Table 3.

Implementation strategies within the external facilitation intervention used to address barriers or leverage facilitators to M-OUD at low-adopting VHA facilities

Facility	Goals	Strategies identified	Achievement of goals
Facility 1	Implement buprenorphine prescribing in outpatient mental health clinic	1. Identify temporary care management staffing prior to new nurse hire 2. Ensure prescribing privileges for all relevant outpatient mental health prescribers 3. Create scheduling mechanisms for outpatient mental health providers to treat patients with buprenorphine	Yes
	Implement buprenorphine prescribing in pain clinic	1. Provide waiver training and privileging for prescribers 2. Pharmacy to assist with care coordination to reduce burden on providers	In progress
	Implement buprenorphine prescribing in residential mental health program	1. Create templates in the electronic medical record to facilitate accurate documentation of buprenorphine visits 2. Provide waiver training and privileging for prescribers	Yes
	Educate primary care providers on buprenorphine	1. Schedule seminar or cyber seminar with national subject matter expert 2. Develop and present medical grand rounds with local subject matter expert	Yes
Facility 2	Conduct pilot to transfer one patient on buprenorphine to another waivered provider outside of SUD for maintenance monitoring	1. Determine criteria providers would accept for stable patients on buprenorphine to transfer back into their care (e.g., number of consecutive clean urine screens)	No
	Examine M-OUD policies to maximize patient eligibility and ensure safety needs are addressed	1. Provider to review other VHA policies, revise current policy, and send to subject-matter expert for review	No
	Identify incentives to encourage providers to obtain waivers and treat patients with buprenorphine-	1. Investigate incentive options for potential prescribers	In progress
	Implement pharmacy care management model for patients on buprenorphine in primary care	1. Identify pharmacy lead 2. Assess willingness of waivered primary care provider to prescribe buprenorphine and hand-off management to pharmacy	In progress
Facility 3	Develop outpatient buprenorphine clinic in mental health clinic	1. Determine whether provider can have a half day clinic in the main mental health clinic	Yes
	Provide buprenorphine initiations in pain clinic that was soon to be established	1. Form a team of providers focused on treating pain who are willing and have capacity to provide buprenorphine initiations	No
	Identify primary care and mental health providers who are willing to have stable patients on buprenorphine returned to them from community providers to prescribe in house	1. Identify providers who are willing and have the capacity to manage patients on buprenorphine in caseload	Yes
	Implement buprenorphine prescribing in VHA satellite clinic	1. Identify actionable steps for making progress in prescribing buprenorphine in a VHA satellite clinic	No
Facility 4	Implement buprenorphine prescribing in a VHA substance abuse treatment program	1. Provider to complete waiver training to prescribe 2. Renew community contracts for one more year to allow new prescriber to bring patients on M-OUD back to VHA gradually	Yes
	Develop mechanism to transfer stable patients on buprenorphine from VHA substance abuse treatment program back to VHA mental health or primary care providers	1. Identify mental health and primary care providers that are waivered and willing to oversee management of patients on buprenorphine already on their caseload. 2. Identify mental health and primary care providers who are waivered and willing to take patients on buprenorphine who are not already on their caseload. 3. Identify additional training or resources that these providers would need to feel comfortable managing patients on buprenorphine	No
	Implement buprenorphine prescribing in primary care through a team focused on pain	1. Identify resources to prescribe buprenorphine	Yes
Facility 5	Implement incentives for providers to become credentialed and prescribe	1. Request financial incentives from mental health regional leadership	Yes
	Expand buprenorphine prescribing in mental health	1. Increase number of waivered, credentialled prescribers in clinic	No
	Expand buprenorphine prescribing to a pain clinic	1. Increase number of waivered, credentialled prescribers in clinic	Yes
	Identify options for transferring stable patients back to primary care	1. Determine criteria providers would accept for transfer of stable patients on buprenorphine back into their care (e.g., number of consecutive negative urine screens)	No
	Provide initiations in the Mental Health residential program	1. Identify education and observation opportunities for clinic staff to increase comfort with initiations	No
Facility 6	Implement buprenorphine prescribing in pain clinic	1. Hire an addiction specialist to increase capacity to prescribe	No
	Implement buprenorphine prescribing in mental health same day access clinic	1. Determine pharmacy processes for buprenorphine dispensing for same day access 2. Evaluate implementation of warm hand offs from mental health same day access clinic to general mental health clinic one month after initiation for patients on buprenorphine 3. Identify nurse champion who can follow-up with patients weekly while in access clinic to support other providers and nurses during buprenorphine stabilization phase 4. Identify provider available as interim coverage for patient education on buprenorphine side-effects, obtain consent for treatment, register patients in the state prescription drug monitoring program, and provide naloxone kits	In progress
	Implement buprenorphine in care teams focused on homeless Veterans	1. Increase number of waivered prescribers in clinic	No
	Increase access to buprenorphine maintenance through telehealth	1. Utilize waivered prescriber to administer telehealth for stable mental health patients on buprenorphine who live far from clinic	No
	Minimize local restrictions on buprenorphine prescription access	1. Remove requirement for providers to receive pharmacy approval prior to prescribing buprenorphine	No
Facility 7	Implement buprenorphine prescribing in pain clinic	1. Hire a part-time psychiatrist or an addiction fellow in the pain clinic to prescribe buprenorphine for patients with pain and OUD 2. Obtain approval from pharmacy to allow physicians with a waiver in the pain clinic to prescribe buprenorphine for patients with pain and OUD	In progress
	Implement buprenorphine prescribing in behavioral health and outpatient substance abuse clinic	1. Increase buprenorphine prescribing by currently waivered providers in both clinics 2. Increase number of waivered providers in behavioral health clinic to increase capacity to prescribe	Yes
	Implement M-OUD prescribing in community-based outpatient clinics	1. Consult with nursing leadership about nurses assisting telehealth mental health providers in community-based outpatient clinics 2. Consult with nursing leadership about offering naltrexone extended release in community-based outpatient clinic 3. Establish a telehealth program in the mental health clinic and have a part-time psychiatrist prescribe buprenorphine for patients with OUD	In progress
	Implement buprenorphine prescribing in primary care	1. Create lists of actionable OUD patients by provider to give physicians information regarding the number of patients in their caseload who may be appropriate M-OUD. 2. Identify incentives to encourage providers to obtain waivers and treat patients with buprenorphine within the primary care mental health integration clinic, establish a part-time, SUD, non-prescribing provider for SUD assessment, and a psychiatrist for prescribing buprenorphine 3. Create a primary care-based treatment team, with embedded mental health, to prompt increased buprenorphine prescribing	No
Facility 8	Expand locations for initiation of buprenorphine by removing local restrictions	1. Meet with nursing leadership to discuss removing local restrictions that initiations must occur in the emergency room 2. Revise standard operating procedure to remove local restrictions on where initiations can occur 3. Meet with pharmacy to discuss mailing buprenorphine to allow clinics without pharmacies to initiate buprenorphine	Yes
	Streamline process for approval for initiation for faster patient access to buprenorphine	1. Determine which steps are essential in the current process of reviewing patients during a weekly committee meeting and which can be removed to expedite access to treatment	Yes
	Implement buprenorphine prescribing in residential substance use treatment program	1. Reach consensus on strategy to time buprenorphine initiation either prior to admission to the residential program or at discharge from the residential program	Yes
	Increase number of prescribers in primary care	1. Identify incentives to encourage providers to obtain waivers and treat patients with buprenorphine 2. Develop nurse care management model with nursing leadership. 3. Establish criteria for patients on buprenorphine to return to primary care provider for maintenance	No