Table 1 Implementation facilitation activities

External facilitators

The investigators in fields of emergency medicine, internal medicine, addiction medicine, and psychology provide expertise in buprenorphine, ED interventions, referral to community services, and techniques related to brief interventions and motivate patients to engage in treatment. External facilitators (EF) lead the focus groups and meet with the site leaders and local champions through individual and group face-to-face meetings at the beginning of IF, and again at 4–5 month into the IF period. Additional calls and emails occur throughout the IF and IF evaluation periods. The EF team meets weekly for 3–4 h and reviews site enrollment, survey completions, and IF activities. All IF activities are cataloged into a data repository. Site checklists (Additional file 1) are reviewed monthly and plans are made to facilitate any needed activities.

Formative evaluation

Anonymous surveys of ED and community providers, followed by focus groups with key ED, community provider, and patient stakeholders in conjunction with one-on-one individual meetings with designated administrative leaders, perceived role models, and opinion leaders provide insights into individuals and organizational readiness, power for change, and ideas to move adoption forward.

Local champions

Local site champions self-identify or are identified by ED or community providers in the focus groups and are recruited to participate. One-on-one discussions occur, and information requested or considered important for each group is emailed routinely. These individuals support activities essential for adoption of ED-initiated buprenorphine. Local champions are not paid by the study to ensure sustainability of practice adoption and reproducibility of the findings.

Stakeholder engagement

Data from the surveys and focus groups are compiled into the domains of evidence, context, and facilitation and shared with local champions and ED and community administrative leaders. The EF team seeks to align ED-initiated buprenorphine with local priorities. A site IF team then forms consisting ideally of champions and leaders with the ability to support change.

Tailor program to site

The EF works with the IF team to tailor their interventions specific to their site based on information gathered during the formative evaluation and all procedures and processes are incorporated into the site’s ED workflow

Provider education and academic detailing (AD)

Efforts are made to facilitate trainings by leveraging local expertise at the sites. Sites are notified of local DATA 2000 (X waiver) trainings and provided information on how to schedule a training. An academic detailing pamphlet was developed to inform the providers specifically noting: Why the ED; what is the evidence; why use buprenorphine; and “how to” treatment algorithms and referral/discharge forms are included. Journal club articles and websites are provided. The EF team provides AD to champions, thought leaders, and providers throughout the IF and IF evaluation period.

Performance monitoring and feedback

The identified lead local champion periodically completes a checklist provided as reporting items as number of providers with X waivers, status of ED policy and procedures for initiating buprenorphine, any EHR upgrades to enhance adoption, presence of formal agreements with community sites to accept ED referral (see Additional file 1 for the complete list). Sites are encouraged to provide feedback to providers when a patient engages in treatment and perform routine departmental quality performance efforts reporting number of patients with OUD administered or prescribed buprenorphine.

Learning collaborative (LC)

Sites are invited to join a monthly Learning Collaborative at the start of the IF period. Lessons learned from participating sites are discussed addressing facilitators and barriers to local processes. The EF team also invites outside experts and champions to discuss their adoption processes. Email listservs are developed and distributed bringing together multidisciplinary site champions as well as like disciplines among sites, such as advanced practice practitioners and residents.

Problem-solving

The EF routinely discusses issues regarding ED, organizational, and community barriers with site champions. Innovative problem-solving ideas and activities are shared in the LC. The EF provides other consultations and materials as needed.

Program marketing

Efforts designed to increase attention to ED-initiated buprenorphine. Handouts as well as pens and pins denote the messages of the “Project ED Health” such as “Buprenorphine saves lives” and “Buprenorphine treatment works” and sites are referred to websites the EF team developed to retrieve information for patients and providers [19, 20].