Safe Families: Community Screening & Linkage to Prevent Overdose
A SAMHSA-sponsored research initiative in Mott Haven, NYC
Mott Haven, located in the poorest congressional district in the continental United States, has been hit especially hard by the overdose epidemic. Emergency room visits and hospitalizations for substance use are nearly three times higher than the New York City average. Families in this community face steep challenges in accessing affordable, high-quality treatment and prevention services.
Closing the Gap in Access
Safe Families addresses this gap head-on through a nurse-driven, community-based program designed to identify risk early and link residents to care. The approach is grounded in the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model, paired with collective action among families, health providers, and social service partners.
The goal: reduce the adverse consequences of untreated substance use while strengthening integration across health and community systems.
Innovation in Action
A particularly innovative aspect of Safe Families is the use of state-of-the-art care management technology. This allows the program to scale and remain flexible across different community settings.
Through a partnership between CLAFH and Huddy Health, the project leverages a cutting-edge digital platform, Huddy Health Community, for substance use treatment and prevention. This technology optimizes how families are:
- Recruited into the program through proactive, community-based outreach
- Evaluated using structured screening and assessment tools to identify risks and needs
- Intervened with timely linkage to prevention, treatment, and recovery services
Community Specific Advantages
Why Mott Haven?
- High burden of need: rates of alcohol and drug misuse far above the citywide average
- Limited access: prevention and treatment services remain out of reach for many families
- Opportunity for impact: implementing scalable, community-centered solutions in one of the hardest-hit neighborhoods
Building a Healthier Future
At its core, Safe Families is about ensuring that every family – regardless of circumstance – has the right to access timely, affordable, and effective care. By combining nursing leadership, proven prevention models, and advanced digital tools, the project is creating a scalable framework for community-based overdose prevention.