During the 2023 Virginia General Assembly session, SB 1415 was passed to amend and reenact § 54.1-3408 of the Code of Virginia. The amendments instructed the Virginia Department of Health (The Department, otherwise known as VDH) to accomplish several directives. During this reporting period, VDH made the following progress towards accomplishing the outlined directives:

1. Directive 1: Begin development of a Commonwealth opioid impact reduction registry. The registry shall include a list of nonprofit organizations that work to reduce the impact of opioids in the Commonwealth and shall list the services provided by each such organization and contact information for each such organization to be published on the Department's website.

As outlined in this report, as a first step in developing the opioid impact reduction registry, VDH undertook an assessment of existing tools and resources that could potentially meet the goals of an opioid impact reduction registry. VDH collected both quantitative and qualitative data to assess options and outline recommendations for registry development next steps. As a result of this multipronged research effort, VDH concluded that the best use of resources would be to enhance and expand an existing program – 2-1-1 Virginia – to serve as the opioid impact reduction registry and meet the Code requirements of this registry, rather than developing an entirely new program. 2-1-1 Virginia is a program run by the Virginia Department of Social Services (DSS) that provides referrals to Virginians for various social services and opportunities.

2-1-1 already includes resources for Virginians for substance use disorder prevention and treatment. VDH concluded that DSS could expand the list of existing resources to ensure the list more robust and DSS could enhance the 2-1-1 taxonomy so that substance use and mental health services are well organized within the database and easily searchable, leading to improved connections between users and community resources. Given that 2-1-1 is well known, easily accessible, and has expertise in identifying and validating community resources, 2-1-1 is well positioned to facilitate community and local government access to organizations aiming to reduce the impact of opioid use disorder in their community. As noted in the recommendations, 2-1-1 would need additional funding to augment its staffing and technology to serve as the opioid impact reduction registry.

VDH discussed the proposal to expand Virginia 2-1-1 to serve as the registry with DSS. They agree with this proposal and provided information to inform this report.

2. Directive 2: The Department is required to develop a process to determine which organizations that work to reduce the impact of opioids in the Commonwealth to include in such registry and what criteria and metrics should be utilized to determine their inclusion in such registry.

VDH conducted a literature review, assessed national outcomes measures, and compiled a state-to-state comparison of registry models in order to determine the best approach to identifying community-based organizations for inclusion in an opioid impact reduction registry. Based on the information gathered, VDH recognized that 2-1-1 already has comprehensive existing processes for identifying and validating organizations for inclusion in their resource directory. VDH concluded that 2-1-1’s existing process could be enhanced specifically for opioid use prevention.

3. Directive 3: The Department is required to examine administrative burdens on local governments in procuring the services of nonprofit organizations on the registry in a timely manner. The Department, within existing resources, may publish an initial list of known nonprofit organizations that work to reduce the impact of opioids on the Department's website that is searchable by zip code.

VDH’s expertise in local government procurement processes is limited. As such, VDH conducted a brief survey of members of the VDH Substance Use Prevention Workgroup, who are experts in substance use disorder prevention and treatment, to solicit feedback on the ease of procuring substance use disorder prevention and treatment services at the local government level. VDH also researched publicly available information regarding facilitators and barriers to procuring such services at the local government level. Based on this qualitative assessment, VDH outlined several barriers, included in this report. With the augmentation of 2-1-1 to serve as the opioid impact reduction registry, local governments should have improved access to a list of community-based organizations that work to reduce the impact of opioids. VDH intends to link to 2-1-1 on its substance use prevention webpages to further facilitate access and awareness.

4. Directive 4: The Department is required to report on the process, criteria, and metrics for the registry, including the verification process to ensure an organization meets the criteria to be listed on the registry, and recommendations on reducing administrative burdens on local governments to contract with organizations on the registry to the Chairs of the House Committee on Appropriations and the Senate Committee on Finance and Appropriations by September 1, 2023.

In this report, VDH details a process, criteria, and metrics for an opioid impact reduction registry, based on the multipronged research conducted, including quantitative and qualitative assessment existing resources and community needs. VDH details several recommendations regarding registry implementation and additional investigations into administrative burdens for local governments regarding accessing substance use prevention and treatment resources.

This plan does not 1) outline a process for listing or credentialing clinical practice or nonprofit organization support for treatment and recovery based on federal and state statutes, regulations, and guidelines governing such treatment and medications for opioid addiction; 2) constitute a product endorsement; 3) include systems integration, defined as the ability to seamlessly move from the referral platform to the electronic health record (EHR) and vice versa, and to automatically transfer data between the two systems; 4) require VDH data governance, as there will be no personal protected health information included or collected by VDH; and 5) include independent product testing.

This plan also does not outline registry elements to track referrals and close the loop to know the referral outcomes. The public will not need to sign into the system with a password, only access the information hub for resources. If an individual level treatment plan is created, the chosen registry partner will implement its data governance policies.

It should be considered that the requirement to limit entries to non-profits may eliminate programs of value to Virginians in need, particularly for-profit treatment programs that accept Medicaid reimbursement. Since this limitation was stipulated in the legislation, it will not be discussed further in this report.

RECOMMENDATIONS

VDH developed the following recommendations after extensive research, detailed in the report below. These recommendations which aim to leverage existing resources to establish the opioid impact reduction registry and follow best practices in the field.

Overarching Recommendations

1. VDH recommends that the Commonwealth use the existing 2-1-1 Virginia program, run by the Virginia Department of Social Services (DSS), as the framework for the opioid impact registry. DSS would be responsible for making updates to the existing 2-1-1 Virginia program to ensure it meets Code requirements for an opioid impact registry, including developing an organizational structure for listing opioid use prevention resources (i.e., the taxonomy of, and pathways to, these resources) and assessing the cost for expanding and enhancing 2-1-1 Virginia accordingly. VDH discussed the proposal to expand Virginia 2-1-1 to serve as the registry with DSS. They agree with this proposal and provided information to inform this report.

2. The Virginia Department of Health (VDH) recommends that DSS/Virginia 2-1-1 create a Registry Governance Team responsible for guiding opioid impact registry activities, including major financial, administrative, legal, and scientific decisions that determine the direction of the registry.

Recommendations for Optimizing 2-1-1 Virginia

The following recommendations outline strategies for DSS to optimize 2-1-1 so that its current capabilities are enhanced to meet the expectations of an opioid impact reduction registry. These recommendations address operational processes, including data strategy plans, workflows, and case ascertainment, necessary to implement a high-quality, user-friendly registry.

3. 2-1-1 Virginia should consult with VDH to create a data strategy plan and implement the 2-1-1 Alliance of Information Referral Systems opioid misuse prevention taxonomy that aligns with national initiatives prioritizing the social drivers of health (e.g., Institute of Medicine’s recommendations, Healthy People 2030 goals), measures proposed under the next stage of Meaningful Use, clinical coding under ICD-I0 Z codes, and agency current reporting requirements.

4. 2-1-1 Virginia should develop workflows, initial focus outcomes, related pathways, and the final product registry based on geographical VDH health district regions, high-burden populations and geographical areas, and resource prioritization models.

5. 2-1-1 Virginia should utilize a combination of active and passive (hybrid) case ascertainment versus requiring a mandate registry reporting.

6. 2-1-1 Virginia should vet a master list of community-based services (e.g., non-clinical nonprofits, with or without an IRS Tax Designation) with a service area of the Commonwealth of Virginia to ensure compliance with inclusion criteria.

Recommendations for 2-1-1 Virginia Continuous Improvement Efforts

The following recommendations address intentional, continuous improvement of the registry so that it best meets the needs of Virginians and generates evidence to support its long-term sustainability. These recommendations outline a framework for piloting, scaling, and evaluating efforts.

7. 2-1-1 Virginia should execute a soft launch of the registry in high-burden areas first and then market the registry more broadly.

8. 2-1-1 Virginia should conduct rigorous programmatic and economic evaluation to demonstrate effectiveness and utilization of an opioid impact registry; develop systems to track and evaluate performance; analyze outcomes to demonstrate effectiveness; and utilize the Plan Do Study Act process, a systematic series of steps that can be applied to understand needed improvements to optimize implementation for quality improvement. DSS will assess funding and staffing resources needed for this process and submit budget amendments as appropriate.

9. 2-1-1 Virginia should conduct ongoing outreach to recruit new organizations onto the registry.

10. 2-1-1 Virginia should provide ongoing staff training and technical assistance for registry organizations and the public.

11. DSS should develop a registry sustainability plan.

Recommendations to Assess and Reduce Administrative Burdens on Local Governments

This recommendation outlines a plan to assess and reduce administrative burdens on local governments to contract with organizations on the registry. As the VDH is not a subject matter expert on local government procurement procedures, VDH will partner with other state agencies who have deep expertise in local government procurement to understand barriers and facilitators and make appropriate recommendations.

12. VDH will solicit technical assistance from the Virginia Department of General Services (DGS) and the Opioid Abatement Authority on how to best analyze the administrative burden to local government contracting.