Table 3 Summary of themes from Clinician and Patient Qualitative Interviews about the SIRI team

I. Intervention characteristics

 Evidence Strength & Quality

• MOUD is an important aspect of SIRI care

• The SIRI team is the most appropriate provider of MOUD

• SIRI team is helpful in guiding the use of IV versus oral antibiotics in a nuanced manner

• “…[MOUD] is the first and foremost treatment that we should be giving [to increase] the odds of the patient being successful and avoiding future use or minimizing use of drugs in the future.” – clinician

• “I do feel comfortable when I’ve worked with the SIRI team in setting up discharges for patients that are gonna be continuing with PICC lines and IV antibiotics and high-risk medications. I think that it’s gonna be a safe discharge as opposed to other times when I haven’t felt like it was gonna be a safe discharge.” – clinician

 Relative Advantage

• The SIRI team serves as a fierce patient advocate in the hospital, supportive of both patients and clinicians

• By being experts on both infections and substance use problems, the SIRI team cuts down on what is usually fragmented care

• Having post-hospital follow up for this population is uncommon and the SIRI team provides needed post-hospital services and patient navigation for a vulnerable population

• “It was incredible. I mean, besides saving my life, like I said, they would always come check on me and make sure I was okay. If anybody didn’t attend for me there in a way that I found comforting, they would yell at ‘em. [Laughing]” – patient

• “Yeah, I liked that the team is willing to go to bat for patients when it's time to talk to the surgeons and communicate with the surgeons… I like having the SIRI team because… they aid with a compassionate perspective, which the general infectious disease team may not.” – clinician

• “I think the ability of this team to bring in other providers together so that we have a coherent treatment plan, not piecemeal by different providers and different consultants, I think is also important.” – provider

 Complexity

• Delineation of responsibilities between the general ID team and the SIRI team could get confusing

• Providing holistic care for patients with SIRI is labor intensive and clinicians felt it may be too big a task for a single team to accomplish

• “I think that you become overwhelmed with too many patients, and there’s not enough staff, not enough people bein’ able to track because one of the important aspects of this is to be able to follow [patients] inside and outside of the hospital. Patients losing their phone, or not living in the address where they live anymore.” – clinician

 Cost

• The team must show a return on investment in order to succeed, especially when it comes to length of stay and readmission rate

• “At the end of the day, it comes down to money, and a lot of times it’s an issue” – clinician

• “[The hospital] obviously is a public hospital, have to protect their resources” – clinician

II. Outer Setting

 Patient Needs & Resources—general

• Clinicians felt SIRI team success depends in part on patient dedication to stop using drugs

• Hospitalized PWID require attention that clinicians are not able to provide

• There is a lack of discharge options for PWID experiencing homelessness, which limits how much the SIRI team can achieve

• Clinicians felt patients need comprehensive behavioral health care

• “It just depends on the stage of readiness for the patient as to whether or not they're willing to accept medication-assisted treatment, if they're willing to accept the buprenorphine or not, if they're ready to get off of drugs or not.” – clinician

• PWID need “…a mental health team, individual therapy, group therapy, psychiatry, and the social worker that can link you to all these resources.” – clinician

 Patient Needs & Resources—Symptom management

• atients noted that lack of treatment of addiction and withdrawal symptoms was the main reason for leaving under patient-directed discharge or avoiding returning to the hospital

• “Take care of the withdrawal first, then you can start taking care of the infection. Or you could do it at the same time, but don’t leave a heroin addict just layin’ in the bed dope sick.” – patient

• “Basically, just make sure that the addiction needs are seen ‘cause that’s the first and most important to get someone to sit still. If we don’t feel good, we’re not gonna sit still.” – patient

 Patient Needs & Resources -Access to follow-up care

• Patients are surprised and appreciate that the SIRI team maintains communication with patients post-discharge to check in on patients in rehab, encourage MOUD, additional programs

• “[They] always followed up calling me, even when I didn’t have an appointment, just to see how I was doing. It was really more personal.” – patient

 Patient Needs & Resources -Patient-Provider Communication

• Patient’s feel uninformed on their medical situation, that clinicians don’t spend the time to explain things to them due to stigma against their substance use

• The SIRI team communicated support and dedication regardless of substance use

• “Like I said, [the SIRI team] wanted to make sure I had a safe place to go when I left and that if I did go back to using that [they] wouldn’t frown upon that, to make sure I came and got clean needles and everything but to hang in there. [They] kept me on methadone and everything.” – patient

 Patient Needs & Resources -Medical Mistrust

• Patients experience stigma in the healthcare system leading to lack of trust of healthcare clinicians

• “I felt like because of my social standing, before I was at [the hospital], I had an abscess on my right arm, and I was treated. It was just before I even made it to get admitted… because of my social standing, I was treated less compassionately than I was once I met [the SIRI team].” – patient

 Cosmopolitanism

• Strong ties with community SUD treatment programs are needed for SIRI team success

• It just seems to be that patients that are seen by [the SIRI] team get into the right places more often. I think it’s because they’re knowledgeable about community resources in ways that I think a lot of the other providers aren’t, because this is their specialty. “

 External Policy & Incentives

• Healthcare policy incentivizes stretching clinicians—especially nurses and hospital physicians—very thin. Vulnerable populations feel the brunt of this

• Clinicians and case managers are pressured to get patients out of the hospital as soon as possible, even when detrimental to long-term healthcare utilization

• “We understand that patient care takes time. It takes dedication, so when we don’t have these laws that protect nurses… that’s another barrier, overwhelming healthcare staff” – clinician

• “There’s that whole disconnect between the policymakers and the money people and what actually needs to happen for the patient population that we serve” – clinician

III. Inner Setting

 Structural Characteristics

• Addiction care as an important aspect of medical care for PWID has not been traditionally prioritized by the health system

• The system is difficult to navigate for PWID and people experiencing homelessness

• The local health system has a history of innovation for care delivery and the SIRI team fits well into this paradigm

• “The people who make the decisions about funding and money are never the ones who are trying to find clothes to discharge a patient to a shelter with their medications and home health.” – clinician

 Networks & Communications

• The SIRI team is not publicized enough; its existence has not been well communicated to the health system stakeholders

• Clinical documentation by the SIRI team is effective in communicating their plan and serves as education to other clinicians

• The SIRI team improved upon the typical lack of communication between patient, physician, and nurse

• “the note template [that the clinicians are using] is excellent, so I think it really helps for the primary team to see that note and to have a good idea of the things they’re looking for in all the assessments.” – clinician

• “The communication with the doctors that are running the service, was excellent that one time. I think continuing that will definitely bolster success. I wish I could have such great communication with all consultants, but for this particularly vulnerable patient population, I think it was very appropriate.” – clinician

 Culture

• Many healthcare clinicians see addiction as a choice, which serves as a barrier to appropriate care

• Patients reported experiencing stigma from non-SIRI team clinicians

• Interviewees felt the hospital does not consider itself an addiction treatment facility and is reluctant to provide any form of treatment for addiction

• “It can be hard to get other providers and health care staff to have compassion, the same level of compassion for other patients when they consider people to have self-inflicted behavior.” – clinician

• “[The hospitalist] was really, really bad. Super close minded, super judgmental. She just felt like she had me all figured out.” – patient

• “When it came to the drug use, they’re like, ‘We’re not a rehab. We’re here for your medical [needs].”’ – patient

 Implementation Climate/Relative Priority

• Clinicians might feel like the SIRI team is getting in their way or taking on their duties

• COVID-19 became the top priority and helping vulnerable, stigmatized populations has taken a back seat

• “Being able, being willing to acknowledge that they’re experts I think is obviously something that people need to acknowledge and to accept and do, even when it is a little bit on their own turf for instance.” – clinician

 Available Resources

• There were concerns about the capacity of the SIRI team to see all patients in need of services

• Clinicians worried that the team would be underfunded and understaffed

• “I suspect that the hospital won’t wanna pay for it because it’s gonna need—this is not a short-term project. This is a project that needs to be here forever as part of the [health] system, and that involves funding and grant-writing.” – clinician

 Access to Knowledge & Information

• There is a lack of institutional knowledge on addiction medicine, management of withdrawal, and MOUD. The SIRI team should be involved with this training

• SIRI team could play a role in helping correct misinformation among clinicians

• “Maybe a nurse doesn’t believe in medication-assisted treatment, they might think that, oh, we’re just providing them drugs. What are we doing? We’re providing then the same thing as they could be getting in the streets, so just some misinformation.” – clinician

IV. Characteristics of Individuals

 Knowledge & Beliefs about the Intervention

• SIRI team ought to serve as the de facto addiction clinicians in the hospital, given the lack of program

• The SIRI team needs special accommodations to be successful: a specific hospital unit, a flexible clinic setup, dedicated nursing staff, a psychiatrist or psychologist, low enough census to spend ample time with patients

• The team should provide ongoing feedback to hospitalists on case outcomes to build understanding and trust in the program

• “…right now don't have any available team dedicated team to treat addicted person like, okay, you want to quit the drugs, let's go to help you quitting.” – clinician

• “You are dealing with patient. Yes, they have this infection. They have those addiction issue, but they have [mental health] issues in the background that [are] preventing this patient from fully profiting from the care we are providing to this patient.” – clinician