Table 2.

Summary of identified themes and exemplar quotes.

Theme		Exemplar Quotes
1. Substance Use Disorder Workflow for HIV Treatment
Connection to behavioral health specialist in medical care		“The way it works at [FQHC] is that for each of our medical floors, there is a specific behavioral health specialist that’s effectively embedded when we’re in the same space, embedded with medical providers. What happened is that somebody, there could be potentially a warm handoff, or at least a referral if it’s not a warm handoff, from a medical provider.” “Internally say if a patient shows up for an appointment with a primary care doctor and they assess them and determine, hey, this person has some substance use or alcohol use issues going on. Let’s refer them to behavioral health. What they will do is send a referral within our messaging system called [name of system], to the behavioral health department.”
Behavioral health specialist intake/assessment completion		“We are looking to try to use the—we are an SBIRT model, so we’ve piloted it with some of our MAT [Medication Assisted Treatment] providers, but probably AUDIT, like the AUDIT—the brief.” “Really, it’s just direct interviewing. I think most of the providers at our clinic are very comfortable discussing issues that I think a lot of providers may shy away from. Sexual histories, substance use histories. We often ask more than in one way about how people drink.”
Behavioral health specialist referral to substance use disorder treatment		“That person [the outreach specialist] then calls the client and says, “…Let’s talk about what your use is right now. Let’s talk about what kinda services we have and what you would be interested in,” and that’s how they get connected.” “We have a recovery [name of program] program, which is one of our internal behavioral health programs that’s focused on substance reduction or total abstinence, depending on what the person’s requesting.”
2. Research Recruitment Workflow
Presence of existing research recruitment protocols		“Our research team does a pretty good job. I think they must do reports through our EMR to try to identify patients, but they also—at least when we were in the office they had a strong presence at our quarterly social services meetings where they’d give us a rundown of what services, or sorry, what studies are going on in house and who would be eligible. They’re also just extremely accessible.” “I know we have a research department, and they’re often in our management meetings. They’re frequently, you know, how I heard about you and your program. They’re often just getting the word out and sending emails to us…”
Staff Involvement in research recruitment		“Probably the provider who would be doing the screen or collect the data…and then having them either sent—most likely probably send a referral, or we call it a TE, a telephone encounter, to your point of contact at [name of FQHC], who then would supply the information to whoever’s gonna do the intervention or be the point of contact to talk more in-depth to the patient…” “Also I think that also having the provider be in the know just because the providers are the ones spending time with the patients and could let them know during their medical visit if this [the research project] is something that they can benefit from.”
Research team informs staff about recruitment		“We’ve had a lot of people Zoom in and be either meeting teams or departments that are promoting services or talking about new services. I think that face-to-face interaction, although it can be lengthy and time-consuming, I think makes it more viable that we will remember the service.” “The easiest things with them [treatment providers] is to make sure they have the information, know what the program or project is about, and then identifying a contact person. Because if they have to figure out who to contact to make it happen, they’re not gonna do it…”
Use of signed release of information (ROI) from clients for research		“I feel like the best way would be to have a specific name and person that we can email to. That’s how we’ve also received external referrals for therapy services through a case manager or a family that says, “Hi, I think I have a person who can benefit from some services.” Then we do the ROI [release of information] piece and refer ‘em that way.” “I think the best way would be for us to have a referral form from you guys and a release of information…and then you can reach out to them.”
3. Barriers to Telehealth Services
3a. Intervention Barriers
Impact of telehealth on healthcare disparities		“A lot of clients, especially the monolingual Spanish speakers, do not have smartphones, so they prefer phone in order to let—or bad internet, or just not a lot of data, so a lot of them have preferred phone sessions versus Zoom.” “A lot of us were still moving about in-clinic interacting with them [individuals with unstable housing] and trying to support them the best way that we could, but the telehealth issue was something that was a barrier”
Client willingness/ability to engage in telehealth		“It’s a mix of things. Some people have access to reliable internet service. I would say it’s 50/50. Some people are more comfortable with telephone, so I think on a given day, I’ll have 50 percent of each.” “Lots of our patients won’t do video…When I asked, it was, phone wasn’t working. There wasn’t a camera on my phone, or they didn’t want me to see where they were staying ‘cause they were embarrassed, or they weren’t in a safe place, and so they didn’t want someone seeing that they were talking to their doctor.”
Challenges building rapport		“Interestingly, I think that it can be communicated care, attunement, empathy can be communicated via Zoom. In fact, it brings us into focus so that our reach is so focused here that I think in some ways, in some cases, it’s actually better.” “Speaking to my previous role, from going from being embedded in a clinic to being virtually embedded in a clinic when a job was not built for that… I am well used to building trust with a stranger in a room and via phone becomes a lot more difficult.”
3b. Setting Barriers
Space challenges		Interviewer: “If we potentially were able to provide the stations, do you think that your agency would be able to give us a little space to set up the station for folks to come in and participate?” Interviewee: “No, especially now with us not being able to use all of our spaces. Before we were pretty packed in, but now, I wonder if we would be able to. I think this is more relevant to the [FQHC site name] space or a smaller space to begin with, but I think that that would be great.” “If it was pre-pandemic times, I would say meeting spaces because we’re always running out of—we were [laughter] and we will again someday. We were always running out of group spaces to meet because there’s so much going on that it was a little bit of a fight to reserve those group rooms…”
High demands on treatment providers		“Right now because our behavioral health system is still kind of overwhelmed, and we do have a waitlist for behavioral health patients, our behavioral health consultants are doing some interim visits with folks just to try to provide that support that people really need right now while they’re waiting to find a full-time therapist.” “We are totally closed to new therapy patients right now and psychiatry, other than people under the age of 30 is closed. We just don’t have enough staff. Enough funding for staff to be able to meet the demand.”
High treatment provider turnover		It’s just a matter of folks being busy and overworked. Add COVID…I would say there’s just continually—I don’t know what the turnover rate is compared to other comparable organizations, but I can say every week I get emails about new staff….” “I feel like maybe I don’t know if this is just a [FQHC city] thing or if it’s all around the nation…. I think that the biggest thing is that there’s a lot of turnover in a lot of these agencies. Right when you feel that you have the connection with the staff and you have a system in place, boom. Everything changes because now they’re under a new leadership.”
Difficulty introducing new clinic practices		“…I think there’s a lot of therapists that have been around that do things the way that they’ve done things without really an intention to shift. I don’t mean that in a negative way at all. I would say there’s an openness, but that’s not necessarily the culture or the norm.” “One thing I’ve learned with the providers at [FQHC] is anything that is too complicated or has too many steps, they’re not gonna do it. That’s the culture. It is what it is, and it has been. That has been one of the biggest barriers.”
3c. Ecological Barriers
Concerns about insurance coverage and compensation for telehealth		“…Whether or not there’s a pot for those who are uninsured and may not have insurance. Yes, depending on the financial circumstances of the client or the patient themselves, it might be a big deal. I will say happily that for most people who want to engage in therapy, there seems to always be a way to do it…” “My understanding is that it will probably—my guess is it might depend on insurance companies, on what they’re willing to reimburse. If they’re continue to reimburse that [telehealth], it will likely be some part of how we move forward as an agency because clients have actually really enjoyed it, for the most part…”
Burden of FQHC paperwork and reporting requirements		“Oh, yeah, right. In the state of [state], right, there is a reporting structure specific to substance use treatment as far as expectations for documentation, timeliness, sign-off by a medical provider for level of care. There is a substantial administrative load for every single client.”
4. Working with SGM Clients
Cultural Humility		“Trans and non-binary clients don’t like to have to educate their providers, and they often have to do it a lot of the time….You don’t wanna have to do that with your provider, and being informed about the issues, why trans people might use substances and the challenges that they may face in making those changes.” “I think having some geographical knowledge of what the [SGM] community in [a specific city] is facing.”
Service Adaptations		“Well, I think that’s a issue regardless of telehealth or in person because this community is generally burdened, given their experiences in the world…I think that, one—again, big picture—one is just I do think that having members of the [LGBT] community as clinicians does help.” “…I think when we talk about substance abuse, specifically within the trans community, it’s hard to isolate one particular challenge of an individual, who’s also facing homelessness and who’s also considering a transition, or who’s working on their homelessness…I think somehow integrating those different components doesn’t mean providing an intervention to all of those components, but finding a way to really integrate these interventions with the different services that the patients are receiving…”
Knowledge about Substance Use among SGM Individuals		“We don’t have good literature about going on and off hormones, but then I also don’t have good literature around using alcohol with the hormones…often what I’m having is how do you safely take your hormones? How do you safely inject? How do you safely while you’re using?” “Someone’s probably not seeking support related to their gender, but it’s related to the alcohol and being treated like any other client. I’ve seen that as a barrier. Then additionally, in the ways that maybe alcohol shows up differently in maybe a queer relationship”
5. Working with Clients from Diverse Racial/Ethnic Backgrounds
Cultural Humility		“That people in our communities, they are so accustomed to scanning the horizon for indicators of nonacceptance that the qualities that people bring, the listening that we bring is so incredibly important from the very first contact…that it have kind of a real human touch that’s present there in an affirming way. I think that’s vital for the people that we work with.” “Expressing a familiarity with working with people of color, expressing the desire to work with people of color. I think people can sense your intentions face to face and maybe even screen to screen…”
Service Adaptations		Definitely making sure that there’s a staff that speak the languages of our patients. I’ve noticed that with patients who are Spanish speaking, once they’ve made a connection with one of our staff that speaks their language, that’s who they go to for everything.” “I really think that part of that is really being inclusive with your service providers. I think having folks of color on staff, folks who potentially identify with the community on staff to, you know, on the backend provide that level of information and insight…”