Background: Hospitalization presents a critical juncture to engage patients with opioid use disorder, but safety net hospitals are less likely to offer transitional opioid programs (TOPs), which initiate treatment and connect patients to care after discharge. This study explored determinants of TOP adoption in 4 diverse safety net health systems. Methods: We interviewed key participants affiliated with safety net health systems and partner community-based organizations about TOPs within their organization. We used inductive coding informed by grounded theory to identify emerging themes related to TOP implementation and thematic analysis to compare determinants across health systems. A deductive approach was then used to map data that aligned with an existing TOP typology to document the presence of specific programs and promote comparison in implementation progress across sites. Throughout the iterative process, we developed analytic themes related to the extent to which TOPs were integrated into each health system. Finally, determinants were mapped to Consolidated Framework for Implementation Science Research domains. Results: Determinants spanned inner and outer setting domains and shaped the presence of TOPs and their integration into routine health system operations. The number and types of care transition models varied across organizations. We grouped health systems into 2 patterns, foundational and embedded, reflecting differences in how their TOPs were organized and supported. Reimbursement rates, inefficient organizational functioning, and stigma hindered TOPs at all phases of implementation, while organizational champions were key facilitators. Foundational programs experienced severe staffing shortages and low organizational support. Embedded programs were distinguished by grant-writing staff and more supportive outer contexts. Conclusions: This study highlights the challenges and opportunities faced by safety net health systems in implementing TOPs. The findings emphasize the need for tailored implementation strategies that address the unique barriers and leverage facilitators within resource-constrained settings, particularly at different phases of implementation.
Fenstemaker et al. (Mon,) studied this question.