"Just Be Relentless," Lessons Learned from In-Hospital Addiction Consult Service Implementation.

Background: Hospitalization is a "reachable" moment to engage people in addiction care. Addiction consult services (ACSs) have been shown to improve outcomes for hospitalized patients with substance use disorders (SUDs). Despite this, most hospital systems do not provide hospital-based addiction care or have an ACS.

Objective: Characterize implementation barriers, lessons learned, and opportunities for future support of ACS implementation.

Design and participants: Semi-structured qualitative interviews with 17 "champions" leading ACS implementation at 11 institutions across the U.S.

Approach: Interviews explored evolution of ACSs, including staffing, service delivery, strategic planning, and barriers and facilitators to implementation. Reflexive thematic analysis was applied to identify emergent themes.

Key results: Five dominant themes characterize ACS implementation: (1) how champions obtain buy-in from hospital leadership. Participants described the impression that ACSs are not revenue-generators as a barrier to implementation and found ways to capture monetary and non-monetary outcomes to demonstrate value; (2) specific attributes are common to ACS champions including persistence, good communication, and leadership skills. ACS champions described needing to communicate strategically with multiple stakeholders across their institution and often pitched their case multiple times before obtaining funding; (3) reliance on external resources. This included informal coaching from other ACS leaders and formal tools such as telementoring networks and published literature to learn to engage leadership and present a business case; (4) ACSs are important drivers of cultural change within institutions in the face of significant stigma and; (5) planning for sustainability. This included demonstrating improved quality of care and patient and provider satisfaction to obtain ongoing support for ACS.

Conclusions: Barriers to ACS implementation are common and significant and the process of obtaining leadership support for implementation is often long and iterative. Broad adoption of ACSs will require support from hospital systems and policymakers including incentives, funding, and infrastructure to support clinical champions.