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LOGIC MODELOverdose Fatality Reviews RMEDIATE-TERMOUTCOMELONG-TERMOUTCOMELaws, Policies, and AttitudesConvening an OFR CommitteeConvening an OFR CommitteeOFR MembersCommunity and SystemMorbidityLaws and policies authorizing andestablishing OFRsaClear policies and procedures for OFR membersand agencies, including data collectionprotocols and confidentiality agreementsSupportive attitudes among OFR membersthat overdoses are preventablePartnershipsEstablish an OFR structure, governingcommittee, OFR staff, strong workingrelationships with Medical Examiner/Coroner,and data use agreementsDetermine OFR team membersTrain OFR team members on OFR processand proceduresPlanning/Holding an OFR MeetingPartnerships with agencies that representmultiple sectors in the communitybEstablish meeting schedule and location(in-person or virtual)Buy-in and support for the OFR fromagency's leadershipcSelect OFR cases to be reviewed, includingany additional relevant information andparticipants. OFR participants may ofteninclude family and friends of the decedentsResourcesFunding to support OFR work, includingleveraging resources from multiple agencies andsectors to increase system-level responseUnderstanding the nature of overdose andlocal resources available to plan response (e.g.,political landscape, resource availability)dAccess to REDCap (data capture tool)OFR training curriculum for OFR memberseData management planfPrepare for OFR meeting: set agenda;review cases; collect case data, includinginterviews with decedent's family members;complete relevant agency forms; invite guests;and take notesFacilitate OFR meeting: move members frominformation sharing to problem solvingOutline post meeting tasks andrecommendationsSystematizing Data CollectiongFollow data collection steps before, during,and after an OFR is conductedMaintain a secure and accurate data collectionsystem, including agency-specific datahOFR structure established and governingcommittee and staff identifiedIncreased self-efficacy to participatein an OFROFR team members selected and trainedIncreased understanding and awareness ofagency’s role in prevention of overdoses andsupport for individuals with substance usedisorders (SUD)Planning/Holding an OFR MeetingMeetings scheduled and location establishedOFR cases selected, and additional informationand participants gatheredIncreased self-efficacy to develop,implement, and monitor recommendationsOFR agenda set, cases reviewed by teammembers, notes taken, and any additional casedata collectedIncreased ability among OFR membersto identify overdose risk and protectivefactors and missed opportunities forprevention and interventionCase information presented, problems identified,and recommendations exploredIncreased knowledge of SUD and natureof drug overdose in their jurisdictionPost meeting tasks outlinedStandardized data collectionSystematizing Data CollectionData are input into collection systemand protocols are adhered to throughoutOFR processCase data is accurate and securedBuilding a Recommendation PlanRecommendations identified andimplementation work plan developedCommunity and SystemIncreased understanding of area agencies’roles and services, community assetsand needs, substance use and overdosetrends, current prevention activities, andsystem gapsIncreased collaboration, communication,trust, and buy-in across service agenciesIncreased identification of service andsystems needs of populations at-risk forSUD and overdosesImproved coordination and collaborationbetween agencies and community conditionsto prevent future overdose deaths, as well asleveraging existing resourcesImplemented policies and programs thatfurther improve community responses andorganizational capacity and increase fundingfor OFRsImproved outreach and service delivery to atrisk populationsReduced stigma against individuals who usedrugs among all agencies and communitymembers involved with the OFR processIncreased shared accountability to monitorlocal substance use and overdose death data,implement recommendations, and assess andmonitor implemented activitiesImproved data related to missed opportunitiesfor prevention and intervention at thecommunity-levelImproved investigation of overdose deaths(coroner, medical examiner, and lawenforcement)Recommendations presented forimplementation in agencyRecommendations assessed and monitoredBuilding a Recommendation PlanIdentify recommendations from OFRiForm subcommittee(s) to finalizerecommendation and implementationtimeline and planPresent recommendation work plan to governingcommittee to implement in their organizationAssess and monitor recommendationsabCurrently, 12 states have passed legislation that authorizes them to conduct overdose fatality reviews, including Arizona, Delaware, Indiana, Maryland,New Hampshire, North Dakota, Oklahoma, Pennsylvania, Rhode Island, Virginia, Utah, and West Virginia. Due to the changing policy landscape,additional states may have passed legislation related to OFRs since this logic model was developed. While OFR legislation is an input in the OFRevaluation logic model, some jurisdictions are conducting OFRs without this legislation. Jurisdictions without legislation use data use agreements atthe agency level and confidentiality agreements for the individuals participating in the reviews.Sectors include law enforcement, health departments and commissions, justice departments, medical examiners/coroners’ offices, corrections, localand state government, education, hospitals and healthcare agencies, behavioral health agencies, and research.cThe agency would need to be willing to have a representative at the OFR and enact recommendations from the OFR.dEvidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States.eRecommended trainings include “Partnerships for Prevention: OFR 101” webinar; “Overcoming stigma, ending discrimination”; “Why addiction is a‘disease’ and why it’s important”; and “Social Determinants of Health: Know What Affects Health”.fCDC requires recipients who collect or generate data with federal funds to develop, submit, and comply with a data management plan (DMP) for eachcollection or generation of public health data undertaken as part of the award and, to the extent appropriate, provide access to and archiving/longterm preservation of collected or generated data. For more information please see CDC’s DMP policy.gCreating an OFR meeting plan and systematizing OFR data collection should happen simultaneously and in tandem.hOFR teams may want to use the OFR Standard Database Template, a REDCap database that allows local OFR teams secure access.iRecommendations will vary based on the local context and should be tailored appropriately. Examples of the various types of recommendationscould include systemic (addressing a gap, weakness, or problem within a particular system or across systems), population-specific, agency-specific,case-specific, capacity-building or research-related, quality improvement, priority recommendation (focus on during a specific time period), primary,secondary, or tertiary prevention.Decreased rate of opioid misuse, opioid usedisorder, and nonfatal overdoseMortalityDecreased drug overdose death rates,including prescription and illicit opioidinvolved overdose death rates

3ProcessEvaluationsProcess evaluationsDOCUMENT AND DESCRIBEHOW A PROGRAM ISIMPLEMENTED. Theynormally occur whenprograms or initiatives areearly in their developmentand are based onstakeholders' needs.B10

Process EvaluationsContextEvaluation QuestionWhat factors affect implementation and maintenanceof an OFR?What is the overdose and/or opioid misuse burden inthe jurisdiction?DATA SOURCES Jurisdictional/statelaws and policies Data use agreements Vital statisticsdata, public healthdata (e.g., HealthData.gov, Community HealthStatus Indicators,National Surveyon Drug Use andHealth, Data.gov),prescribing data OFR team members Stakeholders(e.g., partners, agencyleaders and staff) Administrative data forOFRs, including datacollection protocolsand training curricula Available peerreviewed literature Existing resource:Overdose FatalityReview Practitioner’sGuide toImplementationSample IndicatorsLaws, Policies, and Attitudes Description of laws and policies authorizing and establishing OFRs Description of clear policies and procedures for OFR membersand agencies, including data use agreements and collection andstorage protocols Description of attitudes among OFR members about whetheroverdoses are preventablePartnerships Description of the jurisdiction’s experience with fatality reviews(e.g., homicide, maternal/child/infant) Description of existing multisector partnerships that addressoverdose prevention and/or substance use disorder withinthe community Description of existing level of trust between and amongstpotential OFR partners Description of buy-in and support for the OFR from agency'sleadership and staffResources Description of funding and in-kind support of the OFR, includingresources from multiple agencies and sectors to increase systemlevel response (e.g., staff time, meeting space) Description of the nature of overdoses and drug use trends injurisdiction Descriptions of overdose prevention activities in the community(e.g., naloxone distribution, opioid prescribing behavior, access totreatment) Description of community perceptions and acceptance ofevidence/practice-based interventions and strategies27 Description of OFR training curriculum for OFR members Description of technical assistance needs of OFR members oradditional technical assistance provided to membersDATA COLLECTIONMETHODS Environmental scan Document review Focus groups,interviews, or surveys Informal discussionswith OFR membersand stakeholders Literature review11

Process EvaluationsReachEvaluation QuestionDATA SOURCES OFR team members Sample IndicatorsAdministrative records(e.g., membership listfor OFR and its advisorycouncil, meeting rosters,meeting agendas) Vital statisticsOFR Committee Case list frommedical examineror coroner reportsHow many members were recruited and regularlyparticipate in the OFR or its advisory committee?How often does the OFR team meet or review cases? Number and descriptions of sectors and/or populationsegments represented by OFR members, includingdescriptions of any representatives missing or gaps inOFR member knowledge Number and type of multi-sector representatives whoserve in an advisory capacityDATA COLLECTIONMETHODS Number of OFR team members trained on OFR processand procedures Discussions withOFR members Number of OFR cases selected for and reviewed Number of OFR meetings heldDocument review ofadministrative recordsDoseEvaluation QuestionDATA SOURCESHow many cases are reviewed by the OFR team? Sample IndicatorsOFR CommitteeOFR team membersDATA COLLECTIONMETHODS Number and percentage of core representatives who attendmeetings consistently Discussions withOFR members Number and percentage of meetings advisory committeemembers attend consistently Scan of administrativedata/meeting notesPlan/hold an OFR Meeting Number and percentage of OFR cases reviewed out of thetotal number of overdose cases in the jurisdiction, annually Number and percentage of case stratified by risk or specialtygroups or by population segments12

Process EvaluationsFidelityThere may be circumstances in which strict fidelity to the originalplan may actually work against an intended outcome. In thiscase, adaptation is necessary and expected. Tracking fidelity andpurposeful/data-informed deviations are important for understandingimplementation; however, strict fidelity should not supersedenecessary adaptations that will facilitate outcomes.Evaluation QuestionsDATA SOURCESTo what extent was the OFR Practitioner’s Guide toImplementation model adhered to? To what extent was the OFR program adaptedduring implementation? Why was it adapted?Did this adaptation result in improvements?DATA COLLECTIONMETHODSSample IndicatorsOFR team members Discussions withOFR members Scan of administrativedata/meeting notesOverall Description of how adherence to the OFR Practitioner’s Guideto Implementation model was followed by the jurisdiction Description of changes/adaptations to the OFR overtime Description of how adaptations led to improvements13

Process EvaluationsImplementationEvaluation QuestionsTo what extent was the OFR implemented andmaintained?DATA SOURCES OFR team members Administrative records(e.g., meeting agendas,meeting notes, postmeeting tasks andrecommendations,progress reports) OFR datacollection systems Stakeholders (e.g., partners,agency leaders and staff)What factors facilitated and/or hindered the OFR?What lessons were learned from OFR that can informother OFRs?Sample IndicatorsOFR Committee Description of OFR protocols and organizational structure(e.g., meeting scheduling, facilitation, data sharing) Descriptions of OFR members and advisory committee members Description of facilitator (e.g., agency representative and paidfacilitator) and their roles/responsibilities Description of the level of cooperation and coordination the OFRhas with the medical examiner/coroner in their jurisdictionDiscussions withOFR members Description of the ability of OFR members and agencies to sharedata and case information Descriptions of membership sustainability plan (e.g., recruitment,retention, and attrition of OFR members and advisorycommittee members)Document review ofadministrative records(e.g., meeting agendas,meeting notes, postmeeting tasks andrecommendations,progress reports) Description of efforts to address OFR member burnout orcompassion fatigue Review of OFR datacollection systems Number and percentage of OFR members who are satisfied withthe OFR operation (e.g., membership composition, data collectionand maintenance system, meeting facilitation, and recommendationplanning and monitoring) and its ability to enact changeFormal or informalconversationswith stakeholders(e.g., partners, agencyleaders and staff)DATA COLLECTIONMETHODSPlan/Hold an OFR Meeting Description of meeting schedule and location (in-person or virtual),including any additional participants Description of selection criteria for OFR cases to be reviewed Description of the OFR meeting preparation (e.g., agenda setting,case review, case data collection, relevant agency form completion,and note taking) Description of how stigma reduction is incorporated into OFRmeetings Number and percentage of OFR members who report thatmeetings are effectively and efficiently conducted (e.g., membershave access to necessary data and core OFR representatives areavailable to fill in knowledge gaps)14

Process Evaluations Description of techniques utilized to promoteOFR member preparation prior to OFRmeetings (e.g., checklists, reminders)Recommendation Plan Descriptions of steps taken to developrecommendation implementation plans Number and percentage of OFR meetingsheld on time and/or end on time Description of lessons learned facilitatingOFR meetings (e.g., moving members frominformation sharing to problem solving)Number and types of recommendationimplementation plans developed from theOFR and provided to the advisory committee Description of subcommittee(s) formedto finalize recommendations andimplementation timeline and plan Descriptions of the types of changes requestedin the recommendation implementation plansby audience (e.g., OFR members, communities,and systems) Descriptions of and lessons learned frompresenting recommendation implementationplans to the governing committee Number and descriptions ofrecommendations implemented Descriptions of barriers and facilitators toimplementing recommendation work plansin corresponding agencies Number and description of post meetingtasks and recommendations outlined Percentage of OFR members who perceivethe OFR meetings to be of high quality(e.g., organization, efficiency, flexibility,professionalism, conflict management,ability to move from brainstorming stage torecommendations stage)Systematized Data Collection Process Number and percentage of complete OFRdata submitted on time Description of completeness of OFR data Description of the established mechanismfor ensuring data accuracy and completeness(accuracy is defined as ‘conveying technicallyadequate information’ for this purpose) Description of data collection systemscreated to ensure that agency specific dataand OFR case data are accurate, complete,and timely Description of data management and securitysystem practices employed Description of changes to data quality,timeliness, and completeness Description of best practices, barriers,facilitators, and lessons learned collectingOFR data15

Process EvaluationsIndividualLevel ChangeOutcomesEvaluation QuestionTo what extent did OFRs produce or contribute tothe intended individual-level outcomes?For whom, and in what ways, did individual-levelchanges (e.g., knowledge, skills, intention, selfefficacy, behavior) occur based on establishing OFRs?Short-term Sample IndicatorsDATA SOURCES OFR team members Stakeholders(e.g., partners, agencyleaders and staff)DATA COLLECTIONMETHODS Surveys withOFR membersand/or stakeholders(e.g., pre-postsurvey on awareness,knowledge, attitude,and intention) Interviews withOFR members orstakeholdersOFR members Increased knowledge of substance use disorder and nature ofdrug overdose in their jurisdiction Increased self-efficacy to participate in an OFR Increased understanding and awareness of their agency’s rolein prevention of overdoses and support for individuals withsubstance use disorders (SUD) Increased self-efficacy to develop, implement, and monitorrecommendations in their agency I

needs; substance use and overdose trends; current prevention activities; and system gaps.9 They increase the jurisdiction's ability to prevent future overdose deaths by leveraging resources from multiple agencies and sectors, as well as by providing shared accountability to monitor substance use and overdose death data and implementing