Overall problem and opportunity

• Beaufort County and surrounding area has committed leaders and many services, but the system is fragmented, siloed, and hard to navigate for residents, especially in rural areas and justice settings.

• Transportation, not just services, is a defining barrier: people wait hours around appointments and often disengage from treatment or recovery.

• Youth, justice‑involved individuals, and rural communities outside Washington are consistently under‑served despite being central to the overdose and behavioral health reality.

Why opioid‑settlement dollars should fund this package

• Settlement dollars are meant to build lasting infrastructure for treatment, prevention, recovery, and harm reduction, not one‑off projects.

• The four proposed initiatives translate community voice from the Task Force process into concrete, high‑impact investments tied to courts, hospitals, and schools.

• Each initiative uses existing local strengths (churches, D.A.R.E., Recovery Court, reentry partners, peer supports) rather than building from scratch, which improves feasibility and sustainability.

Initiative 1: Beaufort Peer Bridge Post‑Overdose Response

• Creates a peer‑led bedside response team in hospital and emergency settings so every overdose survivor is engaged before discharge, not left to “figure it out.”

• Provides immediate overdose education, naloxone, and navigation to medications for opioid use disorder, outpatient care, and community supports.

• Includes 7‑day and 30‑day follow‑up so the county can actually track outcomes and reduce repeat overdoses during the highest‑risk period.

• Gives hospitals, families, courts, probation, and law enforcement a clear, single referral pathway after overdose events.

Initiative 2: Rural Mobile Access and Church‑Hub Outreach

• Brings behavioral health, harm reduction, and navigation services directly to Aurora, Belhaven, Bath, and other underserved communities through rotating mobile outreach.

• Uses churches and community gathering places as trusted hubs for information, naloxone, harm reduction supplies, screening, and connection to care.

• Shifts the county from “come find us in Washington” to “we will meet you where you are,” reducing rural inequity and treatment drop‑off.

• Ties transportation assistance directly to treatment and recovery engagement rather than leaving people stuck after they say “yes” to help.

Initiative 3: Youth Diversion, D.A.R.E. Expansion, and Peer Leadership

• Expands D.A.R.E. from a small program to a core piece of the county’s prevention strategy, starting before middle school and repeating through the school years.

• Builds youth peer leadership so athletes, student leaders, and near‑peers carry the prevention message, recognizing students listen more to each other than to adults alone.

• Connects youth diversion, school‑based supports, and family engagement so kids exposed to overdose, suicide, and violence are not left without follow‑up.

• Creates visible, recurring prevention events and structured parent engagement, not one‑shot assemblies.

Initiative 4: Recovery Court and Reentry Aftercare Navigation

• Establishes a 90‑day aftercare and navigation system for people leaving jail, prison, or Recovery Court, beginning before release.

• Directly targets practical barriers that drive relapse and recidivism: ID, phones, transportation, housing, employment, and behavioral health connection.

• Uses peer navigation and coordinated referrals to make sure individuals are not simply told to “find a group” but are escorted into real services.

• Links Recovery Court, reentry partners, probation, jail leadership, and community providers so supervision and services are working the same plan.

Judicial integration under NC practice

• North Carolina judges already have authority to order treatment, counseling, and program participation as conditions of probation, diversion, deferred prosecution, juvenile dispositions, and specialty courts.

• These initiatives can function as court‑connected pathways: for example, ordering high‑risk individuals with overdose histories into the Peer Bridge program as part of probation or Recovery Court plans.

• Rural mobile hubs can count as approved compliance locations for participants who cannot reliably reach Washington, reducing technical violations due to transportation alone.

• Youth diversion and the Reentry Aftercare Navigation Program can be written directly into juvenile and specialty‑court dispositions, aligning settlement investments with existing accountability structures.

Phasing and governance

• Phase 1 focus: Peer Bridge Post‑Overdose Response and Recovery Court/Reentry Aftercare; both target the highest‑risk populations and plug directly into hospitals, jails, and courts.

• Phase 2 focus: Rural Mobile Access/Church‑Hub Outreach and Youth Diversion/D.A.R.E./Peer Leadership to expand reach and build upstream prevention.

• Each initiative has a natural lead: hospitals or a contracted nonprofit for Peer Bridge, the health department for mobile outreach, sheriff/schools/youth partners for D.A.R.E. collaborative, and Recovery Court plus reentry leadership for aftercare navigation.

Proposal for Beaufort County Opioid Settlement-Funded Behavioral Health System Transformation

Submitted by Linked Pathways

Executive Context and System Diagnosis

Beaufort County’s behavioral health ecosystem is not defined by absence of effort or lack of services. It is defined by fragmentation, inconsistent access pathways, and insufficient system coordination across providers, geography, and justice involvement.  The following plan may not be perfect, however it provides actionable framework we can move forward on and amend when needed.

Stakeholder input from the Behavioral Health Task Force identified five structural failures that can be addressed through opioid settlement investment:

• Service fragmentation across providers, agencies, and sectors, resulting in weak referral continuity and limited shared visibility.

• Geographic inequity, with service concentration in Washington and reduced access in Aurora, Belhaven, Bath, and surrounding rural communities.

• Transportation barriers that function as a systemic access failure rather than a logistical inconvenience.

• Insufficient youth prevention infrastructure, particularly peer-driven and early-intervention models.

• Lack of structured engagement pathways for justice-involved individuals, particularly during reentry, probation, and post-crisis periods.

The operational reality is that individuals must currently self-navigate a system that is not designed for navigation under conditions of crisis, addiction, or instability. This results in missed intervention windows, repeated overdose events, probation violations, and preventable recidivism.

This proposal establishes four integrated initiatives designed to function as a coordinated system rather than isolated programs. Each initiative is structured to align with allowable opioid settlement expenditures while embedding directly into existing judicial, healthcare, and community systems.

System Design Principles

All proposed initiatives are built on the following implementation principles:

• Access must be proactive, not passive. Services must reach individuals rather than requiring individuals to locate services.

• High-risk transition points must be prioritized, including overdose events, jail release, and youth behavioral escalation.

• Peer support must be formalized as a system-level function, not treated as an auxiliary service.

• Judicial systems must be used as structured engagement mechanisms within existing legal authority.

• Rural access must be physically and operationally addressed through distributed service delivery models.

• Transportation must be integrated into service delivery rather than treated as a separate issue.

Initiative 1: Beaufort Peer Bridge Post-Overdose Response Program

Objective

Establish a real-time, peer-led intervention model that engages individuals immediately following an overdose and sustains engagement through the highest-risk post-discharge period.

Operational Model

• Deploy certified Peer Support Specialists within hospital emergency departments and in coordination with EMS.

• Establish automatic notification protocols from EMS and emergency departments to the Peer Bridge team upon overdose reversal or admission.

• Provide bedside engagement within hours of stabilization, including:

  • Motivational interviewing.

  • Harm reduction education.

  • Naloxone distribution and training.

  • Immediate treatment pathway explanation.

• Implement structured follow-up protocol:

  • Contact within 24–48 hours post-discharge.

  • Weekly engagement for 30 days.

  • Continued support up to 90 days for high-risk individuals.

• Execute “warm handoffs” to:

  • Medications for opioid use disorder (MOUD) providers.

  • Outpatient treatment programs.

  • Recovery housing and peer support networks.

Staffing Structure

• 1 Program Manager.

• 3–5 full-time Peer Support Specialists (coverage rotation).

• 1 Care Navigator (treatment coordination and scheduling).

• On-call supervisory clinician (for escalation and compliance oversight).

Implementation Steps

1. Formalize agreements with hospital systems and EMS providers for referral triggers and data sharing.

2. Develop standard operating procedures for bedside engagement and follow-up protocols.

3. Recruit and certify peer staff with lived experience and local community credibility.

4. Establish centralized tracking system for engagement metrics and outcomes.

5. Train hospital staff on referral process and integration workflow.

Measurable Outcomes

• Reduction in repeat overdose within 6–12 months.

• Increased initiation of MOUD within 7 days of overdose.

• Increased engagement in outpatient treatment post-discharge.

• Reduction in overdose-related emergency department utilization.

Initiative 2: Rural Mobile Access and Church-Hub Outreach Initiative

Objective

Eliminate geographic and transportation barriers by deploying mobile, community-anchored behavioral health access points across rural Beaufort County.

Operational Model

• Establish a rotating mobile outreach unit serving Aurora, Belhaven, Bath, and surrounding areas on a fixed weekly schedule.

• Anchor service delivery at trusted community locations, primarily churches and community centers.

• Provide on-site services including:

  • Behavioral health screening and referral.

  • Harm reduction services and naloxone distribution.

  • Peer support engagement.

  • Care navigation and appointment scheduling.

• Integrate transportation coordination directly into outreach operations:

  • Schedule rides at point of contact.

  • Coordinate with Medicaid transport, local transit, and faith-based vehicles.

Staffing Structure

• 1 Mobile Program Coordinator.

• 2 Peer Support Specialists.

• 1 Licensed clinician (part-time or rotating).

• 1 Transportation and logistics coordinator.

Implementation Steps

1. Map high-need rural zones using overdose data, EMS call data, and stakeholder input.

2. Formalize partnerships with churches and community organizations as host sites.

3. Procure and equip mobile unit or deploy staff-based mobile model.

4. Develop fixed outreach calendar and publish widely across community channels.

5. Integrate referral pathways with healthcare providers and justice system stakeholders.

Measurable Outcomes

• Increased service utilization in rural zip codes.

• Increased treatment initiation among rural residents.

• Reduction in missed appointments due to transportation barriers.

• Increased naloxone distribution and overdose reversal capacity.

Initiative 3: Youth Diversion, D.A.R.E. Expansion, and Peer Leadership Collaborative

Objective

Build a continuous, peer-influenced prevention and early intervention system targeting youth behavioral health risk before escalation into crisis or justice involvement.

Operational Model

• Expand D.A.R.E. programming across additional grade levels and schools, beginning at elementary level and continuing through high school.

• Integrate D.A.R.E. into a broader prevention framework that includes:

  • Peer leadership development programs.

  • Youth ambassador networks (athletes, student leaders, influencers).

  • Recurring prevention events tied to school and community calendars.

• Establish structured diversion pathways:

  • Referral from schools, law enforcement, and juvenile justice.

  • Immediate connection to peer mentors and behavioral health supports.

• Implement family engagement model:

  • Parent education sessions.

  • Youth-family support planning.

  • Crisis response coordination with schools.

Staffing Structure

• 1 Youth Program Director.

• 2–3 Prevention Specialists.

• 1 Peer Leadership Coordinator.

• Contracted behavioral health clinicians for school-based support.

Implementation Steps

1. Coordinate with school district leadership and sheriff’s office for expanded D.A.R.E. rollout.

2. Develop peer leadership curriculum and selection criteria.

3. Establish referral protocols with schools and juvenile justice entities.

4. Schedule recurring prevention events throughout academic year.

5. Integrate data tracking for youth engagement and outcomes.

Measurable Outcomes

• Reduction in youth substance use indicators.

• Increased early behavioral health intervention rates.

• Reduction in juvenile justice referrals related to substance use.

• Increased youth participation in prevention programming.

Initiative 4: Recovery Court and Reentry Aftercare Navigation Program

Objective

Create a structured, accountable transition system for individuals exiting incarceration or completing Recovery Court to prevent relapse, overdose, and recidivism.

Operational Model

• Initiate pre-release planning within jail or prior to Recovery Court completion:

  • Identification acquisition.

  • Medicaid activation or reinstatement.

  • Housing coordination.

  • Initial treatment appointments scheduled.

• Assign a dedicated reentry navigator prior to release.

• Provide structured 90-day post-release engagement:

  • Weekly contact and monitoring.

  • Transportation coordination.

  • Employment and housing support linkage.

  • Treatment adherence support.

• Integrate directly with probation and court systems:

  • Status reporting where appropriate.

  • Compliance tracking aligned with court conditions.

Staffing Structure

• 1 Reentry Program Manager.

• 2–4 Reentry Navigators.

• 1 Peer Support Specialist embedded in reentry workflow.

• Administrative support for coordination and reporting.

Implementation Steps

1. Formalize data-sharing and coordination agreements with jail, probation, and courts.

2. Develop standardized pre-release planning checklist and workflow.

3. Recruit navigation staff with experience in justice-involved populations.

4. Establish referral pipeline from jail and Recovery Court.

5. Implement outcome tracking tied to recidivism and treatment engagement.

Measurable Outcomes

• Reduction in 6- and 12-month recidivism rates.

• Increased treatment engagement post-release.

• Reduction in overdose among recently released individuals.

• Increased housing and employment stabilization.

Judicial Integration Framework

Under North Carolina law, courts maintain authority to impose conditions of probation, diversion, and specialty court participation that are reasonably related to rehabilitation and public safety.

This proposal operationalizes that authority through structured system alignment:

• Courts may require participation in Peer Bridge engagement following overdose-related offenses.

• Rural outreach sites may be designated as valid compliance locations for individuals with transportation barriers.

• Youth diversion programming may be used as an alternative to formal juvenile adjudication pathways.

• Reentry navigation may be mandated as a condition of probation or Recovery Court completion.

This approach does not expand judicial authority. It increases the effectiveness of existing authority by ensuring that court-ordered participation connects to real, accessible, and coordinated services.

Phased Implementation Plan

Phase 1 (0–12 months)

• Launch Peer Bridge Post-Overdose Response Program.

• Launch Recovery Court and Reentry Aftercare Navigation Program.

Rationale:

• Targets highest-risk populations.

• Aligns with existing justice and healthcare infrastructure.

• Produces measurable short-term outcomes.

Phase 2 (12–24 months)

• Deploy Rural Mobile Access and Church-Hub Outreach Initiative.

• Expand Youth Diversion and Prevention Collaborative.

Rationale:

• Expands geographic reach.

• Builds long-term prevention capacity.

• Reduces future system burden.

Governance and Partnership Structure

Effective implementation requires defined ownership and cross-sector coordination:

• Peer Bridge Program: Led by hospital system or contracted nonprofit, in coordination with EMS and peer organizations.

• Rural Mobile Initiative: Led by health department or designated county entity, with faith-based and municipal partnerships.

• Youth Collaborative: Joint leadership between sheriff’s office, school system, and prevention partners.

• Reentry Program: Coordinated through Recovery Court, jail leadership, and reentry organizations.

A central coordinating body or task force subcommittee should oversee integration, data sharing, and performance monitoring across all initiatives.

Next Steps for Activation

• Convene a targeted implementation planning session with identified lead agencies and stakeholders.

• Select Phase 1 initiatives for immediate development.

• Develop commissioner-ready concept papers including:

  • Budget projections.

  • Staffing plans.

  • Outcome metrics.

  • Legal and judicial integration considerations.

• Establish data infrastructure for tracking outcomes across programs.

• Identify funding allocations from opioid settlement resources.

This proposal converts stakeholder consensus into a structured, operational system designed to reduce overdose deaths, improve treatment engagement, and stabilize high-risk populations through coordinated, accessible, and enforceable pathways.