Roanoke Valley Connection to Care (C2C)

Title of Project: Roanoke Valley Connection to Care (C2C)

Principal Investigator (PI): Mary Beth Dunkenberger 

Co-Investigators: Laura York, Lara Nagle, Liz Allen 

Key Community Partners: Roanoke Valley Collective Response to the Opioid and Addiction Crisis (RVCR); HOPE Initiative; Council of Community Services’ Drop-In Center; Virginia Harm Reduction Coalition; Blue Ridge Behavioral Healthcare; The Rescue Mission; Salem EMS; Western Virginia Regional Jail; Carilion Clinic; Piedmont Community Services, and numerous others. 

Key University Partners:  VT Center for Public Health Practice and Research; Carilion Fralin Biomedical Research Institute (CFBRI); Department of Population Health Sciences; VT Industrial Design Program; VT Center for Biostatistics and Health Data Science; VT Carilion Clinic Department of Emergency Medicine; VT Center for Housing Research.

Description of Project and Project Goals: The C2C project is a novel multi-stakeholder intervention using referral, crisis response resources, case management capacities, and backpacks equipped with potentially life-saving tools to address the goals of:

1) timely referral of persons experiencing or at-risk of overdose or other substance use-related incidents;

2) reduction in overdose and relapse; and

3) connecting consumers to appropriate harm reduction, treatment and recovery programs.

The C2C project applies a Social Determinants of Health (SDOH) framework integrated into the proposed connection, referral, case management and treatment strategies.

C2C strives to introduce innovative solutions to address overdose and other harms of substance use and addiction, with the objective of reducing harm and connecting individuals to treatment and recovery resources. Evaluation of processes and outcomes is central to the project to determine which intervention components are working and which need tweaking. As a primary linking mechanism, C2C relies on the great work and commitment of community partners to achieve its objectives. The ultimate goal is that with established efficacy, our community partners can garner sustainable resources to continue effective practices.

Project Outcomes: The multi-pronged intervention strategy includes the following components implemented with community partners. 

• C2C Backpacks - Includes a full backpack stocked with a blanket, some clothing, personal care items, referral resources to harm reduction and treatment services, and when appropriate, Narcan. The full backpack is intended  for homeless and housing insecure individuals. The C2C lite backpack is a lightweight drawstring backpack with referral information and Narcan, when appropriate training is provided.
• REVIVE! Events and Outreach - The C2C project team collaborates with our community partners to provide training on identifying and treating overdose with Narcan and facilitating access to resources to harm reduction and treatment services. The Council of Community Services Drop-In Center is a key partner in the backpack program in 2022, assisting with coordinating backpack supplies and assembly and provision to other community partners.  
• Responders for Recovery - The C2C team has supported this partnership of the HOPE Initiative and Salem City Fire and EMS to refer individuals experiencing overdose or other SUD health crises to peer recovery support services following an EMS incident.
• PACE to Recovery - Like Responders for Recovery, Piedmont Community Services supports a warm hand-off between peer recovery specialists and EMS providers in Franklin County through its PACE to Recovery Compassionate Response Team (CRT) initiative. PACE to Recovery also embeds peers in two local hospital emergency departments to facilitate access to longer-term treatment for overdose-related incidents.
• Reentry to Recovery - C2C supports the ongoing collaboration of Western Virginia Regional Jail, Blue Ridge Behavioral Healthcare and the HOPE Initiative to provide forensic discharge planning and follow-up treatment services for individuals with a history of SUD who are released from incarceration. 
• Housing Supports - Housing for those needing stabilization to be successful in SUD treatment and long-term recovery is a high priority need for the Roanoke Valley. C2C works with RVCR and other community partners to identify strategies to meet this need. To better understand existing resources and the severity of the need, C2C completed a recovery housing report in 2021.
• Research and Translation Support - The project team supports RVCR and community partners who are exploring evidenced-based and promising interventions, with a focus on how practices can be supported and translated in the Roanoke Valley.  
• Innovative Product Design - C2C is working with a local manufacturer to produce a test run of an innovative backpack design for a dual target audience of individuals in active substance use who need a connection to community services, and a lay audience of weekend travelers who want a functional and flexible backpack for efficient transport of belongings. We imagine a buy one, donate one commercial model that seeks to destigmatize SUD and provide linkages to care. 

Project Materials

• C2C Executive Summary
• Recovery Housing Report Summary