1. Outreach & Engagement Strategies
TRAINER INSTRUCTIONS
Welcome!
This is a half-day overview on Outreach & Engagement with a focus on People Who Inject Drugs (PWID)
The workshop is 3 hours with one scheduled 15 min break.
NOTES
Include Introductions if this workshop does not follow another HHRN training that already had an Introductions section.
Introductions are when each workshop participant can share their name and program or agency they work with.

2. HIV Harm Reduction Navigator Training
Commissioned by NYC DOH National Capacity Building Program for Health Departments and CBOs who have outreach staff and peers providing prevention services for people who use drugs.
Particular focus on PWID and health care issues.
Materials are drawn from HRC’s long experience and other Harm Reduction program peer training programs.
You are experts in the field no matter how long you have been doing outreach. Everyone brings relevant experiences & perspectives to this work.
TRAINER INSTRUCTIONS
The HIV Harm Reduction Navigator Training series was commissioned by NYC DOH National Capacity Building Program for Health Departments for CBOs who have outreach staff and peers providing prevention services for people who use drugs, with a particular focus on PWID and health care issues.
Life or Lived experience is valuable and HHRN workers are already experts in their own field, regardless how long they have been an official Peer or Outreach Worker.
This training will bring participants up to speed with current, evidence-based interventions and language that will be useful out in the field.
NYCDOH: New York City Department of Health
CBO: Community Based Organizations

3. 1. Workshop Overview KEY MESSAGES Purpose of Training
This session explores provider skills for effective participant engagement in outreach-based service models, examining the role of self-disclosure during outreach encounters, and identifying ‘best practices’ to ensure safety for both outreach workers and participants, including de-escalation strategies.
Additionally, this training identifies how HHRNs can more effectively meet diverse client needs by providing appropriate referrals, building alliances, and accessing community resources.

4. Group Agreements Step up, Step Back Non-Judgment Use “I” Statements
Agree to disagree
Confidentiality
WAIT/PUSH/ELMO
TRAINERS INSTRUCTIONS
We are talking about outreach today, so this workshop might bring up sensitive topics for some workshop participants.
Use the training to ask questions and discuss concerns.
It will be important to be respectful of each other during this time.
Are there other group agreements to add? (ex: cell phone or technical device use, one mic, etc.)
KEY MESSAGES
Step Up/Step Back:
Agree to Disagree: We all have own opinions.
WAIT: Why Am I Talking
PUSH or ELMO: Say PUSH, to “push” on training or Everybody Lets Move On

5. Training Objectives Discuss the benefits of outreach.
By the end of this session you will be able to:
Discuss the benefits of outreach.
Recognize client needs, more effectively.
Examine the role of self-disclosure during outreach interaction.
Identify ‘best practices’ to ensure safety for both outreach providers and participants.
Provide more appropriate referrals.
TRAINER INSTRUCTIONS
This is a half-day workshop with one scheduled break.
Workshop includes discussion and activities. 
By the end of this session you will be able to:
Discuss the benefits of outreach.
Recognize client needs, more effectively.
Examine the role of self-disclosure during outreach interaction.
Identify ‘best practices’ to ensure safety for both outreach providers and participants.
Provide more appropriate referrals.

6. Outreach and Engagement
Agenda
Outreach and Engagement 1
Workshop Overview 2
Outreach 3
Effective Communication & Engagement Skills
Break 4
Safety and De-escalation 5
Supportive Referrals 6
Closing & Evaluations
TRAINER INSTRUCTIONS
Brief review to let participants know what to expect for the next three hours.

7. Glossary PWID—People Who Inject Drugs PWUD—People Who Use Drugs
PLWHA—People Living with HIV/AIDS
SUDs—Substance Use Disorders
SAS – Syringe Access Services
SEP – Syringe Exchange Program
AOD – Alcohol & Other Drugs
TRAINER INSTRUCTIONS
Briefly review acronyms
What other terms are there?
HHRN – HIV Harm Reduction Navigators
SAP – Syringe Access Programs
IDU – Injection Drug User*
*This is what they used to call PWID, note how language is fluid and always changing.

8. Sexual Orientation >> to whom we are sexually attracted
Gender Identity >>
sense of self as male or female, neither or both
LGBTQI
Lesbian, Gay, Bisexual, Transgender, Transsexual, Two Spirited, Questioning, Intersex
KEY MESSAGES
Language is fluid and definitions or self-identification adjectives change with time and context.
Recognizing the distinction of Sexual Orientation from Gender Identity will be useful when developing relationships in this work.
Sexual Orientation: to whom we are sexually attracted
Gender Identity: sense of self as male or female, neither or both
Intersex: a person whose biological anatomy and/or genes vary from the expected male or female anatomy and/or genetics
LGBTQQIAA2SP: Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Intersex, Ally, Asexual, Two-Spirit, Pansexual
Examples:
My sexual orientation is I’m Gay, my gender identity is Male
My sexual orientation is Bisexual, my gender identity is Trans Female 8

9. BRAINSTORM: What is the Purpose of Outreach?
ASK
What is the purpose of Outreach?
When you hear it, what first comes to mind in terms of services?
How is this term used by others [in the office, by peers, etc.]?
TRAINER INSTRUCTIONS
Use this brainstorm as a way to open the training, getting a sense of what harm reduction means to participants, including their experiences with harm reduction.
This may be from a personal perspective (how harm reduction was -or was not- incorporated at their agency, or through their experience working as a peer/service provider).
If any responses in particular seem “off-base”, use the following slide to clarify.
Optional
Write down responses on Newsprint w. Thick Pen Markers
Or, ask if a volunteer would write down answers while you facilitate discussion
Or, have this discussion only

10. 2. Outreach
“A process designed to contact individuals in non-traditional settings who might otherwise be ignored or underserved.”
The Open Health Services and Policy Journal; 2010.
Olivet J, Bass. UK E, Elstad E, Kenney R, Jassil L.;
Outreach and Engagement in Homeless Services: A Review of the Literature

11. What is the Purpose of Outreach?
Make connections with people in the community.
Provide harm reduction supplies and education.
Offer support.
Provide a non-judgmental bridge between services.
ASK
What is the Purpose of Outreach?
KEY MESSAGES
Main role: provide outreach and make connections with people in the community (engagement).
Provide harm reduction supplies, education, and support.
Engage individuals in the community about your organization in a neutral setting.
Provide a friendly bridge between low threshold street-based services and higher threshold office-based ones.

12. What is the Purpose of Outreach? You are not expected to do everything
Provide active listening
Provide key referrals:
medical care, syringe exchange, overdose prevention, testing for HIV and Hep C, Hep A + B vaccinations
Remember
You are not expected to do everything
or know all of the answers.

13. Summary of Outreach Skills
Philosophy of unconditional caring & respect
Ability to establish trust & communicate effectively
Equipped with appropriate information: knowledge of local resources relevant to target population, ability to make referrals
Organizational skills, record keeping
Ability to network with at-risk groups
Maintaining appropriate personal boundaries
Ability to work in target population’s community; actively participate in community events
Refer to Characteristics Handout
KEY MESSAGES
Philosophy of unconditional caring & respect
Ability to establish trust & communicate effectively
Equipped with appropriate information: knowledge of local resources relevant to target population, ability to make referrals
Organizational skills, record keeping
Ability to network with at-risk groups
Maintaining appropriate personal boundaries
Ability to work in target population’s community; actively participate in community events
Adapted from NIDA, Community-Based Outreach Model:
A manual to reduce the risk of HIV & Other Blood-Bourne Infections in Drug Users; 2000

14. ACTIVITY: Skills & Characteristics
TRAINERS PREP
Prepared newsprint with “Skills & Characteristics” & “What gets in the way of good outreach” on 2 different sheets
Thick Pen Markers
ACTIVITY INSTRUCTIONS
Separate the room into two groups.
Distribute newsprint and markers for both groups.
Review questions one and two. Keep slide up for duration of exercise so participants can refer to questions throughout activity.
Allow each group to activity for five minutes on question 1 or 2 (designate one question per group to begin).
Then ask groups to switch, adding thoughts/brainstorming for the next question.
After five minutes, ask one representative from each group to read five of the most pertinent or interesting examples that stood out during the brainstorming session.
Allow for five minutes of large group discussion.

15. Skills & Characteristics
Activity:
Skills & Characteristics
Group 1: What skills & characteristics do you think an outreach worker needs?
Group 2: What gets in the way of effective engagement and communication- actions/behaviors/attitudes?
Two groups – groups switch after 5 minutes, review and add to brainstorming lists.
Report back to larger group for discussion.
Keep slide up during Activity
ACTIVITY INSTRUCTIONS continued
Allow each group to brainstorm for five minutes on question 1 or 2 (designate one question per group to begin).
Then ask groups to switch, adding thoughts/brainstorming for the next question.
After five minutes, ask one representative from each group to read five of the most pertinent or interesting examples that stood out during the brainstorming session.
Allow for five minutes of large group discussion.
NOTES:
This brainstorming activity frames this section of the training around communication and engagement skills, and characteristics needed to strengthen alliances with both clients and the broader community.

16. 3. Effective Communication
& Engagement Skills
Foto: CDC/Amanda Mills

17. Effective Communication DOES NOT…
X Act as “expert” or do most of the talking
X Diagnose, label, judge
X Argue the person has a problem and needs to change
X Prescribes solutions
X Pressure, threaten consequences, act punitively

18. Transtheoretical Model of Behavior Change
Stages of Change
Transtheoretical Model of Behavior Change
Pre-Contemplation
“Not considering it”
Contemplation
“Thinking about it”
Preparation
“Planning to do it”
Action
“Doing it”
Maintenance
“Staying with it”
Return/Relapse
“Stop doing it”
KEY MESSAGES
Stages of Change is also called the transtheoretical model of behavior change
There are six stages that make up the process of change
We all go through the process of change shown in the stages of change model.
The stages of change model is not a purely linear model.
People move from one stage to the next at their own pace, can go backwards to a previous step in the process, and can relapse at any time.
An individual may be at different stages for different behaviors (example: someone might be at pre-contemplation around their crack use, but at maintenance around their heroin use).
Relapse or return is a normal part of the process of change that is to be expected.
Relapses help us learn how to make enduring change.
Planning for barriers in the preparation stage and beyond can help prevent the likelihood of relapsing/slipping in the future.
Social support is an important part of the process of change.
MI helps an individual move through the process of change. It does so using different techniques at different stages.

19. PRE-CONTEMPLATION “Not Considering It”
CONTEMPLATION “Thinking About It”
PREPARATION “Planning To Do It”
ACTION “Doing It”
MAINTENANCE “Staying With It”
RETURN/RELAPSE “Stop Doing It”
TRAINERS INSTRUCTIONS
Use same thread for the 6 stages: smoking cigarettes, for example:
PRE-CONTEMPLATION “Not Considering It” – I buy a pack of smokes in the morning and have a few with my coffee
CONTEMPLATION “Thinking About It”-- I hear smoking kills, I know this, I’m just starting to think to slow down maybe
PREPARATION “Planning To Do It” -- I got a plan: I chew that gum for 2 weeks, I stop smoking before 12 noon, I have an end-date
ACTION “Doing It” – I’m not smoking, one day at a time!
MAINTENANCE “Staying With It” – Some say you need 6 months of doing something for real before you hit ‘maintenance’
RETURN/RELAPSE “Stop Doing It”-- – Lapse is doing that one thing maybe once, ReLapse is when you resume the behavior; I bum a smoke from a gal at a party after having not smoked for 6 months (Lapse), I start buying a pack in the morning to go with my coffee (ReLapse). Re/Lapse can come in handy to re-calibrate Preparation: maybe I can’t handle coffee without cigarettes so my next run at this includes drinking tea in the morning (Action) til I feel confident I can have the coffee without cigarettes for two seasons (welcome back to Maintenance) 19

20. Motivational Interviewing (MI) Basics
Motivational Interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.
Miller and Rollnick

21. Directive and Client-Centered
Focused and goal-directed
Elicits exploration of ambivalence
Guides client toward acceptable resolution that stimulates behavioral change
Change comes from the participant, its not imposed
Provider and Participant relationship is collaborative.
KEY MESSAGES
Beware of pushing your goals and ideals instead of eliciting the participants.

22. Expresses Empathy
Understanding of individual’s perspective and frame of reference.
Explores fears or hesitations regarding change; comfort with current habits, rituals, environment, etc.
Counselor conveys understanding and builds an alliance through reflective listening.

23. “I don’t know why everyone is so upset I’m still getting high now and again…it’s not like I’m doing it everyday anymore!”
“So others have expressed concerns about your drug use, but you don't feel the same concern because you are not using as much as you once did.”
Express Empathy

24. Encourages Self-Efficacy & Motivation
Does the client perceive change as being important?
Look for recognition around issues (change talk):
“I guess it doesn’t really make sense.
I don’t even enjoy getting high anymore.
It’s just making my problems worse.”
Is the client confident they’re able to make the change?
Look for optimistic expressions around change.

25. Encourages Self-Efficacy & Motivation
Reinforces the perceived importance of making a change.
“That’s great you feel ready to make a change, and moderating your use sounds like a really positive step!”
Highlight strengths, resources, abilities, history, and belief that change is possible.
Expect success!
KEY MESSAGES
“Last year you cut down your use to weekends only. I remember you describing how hard that was for you, but you made a strong support network that you still have today. I’m so glad you did, because you can reach to them for support now when you need it. That’s great!”

26. Self-Disclosure The role of personal information during outreach:
Disclosure can be a powerful tool.
Keep boundaries in mind.
Always consider the reasons why you are sharing this information – how will this information benefit the participant?
ASK
When is it good to disclose and share your lived experience? When is it NOT?
KEY MESSAGES
Disclosure can be a powerful tool, minimizing status differences and strengthening relationships.
As with any personal information shared, it’s good to keep boundaries in mind.
Always consider the reasons why you are sharing this information – how will this information benefit the participant?

27. Engagement Toolbox Ask open-ended questions Use affirming statements
Reflective listening & summaries
Decision balance
Change plan
KEY MESSAGES
Ask open-ended questions
In the past, how have you overcome an important obstacle in your life?
Use affirming statements
You've accomplished a lot around moderating your use.
Reflective listening & summaries
Just to make sure I’m understanding you correctly…
Decision balance
(ambivalence, contemplation)
Good things about using x/not-so-good-things
Change plan
(determination/preparation)
Client choice based on need and readiness
Menu of options
Make long-term goals into “doable” units

28. Open-Ended Questions Let the client do most of the talking
Open-ended Q do not invite brief or Yes/No answers
Open questions begin with: what, why, how, describe.
Examples:
What do you like about drinking alcohol?
How do you think it will be different if you tell your partner your Hep C status?
Tell me about your cocaine use.*
*Colombo Approach
KEY MESSAGES
Closed Q are yes/no or one-word responses (“Delaware” “4”)
Open Q give the person a chance to run with their response; open in design so as allow the other person’s interpretation of what is being asked, too
Columbo Approach!
It’s when you play the part of detective and use a polite imperative. While not technically an open-ended question, a polite imperative functions in the same way-.
“Tell me a little more about your cocaine use.”
“Talk me through this; you want to leave your old man and you are having sex without a condom on purpose so you can have his baby…”

29. ACTIVITY: Flip That Question!
Refer to Flip That Question Handout
ACTIVITY INSTRUCTIONS
The purpose of this activity is to turn Closed questions into Open questions, not to answer the questions
Have the room pair up
Together, they will write questions on the handout that began as a Closed question
Circulate Activity Handout
Afterwards, ask from each pair to share a response to one of the Closed questions 29

30. BREAK
15 min break.

31. 4. Safety and De-escalation
Safety First:
Always let your supervisor know where you are.
Go out in pairs, watch each other’s backs.
Do you have to go out alone?
Don’t approach people who are signaling they don’t want to be approached.
Don’t interrupt sales of drugs or sex.
Don’t work sick.
KEY MESSAGES
Safety First!
Be aware of your agencies policy/procedures of how you should interact with law enforcement and other community members.

32. Safety and Outreach
Introduce yourself and let people know what you’re doing.
And why.
Wear an agency ID or carry documentation identifying you as a peer just in case.
Trust your instincts!
If you are uncomfortable in a situation, walk away from it. Make contingency plans for worst case scenarios agreed upon by the whole team.
ASK
Anything else?
KEY MESSAGES
Introduce/Identify yourself and inform people what you’re doing and why.
Ex: “My name is Sandy and I work with the health department. I have bandaids, condoms, and gear, do you want anything tonight?”
Wear an agency ID or carry documentation identifying you as a peer in case you are stopped by police.
Trust your instincts! If you are uncomfortable in a situation, walk away from it. Make contingency plans for worst case scenarios agreed upon by the whole team.

33. What is your agency’s protocol in the event you are stopped by police?
Or had an accidental needlestick?
Make this plan and identify a point-person to call at any hour when workers are conducting outreach.
Check the weather.
Keep supervisors informed of your location & activities.

34. Crisis Intervention Strategies
Crises occur when a person can not utilize coping skills to manage stress from a difficult situation.
Providers can help the client feel an immediate de- escalation of anxiety, fear and panic.
Maintaining your personal safety is key!
Refer to De-Escalation Handout
KEY MESSAGES
Crises occur when a person can not utilize coping skills to manage stress from a difficult situation, often leading them to feel powerless, and lacking emotional regulation and/or self-control.
By intervening effectively in a crisis situation, providers can help the client feel an immediate de-escalation of anxiety, fear and panic, preventing harm to self or others.
Maintaining your personal safety is key!

35. Example Strategies and Action Steps
Project calmness; acknowledge and validate feelings; encourage the person to talk; listen closely and patiently.
Maintain a relaxed and attentively open posture; non- challenging or threatening.
Point out choices/options, break big problems into smaller ones.
Position yourself so that have easy access to an exit if you are in an office or private space.

36. Maintaining Safety: What to Avoid in a Crisis
T.A.C.O.S.
X Threatening
X Arguing
X Challenging
X Ordering
X Shaming
KEY MESSAGES
TACOS stands for:
X Threatening the individual
X Arguing or contradicting the individual
X Challenging the individual
X Ordering or commanding the individual
X Shaming or disrespecting the individual

37. 5. Supportive Referrals
Identifying client needs that cannot be met by yourself or agency (beyond base of knowledge, skills or responsibility) and assist participants in accessing available support systems and community resources.
ASK
What does Supportive Referrals mean to you?

38. Providing Supportive Referrals
Referral Forms
Communication with a Contact
Provide Assistance
Timely Follow-Up
Re-Assess Plan of Care

39. Building a Strong Referral Network

40. ACTIVITY: Referrals TRAINERS PREP
Post prepared newsprint on the walls around the room.
Nine (9) sheets with referral categories as headings.
Have thick pen markers ready.
To start, have one or two examples of local referrals.
NOTES
The purpose of this activity is to brainstorm local referrals for various categories and pull from other’s experiences, backgrounds, and resources.
This provides HHRNs an opportunity to network w. other HHRNs and learn about services provided at other agencies.

41. Group Activity: Referrals
Break into groups
Each group can start at opposite sides of the room, brainstorming local referrals for each category
One person from each group report back examples of referral options to large group for discussion or expansion
ACTIVITY INSTRUCTIONS
Point out the prepared newsprint around the room.
Break one large group into two smaller groups.
Each group gets thick marker pens.
Ask each group to start at opposite ends of the room
Allow each group 1-2 minutes to write down as many referral ideas as they can for each category, preferably local.
After each group has worked there way through each category (10-15 minutes total), ask one representative from each group to move through each category, pointing out 1-2 examples of referral options.
Pull up next slide and leave up during activity.
Optional
If time is running short the facilitator can walk through each category and read 3-5 examples of referral options.

42. Group Activity: Referrals
Hep C, HIV, STI Testing (including Hep A + B vaccinations & care)
HIV, Hep C Primary Care and Treatment
Dental Care
Mental Health Services
Support Groups
Alcohol & Substance Use Treatment
(Suboxone, MMTPs,
in/out-patient, )
Harm Reduction/
Syringe Access Programs
Overdose Prevention
Case Management & Housing
Keep slide up for Activity
ACTIVITY INSTRUCTIONS continued
Allow each group 1-2 minutes to write down as many referral ideas as they can for each category, preferably local.
After each group has worked there way through each category (10-15 minutes total), ask one representative from each group to move through each category, pointing out 1-2 examples of referral options.
Pull up next slide and leave up during activity.

43. Reflective Practice: Outreach & Engagement
Identify
What are specific engagement skills you can improve on during your interactions with participants during outreach? Think about “desirable characteristics of outreach workers.”
Explain
Describe important issues related to self-disclosure to a colleague or in group supervision, including an example where you were uncertain whether or not to disclose.
Apply
After identifying areas for improvement, begin to implement your engagement strategies. Discuss how it impacted your outreach encounters and share during supervision and/or with your peers.
Refer to Worksheet
TRAINER INSTRUCTIONS
These are a few ideas to apply the day’s workshop into practice.
Encourage participants to share in supervision, with peers, and/or with colleagues at their agency.

44. Put completed surveys in the folder
6. Closing & Evaluations
Anonymous Surveys:
Put completed surveys in the folder
Refer to Blank Evaluation Handout
TRAINERS INSTRUCTIONS
Ask participants to complete the anonymous survey.
Provide a large manila envelope or folder for participants to put their completed surveys.
Optional
Plus/Delta is a closing exercise where every person can give one example of what worked or was effective about the day’s workshop, and one suggestion that could improve the workshop.
Each person has a turn with the option to say “Pass.”
The purpose of this closing exercise is to give each participant a chance to share their opinion verbally if writing is not how they express themselves best.
Avoid having discussion on responses, this exercise is meant to move forward to wrap up the day.

45. HRC thanks you for participating in this workshop!