Appendix Table 2.

Themes of Harm Reduction-Informed Care by Clinic

Theme	Free-Standing Clinic Model	Co-Located Model in Syringe exchange program	Co-Located Model in Hospital System
Provider as both learner and informer	- Providers provider a realistic range of support options - Patient guides the provider to understanding what will be the safest course of action for them - Patients are not required to be compliant to providers, providers are expected to be compliant to patient needs	- Providers take cues from the patient - Providers give patients all the tools and resources to make their decisions, but accept that decisions are theirs to make - Providers let patients know they are autonomous in their treatment decisions	- Providers create treatment plans in conjunction with the patient and in which the patient has decision-making power - Providers understand that patients know more about drug use than the providers
Pragmatic measures of success	- Providers are responsive to patient goals and do not push their own agenda - Providers goals are to cultivate a trusting relationship with patient - Definition of success dependent on individual patient - Any positive change is acknowledged	- Celebrate small successes - Patients identify needs to address, not required to be SUD-related - Success can be patient engaging for a follow-up visit, getting stable housing, getting a job, refilling medication - Having a relationship with the patient is a success	- Patient decides treatment goals and are not required to have abstinence as a goal - Patient success is based on their own goals and needs - Reality-based care focused on the process, rather than the outcome - Communication and engagement with patient is success
Interdisciplinary and collaborative care teams	- Morning meetings with clinic staff to review schedules - Day-to-day operations are collaborative - Every voice is valued - Interdisciplinary care	- Weekly clinic meetings - Interdisciplinary approach - If needed, two providers will meet with an individual patient	- Interdisciplinary care - Constant communication between staff - Weekly check-ins with entire team - Providers call each other for support in patient interactions
Developing a stigma-free culture	- Careful about hiring and screening applicants - Recognizing that the medical system is patriarchal - Servant leadership - Mandatory, ongoing training	- Providers do not impose the medical system on patients and uphold patients ownership and belonging in the space - Hiring the correct people	- Ongoing and supporting training - Provider recognition of biases and privileges - Hiring the right providers
Creating a comfortable and welcoming physical space	- Avoid use of stigmatizing language - Do not release information to courts or criminal justice system without patient consent - Staff remember patient names and other personal details	- Friendly signage - Radical welcome; ‘we take you as you are’ - Patients welcome to come in and chat without seeing a provider - Patients can bring dogs or belongings into the clinic - Patients are not burdened with paperwork - Give out snacks to patients - Allow patients to use bathrooms and showers	- Avoiding use of stigmatizing language - Social justice and racial justice initiatives - Avoid use of labels in medical charting - Give patients snacks - Hand out metro cards
Low-threshold care with flexible scheduling	- Patients not penalized for missed appointments - On-demand services - Do not withhold treatment because patient discloses drug use	- Walk-in model - Are not punitive with positive urine toxicologies	- Do not require abstinence - Do not refuse treatment or kick someone out because of a positive urine toxicology - Patients not penalizing for late or missed appointments - Same-day access to services
Reaching beyond the clinic to disseminate harm reduction orientation	- Staff train local providers and community organizations on harm reduction		- Providers teach at medical schools
Creating robust referral networks to enhance transitions of care	- Careful with referrals and creates ties with external providers	- Careful with referrals and creates ties with external providers	- Careful with referrals and creates ties with external providers
		- When external care is necessary, staff make appointments for patients and remind them of visits

Abbreviation: SUD, Substance use disorders.