Early-stage implementation of peer-led interventions for emergency department patients with substance use disorder: Findings from a formative qualitative evaluation

Abstract

Introduction

Emergency department (ED)-based peer recovery coach (PRC) programs can improve access to substance use disorder treatment (SUD) for ED patients. As literature on early stages of PRC implementation is limited, we conducted a qualitative assessment of ED PRC program implementation from several US-based PRC programs focusing on barriers and facilitators for implementation and providing recommendations based on the findings.

Methods

We collected qualitative data from 39 key informants (peer recovery coaches, PRC program managers, ED physicians and staff, representatives of community-based organizations) via 6 focus groups and 21 interviews in February–December 2023. We transcribed audio-recordings and analyzed data using codebook thematic analysis.

Results

We identified the following major themes related to specific barriers and recommendations to address them. To facilitate timely linkage to PRCs, programs would regularly inform ED staff about the program and its linkage procedures, establish trust between PRC and ED staff, streamline the linkage procedures, and choose an “opt-out” linkage approach. To address barriers related to external referrals, programs use “warm handoff” and “warm line” strategies, maintain and update a comprehensive catalog of resources, and familiarize peer coaches with local service providers. Telehealth services implementation requires addressing logistical barriers, ensuring patients' privacy, and training peer coaches on building trust and rapport online. Peer coaches' wellness and quality of services can be improved by limiting PRC's workload, prioritizing quality over quantity, facilitating self-, peer- and professional care to mitigate stress and burnout; and, importantly, by providing supportive supervision and training to peer coaches and advocating for PRC team as an equal partner in the ED settings. To facilitate PRC program adoption and sustainment program managers engage local communities and program champions, seek diverse sources of funding, and advocate for structural changes to accommodate recruitment and retention of peer recovery coaches.

Conclusions

We compiled a wealth of best practices used by PRC programs to address numerous implementation barriers and challenges. These recommendations are intended for PRC program planners, managers and champions, hospital leadership, and state and local public health agencies leading SUD epidemic response.