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  • Central Shenandoah Valley Family Collaboration: Substance Abuse Prevention and Treatment for At-Risk Families

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Project Description


Through the funding opportunity, Sentara RMH Medical Center (SRMH) provides integrated activities and services designed to improve well-being, increase permanency, and ensure safety of children who are in or at-risk of being placed in an out-of-home placement as a result of a parent's or caretakers substance use disorder. The program accomplishes these goals by supporting interagency collaboration and integration of services.

SRMH estimated 50 percent of local at-risk families have substance use disorders. Home visiting staff at programs in the region are not prepared to address the family needs comprehensively because they lack training and expertise about substance use disorders. Through a multipronged approach that includes direct services, capacity building of a regional partnership, as well as enhancement of the practice skills of SRMH and partner agency staff, the partnership aims that through interagency collaboration and integration of services, the community will reduce the percentage of children entering out-of-home care by 10%.

The Substance Abuse Prevention and Treatment for At-Risk Families (STARS) program uses Recovery Support Specialists (RSS) to provide the needed expertise and treatment resources to address substance use disorders for the target population. The RSS uses Motivational Interviewing and Cognitive Behavioral Therapy as evidence-based interventions with families. In addition, the service array includes Healthy Families, a nationally recognized evidence-based home visiting program model designed to work with families who are at-risk for adverse childhood experiences, including child maltreatment. The grantee has expanded the target population for Healthy Families to include new parents with substance abuse issues and with a child three months or younger.

Target Population

Central Shenandoah Valley Family Collaboration Targeted:

General: The target population is families at-risk of having a child removed, or already in an out-of-home placement.

Adult Inclusion/Exclusion Criteria: Families with two or more risk factors, with one risk factor being substance abuse, are offered services.

In-home/Out-of-home Focus: Both

Serving Voluntary Families: Yes, this project focuses on assessing families early to begin intervention services before the family is in crisis

Major Program Goals

Goal 1: Provide integrated activities and services that are designed to improve well-being, increase permanency and ensure safety of children who are in or at-risk of being placed in an out-of-home placement as a result of a parent’s or caretaker's substance use disorder by supporting interagency collaboration and integration of services.

Obj 1.1: Work with the Home Visiting Consortium to provide Motivational Interviewing training to all home visiting workers in the Central Shenandoah Valley Region and with local trainers to provide Motivational Interviewing training to persons working with families that are not home visitors

Obj 1.2: Provide evidence-based services, based on family need, to families with at least two risk factors for out-of-home placement, with one risk factor being substance abuse.

Obj 1.3: Expand the Inter-professional Family Review Team case consultation meetings that include family goal planning and professional development for family support workers to all members of the Central Shenandoah Valley Family Collaboration.

Obj 1.4: Provide recovery support coaching for families affected by substance use disorders living in the three cities and five counties of the Central Shenandoah Valley Family collaboration by expanding the number of available professionally trained staff and using Cognitive Behavioral Therapy.

Obj 1.5: Expand services to minority populations, primarily located in Harrisonburg and Waynesboro and available to the rest of the region, by working with the New Bridges Immigrant Resource Center.


Major Program Services

Case Management

  • Development of an integrated case management system
  • Cross-system case review meetings

Wrap Around and In-Home Services

  • Substance abuse services referrals and follow-up with coaching
  • Recovery support specialist
  • Services to promote family wellbeing

Parenting / Family Strengthening

  • Family Screening and Assessment
  • The Incredible Years Parenting Program
  • Parents as Teachers
  • Staying Connected with your Teen

Children’s Services

  • Screening and assessment for trauma and other behavioral, developmental issues

Evidence-Based Practices

  • Motivational Interviewing
  • The Incredible Years Parenting Program
  • Parents as Teachers
  • Staying Connected with your Teen
  • Cognitive Behavioral Therapy
  • Healthy Families

Partner Agencies and Organizations

The Regional Partnership Grants encourages service providers to develop and/or strengthen cross-system linkages between substance abuse treatment, child welfare, dependency court, and other service systems. The following partners are included:

Community Health

  • Sentara RMH Medical Center
  • Integration Care Management
  • Continuum of Care Community Health Workers
  • Health Department – Public Health Nurses- Central Shenandoah Health District (Harrisonburg/Rockingham, Waynesboro, Augusta/Staunton, and Highland Counties)

Child Welfare

  • Department of Social Services
  • Prevent Child Abuse Virginia
  • Healthy Families of the Blue Ridge
  • Healthy Families of Virginia
  • Healthy Families of Page County
  • Healthy Families of Shenandoah County
  • James Madison University

Substance Abuse and Mental Health Treatment Services

  • Harrisonburg –Rockingham Community Services Board
  • RMH Center for Behavioral Health
  • Metro Center - Harrisonburg

Maternal and Child Health

  • Community Health Workers
  • Shenandoah Women’s Health Care
  • Harrisonburg Obstetrics and Gynecology
  • Central Shenandoah Health District
  • Harrisonburg Community Health Center

Community Child and Family Services

  • Resource Mothers Program
  • Parenting Education and Support
  • Child Care Aware
  • Virginia Home Visiting Consortium


  • deValpine Research LLC

Dissemination Activities

The grantee has implemented a multifaceted dissemination plan that includes regular dissemination activities and a publically accessible website. The Shenandoah Valley Services Map is available as a resource for service providers and individuals help disseminate information about services located in the Shenandoah Valley and surrounding areas. Press releases are developed through the SRMH Medical Center Marketing Department twice a year to disseminate data and to educate the public on protective factors for children, the effects of substance use disorders on children, activities related to the collaboration of the Central Shenandoah Valley Family Collaboration and other appropriate topics. A quarterly data report is disseminated to all partner agencies.

In Years Two through Five of the funding opportunity, Sentara RMH will submit a request to present data at regional, state, and/or national conferences. During the fourth year of the grant, the SRMH evaluator will submit an article to a peer reviewed journal. In addition, conference presentations that describe lessons learned and outcomes of the program will be pursued.

Sustainability Strategies and Activities

Involvement of Partners: Expand the Inter-professional Family Review Team to all members of the Central Shenandoah Valley Family Collaboration with meetings every month.

Institutionalizing Strategies: Providers across the Shenandoah Valley have increased skills and capacity as a result of training for over 100 home visitors. The Home Visiting Consortium has ongoing capacity to continue to train new workers.

Additional Funding: State of Virginia General Assembly budget increased TANF funds to home visiting programs including a $4.5 million increase to Healthy Families of Virginia, $1 million to Virginia Resource Mothers Program. The grantee is also seeking funding through the Maternal Infant Early Childhood Home visiting Program request for proposal in partnership with Healthy Families of Page and Shenandoah Counties.

Administrative Structure

Sentara RMH Medical Center, lead agency for this project, is located in Harrisonburg, Virginia. It is a member of Sentara Health and is a community hospital that has been providing healthcare services since 1912. The Sentara RMH Community Health Department's Community Health Manager has direct responsibility for the overall Sentara RMH Community Health Programs and provides supervision to the Project Director.

The Project Director has dedicated 100% of her time to provide leadership to the Central Shenandoah Valley Family Collaboration and oversees all aspects of the grant including reports and fiscal oversight, staff recruitment and supervision, implementation of evaluation and data collection. The Central Shenandoah Valley Region actively collaborates through the inter-professional Family Review Team. This team includes representatives from Healthy Families of Page, Shenandoah, the Blue Ridge and the Hand-in-Hand Resource Mothers and has expanded to include all home visiting programs in the area, including the Health Department nurses and professionals providing treatment for substance use disorders.


Each grantee is conducting a local evaluation to learn more about promising approaches to working with families that have children at-risk of removal and affected by parental substance use disorders. Sentara RMH Medical Center is conducting a descriptive study of families served in the Central Shenandoah Valley Family Collaboration. The program serves parents, expectant parents or caregivers who have substance use issues and at least one other risk factor (for example, poverty, domestic violence and history of depression /mental illness) and have had or are at-risk for having a child removed from their care. Families are eligible to receive Healthy Families home visiting services using Motivational Interviewing (MI), and Specialized Treatment and Recovery Services using Cognitive Behavior Therapy and MI. Parents can choose voluntarily to enroll in one or both services. The program plans to serve approximately 125 families. The local evaluation includes an outcome study and possibly other components to examine program implementation, such as attendance and fidelity monitoring, staff knowledge assessment and partnership surveys.

Outcome Study Design: The outcomes study includes families in the Central Shenandoah Valley Region of VA, comprising six counties. Sentara RMH Medical Center is measuring child permanency, child safety and adult recovery outcomes for all those who consent to the evaluation using administrative records from the local Community Services Boards and the local Department of Social Services offices. The project uses primary data to assess child well-being and family functioning and stability outcomes. Data is collected when parents enter and exit the program.

RPG National Cross-Site Evaluation Participation: The grantee also contributes outcomes, program implementation and partner collaboration data to the RPG national cross-site evaluation.


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