“They Don’t Just Need a Handshake or a Handoff, They Need a Hug”: A Qualitative Assessment of the Care Transition Experience of Patients with Substance Use Disorders After Hospital Discharge

Abstract

Background

Hospitalizations are common among people with substance use disorders (SUD). Transitioning to follow-up medical and SUD care after discharge is a complex process affected by numerous medical, environmental, and psychosocial factors. Little is known about the experiences of patients with SUD during post-hospitalization care transitions.

Objective

We sought to better understand the care transition experiences of people with SUD in the immediate post-hospitalization period.

Design

We conducted a qualitative study at a single academic hospital site.

Participants

We interviewed 25 recently hospitalized individuals with a SUD.

Approach

Participants were recruited during their hospitalization, and semi-structured interviews were completed via telephone 1–3 weeks after hospital discharge. Interviews were transcribed verbatim and coded. Thematic analysis was performed to inductively extract key themes from coded transcripts.

Key Results

We identified six themes pertaining to post-hospitalization care transition experiences: (1) the timing and circumstances of hospital discharge were often unpredictable, which could be destabilizing for patients; (2) careful planning and thorough communication by hospital care teams at discharge were valued by patients but happened inconsistently; (3) substance use disorder treatment was desired and offered frequently via a spectrum of active and passive approaches; (4) patients faced multifarious challenges to following through with a care plan after discharge; (5) community supports and a sense of connection are key facilitators of SUD and medical care linkage after hospital discharge; and (6) proactive outreach, individualized care plans, and continuity of care are valued during post-hospitalization care transitions.

Conclusion

Our themes suggest several distinct and actionable steps to improve post-hospitalization care transitions based on the perspectives of people with SUD who were actively transitioning care. In the hospital, SUD treatment initiation, proactive planning around discharge, and predictability were valued. In the outpatient setting, a supportive community, assistance with basic amenities, and post-discharge outreach were valued.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-025-09614-3.

INTRODUCTION

Hospitalization is common among individuals with substance use disorders (SUD). It is estimated that one in nine hospitalized patients in the USA has a SUD.¹ These hospitalizations may be directly related to substance use (e.g., withdrawal, overdose), related to the interplay of substance use and underlying health conditions (e.g., stimulant-related heart failure exacerbation), or for reasons completely unrelated to substance use.² Medical hospitalizations represent important opportunities to engage individuals with SUD and offer treatment and harm reduction counseling, establishing hospitals as a cornerstone of the Substance Abuse and Mental Health Administration’s “No Wrong Door” philosophy for SUD treatment.³ Several innovative models to facilitate hospital-based SUD treatment are emerging in diverse inpatient settings around the USA.^4–8

While medical hospitalizations may serve as an entry point to accessing SUD care, they can also be destabilizing events. Patients may leave the hospital debilitated from physical illness, burdened with new medications and their attendant side effects, and faced with a complex follow-up plan. Furthermore, patients may have had little or no exposure to opioids during an extended hospitalization, decreasing tolerance, and increasing the risk of overdose in the immediate post-hospitalization period.^9–11 Some individuals may be returning to unstable environments, where a lack of social supports and inadequate access to basic amenities may impact their ability to link to long-term medical and SUD care.^12,13 Unfortunately, there are few evidence-based models to support patients with SUD as they navigate this complex and potentially dangerous transition.^14–16

Understanding the perspectives and priorities of people with lived SUD experience (PWLE) regarding post-hospitalization care transitions is central to the effective design and implementation of interventions to improve post-discharge care. Prior qualitative research involving hospitalized patients with SUD has highlighted the importance of partnering with patients in the hospital in a compassionate and person-centered manner to offer treatment initiation, harm reduction counseling, and post-discharge care coordination.^12,13 However, little is known about the experiences of patients with SUD during the immediate post-hospitalization period. We conducted a qualitative study of recently hospitalized individuals with SUD, examining their perspectives on post-hospitalization care transitions. We believe that this work is instrumental in informing future research priorities and care innovation in this area.

METHODS

Study Design

We conducted a qualitative study of recently hospitalized patients with documented SUD. Trained qualitative researchers conducted semi-structured interviews with participants between 7 and 21 days after discharge from a medical hospitalization. Verbal informed consent was obtained by the research team prior to each interview. The study was approved by the Institutional Review Board at the University of Utah.

Setting and Participants

Our study recruited 25 patients from a single academic hospital site in Salt Lake City, UT, between November 2023 and June 2024. Our recruitment target was chosen a priori based on prior research indicating that thematic saturation is likely with this sample size.^17,18 Inclusion criteria included current hospitalization, age ≥ 18 years old, a documented SUD in the electronic health record (EHR), verbal confirmation of current substance use, and the ability to conduct an interview in English or Spanish. Participants could be admitted for any medical reason. Exclusion criteria included tobacco use as the sole SUD, current incarceration, no access to a telephone or other means to conduct a remote interview, and a primary psychiatric admitting diagnosis (e.g., suicidal ideations). Inpatient medical team patient lists and the addiction consult team patient list were screened daily for potential participants. Eligible patients were approached by the research team, screened for eligibility, and consented during their hospital admission. Between 1 and 3 weeks after discharge, trained qualitative researchers contacted patients via telephone and conducted ~ 30-min semi-structured interviews. The timing of interviews was chosen such that patients would be most likely to be actively engaged in the process of navigating follow-up appointments and other aspects of post-discharge care. Participants were renumerated with a $50 gift card upon completion of the interview.

Interview Guide Development

Our interview guide was designed and refined by study team members (MI, DB, KS) with input from the Utah Clinical and Translational Science Institute Qualitative Core (PG, SZ). Questions were divided into three domains: (1) patient experience in the hospital; (2) patient experience around the time of hospital discharge; and (3) patient experience since leaving the hospital (Supplement). Questions were based on the combined clinical and research experience of study team members, which included two Board-certified addiction specialists, a hospitalist, a primary care physician, a SUD researcher, and qualitative research experts.

Data Collection

Data was collected by trained interviewers from the University of Utah. The interviewers had no clinical relationship with the participants. Interviews were audio-recorded, transcribed verbatim, and de-identified. Basic demographic information and treatment history were collected from the EHR.

Analysis

A codebook was created from the de-identified interview transcripts by two trained qualitative researchers (TA, ST). Coding was performed using an “open-coding” process.¹⁹ The qualitative experts selected a sample of n = 5 (20%) transcripts to code and discuss during codebook development to ensure intercoder reliability. Subsequently, a thematic analysis of coded interview transcripts was conducted to inductively extract themes. The content experts (MI, AH) and qualitative experts (TA, ST) independently extracted key themes from the coded transcripts using an inductive approach developed by Crabtree and Miller, which shares key features with grounded theory.^19,20 A presumptive list of themes was developed by the study lead (MI) based on a comparison of these results and shared with the study team for feedback. A final list of themes was developed, incorporating feedback from the study team. The software platform Atlas.ti was used to facilitate coding and analysis.²¹ We followed COREQ guidelines for reporting qualitative results.²²

Role of the Funding Source

This project was funded by a University of Utah Department of Internal Medicine Seed Grant. The funder played no role in the design, conduct, or evaluation of this research.

RESULTS

We identified 431 eligible participants through EHR review. Two hundred and nineteen individuals left the hospital before they could be approached, and 62 did not meet full inclusion/exclusion requirements. Of the remaining 150 eligible patients, 37 individuals agreed to participate in the study and were consented. Twelve individuals were unable to be reached after hospital discharge, and 25 participants completed interviews (Fig. 1). All interviews were completed between 1 and 3 weeks after hospital discharge. The average age in years of participants was 44, and 14 (56%) identified as male. The average length of hospital stay was 7.68 days. Alcohol, methamphetamine, opioids, and cannabis were the most commonly reported substances used. Eleven participants (44%) had four or more medical diagnoses. Full clinical and demographic characteristics are shown in Table 1.

Figure 1.

CONSORT diagram displaying recruitment and enrollment for the study.

Table 1.

Participant Characteristics

Age at admission
	20–29	2(8%)
	30–39	4(16%)
	40–49	15(60%)
	50–59	2(8%)
	60–69	2(8%)
	Average age (SD)	44.44 (9.07)
Sex		n (%)
	Female	10(40%)
	Male	14(56%)
	Other	1(4%)
Race (self-report)
	American Indian/Alaska Native	1(4%)
	Hispanic/Latine	2(8%)
	White	19(76%)
	More than one race	2(8%)
	Not listed	1(4%)
Length of stay (days)
	1–10	17(68%)
	11–20	7(28%)
	21–30	1(4%)
	Average length of stay (SD)	7.68 (6.40)
Current substance use (self-report)
	Alcohol	16(64%)
	Cannabis	8(32%)
	Fentanyl	2(8%)
	Heroin	6(24%)
	Methamphetamine	7(28%)
	3,4-Methylenedicxymethamphetamine	1(4%)
	Tobacco	4(16%)
Medications prescribed at discharge
	Naltrexone	7(23.3%)
	Buprenorphine	9(30%)
	Methadone	1(3.3%)
	Naloxone	9(30%)
	Acamprostate	1(3.3%)
	None of the above	3(10%)
Health insurance
	Medicare	1(4%)
	Private	6(24%)
	Medicaid	17(68%)
	Uninsured	1(4%)
Number of medical diagnoses
	4 or more	11(44%)
	Less than 4	14(56%)

Six themes were extracted from coded interview transcripts (Table 2).

Table 2.

Key Themes Related to Post-Hospitalization Care Transitions

Theme
1. The timing and circumstances of hospital discharge were often unpredictable, which could be destabilizing for patients - Patients experienced many elements of hospital discharge without warning (e.g., timing, medication changes), which disrupted care transitions even before departing the hospital - Last minute changes to care plans (and sometimes care teams) led to anxiety and at times a breach of trust
2. Careful planning and thorough communication by hospital care teams at discharge were valued by patients but happened inconsistently - Shared decision making around the timing and circumstances of discharge was valued - Lapses in communication and faulty assumptions about patients’ abilities to carry out elements of the discharge plan led to confusion, worry, and delayed care in the post-discharge period - Interdisciplinary discharge counseling was valued, as each team member had unique contributions to improving post-discharge care
3. Substance use disorder treatment was desired and offered frequently via a spectrum of active and passive approaches - Medications for SUD were perceived as an important support during care transitions - Patients valued care teams ‘taking the first step with them’ and actively facilitating linkage to continuity of SUD care over passive approaches (e.g., providing a list of community resources)
4. Patients faced multifarious challenges to following through with a care plan after discharge - Basic life amenities like housing, transportation, telephone access, insurance, and financial strain had substantial impact on connecting to community care - New medical and SUD-related sequelae of hospitalization impacted ability to safely transition to community care - Stigma experienced in healthcare environments affected linkage to community-based care
5. Community supports and a sense of connection are key facilitators of SUD and medical care after hospital discharge - Family, friends, and case managers were commonly seen as major facilitators of healing and care linkage after hospitalization - Care transitions were often imbued with loneliness, especially when individuals had to avoid loved ones to prioritize SUD care
6. Proactive outreach, individualized care plans, and continuity of care are valued during post-hospitalization care transitions - Patients desired proactive team-based outreach in the post-discharge period to ensure continuity of medical and SUD care - Patients saw post-hospitalization outreach as a gesture of moral and emotional support as well as a health intervention

Theme 1: The Timing and Circumstances of Hospital Discharge Were Often Unpredictable, Which Could Be Destabilizing for Patients

Challenges with care transitions often started in the hospital and were related to unpredictability around hospital discharge. Patients encountered many elements of their discharge plan without advanced notice, particularly related to the timing of discharge and last-minute changes to key elements of the discharge plan. These last-minute changes to care plans sometimes led to a breach of trust between clinicians and patients that could disrupt continuity of medical and SUD care after discharge. For example, one participant reported:

I’d say the doctor and addiction specialist probably spent at least six hours with me, and we came up with a plan, and they listened to me. It wasn’t exactly the plan I wanted, but they made some concessions, and I made some concessions, and I felt like we had a really good plan. But then when the new doctor came in, somehow that plan just got thrown out the window, and he just started planning for my discharge immediately… He took me off all of the medications really abruptly and discharged me, and I just had to come back to my apartment instead of going along with the plan that we had spent a lot of time working on.

Unpredictable circumstances around hospital discharge often had an immediate impact on care transitions, at times placing patients in untenable situations directly after leaving the hospital.

[T]hey said, okay, we got you ready to discharge, here’s your papers, and how you gettin'home?... it was towards the end of the month and I didn't know if I had enough money in my account to even get an Uber. And I said, you know, do you, do you offer some transportation home? And she said, well we can give you a token and you can ride the bus. And I'm like, I can hardly walk. I don't even know if I can stably get from where, where I get dropped off, you know, downstairs, up to my apartment, down the hall to my apartment, much less take a bus...

Theme 2: Careful Planning and Thorough Communication by Hospital Care Teams at Discharge Were Valued by Patients But Happened Inconsistently

Communication with care teams around the time of discharge was seen as crucial to an effective care transition. Participants valued shared decision-making and interdisciplinary perspectives on their post-discharge care. For example, one participant commented:

[T]hat doctor explained the medication she was sending me with and then she said, I’m going to have the pharmacist come in, deliver the medication, and she’s going to go in more detail about which medication does what, when to take it, and what to expect from it. … [the] pharmacist came in sometime later, brought the medication with a packet, pages for each medication, what they do and what to expect from them… then another social worker came in a second time just to kind of ask about do you need—do you walk with a cane? Or do you have stairs at your apartment? Do you need assistance getting up to your apartment? Do you need this? …they were making sure that when I went home… I wasn’t in any distress of getting into my home or feeling safe and making sure that I had what I needed, whether that be someone who needs a wheelchair, crutches, or a cane, or oxygen, or something.

Conversely, some patients perceived that inadequate communication and planning at the time of discharge could lead to potentially dangerous lapses in treatment.

[T]hey told me to follow up with my regular physician within a week or two weeks max. But I called and he actually doesn’t have an appointment until May… it’s been 10 or 11 days since I’ve been discharged and I won’t see him for a couple months versus their recommended week. And I got a 30-day supply of the medication but I won’t be able to… see my physician for a couple months.

Another facet of communication that was perceived as important was engaging patients in shared decision-making around discharge planning. This was seen as a way to mitigate the destabilizing effects of patient-directed discharge in particular.

I had told my doctor that I wanted to leave but I wanted to do it safely and not have to do like an AMA [against medical advice] or anything like that, and he got it all set up. And the pharmacy had come up and brought me my meds I was taking home, like an hour before I was discharged. So it just went really smoothly.

Theme 3: Substance Use Disorder Treatment Was Desired and Offered Frequently Via a Spectrum of Active and Passive Approaches

In general, people desired to have their SUD addressed during their hospitalization and incorporated into their discharge plans. Most people received medications to treat their SUD and viewed them as important supports:

They made sure I had all my meds and understood ‘em all and understood the SUBOXONE and raised me up to what I asked them to, they had me on 4 mg every 12 hours. and I was like, that’s just not cuttin’ it so they raised me up to 8 every 12 hours. And that… wasn’t workin’ and then they still raised it up so it seems to be holdin’ now.

Participants reported variable experiences with SUD counseling at discharge. At times it was done passively, such as handing the participant a list of community resources. In other cases, hospital care teams took the extra step to facilitate linkage to continuity of SUD care. Many participants valued this more active approach:

[S]etting up that initial appointment is one of the hardest things to do. I think that if the doctors actually could do that for us then it's givin’ us that commitment right then, and we don't have to make that leap, that scary leap on our own. It's already done for us, you know.

Theme 4: Patients Faced Multifarious Challenges to Following Through with a Care Plan After Discharge

Patients faced numerous barriers to linking to medical and SUD care after hospital discharge. Many of these were related to inadequate access to basic amenities, such as transportation, health insurance, housing, financial stability, and a telephone.

I live in [city] where there's no buses… and I don't have my own vehicle and so it's very difficult getting around and trying to find somewhere [for SUD treatment] close to me.

Other participants commented:

I’ve tried just filling my prescriptions which I wasn’t able to do. I am going to try to use the Rx, whatever that is, to see if it will make it any cheaper for me until I get paid…

And

[M]y phone’s screwed up right now and I can’t even really afford to go get another phone… He [roomate] gets mad and he cuts me off the internet. Then I have no way to get phone calls or get my messages.

Other factors impacting linkage to follow-up care included stigma — sometimes experienced at the very sites that participants were being referred to for follow-up care. One participant commented:

I wouldn’t say [Primary Care Clinician]’s been extremely helpful at all. In fact, she hasn’t been helpful, personally. I just feel like they look at it as, oh, it’s an addiction problem. And they don’t look at it any other way… it’s like she immediately kind of treats me like I am this lower peon. And there’s just something there that I can feel and I don’t like it. I really don’t like it.

At times, the health-related sequelae of hospitalization impacted a participant's ability to safely care for themselves at home:

I live on the fourth floor of my apartment building and I couldn’t get up the stairs… and I didn’t have a phone… I had to flag down a cop so he would call the ambulance to take me up there [back to the hospital].

Theme 5: Community Supports and a Sense of Connection Are Key Facilitators of SUD and Medical Care Linkage After Hospital Discharge

Participants repeatedly highlighted support from family, friends, and case workers as instrumental to promoting recovery in the post-hospitalization period. These individuals provided emotional comfort, assistance with essential activities, such as food preparation and transportation, and help with appointments, medication adherence, and other key elements of the care transition plan.

I have a case manager from [nonprofit]…They call me and they talk to me and see how I’m doing and if I need help…They help me do whatever I need to do.

Another participant described how his sister provided support after hospital discharge:

So she's my family and she supports me all the way. I mean she helps me if, if I need to do somethin’ like when I was tryin’ to figure out the insulin, she got right down and dirty in there and helped me to do it. I mean she was, didn’t know what she was doin’, but she, she gave it hell.

Conversely, some participants were estranged from family and friends. This could lead to a deep sense of loneliness in the post-hospitalization period. Peer support networks played an important role in these cases as sources of emotional support, SUD expertise/advocacy, and social connection.

I just wish that people realized that people that have addiction problems just need to feel loved. I just feel like you need a sense of community, ‘cause in my experience, all my addictive problems start with just being really lonely. And just not feeling a connection to friends or partners or, or family.

Another participant commented:

I cook, I watch TV, I go outside and come back in and I, I really don't have a group of people that I can interact with to help keep me engaged in socialized behavior. You know, I basically isolate and without, without that bridge to connectivity [crying] with another human, I, my success is probably not gonna be very strong.

One participant sympathized with another patient he met in the hospital and wanted to provide peer support despite contending with his own medical illness and SUD.

This one guy I met up at the hospital… they cut his leg off because he had had a sore on his leg before and then they give him a prosthetic leg… I know how that guy feels. I’ve seen the worry and stuff in his eyes. He just, he didn’t know what to do. He didn’t wanna leave the hospital and they was tellin’ him he had to go home. And he left like the day after I left. And I went up there to see him, I rode my bike up there the day after I got outta the hospital. When it was all snowy up there, it was colder than shit that day. But I rode my bike up there to see him and when I got up there, he was already gone. So I didn't know where… he lived… And it’s sad because I would’ve went over and helped the guy if I could.

Theme 6: Proactive Outreach, Individualized Care Plans, and Continuity of Care Are Valued During Post-Hospitalization Care Transitions

When asked to describe an ideal discharge plan for hospitalized patients with SUD, participants highlighted post-discharge outreach, individualized care plans, and continuity of care across settings as being important elements. Outreach and continuity were not only perceived to address parts of the care transition plan that might have fallen through the cracks, but also as a source of emotional support and motivation. One participant commented:

[T]o sit down and have a person come to you and say, okay, we're gonna send you home. We are really concerned about your well-being and the future that you are walking into once you, you go through those doors. And we wanna give you the best chance to do that so here's what we’ve got for you… you're gonna get a phone call from [nonprofit] [and] you have a coach lined up. We're gonna contact [nonprofit] and make sure that that's happened… The phone call from the nursing, have you been able to shower and cook meals for yourself and stuff like that, that's great… for people that have mental health and substance abuse, co-occurring situations… they don't just need a handshake or a handoff, they need a hug. To encompass or circle them and make sure that they know that they have, they have people that genuinely care.

Another participant commented:

So in my perfect world… my discharge would be definitely different from other people so. And especially somebody who is suffering from addiction, I mean, I would love to come home and have a whole team come to my home.

While a desire for team-based outreach after discharge emerged as a common theme, no participants reported experiencing this type of care.

DISCUSSION

Post-hospitalization care transitions are complex and high-risk events for individuals with SUD. Understanding the experiences and priorities of PWLE is instrumental in designing improved care transition models. To our knowledge, our study is the first to elicit the perspectives of patients with SUD in the immediate post-hospitalization period on their care transition experiences. Given the unique factors impacting linkage to continuity of medical and SUD treatment experienced by patients with SUD, we believe that our study represents an important contribution to the care transition literature.

Our interviews generated six themes that have direct relevance to enhancing care transitions for people with SUD after medical hospitalization. Our results highlight various points of the care transition process where our participants’ experiences might inform clinical practice and care innovation (Table 3). Starting in the hospital, patients expressed a desire for predictability around the time of hospital discharge. This could be protocolized through daily updates on discharge planning, giving patients an opportunity to ask questions and make care transition arrangements. Existing tools like rounding checklists could facilitate this intervention,²³ as could equipping patients with patient-facing discharge checklists to help facilitate their active participation in care transition planning. These checklists could be modelled on existing resources from groups such as the Agency for Healthcare Research and Quality²⁴ and include items like confirming appointments for follow-up medical and SUD care, arranging transportation, documenting communication preferences, leaving the hospital with naloxone in hand, and anticipating required community supports to meet daily necessities. Research has shown that patient-centered communication practices such as these may actually increase efficiency in clinical encounters.²⁵ Interdisciplinary discharge coordination to anticipate factors like telephone access, mobility issues, timely follow-up appointment availability, and insurance gaps may be facilitated through the EHR and help to avert unforeseen obstacles to linking with follow-up care.²⁶ Finally, protocols and programs (e.g., addiction consult teams) that promote initiation and titration of medications to treat SUD in the hospital can facilitate access to SUD treatment and care linkage prior to discharge.^11,27–32

Table 3.

Implications for Clinical Practice Based on Each Theme

After hospital discharge, participants reported that building up community supports, providing post-discharge outreach, and ensuring that basic necessities like transportation, telephone access, medication access, and mobility were met were all important in successful care transitions. In cases where a network of family and friends is not available, peer support specialists and case workers may play important roles in facilitating safe linkage to community-based follow-up care.^{11,13,28–30,33–37} Adequate insurance reimbursement for these services is necessary to grow their impact within health systems. Programs that provide access to free smartphones, low-barrier SUD treatment options (e.g., telehealth, walk-in),^38–40 and temporary supportive housing with integrated SUD and medical care after discharge⁴¹ are within the purview of health systems and should be led by these entities with state and federal support. Finally, community outreach programs such as street medicine teams, transitional care managers, and peer navigators can address participants’ desire to have more robust continuity with their care teams during post-hospitalization care transitions.^34,35,42,43 Expanding the reach of these programs by initiating care in the hospital prior to hospital discharge, while resource-intensive, has demonstrated efficacy in strengthening post-hospitalization transitions of care.^15,42,44,45

Limitations

We recruited participants at a single academic health center in an urban area with an addiction consultation service, limiting the generalizability of our results. Our sample was relatively young and predominantly white, which limited our ability to assess how intersectional factors such as older age, immigration status, and structural racism affect care transitions. We were also unable to distinguish how particular substance use patterns, reasons for hospitalization, housing status, or degree of social support may have affected patient perspectives on care transitions. Future research should investigate how these factors affect patient experience. A small percentage of eligible patients completed interviews, which may have selected for participants who were more interested in SUD treatment, who had more serious medical illness (i.e., longer length of stay), and who had enough social stability to participate in a telephone interview after discharge. Despite these limitations, we feel that our study’s results serve to amplify the priorities and experiences of a marginalized population with meaningful implications for patient care.

Our study engaged individuals with SUD directly following a medical hospitalization to better understand their experiences and priorities pertaining to post-hospitalization care transitions. Our six themes each represent an area where health systems, clinical teams, and individual clinicians can take action to improve care for patients with SUD during a high-risk time. Future research should incorporate these patient priorities, along with longitudinal guidance and leadership from PWLE, to design and evaluate novel post-hospitalization SUD care transition models.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contribution:

MI conceived of the project, drafted, and revised the manuscript. MI, KS, DB, PG, and SZ created the interview script. TA, ST, and PG conducted and coded the interviews. MI, TA, ST, AH, PG, and SZ conducted thematic analysis. All authors contributed to designing the study approach and/or formulating the conclusions. All authors provided critical feedback and contributed to the writing of the manuscript.

Funding:

This work was funded by a University of Utah Department of Internal Medicine Seed Grant.

Data Availability:

Interview guides are provided as supplementary materials with this submission, and deidentified data from this study are available on request.

Declarations:

Ethical Approval:

This study was approved by the University of Utah IRB.

Consent to Participate:

All participants participated in an informed consent process prior to enrolling in this study as described in the manuscript text.

Consent to Publish:

All parties have provided consent to publish the results of this study.

Conflict of Interest:

The authors declare that they do not have a conflict of interest.