Table 2 Examples of barriers and facilitators described by facilities and classified by i-PARIHS constructs
| Â | i-PARIHS construct | Barrier example | Facilitator example |
|---|---|---|---|
Innovation (focus or content of innovation effort) | Degree of fit with existing practice and values | Approval for buprenorphine is difficult given current requirements for 4 positive consecutive urine drug screens for opiates and no other substances | An established pain clinic has a current role in identifying patients with OUD, initiating buprenorphine, and transferring care back to primary care |
Clarity | M-OUD treatment is referred to community clinics (non-VHA providers), so roles and responsibilities of VHA staff regarding M-OUD is not clear | Facility currently has clear criteria that patient misuse or diversion (selling) of buprenorphine results in loss of medication eligibility | |
Relative advantage | No barriers reported | Non-VHA community clinics can have long wait lists and may not accept VHA insurance, which provides a relative advantage for VHA facilities to treat and manage patients on M-OUD | |
Context (multiple layers that can facilitate or constrain implementation) | Local level: Mechanisms for embedding change | Clinic staff attempted to remove restrictions on where buprenorphine initiations could occur (currently only in the emergency room in a separate building); however, they were met with resistance due to concerns for adverse events related to buprenorphine initiation | Facility previously identified team to clarify and implement buprenorphine initiation strategies to increase access |
Organizational level: Organizational priorities | VHA employs multiple initiatives to improve Veteran care, which often leads to competing priorities | Organizational leadership is aware SUD-16 metric is low and are requesting improvement | |
External Heath System Level: Environmental stability | Rurality of facility brings the challenge of maintaining an adequate number of trained and waivered staff to provide adequate coverage | No facilitators reported | |
Recipients (people who enact and influence the implementation) | Motivation | Limited interest from non-SUD disciplines and clinics to manage patients on buprenorphine | Providers want to get the necessary training to prescribe buprenorphine |
Skills and knowledge | Facility does not have a provider who is waivered to prescribe | Facility has a new provider with experience in a buprenorphine clinic | |
Time, resources, and support | Lack of adequate space and provider capacity to prescribe buprenorphine and manage an increase in patient caseload | Mental health residential programs have staff who can be re-allocated to provide buprenorphine and manage patients |