Case Studies
July 6, 2026
Conducting interdisciplinary fatality reviews to prevent overdose deaths: Winnebago County, WI
Published on: July 6, 2026
- Issue Areas
- Health and well-being
- Outcomes
- Stable and healthy families
MORE ABOUT THE STRATEGY USED IN THIS CASE STUDY Substance use prevention and treatment, Improving access to health care
Overview
Summary
- Like many communities across the United States, Winnebago County saw persistently high rates of drug-related overdoses and deaths during the 2010s. The crisis culminated in 2017, with 34 overdose fatalities, an alarming number for a community of under 175,000 people. Local leaders recognized the need for a more focused, action-oriented approach to preventing overdose deaths.
- In 2018, Winnebago County launched an Overdose Fatality Review (OFR) team. The OFR convenes cross-sector partners to conduct case reviews of overdose deaths, identify patterns, and recommend strategies for system-level change to prevent future fatalities. Between 2018 and 2026, OFR and its partners have implemented 56 of its 67 recommendations and launched 13 projects to support individuals with substance use conditions and to prevent overdose deaths.
- Keys to OFR’s success include hiring a neutral, high-quality facilitator; creating clear structure for case review meetings; establishing a safe, blame-free environment during meetings; demonstrating momentum by translating recommendations into action; and including individuals with lived experience of recovery.
- Obstacles to OFR’s success included initial concerns over legal liability, misaligned perspectives on harm reduction strategies across partners, challenges securing long-term funding, and the team's limited influence over state and federal policy.
Results and Accomplishments
49%
Fatal overdoses in Winnebago County decreased by 49% in 2024 (24 deaths) compared to 2023 (47 deaths). In 2025, 26 deaths occurred, near the 2024 level.
2,091
Between 2022 and 2026, the Sobriety Treatment Assisted Recovery (STAR) program served 2,091 inmates.
2,330
Between 2020 and 2025, the Handle with Care program allowed law enforcement to notify area schools on 2,330 occasions where students may have experienced trauma.
- Replicating a national model to prevent overdose deaths: In 2018, Winnebago County launched an Overdose Fatality Review (OFR) team. Originating in Maryland, the OFR model focuses on convening cross-sector partners to conduct case reviews of overdose deaths, identify patterns, and recommend strategies for system-level change to prevent future fatalities. The approach continues to show results – in 2024, Winnebago County saw a 49 percent decline in overdose deaths compared to 2023. In 2025, the county saw a similar number of fatalities as in 2024, sustaining the reduced level of overdose-related deaths.
- Translating recommendations into tangible action: Winnebago County’s OFR stands out from OFRs in other communities because of its success in turning its recommendations into action. Since launch, OFR has implemented 56 of its 67 recommendations and launched 13 projects to support individuals with substance use conditions and to prevent overdose deaths.
- Implementing projects to address community needs: Among OFR’s most impactful projects are the Peer Response Team and Handle with Care. The former, spearheaded by Solutions Recovery, allows community members to connect with individuals in recovery who can direct them to harm reduction and treatment resources. The Peer Response Team model later served as the foundation for the STAR Program in the Winnebago County Jail. STAR provides inmates with access to a “recovery pod” and one-on-one peer coaching, among other supports. Separately, Oshkosh Area School District and law enforcement partners led the county-wide implementation of Handle with Care. The program created a referral process to ensure schools are notified and can properly support students who are at the scene of traumatic events, like overdoses. When adopting the national Handle with Care model, the OFR partners created an innovative disposition code system to ensure referrals are received in a timely fashion and sent to the right place.
- Supporting collaboration across partners: Since launch, Winnebago County’s OFR has nearly tripled in size – from 12 to 33 participating partner organizations. These partners represent virtually the full-spectrum of the county’s public health, healthcare, public safety, social services, and educational institutions. Through regular meetings and joint projects, partners have deepened their understanding of each other’s work on overdose prevention and beyond. This shared understanding pays dividends, as partners feel empowered to problem-solve and collaborate across organizations in a way that rarely occurred before OFR.
- Fostering a recovery-friendly community: OFR's work has built awareness and reduced stigma surrounding substance use and addiction in Winnebago County. Its biennial “We Heart You” community events, which celebrate individuals recovering from substance use and the organizations that provide critical substance use and mental health services, are among OFR’s most visible efforts to shift local perception and create a more “recovery-friendly” community.
Solution
What was the challenge?
- Rising overdose deaths driven by heroin use: As in communities across the United States, Winnebago County saw persistently high rates of drug-related overdoses and deaths during the 2010s, largely driven by heroin use. The crisis culminated in 2017, with 34 overdose fatalities, an alarming number for a community of under 175,000 people.
- Leaders recognize the need for a new response: At the time, Winnebago County’s Heroin Task Force and the Drug and Alcohol Coalition focused on broader substance use prevention strategies. While this work was vital, local leaders recognized the need for a more focused, action-oriented approach to preventing overdose deaths.
- Identifying a coordinated, action-oriented model: Inspired by the Milwaukee Homicide Review Commission, leaders in Winnebago County sought out a similar fatality review model focused on overdoses. These reviews allow multidisciplinary teams to examine relevant aspects of a decedent’s life – from adverse childhood experiences to interactions with law enforcement – to identify opportunities to prevent future deaths. The overdose fatality review model, gradually expanding across the country at the time, promised to deliver the cross-sector collaboration Winnebago County needed to push back on the opioid crisis.
What was the approach?
- Adapting a national model locally: Winnebago County’s Overdose Fatality Review (OFR) launched in 2018, with the Public Health Department serving as its fiscal agent. Convened and managed by a neutral, independent facilitator, the team meets monthly for structured, confidential case reviews of the life cycles of individuals who died from overdoses.
- Convening a multidisciplinary team: The OFR now includes 33 agencies, representing a wide-range of public health, healthcare, education, social services, law enforcement, and other stakeholders in Winnebago County. Each partner interacts with individuals with substance use conditions at different stages in their lives, allowing OFR to build a comprehensive view of a decedent’s life during case reviews. As the broader OFR team reviews cases, they aim to surface patterns and potential strategies to prevent future overdose deaths.
- Setting recommendations for system-level changes: The OFR’s Recommendation and Monitoring Subcommittee reviews data and themes surfaced in monthly case reviews. The subcommittee then formulates recommendations for system-level changes to prevent future overdose deaths. These recommendations are referred back to the broader OFR team for approval; since 2018, the team has approved 67 of them. In recent years, OFR has made a wide-range of recommendations, from creating a tool to help people with substance use conditions navigate relevant resources to increasing community awareness about the risk factors leading to overdose deaths.
- Converting recommendations into actions: Winnebago County’s OFR does not stop at making high-level recommendations. The OFR team regularly convenes working groups to act on the group’s recommendation, an approach that has yielded 13 projects implemented by the group and its partner organizations. For example, in response to an early recommendation to create a tool to help individuals navigate local resources, OFR launched the “We Heart You” app, which helps users connect to substance use treatment, social services, and harm-reduction tools (e.g., Naloxone), among other resources.
Who was involved?
- Winnebago County Public Health Department: Winnebago County Public Health serves as OFR’s fiscal agent, oversees its grants, provides access to epidemiological data, and serves as a subject matter expert. As part of these roles, the department contracts with Jennifer Skolaski, who serves as OFR’s independent coordinator and meeting facilitator. The department also led the implementation of an OFR recommendation to distribute free Narcan and provide training on its use.
- City and county departments: The County Medical Examiner’s Office identifies potential cases for OFR review and provides key background information, like toxicology reports. Other county- and municipal-level health and human services departments participate in OFR, providing expertise on their programming and specific geographies within Winnebago County.
- Law enforcement and criminal justice partners: In addition to the Winnebago County Sheriff’s Office and District Attorney’s Office, multiple municipal and university-based police departments participate in OFR. These partners provide critical context on decedents' interactions with law enforcement and the judicial system during case reviews. These agencies also support the implementation of OFR recommendations in criminal justice contexts. For example, the Winnebago County Sheriff's Office led the STAR program, which provides inmates in the county’s jail with access to a “recovery pod,” one-on-one coaching from trained recovery coaches at Solutions Recovery, and treatment for alcohol and opioid dependence from Winnebago County Human Services.
- Healthcare and behavioral health systems: Healthcare providers provide content and expertise on key aspects of the continuum of care for individuals with substance use conditions, such as primary care and emergency department visits. These partners have also spearheaded work to increase the number of dual-diagnosis counselors in Winnebago County, part of a recommendation from OFR to boost the number clinicians able to provide integrated mental health and substance use services.
- Substance use treatment providers: Substance use treatment providers provide OFR with critical subject matter expertise and connect OFR to individuals with lived experience of recovery from substance use.
- School districts: Oshkosh Area School District (OASD) provides OFR with historical context on decedents’ early life during case reviews, serves as a connection to children and families impacted by substance use, and advises on recommendations related to prevention and diversion programming for youth. In response to an OFR recommendation, OASD also led the work to install Overdose Aid Kits and train staff on their use in all of the district’s middle and high schools. OFR is also connected to other public and private school systems in the county through the Handle with Care program.
- Fire departments and EMS: First responders provide insight into the immediate circumstances surrounding overdose incidents, along with broader needs they are witnessing in the community. These partners also support the implementation of new programming. For example, the Oshkosh Fire Department launched a “leave-behind kit” program, in which first responders distribute Naloxone kits during calls for service or at community events. Over time, this program has expanded, with Gold Cross Ambulance partnering with local public health departments to offer kits across four area counties.
- Other community- and faith-based organizations: These partners speak to Winnebago County’s broader safety net for vulnerable populations, like its homeless population, who are often disproportionately impacted by substance use.
- Local recovery community: Individuals with lived experience of substance use recovery provide invaluable perspective to OFR’s work. For example, because of feedback around the importance of peer support, Solutions Recovery launched the Peer Response Team.
How was this approach funded?
- Leveraging federal funding to launch OFR: The OFR initially launched in 2018 with federal Overdose Data to Action (OD2A) funding passed through the State of Wisconsin. This early funding specifically covered costs associated with monthly case reviews, including limited funding for an independent facilitator's time.
- Identifying implementation-focused funding: Within a couple years of OFR’s launch, the team had made multiple programmatic recommendations and sought funding to build the capacity needed to implement them. To achieve this, the county government braided multiple state and federal funding streams based on the eligibility of OFR’s priority projects.
- Scaling up with BJA funding: OFR’s biggest breakthrough came in 2022, when it secured a three-year, $1.3 million grant through the Bureau of Justice Assistance’s Comprehensive Opioid, Stimulant, and Substance Use Program (COSSUP). This funding allowed OFR to dramatically grow its own capacity by increasing the number of hours its coordinator and facilitator could work each month. The grant also provided funding to launch projects, like the Peer Response Team, and expand others, like the Fox Cities Victim Crisis Response Team.
- Navigating ongoing financial constraints: Despite these successes, sustainable, long-term funding remains a challenge for OFR, in part due to recent instability in federal funding for substance use programming.
Timeline
Informal efforts like the Heroin Task Force, which later became the Winnebago County Drug and Alcohol Coalition, laid the foundation for a more formalized response to growing overdose numbers.
As in other communities, Winnebago County continued to battle overdoses, largely as a result of the opioid crisis. In 2017, the county saw a spike in overdose deaths, creating additional pressure to find new solutions.
Winnebago County established its OFR team using OD2A grant funding, bringing multidisciplinary partners together to review fatal overdoses.
Oshkosh Area School District and law enforcement agencies launched Handle with Care, a program to ensure schools are notified and can properly support students who are at the scene of traumatic events, like overdoses. The program later expanded to other area schools.
OFR secured a three-year, $1.3 million grant through the Bureau of Justice Assistance’s Comprehensive Opioid, Stimulant, and Substance Use Program (COSSUP) to expand its capacity and support implementation of its recommendations.
OFR and its partners held the first We Heart You event, which aimed to connect the recovery community and the broader community. The event returned in 2024 and 2026.
OFR launched the “We Heart You” app, which helps users connect to substance use treatment, social services, and harm-reduction tools (e.g., Naloxone), among other resources.
After a spike in overdose deaths in 2023, OFR and its partners saw success as fatal overdoses fell to 24, a 49% decline year-over-year.
In 2025, Winnebago County saw 26 overdose fatalities, sustaining the significant reduction in 2024.
Winnebago County’s OFR reached 100 overdose fatality reviews, each providing insight into how to prevent future overdoses in the community.
Implementation
What factors drove success?
- Hiring a neutral, high-quality facilitator: Winnebago County opted to hire an independent contractor to facilitate its OFR. As the facilitator sits outside of any individual partner organization, she is able to act with independence and impartiality, allowing her to build trust and mediate conflict more effectively.
- Creating a clear structure for case review meetings: OFR creates predictable, efficient case review meetings through a structured agenda, strong facilitation, and delegation of tasks to subcommittees and working groups. The efficient meetings ensure that participants – who are all busy professionals – feel their time is respected.
- Establishing a safe, blame-free environment: At the outset, partner organizations worried that case reviews could result in individual agencies being blamed for overdose deaths. OFR has proactively taken steps – like instituting onboarding for new representatives from partner organizations – to create a team culture focused on solutions rather than assigning blame. This approach has built trust among partner organizations and allowed them to focus on collaboratively identifying and addressing system-level gaps to prevent future overdose deaths.
- Commitment to taking action: Partner organizations continue to participate in OFR because of its ability to translate recommendations into action for the community. Rather than make recommendations alone, OFR’s use of working groups to implement new programs and initiatives, giving partners a sense of momentum and a tangible “return” for their time invested into the team.
- Inclusion of individuals with lived experience: Integrating people in recovery into the OFR ensures that the team's proposed interventions are practical, efficient, and grounded in reality. Elevating the voices of the recovery community within OFR meetings and at community events has also helped reduce stigma towards those with substance use conditions.
What were the major obstacles?
- Concerns over legal and data-sharing issues: Early on, partners were hesitant to share information about decedents during case reviews due to concerns over HIPAA violations, open meeting laws, and the potential for organizational liability or "finger-pointing.” Establishing standards for confidentiality and data-sharing, conducting case reviews with limited identifying information about the decedent, and educating partners on the legal provisions that allow for death reviews allayed most of these fears. In 2026, after years of advocacy calling on the State of Wisconsin to create a clearer legal framework for fatality review teams, as is common in other states, Governor Tony Evers signed legislation to support teams like Winnebago County’s OFR.
- Aligning partners’ perspectives on harm reduction: At times, some OFR partners, particularly in law enforcement and the Medical Examiner, expressed skepticism about harm reduction initiatives. These partners questioned whether providing safer use supplies would in fact encourage further drug use, a common concern in communities working on harm reduction efforts. Strong leadership on the part of leaders in law enforcement to educate their staff on the purpose and value of harm reduction strategies helped overcome initial skepticism.
- Securing a sustainable source of funding: The lack of a permanent funding source for OFR is an ongoing pain point, particularly in the current federal funding environment. Winnebago County and its partners continue to pursue additional funding, but the sunsetting of the $1.3M BJA grant in 2026 risks OFR’s ability to continue operating at the same staffing levels.
- Limited ability to influence state and federal policy: While the OFR excels at operationalizing recommendations locally, many critical opportunities to reduce overdose deaths sit with decision-makers at the state and federal level. Winnebago County’s OFR does make recommendations to its State Advisory Group, however policy change can nonetheless be slow at higher levels of government.
How was the approach measured and refined?
- Using case reviews and epidemiological data to shape strategy: Through case reviews and other public health data, OFR is able to track Winnebago County’s evolving needs in preventing overdose deaths. The data-informed approach allows OFR to make responsive recommendations. For example, OFR knew that wider availability of emergency overdose reversal medications could prevent fatalities; when data revealed that non-fatal overdoses were increasingly occurring among younger residents, the team partnered with the Oshkosh Area School District to install Overdose Aid Kits and train staff on their use in all of the district’s middle and high schools.
- Responding to the evolving landscape of drugs: While Winnebago County’s initial overdose crisis was primarily driven by heroin, the types of drugs causing overdose deaths have shifted over time. Since OFR’s launch, fentanyl has remained the primary challenge, with methamphetamine, cocaine, and unregulated “designer drugs” appearing more in recent years. In response to the evolving landscape, OFR continues to stay up-to-date on best practices in harm reduction. For example, when Winnebago County saw a rise in deaths associated with methamphetamine use, the team brought in state-level experts to offer training on drug trends.
- Tracking data to demonstrate impact: The OFR team collects programmatic data for many of the projects it implements in order to demonstrate their impact. As part of its annual reports, OFR also tracks overdose deaths in Winnebago County to speak to its broader impacts. These data are captured through REDCap, a secure data collection platform; the Medical Examiner’s Office’s data systems; and other internal systems.