Organizational perspectives on barriers and facilitators to an integrated care model for opioid use disorder and serious injection-related infections

Abstract

Background:

Rising rates of serious injection-related infections (SIRI) and hospitalizations have been documented nationally in the context of the ongoing opioid and polysubstance use epidemic in the United States. This qualitative interview study assessed multi-level facilitators and barriers to the implementation of an integrated inpatient opioid use disorder (OUD) and SIRI care intervention among organizational stakeholders in the healthcare setting as a secondary aim of a randomized clinical trial.

Methods:

The PRISM (Practical, Robust, Implementation, and Sustainability Model) implementation science framework guided stakeholder interviews. Eligible stakeholders were at least 18 years old and employed in an inpatient or outpatient care setting that served the study patient population. Qualitative interviews assessed contextual factors that supported or hindered the implementation of the novel study intervention and priorities for sustainability and future investment. Interviews lasted approximately 60 min. Qualitative coding and analysis were conducted in NVivo.

Results:

Overall, thirteen stakeholders were interviewed, including clinicians from cardiothoracic surgery, hospital medicine, infectious disease, and addiction medicine, hospital administrators, social work and case management staff, pharmacists, Bridge Clinic staff, and staff from home infusion. Within the four overarching PRISM domains thirteen critical elements were activated by the study intervention that represented key barriers and facilitators to implementation, including: Intervention (Coordination across departments, Strength of the evidence base, Burden, Barriers of frontline staff, SUD stigma); Recipients (Clinical leadership, Organizational health and culture; Patient disease burden, Patient demographics); External Environment (Community Resources, Reimbursement); and Implementation and Sustainability Infrastructure (Dedicated team, Plan for sustainability).

Conclusions:

Examination of implementation determinants highlighted organizational and external barriers and facilitators. Barriers centered on the complexities of care coordination across departments, the inpatient-outpatient transition, and specialized training needs; these appeared modifiable through adoption of specific implementation strategies. The presence of critical clinical infrastructure to support this transitional OUD-SIRI integrated care model was an essential facilitator, which could represent a challenge for other health systems. External factors, including low resource availability, and SUD-related stigma that excludes patients from opportunities to receive care in the community, collectively pose challenges to wider implementation and sustainability.

1. Introduction

Rising rates of serious injection-related infections (SIRI) have been documented nationally in the context of the ongoing opioid and polysubstance use epidemic in the United States (Marks et al., 2022; Springer et al., 2020). Bacterial infections including cellulitis, sepsis, and endocarditis are increasingly common medical complications among people who inject drugs (PWID) (Wheeler et al., 2025) and hospitalizations for SIRI are likewise increasing, with younger age groups particularly impacted (McCarthy et al., 2020). Notably, hospitalizations for opioid use–related infective endocarditis have increased more rapidly among rural residents compared to their urban counterparts in recent years, and rural patients with SIRI are increasingly cared for in urban academic medical centers (Nenninger et al., 2020). Infective endocarditis and other SIRI are often clinically complex and may necessitate management by a multidisciplinary clinician team (Baddour et al., 2015) with access to robust wraparound services (Wurcel et al., 2024). For people with opioid use disorder (OUD) and SIRI, many rural communities lack resources and access to integrated specialty care, which may hinder successful management in local healthcare facilities (Levy et al., 2022). Integration of SIRI care and addiction treatment with medications for OUD (MOUD) has become increasingly important in improving patient outcomes, as transformative models of care have provided evidence of synergistic benefits for OUD and infectious disease outcomes (Baddour et al., 2022; McNamara et al., 2021; Seval et al., 2021).

Increasingly, studies have examined the use of outpatient parenteral antimicrobial therapy (OPAT) in treating SIRI among patients with OUD, since OPAT is safe, cost-effective, and highly acceptable to patients generally (Fanucchi et al., 2020), provided that the conditions for successful outpatient management are met, including attention to addiction care and MOUD treatment (Dalai et al., 2024). Several retrospective studies (Appa & Barocas, 2022; Price et al., 2020) and one small randomized clinical trial (Fanucchi et al., 2020) suggest that OPAT for PWID with OUD can be safe and feasible, especially when antibiotic treatment is offered in conjunction with MOUD with a patient-centered approach and as needed ancillary services (e.g., counseling and recovery support, treatment for common psychiatric conditions) (Fanucchi et al., 2019). A recent national survey on practice patterns and attitudes of infectious diseases clinicians in the U.S. found that more than 70% reported offering OPAT to PWID across a variety of practice settings and types (Solomon et al., 2023), a notable increase from 2017 in which just 30% endorsed such care, even for patients who were receiving MOUD (Rapoport et al., 2018). This increase appears to reflect growing awareness among clinicians of the evidence base for OPAT in PWID and willingness to implement clinically innovative models of care (Solomon et al., 2023). Nevertheless, a recent study of PWID at a large academic medical center found that in the year post-SIRI hospitalization, mortality and rehospitalization were common, and receipt of MOUD was modest overall (Kimmel et al., 2024). As the clinical landscape for antibiotic therapy evolves to include more oral therapy options and promising long-acting injectable agents for SIRI (Goodman-Meza et al., 2025; Pertzborn et al., 2023), the indications for OPAT may continue to be refined and the preferred treatment strategies for PWID continuously assessed. While OPAT indications may change over time, it is clinically widely utilized both nationally and internationally (Manders et al., 2025; Reidy et al., 2024; Wolie et al., 2024) given its established efficacy for complex and resistant infections (Tong et al., 2025). Thus, understanding the scale-up and implementation of OPAT for populations with OUD remains vitally important.

Emerging research has identified multi-level challenges to implementing new clinical care models for SIRI and OUD, particularly those that span the patient journey from hospital to community (Springer, 2024). Qualitative research examining an integrated SIRI and substance use disorder (SUD) inpatient care intervention identified a number of implementation barriers, ranging from the perceived complexity of the team intervention to clinician-level knowledge gaps and stigma surrounding MOUD (Hervera et al., 2023). Recent research gathering patient and stakeholder input regarding the use of peripherally inserted central catheters (PICCs) to support outpatient care for PWID found overall high acceptability and agreement that PICC use can optimize care opportunities, yet also noted a substantial barrier in that clinician perceptions and decisions to offer PICCs were heavily influenced by negative anecdotal experiences (Morales et al., 2022). Overall, integrated OUD and SIRI care models that span transitions from inpatient to ambulatory care settings are understudied, particularly from an implementation science perspective. Notably, the complexities of managing and controlling infection, conducting clinical follow-up, as well as remote monitoring of retention in substance use treatment and other health outcomes (Wurcel et al., 2024) likely represent substantial challenges to the widespread implementation of such transformative care models.

This paper reports on an organizationally focused qualitative study of the facilitators and barriers to implementation of an integrated OUD and SIRI care intervention model in an academic medical center setting that serves a largely rural catchment area, guided by the PRISM (Practical, Robust, Implementation, and Sustainability Model) implementation science framework (Feldstein & Glasgow, 2008). Conducted concurrently within the context of a randomized clinical trial, qualitative interview approaches with stakeholders were used to assess contextual factors that supported or hindered the implementation of the novel clinical intervention and to gather evidence on priorities for sustainability and future investment, including systems level challenges that impact this innovative intervention model. The overall goals of the qualitative work were to inform and guide future implementation efforts and improve planning for dissemination and sustainability of the intervention.

2. Methods

2.1. Study design

A qualitative interview study assessed multi-level facilitators and barriers to intervention implementation among key clinical care team members and organizational leaders in the healthcare setting that occurred as a secondary aim of a NIDA-funded parallel group randomized superiority trial in hospitalized adults with OUD and SIRI. The trial evaluated the effectiveness of an experimental integrated outpatient care model (B-OPAT: buprenorphine treatment with OPAT) compared to treatment as usual (TAU) on illicit opioid use outcomes in the 12-weeks after hospital discharge (see Table 1 for trial intervention description). Key patient inclusion criteria for the trial were: age 18 and above; hospitalized at the study site with OUD and SIRI; accepting of buprenorphine treatment; anticipated to be discharged home after medically stabilized with home environment feasible for OPAT (e.g., running water, refrigeration); have 5 or more days of antibiotics remaining at the time of discharge; and self-reporting no desire to inject into the PICC). A description of the study protocol and patient population has been published elsewhere (Fanucchi et al., 2022).

Table 1.

Clinical intervention elements in Treatment As Usual (TAU) and integrated Buprenorphine with Outpatient Parenteral Antibiotic Treatment (B-OPAT) trial arms.

	Inpatient management	Discharge transition planning	Outpatient care
OUD Clinical Care (Both arms)	Addiction medicine consult	Confirm insurance coverage	Continued outpatient treatment of OUD with buprenorphine
	Buprenorphine (BUP) initiation and titration to stabilization if not already done by hospital medicine	Rx for BUP/or administration of XR-BUP at discharge
	Overdose education with naloxone teaching and dispensing or naloxone prescription at discharge	Follow-up appointment scheduled at outpatient addiction practicea	Additional naloxone provided if needed
	Teaching on safer injection practices	Provide info on local syringe services programs	Counseling and peer support offered
	Psychosocial needs assessment (housing, food, transportation) and programs referral	Confirm patient has transportation, and/or arrange Medicaid or other transportation service	Continued care coordination to address psychosocial needs
SIRI Clinical Care (Both arms)	Primary medical evaluation and management	Outpatient appointments scheduled for ID and other relevant disciplines (e.g. orthopedics, cardiothoracic surgery)	Patient attends outpatient follow up appointments for treatment of SIRI and comorbid medical conditions
	Infectious Disease (ID) consult-determine antibiotic treatment course	ID OPAT teamb evaluation -Confirm insurance coverage for recommended antibiotic therapy	Oral antibiotics continue for some indications - In cases of patient-directed discharge, ID makes oral antibiotic recommendations if applicable
	PICC placement and ongoing care in the hospital with dressing changes	PICC removed prior to discharge if antibiotics completed inpatient
B-OPAT Clinical Care	Study PI notifies ID consulting physician that the patient has been randomized to BOPAT	ID OPAT team evaluation -Education on antibiotic self-administration via PICC provided to patient and support person	ID OPAT team continues to follow antibiotic course and safety monitoring
	ID physician agrees to follow when patient is discharged with PICC to complete antibiotics	ID physician makes recommendations for lab monitoring of antibiotics	ID physician sees patient within 2 weeks of discharge or sooner if needed ID OPAT team determines if any needed antibiotic changes, sends new orders to home infusion company.
		Discharge planning team refers patient to home infusion and home health agencies	PICC dressing changes and lab draws occur weekly at the B-OPAT OUD clinic if no accepting home health agency
		Home infusion agency conducts patient evaluation and education and arranges delivery of antibiotics and PICC supplies to the home	Home infusion agency delivers additional antibiotics and PICC supplies to home as needed. Study team clinicians lead troubleshooting PICC functioning (e.g., if not flushing), need for more PICC supplies, and unanticipated home infusion delivery delays
		Study physicians confirm with receiving B-OPAT clinic that they have discharge plan summary that includes name of ID physician following, labs needed, any unique participant needs	Study team clinicians and research staff lead outreach responses to participants if they do not attend medical appointments or if there is a need for advocacy to help participant retain access to OPAT or buprenorphine.

^aTAU participants may be discharged to skilled nursing facilities or other residential settings. For BOPAT participants, the discharge planner will try to schedule at least two appointments at the OUD clinic.

^bID OPAT team includes the consulting ID physician, ID pharmacists, nurse navigators who conduct a standardized OPAT assessment and complete patient antibiotic and PICC education if the patient has been deemed eligible for OPAT. Patients randomized to B-OPAT in the trial are eligible for OPAT.

2.2. Study setting

The study was conducted at the University of Kentucky (UK), and UK HealthCare, which includes the hospitals and clinics of UK. UK HealthCare is a 1142 bed tertiary referral academic medical center in Lexington, Kentucky, and serves as the primary Level 1 trauma center for the eastern part of the state, including Appalachia. Study patient participants were receiving inpatient care at either of two affiliated hospitals and ambulatory care for addiction and infectious disease was provided at the UK First Bridge Clinic (e.g., weekly PICC dressing changes, blood draws as needed for monitoring of infectious disease treatment, MOUD management, telehealth availability, and as needed on-site counseling, peer support and case management services with transportation assistance).

2.3. Study procedures

Following accepted parameters for sample size adequacy (Guest et al., 2006), the stakeholder qualitative sample size was set at 15 overall, with flexibility to increase or reduce the number of interviews based on thematic saturation. To be eligible for the qualitative study, stakeholders were required to be at least 18 years of age and to be employed in an inpatient or outpatient care setting that served the study patient population. The study team identified potential stakeholder participants based on their clinical or organizational roles, and level of interaction with B-OPAT patients, including those with experience providing direct care for persons hospitalized with OUD and SIRI or those who participated in organizational policies and protocols related to the care of the patient population. The study team generated a listing of potential stakeholder types, roles and specific interviewees, after which the lead qualitative research team member selected and invited potential stakeholders to participate through direct email communication. The recruitment email explained the goals of the interview.

2.4. Data collection

In-depth stakeholder interviews were guided by the PRISM framework (Feldstein & Glasgow, 2008), which considers how the external environment, intervention design, implementation and sustainability infrastructure, and the multi-level recipients of an intervention (adopting organizations, health care teams, clinicians and patients), influence implementation outcomes. The qualitative research lead and study PIs collaborated to develop the interview guide to assess contextual, organizational, and environmental factors salient to B-OPAT intervention adoption and implementation, to understand current capacities, workflows and operations, competing priorities, policy and systems changes, intervention acceptability (Sekhon et al., 2017), and other factors that could potentially impede or support implementation and sustainability (see Supplementary materials for a copy of the interview guide). A female research team faculty member (HLS) with extensive experience using qualitative techniques with patients with SUD and clinician stakeholders facilitated all one-on-one stakeholder interviews. The investigator conducting the interviews was not directly involved in the conduct of the clinical trial and had no direct working relationships with participants. Stakeholder interviews were conducted one-on-one and took approximately 1 h to complete.

Consistent with the study plan, stakeholder interviews commenced approximately six months after patient enrollment into the clinical trial began, in order to ensure that stakeholders had adequate exposure to the B-OPAT intervention implementation before participating in interviews. Stakeholder interviews occurred across a two-year timespan, from 2021 to 2023. With one exception due to participant preference, all qualitative stakeholder interviews were conducted virtually; all were audio recorded for verbatim transcription, coding and analysis. This study was reviewed and approved by the Medical Institutional Review Board at the University of Kentucky. All stakeholders provided written informed consent to participate in the qualitative interview.

2.5. Coding and analysis

All stakeholder interviews were professionally transcribed and quality control checked by the study team. The qualitative research lead developed the initial interview codebook using a hybrid inductive-deductive approach (Fereday & Muir-Cochrane, 2006), which combined pre-established codes driven by PRISM with emergent codes developed directly from the data. The team first applied the PRISM framework to define codes capturing key dimensions of the external environment, organizational perspectives on the B-OPAT intervention, implementation and sustainability infrastructure, and the multi-level recipients of the B-OPAT intervention, and then integrated key concepts derived from in-depth reading and open coding of transcripts to generate important codes not captured by PRISM. The coding team used consensus coding techniques to refine initial codes and resolve discrepancies. Two independent coders then coded each interview transcript; bi-weekly team discussion and resolution occurred iteratively as an ongoing process until coding saturation was reached. Structured coding comparisons examine inter-coder reliability (McHugh, 2012) to ensure consistency and rigor in the coding process. Inter-coder reliability examination indicated acceptable levels of coding agreement (kappa =0.74), based on established standards (Landis & Koch, 1977; O’Connor & Joffe, 2020). The analysis phase involved in-depth transcript reading and examination of all coded text passages to identify systematic patterns and relationships within and across themes, following the principles of thematic analysis (Braun & Clarke, 2006). All coding and analysis was conducted using NVivo.

3. Results

Overall, thirteen stakeholders participated in these in-depth qualitative interviews. Stakeholders were key members of the inpatient and outpatient clinical care teams and organizational leaders from the academic medical center setting who provided perspectives from different vantage points and touchpoints with OUD and SIRI patients. Stakeholders interviewed included: one cardiothoracic surgeon, one hospitalist physician, two hospital administrators/physicians, one physician and one social work staff from the Addiction Consult team, three members of the Infectious Disease team occupying different roles (physician, nurse and pharmacist), one hospital case manager, two members of the First Bridge Clinic team (APRN and RN) who provided clinical follow-up of B-OPAT patients, as well as one regional director of home infusion services.

Table 2 presents the mapping of the four overarching PRISM domains (Intervention; Recipients; External Environment; and Implementation and Sustainability Infrastructure) to coded interview narratives, revealing thirteen critical elements activated by the B-OPAT intervention trial at the organizational level with thematic salience. In the presentation of results, on the focus is on the most highly activated PRISM elements in each domain, which were determined by coding prevalence and coding density in the interview narratives.

Table 2.

B-OPAT stakeholder interviews: primary themes mapped to PRISM domains.

PRISM domain	PRISM element activated	Subtheme(s)	Example quotes
Program (B-OPAT Intervention)  Organizational Perspective	Coordination across departments	Need to optimize communication and feedback loops for care coordination	I think the main issue was optimizing communication between the bridge clinic team and the OPAT team. There just has to be really seamless communication to make things work well. Because it's just a lot of people involved.
		Benefits of Addiction Consult Service for managing complex patients	I would say one of the best resources we have in the hospital now is actually the addiction medicine service… I think it would be very, very difficult to do a lot of what we are able to do and accomplish with our patients without that service.
	Strength of the evidence base	Destigmatizing care through evidence	I was really excited when I heard that they were going to be doing B-OPAT study because I'd love to see the evidence because I think I am split about 50/50 to be perfectly honest. I want them to have the chance for sure.
		Balancing provider concerns and patient autonomy	I do have particular concerns. Again, I think sometimes people think it's just the IV drug use and just using the PICC line for drugs, which I actually don't think it is. I think it's more the ability to give yourself hospital level care in your home
	Burden	Patient follow-up & communication	The problem is if people don't have the monitoring obtained as they're supposed to. And so knowing that you're not getting the feedback you're supposed to be getting. And that's very hard to keep track of.
	Barriers of frontline staff	Specialized training needs	One of the most important things is good training for the staff in the clinics that are going to be taking care of these patients. Because in general, I come from primary care clinics. None of my nurses or techs would ever touch a PICC line. That's just not something that's done in a general clinic.
	SUD stigma	Erosion of trust	The assumption is that anyone who has a history of substance use disorders is going to be less likely to participate actively in their care and are going to be less likely to follow up.
		Behavioral challenges & anchoring biases	There's a large group that’s maybe either apprehensive or opposed to it [OPAT] because they may have had negative experiences in the past with the patient population.
Recipients  Organizational Characteristics	Clinical leadership	High volume of SUD/SIRI patients	Our operative work, 16% of it is endocarditis. And we've learned how to manage the disease process from that volume.
		Presence of physician champions	You have to have someone who's, first of all, someone who's passionate about it, some physicians who are passionate about it to stimulate the system to do it, and I think that we've got that. In the past, it was not that way. But once people see that, they get on board.
	Organizational health and culture	Uniqueness of academic medicine	Academic medicine is different because it is a bunch of people who are here because we want to make the world better, we do research, we educate, we make less money, we do all sorts of things.
		Evolving attitudes for SUD care	I think a lot of barriers have been the stigma with the disease and then the willingness of people to really champion that in certain areas. I don't know that that's the case here anymore. But I think, culturally, changes happen slowly over time. And I'm seeing that kind of change happen slowly for the better.
Patient Characteristics	Disease Burden	Medical complexity/comorbidities	Patients have trauma, recent overdoses, lots of physical pain, are very unwell, and the hospitalization can also be traumatizing.
		Low social capital/SDOH	One of the pieces that they do tend to kind of focus on is, is there someone else in the home who can … what's their phone number? Are you living with anyone? Does this person have a car? Are they going to be able to help you get to appointments?
	Demographics	Rural, low-resource areas	Patients from rural areas, there is essentially zero infrastructure, people do not appreciate the impact of this, healthcare is not great.
		Distance to care	Distance to care is a huge problem, the best care is here at UK, they often cannot access specialty care, its hours away.
External Environment	Community Resources	Limited healthcare access	In rural hospitals they just have many, many beds closed. So, you start talking to them about having a substance use person in their bed for six weeks, they're like, “No.”
		Low resource availability	Until you've had to work with outpatient, with community resources, you may not recognize all the barriers, and they change.
		Increased access to MOUD	Definitely more availability to get into clinics throughout the state. There's better access now than there was. And I think better knowledge as well.
	Reimbursement	Financial concerns	Until we decide that healthcare is not a for-profit industry, you're going to have to prove financial benefit. It's not going to work until you do.
		Payment structure	We pay for things based on acuity, instead of really based on benefit.
Implementation & Sustainability Infrastructure	Dedicated team	Support network	As the provider too, having a sense that I won't be asked to do 12 more things in my day, that there's a support network built into this, that there will be reliable staff and there's a plan.
		Transitional care	This study would be better served if they had a dedicated case manager for all the things. Because I know that medically obviously that's the most important part of these people's care. But that being said, those barriers that they are up against to receive that care, that can totally make or break what's happening to them.
	Plan for sustainability	Funding support for staffing	Those patients are needing that really extra layer of funding support, coordination, follow up visits, and we would need to have all the staffing and infrastructure and communication in place to make that work.
		Availability of clinic time	For twice weekly appointments that's a lot. I know I, as a provider, I would not have nearly the capacity to see patients twice weekly to see them as they're seen on this study. I wouldn't have that kind of capacity in clinic.

3.1. Organizational perspectives on the B-OPAT intervention

3.1.1. Coordination across departments: optimizing communication and coordination

One of the most prevalent themes in stakeholder narratives related to the B-OPAT intervention was the significant medical complexity of the study patients, which for optimal management required intervention and involvement of multiple departments and clinicians in different specialty areas. Although the presence of expert multidisciplinary teams within the academic medical center was seen as a foundational facilitator of the B-OPAT intervention, seamless communication and coordination across the large universe of care team members represented the most commonly reported barrier to the intervention as well, in terms of ensuring that role clarity and task management responsibilities were evident and coordinated among frontline team members. Stakeholders noted that ongoing flexibility and monitoring of communications was essential to ensure that information was shared in a timely way, for the benefit of both clinicians and patients. From a clinician perspective, this was especially important for ensuring elements of care were executed appropriately. As one infectious disease clinician noted…

If someone else isn't familiar with that back and forth workflow and tries to jump in and put some of their own orders in, it just … there just has to be really seamless communication to make things work well. Because it's just a lot of people involved.

3.1.2. Benefits of the addiction consult service

The Addiction Consult and Education Service at the institution was noted by the majority of stakeholders as an essential facilitator of inpatient addiction care in general, but also specifically in supporting the B-OPAT trial. It was broadly seen to have important reach and efficiency in supporting successful inpatient addiction treatment and management, as well as an essential function in providing support to other medical teams and patients…

I would say one of the best resources we have in the hospital now is actually the addiction medicine service. So I've been working here about two or three years now at UK. And I think the addiction medicine team's been up and running since I've been here and they're amazing. So I think it would be very, very difficult to do a lot of what we are able to do and accomplish with our patients without that service.

The Addiction Consult Service was also seen to perform an important role in providing education for members of frontline care teams that may lack understanding of addiction, and in helping to promote and expand evidence-based addiction care approaches. Critically, frontline staff also viewed the service as a support to bridge relationships between care teams and patients, including those enrolled in the B-OPAT trial. As one inpatient care team member described:

We're in a much better position. We now have ACES, our addiction consult. That's the consult service and hospitalists are very good about as soon as we get a patient here and they're admitted and we find out that they do have an addiction, they consult ACES immediately. The benefit to the patient is tremendous because they're the specialists. We don't know.

3.1.3. Strength of the evidence base

Several stakeholders described the importance of the B-OPAT trial as an evidence-generating opportunity, citing that current care guidelines lack clarity for decision making and can lead to differences of opinion in care management among different specialties that are involved in patient care. Relatedly, members of the clinical team expressed strong support for expanding the evidence base by participating in the trial, seeing it as potentially transformative for patient care. As one team member remarked:

If you have any history of injection drug use, you are not a candidate for OPAT regardless. This could be years and years in the past. And that never really sat really well with me because if you believe in recovery and you believe in addiction as a disease process, I don't want to say the word discriminatory, but it certainly just didn't seem fair that they didn't even get a chance based on those criteria.

In a similar way, the majority of stakeholders reported promising anecdotal observations from their early interactions with the B-OPAT study and enrolled patients, commenting consistently on their perceptions that the wraparound support services and care coordination available to patients would yield successful clinical outcomes.

One of the most critical and clinically innovative elements of the B-OPAT intervention is the early discharge to outpatient care at the UK First Bridge Clinic, which allows patients to complete IV antibiotic therapy at home with a PICC once they are medically stable, thereby avoiding an extended hospital stay. This care aspect evoked substantial discussion from stakeholders who anecdotally described it as very beneficial for patients' mental health and social functioning, and a facilitator of “getting antibiotics into people who might not stay inpatient.” Importantly, a minority also described positive impacts to patient autonomy, with some perceiving the opportunity for early discharge as transforming the care experience. As one clinician noted…

I think I've seen it be positive just because people, they don't have a lot of control and I think they feel like they're being trusted to do something and they don't probably get that impression a lot while they're here. So in that way, I think it creates like a positive relationship between the hospital staff and the patient.

A minority of stakeholders shared modest concerns regarding the early discharge model, largely regarding care continuity outside of a controlled hospital environment. As one clinician discussed:

I do have particular concerns. Again, I think sometimes people think it's just the IV drug use and just using the PICC line for drugs, which I actually don't think it is. I think it's more the ability to give yourself hospital level care in your home, is actually … for some patients it works great and it's super easy and they pick it up really quick. But there's so many patients who just can't do that for so many different reasons.

Notably, although the majority of stakeholders acknowledged the potential for PICC line misuse, this was generally weighed as a lower concern relative to the potential for expanding opportunities for the completion of antibiotic treatment and gathering evidence on success rates. Generally, stakeholders appeared to recognize the complexity of patient issues with OUD and SIRI, understanding that the potential for relapse exists regardless of the location of the patient, including in the inpatient setting (Fanucchi et al., 2018). As one OPAT team stakeholder discussed:

I think there's also this big safety thing that's like, well, this patient is going to use this PICC line to inject…. To me, it doesn't really matter where the patient is per se. If they're still in the hospital, they're going to relapse, they're going to have these hiccups in the road. And I do think that the perceptions are changing from that respect. But to me, I think a lot of barriers have been the stigma with the disease and then the willingness of people to really champion that in certain areas.

This sentiment was echoed by a home infusion stakeholder who shared her experience in the community:

There are going to be patients that this doesn't work for, but there are patients that have no history of IV drug abuse or addictive behavior who frankly don't do well on their therapy either. There are going to be failures and accepting those failures and saying, “Okay, how can we go back and get a root cause analysis on why this patient failed? Did we miss something when we were discharge planning, or was the support not there that we thought was there?” I think those are the questions that we get asked the most when we're talking to our colleagues that are trying to get something started. Also, just the fear that this patient's going to go out and they're going to use their line for something else. Well, if we discharge that patient, they could still go out and shoot it directly into their vein.

3.1.4. Burden: follow-up and communication

Stakeholders reported isolated or sporadic challenges with standing up the B-OPAT intervention in its early phases, such as frustrations of scheduling, and anxiety about new roles and tasks, yet overall these were rarely reported as creating burden. Follow-up monitoring and ongoing communication with patients in the outpatient setting was widely perceived to represent the primary burden for clinical team members. As one physician stakeholder observed:

There's also some patients, I think it's probably the minority, that have been very, very difficult to care for and challenging and just very sad. And so that's been hard. There's been patients that there's been a significant amount of time and just tough time catching up with some patients. And again I think a lot of it is probably as much related to things apart from just their substance use itself, but other social circumstances and everything around their care. Just some of the communication parts have been very difficult.

3.1.5. Barriers of frontline staff: training needs

Several stakeholders called for more widespread trauma-informed care and sensitivity training for clinicians and staff that work with OUD and SIRI patients, to promote understanding, communication and a more effective therapeutic alliance. Specific to the B-OPAT intervention, staff stakeholders mentioned the critical importance of learning appropriate language around OUD and person-first language, and noted the need for comprehensive training with staff who may have worked previously in other clinical environments and not in direct SUD care.

Access to specialized training and care was also perceived as essential to facilitating the operations of the B-OPAT intervention. For example, one clinician shared of her experience…

One of the most important things is good training for the staff in the clinics that are going to be taking care of these patients. Because in general, I come from primary care clinics. None of my nurses or techs would ever touch a PICC line. That's just not something that's done in a general clinic.

Additionally, education and training about other relevant internal and external programming, akin to general resources orientation, was perceived as highly important in order to overcome silos in care and alleviate resource deserts in communities upon discharge.

3.1.6. SUD stigma

Though not a formal domain within the PRISM framework, the vast majority of stakeholders mentioned high background SUD-related stigma, both in the institution and in the community, as a major barrier to changing the care landscape for patients with OUD and SIRI in the inpatient and ambulatory setting. Regarding the B-OPAT intervention, longstanding bias and erosion of trust were noted as limiting factors in building support for new interventions and effectively championing them, due to harmful perceptions that patients with SUD are disengaged or manipulative. Several stakeholders described colleagues or care team members at all levels who were apprehensive or opposed to care changes based on negative perceptions of the SUD patient population. As one physician stakeholder expressed…

I think that a lot of people in general have the approach that this is a self-inflicted wound and it's their fault, and they need to deal with it. They really don't garner the respect that we would give to everybody else. Yeah, I see that pretty strongly actually.

Though not specific to the B-OPAT intervention, several stakeholders in the inpatient setting commented on the challenging dynamics and adversarial relationships that can emerge between hospital staff and patients during lengthy hospital stays, causing distress on both sides, and uncertainties about managing these situations appropriately. These challenges sometimes resulted in negative outcome expectancies among clinicians and staff. As one organizational leader described:

Substance use disorder has anchoring bias created that it is more work. Person has a moral flaw, person is disruptive, non-adherent, will leave against medical advice. So all these negative perceptions or modifiers or characteristics get attached. We don't see things objectively. We don't see that this is a disease. And when I say “we,” that means all of us as humans. We get carried away with that bias rather than making a positive risk and benefit analysis.

Importantly, several stakeholders expressed optimism that the evidence gathered in the B-OPAT trial may shed light on changes to the current standard of care that requires long and challenging hospitalizations. Notably as well, clinician attitudes were seen to evolve through additional clinical experience and exposure, and a small number spoke of changes in their personal attitudes through observation of new approaches to guide care:

Working on the floor and having this patient population, you can be a little jaded about it… I think what really just changed my mind is that we're not sending people out to just figure this out. Our OPAT people, they go out. It's just normal stuff, it's home healthcare. But with our BOPAT people, they've got people at the [clinic] that they can have their psych stuff done. They can talk to counselors. They have people constantly checking on them. There's just the support system that helps them to become more successful.

3.2. Intervention recipients: organizational characteristics

3.2.1. Clinical leadership: high patient volumes

Across all stakeholder types and roles, there was recognition that patients with SUDs were at such a high volume at the institution that it had become strategically vital to consider the clinical structures and organizational services needed to provide quality care to the patient population. As one physician stakeholder remarked:

Our operative work, 16% of it is endocarditis. And we've learned how to manage the disease process from that volume…We're struggling with that with the patients we accept for transfer, inpatient transfer. Our transfer process right now sometimes gets a little crazy with the physician who doesn't know the specialty but being the first touch. But if they can get to the second touch… we get called about endocarditis constantly.

3.2.2. Presence of physician champions

Relatedly, many stakeholders described the importance of physician leaders in championing the adoption of changes in clinical practice, sometimes through grass roots efforts to improve training and evidence-based care in their area of specialization or through acquiring funding to test novel clinical care approaches. For physician stakeholders in particular, the advocacy and clinical leadership of a physician colleague was often considered highly persuasive in adopting and optimizing new approaches to care management. As one observed:

You have to have someone who's, first of all, someone who's passionate about it, some physicians who are passionate about it to stimulate the system to do it, and I think that we've got that. In the past, it was not that way. But once people see that, they get on board. I'm very proud of it because it's not been administratively driven. It's not been mandated. It's just been a group of doctors and nurses and techs and everybody else just doing it.

3.2.3. Organizational health and culture: uniqueness of academic medicine

Stakeholders broadly recognized that the organizational structures and foundational mission of academic medical centers was essential for supporting the implementation and evaluation of a novel clinical care model in a randomized trial. It was frequently noted that UK has effectively incorporated multidisciplinary approaches to manage SUD patients' needs, including standing up the Addiction Consult Service that was noted earlier as a major facilitator of the B-OPAT intervention. Stakeholders commonly contrasted the culture of academic medicine to that of for-profit care organizations:

Healthcare is very entity specific. [Hospital] wants you to come in, and they want to charge you while you're there. They're a for-profit hospital. You come there, money, you leave, they don't care. They don't want you to come back, because then they get dinged by CMS. Academics is different, because it's a bunch of people who are here because we've all said, “Hello, we've got to make the world better in some way. We've got to do research. We make less money. We educate. We do all those sorts of things.”

3.2.4. Evolving attitudes in SUD care

Relatedly, stakeholders commonly reflected that a variety of organizational pressures, tied to the high volume of patients and large demands on clinical time and resources, had generated both changes to clinical care structures and evolving attitudes on caring for patients with SUDs. Several stakeholders reflected a sense that collective efforts are needed by all members of the care team, and that it is everyone's responsibility to provide quality and evidence-based care for SUD. As an example, one stakeholder shared a shift within his clinical division that emerged in a grassroots way:

If hospitalists and ED physicians don't pick up on substance use disorder understanding, and buprenorphine prescriptions, we will have more and more likelihood of deaths or us being unsuccessful. If the substance use disorder is controlled or appropriately managed, then the likelihood of death decreases. That's the reason we took a poll from the division and 88% of the people were in favor of substance use disorder training and making it mandatory for everyone who's joining in future. It does not depend upon my comfort. If I'm not comfortable managing diabetes, I should not be an internist. If I'm not comfortable managing substance use disorder, I should not be a hospitalist.

Such attitudes and elements of internal culture represent important potential facilitators of novel clinical care approaches, such as the B-OPAT intervention.

3.3. Intervention recipients: patient characteristics

3.3.1. Disease burden: medical complexity and low social capital

The vast majority of stakeholders reflected on the severity of B-OPAT patients' current illness, acknowledging the level of medical complexity associated with heart valve, bone and soft tissue infections, and the need for long-term IV antibiotics to resolve the infections and complete hospital care. At the same time, many also recognized the psychosocial challenges for patients that are confronted during a protracted hospital stay, and the potential to cause harm in extended inpatient care scenarios. As one inpatient stakeholder observed:

This whole process is a pain. And to some level for some people, a little bit traumatizing, especially because of the events that most often precede, this hospitalization. They've all recently had overdoses or they have recently had use that has just complicated their lives to an unmanageable point or if nothing else, they were in a lot of pain, they were just physically unwell… And we're talking about folks who have just incredible amounts of trauma and just lifetime surrounded by other folks who also have this disease of addiction.

Stakeholders noted that B-OPAT patients and SUD patients in the hospital more generally tended to have lost many important social connections, to lack social support from friends and family, having little social capital to draw on for assistance. Within this context, stakeholders consistently mentioned the importance of attending to overlapping social determinant barriers, as well as OUD and mental health care, in an integrated fashion to support the feasibility and safety of OPAT care for patients that have experienced a cascade of negative life events. It was largely expressed that the B-OPAT trial had been successful early on in identifying patients with adequate support systems that could facilitate the outpatient components of their care.

While there was some expressed level of concern that OUD and SIRI patients would have potential complications with outpatient antibiotic care, stakeholders directly connected to the B-OPAT trial noted that patients were themselves very comfortable with PICC line care and were highly teachable regarding home care of the PICC line. It was noted that during bedside education on the PICC, patients were highly engaged and posed good questions, supporting their ability to participate in OPAT. As one nurse stakeholder observed:

None of the patients so far have complained about the mechanics of the PICC line or, “Am I able to use the PICC line,” or anything like that. There's not been anything like that that's happened.

3.3.2. Demographics: rurality and distance to care

A common theme among the majority of stakeholders was the layered barriers of geographic distance and rurality that adversely impact patients' receipt of ongoing follow-up care, both generally and in the context of the B-OPAT intervention. Stakeholders emphasized the major gaps in infrastructure available to rural patients in Kentucky, which were felt to represent significant challenges for both patients and clinicians. As one clinician observed:

Some of the patients that stand out as being some of the hardest patients that we've cared for I feel like have been patients who are further away and are in places where it's just difficult. Sometimes there's like cell phone reception issues, if people have cell phones, and then also the transportation piece is difficult… And so having some kind of way to help address those barriers in a geographically dispersed population I think is important.

3.4. External environment

3.4.1. Community resources: limited healthcare access and low resource availability

A highly prevalent theme that emerged among stakeholders was the impact of Kentucky's under-resourced rural communities as a substantial barrier to seamless patient care and clinical follow-up, with many stakeholders highlighting notable deficits in the health system beyond the state's urban centers. Comparatively, Kentucky was noted to lag in the availability of medical respite or skilled nursing facilities, as well as home health services and coverage by primary care physicians in some of the most medically underserved communities. Within this context, stakeholders expressed numerous challenges to accessing consistent resources for patients in the ambulatory setting:

You drive 20 miles, and there is nothing, nothing. It's not just healthcare. The schools aren't great. The infrastructure's not great. The jobs aren't great. The healthcare is not great. People just don't have a lot… In rural hospitals they just have many, many beds closed.

The B-OPAT intervention was able to surmount many of these challenges by leveraging existing transportation programs and outpatient care resources of the academic health system, and integrating home infusion services to ensure that antibiotic medicines were delivered safely, which empowered patients to perform the needed home care. As related by a home infusion stakeholder:

When they know that this is a potential patient that's going to be randomized to the B-OPAT study that will potentially go home on IV antibiotics, we're alerted at that point so we can start getting what we need in line for home. We have a liaison there on site that will go talk to the patient, do an evaluation, get our consent or our compliance contract signed and then feed anything back to us that we need to be aware of as the clinical team that may be filling that prescription. Then managing them on an ongoing basis…and doing a weekly check-in to call and say, “Hey, how are you?”

3.4.2. Increased access to MOUD

A bright spot that was perceived to facilitate the B-OPAT intervention was increased access to MOUD. Many stakeholders commented on the improved availability of MOUD clinics in communities and the widespread acceptance of insurance at these clinics, which created opportunities for continuing addiction care in patients' home communities. This change in the care landscape was considered an important facilitator of the intervention, as patients could feasibly transition their OUD care closer to home as they desired:

It wasn't that long ago that you couldn't use insurance. There weren't that many clinics in people's cities. So we do a lot of education on not only do they take your insurance, we'll make sure you have insurance that you can use. They'll take it and we'll make you an appointment. So you don't have to do anything. All you have to do is show up.

3.4.3. Reimbursement: financial concerns and payment structures

Reimbursement concerns emerged as a prominent theme among high level administrator stakeholders, though many stakeholder types also acknowledged the general importance of demonstrating financial viability of the B-OPAT intervention. There was a notable tension in the stakeholder narratives, as many recognized the patient-level benefits of reducing length of stay in the hospital, and also noted that the current model of inpatient care for OUD and SIRI was non-optimal in the context of hospital and care operations. As one stakeholder observed:

We turn away patients every day from UK. Every day, people call here and say, “I have somebody who's sick in my ED, and I need to send them to you.” And, we say, “We can't, because we don't have a bed. Our ED is overflowing. Our ORs are full. We don't have the space.” Then, I go upstairs. I see 25 people in a long length of stay unit taking up a bed, because they have substance abuse, which I'm not necessarily sure I'm really even treating. But, they're here because they need IV antibiotics, which if it were me or you, we would get at home. But, they don't have a safe discharge. How is this making sense as a whole?

Hospital administrators grappled with budget constraints and numerous financial commitments, which invoked consideration of cost-related implementation outcomes as a priority. Stakeholders noted that fee for service payment structures demand priorities in hospital care that may diverge from quality of life and population health outcomes, which raised questions surrounding the most appropriate role division in delivering elements of the B-OPAT intervention…

That's a disconnect that me as their manager, supervisor, the person they report to, who wants them to do the work, RVU [relative value unit] billing generating activities also. Now, if this is a physician's role and they are able to bill appropriately, it is okay. But if not, then can this work, or should this work be outsourced to the psychology side?

Outpatient clinician stakeholders expressed similar concerns with payment structure and reimbursement, noting that in some cases, current clinical volumes may be prohibitive for providing intensive patient follow-up needed for successful outpatient management.

3.5. Implementation and sustainability infrastructure

3.5.1. Dedicated team: support network

The large majority of stakeholders noted the importance of dedicated staff and clinician time allocated to the B-OPAT intervention as a key element of successful implementation for the novel intervention, this was one of the most often mentioned facilitators of the intervention. In the context of the B-OPAT clinical trial, resources were allocated for dedicated research staff, who were typically tasked with patient outreach, screening and recruitment, which was widely perceived to be working well and essential to the successful identification of patients and overall efficient operation of the intervention trial.

Dedicated staffing allowed multidisciplinary clinical clinicians to interact with study patients and provide clinical care without assuming additional administrative or coordination burden that would hinder their ability to participate effectively in the trial. Relatedly, the presence of a dedicated outpatient low barrier addiction treatment clinic (UK First Bridge) which housed integrated addiction, behavioral health and wraparound services, and PICC care was viewed as a critically important facilitator for providing seamless patient-centered services based on patient needs and acuity.

3.5.2. Transitional care

The sole staffing barrier that was noted by stakeholders was a dedicated case manager to coordinate and oversee barrier relief activities that would allow patients to successfully access needed services in the transitional period to outpatient care, which were significant in the context of under-resourced home communities of many patients. As one stakeholder noted:

This study would be better served if they had a dedicated case manager for all the things. Because I know that medically obviously that's the most important part of these people's care. But that being said, those barriers that they are up against to receive that care, that can totally make or break what's happening to them.

3.5.3. Plan for sustainability: funding support for staffing

For many stakeholders, the experience of the B-OPAT trial provided an opportunity to consider investments that would be required to make the holistic low-threshold OUD and SIRI care model sustainable in the context of the academic medical center environment. Nearly all stakeholders interviewed commented on the high complexity of the patient population, which most felt would require additional support and increased follow-up monitoring, specifically when compared with traditional OPAT patients. Broadly, stakeholders called attention to the need to recognize and allocate staffing based on reasonable time and effort commitments. As one OPAT team stakeholder described:

One would be the staffing. I think that the care coordination that they get via the First Bridge, whether it'd be with a nurse there that can help coordinate not only their addiction and the social worker, but getting them to and from appointments. That's something that my team currently doesn't have, is that added staff member. We would probably want another nurse to help coordinate care… And I think that that is where we'd actually proposed a multi-phase expansion of our team that emulates what the NIH study has.

3.5.4. Availability of clinic time

Similar in many ways to the concern for staffing, a second major issue that emerged for sustainability was the investment of financial resources to expand clinic time. As one stakeholder noted, “we struggle, even in general, getting our patients back into clinic. Kentucky's not a very affluent state”. Several clinician stakeholders observed and commented on barriers of timely availability for clinic appointments that would be required to support the intensive schedule of follow-up appointments for those receiving early hospital discharge and PICC care. Many perceived that this barrier could potentially impact the feasibility to provide such care outside of a clinical trial context. For many this concern was tied to the essential role of the UK First Bridge Clinic in providing rapid and low-barrier outpatient care that was otherwise not readily available.

4. Discussion

This qualitative study of organizational stakeholders documented a number of thematically salient barriers and facilitators impacting the implementation of integrated and innovative OUD and SIRI care for medically complex patients during their inpatient and transitional care. Guided by the PRISM framework, several important elements of Organizational Perspective, Organizational Characteristics, and Implementation and Sustainability Infrastructure emerged as key drivers of successful implementation for the B-OPAT intervention. Key facilitators included: 1) the established presence and credibility of the Addiction Consult Service as a cohesive coordinating entity to support adoption of evidence-based addiction care, clinical practice enhancements and educational opportunities for clinical team members, 2) receptivity of clinicians to apply evidence and develop clear clinical pathways that destigmatize OUD and SIRI care; 3) the clinical leadership of physician champions in the academic medicine setting to advocate for culture change and promote patient-centered care; 4) an intervention team structure that minimized burden to collaborating clinicians with task management by research team members and dedicated staffing models; and, 5) curated specialized training for frontline intervention staff to close knowledge gaps and address specific barriers to task performance.

Key barriers to the B-OPAT intervention in these PRISM domains were largely tied to: 1) logistical complexities and coordination of communication among large and diverse clinical teams; 2) SUD stigma both within and outside the health system that produced hesitancy and skepticism about practice changes; 3) concerns about the availability of adequate clinic time to support the relatively intensive schedule of outpatient intervention visits required, which in the B-OPAT trial was offset by provision of post-hospital low barrier SUD outpatient treatment and follow-up at the UK First Bridge Clinic. In the domains of Patient Characteristics and External Environment additional barriers were largely related to the significant challenges of caring for rural patients from underserved communities with low resource availability, and the associated clinical concerns about ensuring appropriate follow up and support structures for patients that were distant from the study site.

Overall, our findings resonate with existing qualitative research on implementation determinants for SIRI and SUD care interventions (Hervera et al., 2023; Morales et al., 2022), with some distinctions that may reflect both the unique organizational positioning and external setting of the B-OPAT study intervention site. In particular, our finding on the central facilitation role of the Addiction Consult Service was notable in this regard. Despite a robust evidence-base demonstrating the impact of hospital-based Addiction Consult Services for MOUD initiation, post-discharge retention, and other important outcomes (Danovitch et al., 2024; Englander et al., 2022; McNeely et al., 2024; Ober et al., 2025), many hospitals do not have such service units, which can lead to missed opportunities for identification, treatment and management of SUD that complicates hospitalizations. Addiction Consult Services require significant organizational resource investment, time, stakeholder buy-in and planning to launch (Evans et al., 2024), however, in our study, the presence of this core model was viewed as essential for launching or trialing further care innovations, such as the B-OPAT intervention itself. Additionally, the B-OPAT trial was positioned to leverage a seamless treatment pathway in the community through the partnership with UK First Bridge Clinic, which was considered by study stakeholders to be critical infrastructure to support the relatively intensive ambulatory treatment protocol in the current trial. The development of these clinical infrastructure components would appear to be key considerations for successful implementation of the B-OPAT intervention, particularly in organizations outside of an academic medical center environment.

Stakeholder descriptions of structural SUD-related stigma presented notable barriers to implementation in both the internal organization and external context, which aligns with previous research documenting pervasive enacted SUD stigma in hospitals and other healthcare settings (Hoover et al., 2021). Although clinician stakeholders in the present study were reluctant to explicitly identify practices as discriminatory, several pointed to key examples of structural stigma that limited care opportunities for patients with SUD, whether it be policies excluding these patients from consideration for OPAT, community-based skilled nursing facilities or home health agencies refusal to accept patients with SUD, or negative anchoring biases surrounding SUD at the clinician level. Stakeholders generally noted strides in overcoming SUD stigma within the inpatient setting, describing evolving organizational culture that was often seeded by the Addiction Consult Service, physician advocacy and clinician-driven grass roots initiatives to increase and mandate SUD training (South et al., 2023, 2025). Recent research urges the adoption of universal screening and diagnosis of OUD in hospitals and timely initiation of MOUD thereafter, as an approach to mitigate potential bias in the assessment and treatment process (Springer, 2024), and calls for hospitals to ensure that community-based referral partners accept people who use drugs and provide evidence-based MOUD care.

Finally, external environment factors related to the study setting and catchment area also featured prominently in stakeholder narratives regarding potential intervention barriers. As a tertiary referral hospital, the health system is positioned to receive the most medically complex patients from Kentucky's eastern Appalachian region, which includes patients with infective endocarditis and other SIRI that local hospitals are ill equipped to manage due to insufficient access to integrated specialty care. The longstanding and growing challenges faced by rural hospital systems are well known, ranging from financial viability to workforce shortages (Carroll et al., 2024; Frakt, 2019), which suggests that referral to specialty care in academic medical centers will continue to be the norm for complex inpatient SIRI care, yet stakeholders generally perceived that under-resourced rural communities would remain a substantial barrier to executing seamless transitional patient care and clinical follow-up in the ambulatory setting. In this regard, the ability to transition complex patients to community care in resource poor areas of the state was noted as a potential barrier to consider in future expansion of the B-OPAT intervention model, suggesting very high priority to build partnerships with home health and community clinics that can provide support to patients with SUD and SIRI.

4.1. Limitations

This study has notable limitations that are important to consider. First, stakeholders were invited to participate from across clinical and administrative areas and roles, and though the large majority agreed, non-response to our interview request did occur on occasion. As such, the sample may not be representative of all stakeholder viewpoints and experiences, and due to self-selection, may be biased toward individuals who were more comfortable expressing their views regarding SUD care and the B-OPAT intervention model in particular. This concern is likely mitigated to some extent by the use of an experienced, neutral qualitative interviewer who was external to the operations of the clinical trial. Furthermore, the sample is limited to a one-time cross-sectional interview, which occurred relatively early in the life-cycle of the B-OPAT trial. Therefore, we were not able to capture evolving perspectives or shifting views that may have occurred as a result of continued exposure to the intervention implementation; in this respect, interviews are limited to the early implementation period. Finally, the sample size of 13 was small, and though data saturation was achieved among the 12 internal stakeholders, there was limited representation from stakeholders external to the academic medical center hub, with just one participant representing community-based home infusion services. The limited information on SUD and OPAT care from community perspectives is important to note, as interviews may have failed to capture important nuances of transitional care that could influence future scalability of the intervention. As such, participating stakeholders cannot be viewed as representative of healthcare stakeholders more broadly. In a similar way, the study location in an academic medical center may limit the applicability of our findings to other hospital settings, such as smaller community-based hospitals or those with differing care designations.

4.2. Conclusions

The present PRISM-guided qualitative examination of implementation determinants highlighted key barriers and facilitators of the novel B-OPAT intervention identified by a range of engaged stakeholders. Within this context, there was clear recognition of the medical and social challenges faced by the patient population impacted by OUD and SIRI, and acknowledgement of the need for multidisciplinary teams to coordinate care management and collaborate effectively to synergize care and improve opportunities for follow-up. Initial stakeholder observations of the B-OPAT intervention indicated that enhanced care coordination was directly impactful to patient care. Stakeholders expressed optimism that the B-OPAT trial would generate important evidence to inform, improve and destigmatize current clinical practice for this population. Taken together, the organizational level implementation barriers encountered in this trial were largely logistical and appeared modifiable through adoption of specific implementation strategies, however, the presence of critical clinical infrastructure to support the care model was essential, and could represent a rate limiting investment for other health systems to consider in the future. External factors, including low resource availability and SUD-related stigma that excludes patients from opportunities to receive care in the community, collectively pose ongoing challenges to the implementation and sustainability of more patient-centered care models, including B-OPAT.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.josat.2026.210025.