Article Figures & Data
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Themes of harm reduction-informed medical care by organizational level.
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Site 1 Site 2 Site 3 Model Free-standing clinic model Co-located model in Hospital System Co-located model in Syringe exchange program Setting Non-Urban, Ithaca NY Urban, East Harlem NY Urban, Bronx NY Services Primary care, medication for opioid use disorder (MOUD), Human Immunodeficiency Virus (HIV) and Hepatitis C (HCV) testing, pre-exposure prophylaxis (PrEP), Mental health, social services Primary care, MOUD, risk reduction counseling, HCV treatment, overdose response training, and behavioral services Primary care, MOUD, HIV and HCV treatment, PrEP, referrals to specialty care Number of Interview Participants 7 (Director of operations, clinical supervisor/primary care provider, director of financing strategy, psychologist, physician, community health worker) 7 (Patient navigator, nurse care manager, nurse practitioner, physician, social worker, research physician (2), operations coordinator) 6 (Nurse, care coordinator, physician (2), registered nurse, project director) Themes Examples Illustrative Quote(s) Provider as both learner and informer Provider views patients as experts in their own drug use and strives to learn what patients’ goals in treatment are
“Letting the patient feel like they're autonomous in their treatment decisions is really important. I actually will tell patients, consider me a tool for your health and I will take on the doctor role and I will tell you what my advice is and my recommendations, but I don't ever want you to feel like I'm trying to tell you what to do.” Providers are not directive or forceful but function as sources of information for patients, providing a realistic range of support options to develop a treatment plan consistent with? patient’s goals.
Provider aims to be compliant to patient’s needs (not vice versa) and to help patients adopt safer behaviors.
“Harm reduction means you're giving somebody all the tools, you're informing the person, the participant. You're giving them all the tools they have to make the safest decisions, but ultimately, their decisions are their decisions” Pragmatic measures of success Providers recognize that complete abstinence may not be a realistic goal for many patients.
“I would qualify that success is that they're engaging with us, having an honest relationship with us, and are able to come to us when there are new problems coming up for them.” Focus is placed on the process of treatment rather than outcomes
Measures of success based on care processes (ie, patient engagement and retention), having an open, honest relationship with patients, and reaching patients’ self-identified goals.
“We're not expecting that people are going to be completely abstinent, that might not even be their goal and that's totally okay. But just seeing progress and being happy with that. Like, patients like coming in time to get a refill, that's great” Collaborative and interdisciplinary care teams Ensuring a wide range of providers and specialists are available to address varied patient needs
“We’re constantly talking to each other. We have weekly team meetings. We’re constantly emailing each other about the various needs of our patient. We know each other, we’re a small team and I think that makes it very easy for me to pick up the phone and call.” Routine staff meetings to collaboratively discuss issues and questions related to patient care
Relying on other team members for support during difficult situations
Developing a stigma-free culture Having strong leadership team dedicated to harm-reduction
“We create an environment where people are free to discuss their drug use without fear of being stigmatized or judged, so that we can give people the tools to reduce their harms around the health issues that arise for people who inject drugs”
“We do interview all of our clinic-facing providers, like nurses and front desk and everything. They do an interview with the team huddle. And this guy came on last week and he was like, I just really want to treat addicts and everyone’s eyes rolled. And that was the end, the guy didn’t get the job”Intentional hiring and screening practices for culture-fit
Ongoing training and education on using stigma-free language versed in trauma-informed care (ie, in charting) and treating all patients with respect
Constant communication and check-ins between staff to ensure fidelity to harm-reduction principles
Creating a comfortable and welcoming physical space Providing showers, bathroom, and laundry facilities on site
“Patients have a comfortable relationship with the clinic. Some of them, they come in, and often we're not even registering them with the doctor. They're just sitting and talking to us in the nurse’s office. We're not busy, and they can come in and talk to us.”
“Our staff works really hard at making sure that patients don't feel stigmatized, that they don't feel judged or looked upon as less than. I think physically the fact that patients can come in and grab a cup of coffee, which if you're injection drug users, the fact that you have the space to do that safely in, I think is really quite critical.”Allowing patients to bring belongings such as large bags, carts, pets in the clinic
Handing out snacks to patients to make wait times less onerous
Remembering patients’ names
Reducing paperwork burden for patients
Low-threshold care with flexible scheduling Adopting a walk-in model for appointments with no penalties for no-shows or late arrivals
“In our clinic, we have basically a policy that patients certainly need appointment times, but often they're late for their appointment times or early for their appointment times, and we'll basically see them whenever. So that just allows a lot more flexibility for them to be able to be seen.”
“We do urine toxicology tests. We try to say that very much upfront, this is not punitive, this is it just to have an open conversation. We're not trying to stop your prescription. Even if you're using opioids”No penalties or discontinued services for disclosing medication misuse
Using urine toxicology to start conversations rather than for punitive purposes
Enacting policies to protect patient privacy (i.e. to courts)
Reaching beyond the clinic to disseminate harm reduction orientation Carving out time to teach harm reduction principles in medical schools and residency training programs
“Very few current internal medicine residency programs even teach what harm reduction is, or how to provide low threshold MAT. We are involved in a training program locally to do just that.” Holding training sessions with other local community organizations
Creating robust referral networks to enhance transitions of care Developing referral networks to ensure patients are treated with respect when receiving services outside of the clinic
Supporting patients during external transitions (ie, scheduling external appointments, providing MetroCards)
“We don't send people to places where they're going to be treated poorly or abused by providers, we're not going to send them because that reflects back on us. So, we're careful about our referrals naturally.” Interview Questions Section I: Program Descriptive Information 1. Briefly describe the type of practice and the services provided
2. Briefly describe the history of the program’s integrated services
3. Briefly describe the interactions between patients and staff members
4. Briefly describe the organization of the care team
Section II: Harm Reduction Approaches and Services What do you consider to be critical elements of harm-reduction-informed care? 5. What does a harm reduction-oriented model of treatment look like in your practice?
6. How would you describe your organization’s philosophy toward patient care?
7. Could you provide me with an example of applying these philosophies to delivering care to patients?
8. How do you assess whether you are being true to these concepts?
9. What mechanisms does the practice have in place to build a culture of harm reduction?
10. Describe the decision-making process that takes place in your clinic around patient care.
11. Describe how you enact and integrate the following harm reduction concepts in your clinic:
Humanism: Providers have respect for patients and the decisions they make, providing care without moral judgments.
Pragmatism: Providers have realistic expectations and support a range of options for reducing harm.
Individualism: Support is tailored to individual patients’ needs.
Autonomy: Patients and providers negotiate the best plan of care.
Incrementalism: Any positive change acknowledged and reinforced.
Accountability: Patients are responsible for (and experience) the consequences of their behavior but are given additional chances to improve.
Section III: Facilitators and Barriers 12. What factors help facilitate the provision of harm-reduction oriented care in your practice?
13. What factors prevent the provision of harm-reduction oriented care in your practice?
14. What advice do you have for providers that want to adopt a harm-reduction-oriented approach to care integration?
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