Management Maturity Model (Maturity Model) to create an instrument, the Project Maturity Adherence Tool (PMAT) to better understand the state of complex, collaborative community-based programs that address substance use disorders (SUDs), opioid use disorders (OUDs), mental health disorders, community safety and well-being, and fatal overdoses in the United States. It represents a shift in the purpose of employing this model from industries like engineering, software development, and business to community-based initiatives to address behavioural health issues. In this setting, its primary purpose is to create structured communication within and between geographically dispersed, multifaceted initiatives that are united by common goals and funding streams but may have great diversity in how they operate.
Key Words Behavioural health disorders; community collaborative response; fatal overdose; law enforcement-engaged initiatives; Capability Maturity Model; opioid use disorders; Project Management Maturity Model; substance use disorders.
Over 1 million people have died in the United States from drug overdoses since 1991 (Centers for Disease Control and Prevention [CDC], 2024a). This epidemic has been exacerbated by the development of synthetic opioids such as fentanyl, resulting in 10 times the deaths as compared to 1999. The CDC’s 12-month reported overdose death toll in the United States for the period ending June 2024 is 90,157 (CDC, 2024b). While police focused on enforcing drug laws and making arrests, public health and community organizations had been engaging with vulnerable persons with substance use disorders (SUDs) and mental health disorders, implementing harm reduction strategies while working to connect those suffering from these disorders to treatment, care, and recovery (Firesheets et al., 2022). By 2015, law enforcement agencies and public health officials recognized that innovation was needed to address SUDs (Police Executive Research Forum, 2017; Yatsco et al., 2020). The field of deflection was born. These programs focused on police utilizing law enforcement’s “front-row seat” to the crisis, engaging persons with SUDs while breaking down traditional silos that existed between police, public health, and community organizations (Firesheets et al., 2022). The core objective of law enforcement-engaged models is to redirect or to “deflect” individuals suffering from SUD or opioid use disorder (OUD) away from the criminal justice system by supporting referrals to services, treatment, and recovery (Ross, 2021; Schiff et al., 2017).
Leveraging collaborations between law enforcement, behavioural health, public health, recovery, and community partners to address the overdose crisis resulted in the development of complex, collaborative, community-based initiatives to address SUD/OUD in the United States (Balfour et al., 2022; Diriba & Whitlock, 2022; Shepherd & Sumner, 2017). For example, the Torrington Connecticut C.L.E.A.R. (Community, Law Enforcement, and Addiction Recovery) initiative paired sworn officers with behavioural health, community, and peer recovery partners to provide outreach engagement to persons suffering from SUD, OUD, alcohol use disorder (AUD), and other behavioural health issues. Since implementation, Torrington has realized a 47% decrease in overdose fatalities from 2022 to 2024, far exceeding state and national trends.
At a high level, community collaborative initiatives share the common goals of reducing the use and abuse of opioids and other substances, increasing access to treatment, decreasing the SUD/OUD death rate, and improving health outcomes in areas with SUD/OUD hot spots (Underwood et al., 2021). Beyond that, they vary by types of interventions, outreach methods, program composition, agencies involved, populations served, and evaluation methodology (Bagley et al., 2019; Bailey et al., 2023; Champagne-Langabeer et al., 2020). This creates both internal and external challenges including establishing and coordinating multi-sector partnerships, fostering communication between health, law enforcement, and community-based agencies to work together across sectors, educating communities, dispelling misperceptions and stigma around SUD/OUD and mental health disorders in communities, creating data access and integration (Underwood et al., 2021), managing case flow, and evaluating outcomes. The complex nature of both the problem and its solutions has created considerable variation across initiatives; every program and community is unique. This makes it harder to understand the efficacy of various practices, which leads to difficulties in determining how and where to apply efforts and resources. Data collection and sharing are key to creating repeatable, sustainable, and successful responses (Manchak et al., 2022). However, the field lacked consistent tools and approaches for understanding both the composition and outcomes of the various initiatives across the United States.
Cordata’s Operation to Save Lives (O2SL) and Quick Response Team (QRT) National was founded by three police chiefs who experienced success in bringing public safety, public health, and communities together to reduce fatal overdoses using the community collaborative approach and wanted to share their experience and success with others. Their work has expanded to include addressing the needs of persons with mental health disorders identifying and supporting drug-endangered children and other behavioural health community challenges. They have taken the lessons they have learned to municipalities, counties, and states in assisting vulnerable populations impacted directly and indirectly by these problems. O2SL and QRT National provide training, mentoring, consulting, research and data collection, and web-based software tools for the integration of program linkages, communication, and metrics. However, O2SL and QRT National have faced challenges in identifying each initiative’s full capacity of programs and services. They needed a structured, standardized communication and assessment tool that would allow for a clear and systematic understanding of the incredible complexity and variety of efforts conducted by each client. This led to the creation of the Project Management Adherence Tool (PMAT), which was grounded in the Project Management Maturity Model (Maturity Model) to determine the current state of each initiative, creating a baseline from which cross-program and over-time comparisons can be made. With this information, initiatives develop strategic plans, determine where to apply resources, and identify areas for improvement in the ever-changing and complex landscape of SUDs, mental health disorders, and communities facing other problems today.
The Project Management Maturity Model (Maturity Model) is defined as “a formal tool used to assess, measure and compare an organization’s practices against best practices or those employed by competitors, to map out a structured path to improvement” (Fabbro & Tonchia, 2021; Grant & Pennypacker, 2006). Maturity Models have provided a framework for assessing the current state of a project and identifying opportunities for process improvement. They are rooted in the Capability Maturity Model (CMM) developed by Carnegie Melon University’s Software Engineering Institute (Ethiraj et al., 2004; Paulk et al., 1993) and have been applied to various business and other industry applications. The basis of the model is that there are maturity levels that projects can attain such as initial, repeatable, defined, managed, and optimized. Maturity levels are increased sequentially and only when all previous levels are achieved and maintained. Movement between levels is determined by the characteristics of the project processes defined as “disciplined, standard/consistent, predictable, and continuously improving” respectively. Maturity models help bring together separate organizational functions, help set goals and priorities, and serve as a benchmark for tracking comparisons when striving for continuous improvement (Gomes & Romao, 2025).
In the years since its inception, there have been many applications and adaptations of the Maturity Model as different industries have adopted it. Despite the various forms it takes, its primary purpose has been maintained (Pöppelbuß & Röglinger, 2011). In this way, it is both descriptive and prescriptive and can be used to compare within and across projects over time. Research has not supported one correct form of Maturity Models, which has freed users to adapt it to various industries, including non-profit organizations (Marciszewska, 2018). Cordata’s O2SL and QRT National decided, because of both its adaptability and its alignment with their needs, to use the Maturity Model as a basis for better understanding the state of initiatives.
The PMAT is a self-administered questionnaire that provides a framework for assessing the current state of a site’s community safety and well-being and/or of its deflection initiative. Program maturity is defined on a continuum that indicates the level at which the program can be self-perpetuating, collect, analyze, and report efficacy data, engage in process improvement through monitoring and feedback, introduce innovation, and contribute to the national development of knowledge and initiatives through the dissemination of outcomes. Programs are complex, and so is assessing their maturity. Programs may be at the upper end of the continuum in some areas and have not even approached that in others. The instrument is designed to give an overall score, a “domain” or topical area score, and scores within different domain subtopics.
The PMAT is comprised of 146 quantitative and qualitative questions covering six domains. These domains were developed from both content analysis of the features of thriving community collaborative programs and the alignment with best practices in programming to address SUDs, mental health disorders, and behavioural health challenges in communities. Added to the Maturity Model premises, it creates a practical way of grouping areas for assessment and improvement. They include the topical areas of (1) Learning and Improvement, (2) Infrastructure and Operations, (3) Community Alignment, (4) Partnerships, (5) Sustainability, and (6) Outcomes. Learning outcomes and improvement focus on training, education, and awareness, infrastructure and Operations look at program management and administration, team composition, and technology, data incident tracking, analysis, and reporting. Community Alignment considers the ability of the program to address minority underserved, and marginalized populations and identify structural barriers for these populations. Partnerships identify who is involved with the program seeking comprehensive participation that includes jail re-entry, drug court, veterans drug court program, stakeholder partnerships, community collaboration, healthcare, treatment, and public and behavioural health partners. Sustainability is comprised of questions regarding the program teams, marketing and public relations, budget oversight and management. Outcomes examine how programs define and determine “success.”
Sites self-administer the PMAT questionnaire. Afterward, they meet with the O2SL and QRT National Review Team in a 90-minute virtual consultation to discuss their answers offering clarification and ensuring accuracy. This discussion is recorded, transcribed, and used to update the PMAT with information from the consultation. The consultant then rates each answer using the CMM rubric. This 5-point Likert scale rubric has clearly defined criteria that relate to the steps of the Maturity Model (1 = initial, 2 = repeatable, 3 = defined, 4 = managed, and 5 = optimized). The ratings of each section are combined to form a domain score, which is weighted to create a composite score indicating the overall program’s maturity. The scoring allows for historical and cross-site comparisons. Domain and subtopics with higher scores represent more mature practices. Lower scores indicate an area that is less mature and potentially a place to target increased resources or activity. The PMAT can be readministered periodically (typically annually) to provide programs with up-to-date feedback and historical comparisons, showing how their efforts are affecting the overall maturity of the initiative.
While the development and scoring of the PMAT was intended to be informative versus evaluatory, steps were taken to ensure that it is an empirically grounded instrument. PMAT questions were developed by a team experienced in executive-level program implementation in communities with long-established, successful deflection, community safety, and well-being initiatives. These questions were then externally reviewed by a panel of subject matter experts and revised to the version currently in use which, when aggregated, represents the maturity of the program. To quantify the results into measurable constructs, a panel of experts representing research, law enforcement, fire/emergency medical services (EMS), social work, and persons with lived experience in SUD was invited to complete a survey that rated and ranked PMAT questions and assigned a weight to the domains. Likert scale ratings correspond to a common rubric used across all instruments. Statistical analysis was used to calibrate the weighting of the tool. Once the scoring was established, it was tested against past completed PMAT instruments for continuity. A live pilot tested for interrater reliability in scoring the PMAT, expert panel agreement with weighting, and user acceptance of scores. Unscored questions were added to the PMAT to elicit user feedback on questions, scores, and processes.
States that have implemented the PMAT include Connecticut, Wisconsin, Kentucky, Ohio, West Virginia, New York, and Texas. The PMAT has been widely accepted by sites as an effective tool for establishing project baselines, identifying needs, and gaps in services and resources, tracking outcomes, and understanding the overall maturity of initiatives over time. This is largely attributed to the value it has provided to sites in creating a structure for taking stock of the various complex efforts of the initiative and communicating in a common language within and between programs. One rural outreach site in southeastern Kentucky has demonstrated remarkable progress in its Deflection Outreach initiative and partnered Situation Table collaboration since its first Program Maturity Assessment Tool report. Over the past 4 years, this site has significantly improved its PMAT maturity scores across multiple domains. At the same time, the county has achieved a substantial reduction in overdose-related fatalities – a key goal of this collaborative effort. Between 2021 and 2023, fatal overdoses decreased by 31%. Additionally, non-fatal overdoses and hospital encounters involving SUD diagnoses have declined by 9.1% and 15.6%, respectively. These outcomes align with the priority measures identified by this region’s Deflection Outreach team and the Situation Table in the county.
Similarly, a suburban community in Connecticut has experienced notable success after implementing its Deflection Outreach initiative and participating in the PMAT process starting in 2022. Over this period, the community has achieved continuous improvement in its PMAT Overall Maturity Score. Alongside these advancements, the community has seen a yearly reduction in overdose deaths, with a 27% death decline in PMAT year one and a further 47% death decline in PMAT year two. Another initiative in Connecticut experienced a loss of both leadership and resources, which impacted their ability to sustain key parts of their program and services. Second-year PMAT scores for this initiative were significantly lower than year one. This is consistent with what is expected to happen if initiatives regress.
Utilizing the PMAT process in the Connecticut (C.L.E.A.R) initiative allowed a municipal chief of police to identify a gap in his department that led to his requesting customized deflection training for all of his patrol officers and sergeants (shift supervisors). As a result, the chief has seen a dramatic cultural shift throughout his department in its positive response to addressing SUDs, resulting in more compassionate, engaged, effective, and understanding interactions when officers respond to SUD-related calls for service.
Another West Virginia law enforcement leader offered this feedback in an email:
“There are times I feel were stalemate or stuck in a rut. My team members now have a year plus under their belts and it shows. When I read your email and read the final review it not only reminded me of how valuable this program is but it also reminded me of how important and how proud of my team for what they do. With QRT it truly is a collaborative effort from all sides. After I finished reading the email I called for my team, and I shared the good news with them. I told them at times we feel beaten and get down but over the past year they have only grown our program and put a foothold with LE and EMT’s help to battle this problem we all share. My team shared some with me how they feel the team has impacted our community and they themselves are seeing a decrease in ODs in [redacted] and I told them that they are the main contributors to this program and the efforts put forward every day.”
Comprehensive, community collaborative approaches are difficult in every way. The PMAT serves to open communication and help initiatives understand what they are doing and how it relates to efficacious practices in the field. This leads to the identification of the tangible actions needed to achieve their goals. Looking at scores over time, the PMAT maturity scores have consistently increased with site progress such as the addition of capabilities, training, or partnerships, and have decreased when certain services or activities are reduced. This has helped initiatives to apply their scarce resources and efforts to the components that have the biggest impact on their desired outcomes. The PMAT is vital to strategic planning and program management. It identifies strengths, gaps, and needs, indicates the maturity of a program, reports outcomes, and establishes a baseline of performance.
The PMAT has been invaluable in state-level multi-site initiatives by providing a detailed picture of each participating region. In the 3 plus years since its inception, the PMAT has increased communication and understanding, improved service delivery, driven outcomes, and allowed the state to see across multiple sites and levels to understand initiative efficacy and resource allocation. While the PMAT began as a tool to help Cordata’s O2SL and QRT National experts better understand and communicate with partner sites, its use has greatly expanded with user acceptance. It has been used by sites as a baseline supplying data for grant proposals and readministered periodically to inform sites on their progress. This relatively new model for the integration of justice into coordinated systems of care requires data and evaluation to identify the operational features that drive success (Worobiec et al., 2023). This tool provides invaluable insights into how to best understand and deliver responses to the SUD/OUD crisis, mental health disorders, and behavioural health issues, making it a promising practice in enhancing a collaborative’s ability to plan, execute, and routinize efforts to overcome a variety of public safety and behavioural health issues in our communities. As the number of sites having multiple years of PMAT participation increases, it is anticipated that an in-depth study of the instrument and its role in supporting initiatives will be conducted, shedding further light on the use of the Maturity Model in programs working to reduce behavioural health problems in communities.
The authors have no conflicts of interest to declare.
*Baldwin Wallace University, Berea, OH, USA
†O2SL and QRT National, Cordata, Cincinnati, OH, USA
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Correspondence to: Dr. Carol Gregory, Baldwin Wallace University, 275 Eastland Road, Berea, OH 44017, USA. E-mail: cgregory@bw.edu
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Journal of CSWB, VOLUME 10, NUMBER 1, March 2025