Survey analysis
In the survey, all respondents were asked to complete CFIR scale and demographic items. Behavioral health providers (BHPs; include those with LADAC, LCSW, LMHC, LMSW, LPCC, or PsyD credentials) and medical providers (MPs; include those with MD, PA, NP, or RN/LVN credentials) were asked some additional questions at the end of the survey about their clinic workflow (e.g., extent to which their appointments were in-person or virtual). Any respondent that answered 80% or more of the core questions were included in the analysis. This 80% cutoff rule was used because when missing data were analyzed, an 80% cutoff typically included respondents who had answered at least some items in the main sections of the survey (e.g., respondents that answered the CFIR questions but then did not complete the demographic items located at the end of the survey).In the survey, questions asked about the respondents’ clinic environment, not about the healthcare system as a whole. Responses were aggregated to the healthcare system level to protect the confidentiality of respondents (e.g., some clinics had fewer than 30 staff total), and to facilitate a comparison across the three distinct systems. Furthermore, each system relied on system-wide top leadership teams, and in some instances, staff members worked at more than one site in a system.Constructs were analyzed based on percent of favorable responses in which ratings of agree or strongly agree were considered favorable in order to gauge relatively strong versus weak context areas. Most survey items were phrased in an affirming way (e.g., “This clinic does a good job…”). Therefore, in most instances, construct scores that fell below 50% favorability (e.g., in which less than 50% agreed or strongly agreed) were considered areas for improvement. Three constructs, complexity and the two stigma scores, were exceptions in that due to question wording, high percent favorable ratings indicated deficits or areas for improvement. Scores were not reversed for those three constructs because it was simpler and clearer to keep those items as is; for example, it was unclear if reverse scoring the items would reflect respondents’ survey selections (e.g., disagreeing or strongly disagreeing that “most people believe that a person who is addicted to opioids cannot be trusted” may not be the same as agreeing or strongly agreeing that “most people believe that a person who is addicted to opioids can be trusted”).