TABLE 1—

Facilitators of and Barriers to Implementation of the Levels of Care Standards and Attainment of Higher Certification Levels: Rhode Island, 2017–2018

Implementation Area	Facilitator	Barrier
Intervention characteristics	Belief in effectiveness of Levels of Care policies	Intervention externally developed
	Policy adaptability to local context	Skepticism of effectiveness of Levels of Care policies
		Adaptable requirements unclear
Out-of-hospital variables	Public pressure to address opioid overdose crisis	Unsuccessful stakeholder engagement
	Hospital-to-hospital competition, public relations pressure to be seen as “taking action”	Limited outpatient availability of medication for OUD with respect to both individual providers and clinic hours of operation
	Strong community–hospital partnerships	Lack of or weak community–hospital partnerships
	RIDOH regulatory requirements
	Provision of state-sponsored training related to OUD medication
In-hospital variables	Interdepartmental collaboration: pharmacy, social work, psychiatry, emergency medicine	Lack of interdepartmental collaboration and coordination
	Support and engagement of hospital leadership	Lack of organizational prioritization
	Institutional purchasing of naloxone, fentanyl testing	Unengaged/remote hospital leadership
	Electronic medical record order sets, provider reminders, custom forms, report generation	Cost of naloxone and fentanyl testing
	Dedicated staff for overdose reporting	Time and labor burden of overdose reporting
	Local expertise in addiction medicine, OUD medication	Unavailability of local addiction medicine specialists and buprenorphine waivered providers
Individual stakeholder characteristics	Provider knowledge about OUD and comfort with initiation of OUD medication RIDOH technical assistance	Stigma toward patients with OUD and OUD medication
		Provider training and self-efficacy in initiating OUD medication
Implementation process	Local champions in emergency medicine, social work, psychiatry RIDOH technical assistance	Absence of local champion
		Lack of staff or training to carry out policies

Note. OUD = opioid use disorder; RIDOH = Rhode Island Department of Health.