Appendix Table 2.

Themes of Harm Reduction-Informed Care by Clinic

Theme	Free-Standing Clinic Model	Co-Located Model in Syringe exchange program	Co-Located Model in Hospital System
Provider as both learner and informer	Providers provider a realistic range of support options Patient guides the provider to understanding what will be the safest course of action for them Patients are not required to be compliant to providers, providers are expected to be compliant to patient needs	Providers take cues from the patient Providers give patients all the tools and resources to make their decisions, but accept that decisions are theirs to make Providers let patients know they are autonomous in their treatment decisions	Providers create treatment plans in conjunction with the patient and in which the patient has decision-making power Providers understand that patients know more about drug use than the providers
Pragmatic measures of success	Providers are responsive to patient goals and do not push their own agenda Providers goals are to cultivate a trusting relationship with patient Definition of success dependent on individual patient Any positive change is acknowledged	Celebrate small successes Patients identify needs to address, not required to be SUD-related Success can be patient engaging for a follow-up visit, getting stable housing, getting a job, refilling medication Having a relationship with the patient is a success	Patient decides treatment goals and are not required to have abstinence as a goal Patient success is based on their own goals and needs Reality-based care focused on the process, rather than the outcome Communication and engagement with patient is success
Interdisciplinary and collaborative care teams	Morning meetings with clinic staff to review schedules Day-to-day operations are collaborative Every voice is valued Interdisciplinary care	Weekly clinic meetings Interdisciplinary approach If needed, two providers will meet with an individual patient	Interdisciplinary care Constant communication between staff Weekly check-ins with entire team Providers call each other for support in patient interactions
Developing a stigma-free culture	Careful about hiring and screening applicants Recognizing that the medical system is patriarchal Servant leadership Mandatory, ongoing training	Providers do not impose the medical system on patients and uphold patients ownership and belonging in the space Hiring the correct people	Ongoing and supporting training Provider recognition of biases and privileges Hiring the right providers
Creating a comfortable and welcoming physical space	Avoid use of stigmatizing language Do not release information to courts or criminal justice system without patient consent Staff remember patient names and other personal details	Friendly signage Radical welcome; ‘we take you as you are’ Patients welcome to come in and chat without seeing a provider Patients can bring dogs or belongings into the clinic Patients are not burdened with paperwork Give out snacks to patients Allow patients to use bathrooms and showers	Avoiding use of stigmatizing language Social justice and racial justice initiatives Avoid use of labels in medical charting Give patients snacks Hand out metro cards
Low-threshold care with flexible scheduling	Patients not penalized for missed appointments On-demand services Do not withhold treatment because patient discloses drug use	Walk-in model Are not punitive with positive urine toxicologies	Do not require abstinence Do not refuse treatment or kick someone out because of a positive urine toxicology Patients not penalizing for late or missed appointments Same-day access to services
Reaching beyond the clinic to disseminate harm reduction orientation	Staff train local providers and community organizations on harm reduction		Providers teach at medical schools
Creating robust referral networks to enhance transitions of care	Careful with referrals and creates ties with external providers	Careful with referrals and creates ties with external providers When external care is necessary, staff make appointments for patients and remind them of visits	Careful with referrals and creates ties with external providers

Abbreviation: SUD, Substance use disorders.