“I want to stay here”: Patient and Staff Perspectives on Transitioning from a Low-Threshold Buprenorphine Program to Clinic-Based Care

Background The Project Connections At Re-Entry (PCARE) Van is a low-threshold buprenorphine program operating outside the Baltimore City Detention Center. Like other low-threshold programs, PCARE seeks to engage a vulnerable population in care, stabilize patients, then transition patients to longer-term care; however, <10% of patients transition to clinic-based buprenorphine treatment. Our goal was to better understand these low transition rates and center patient perspectives in discussion of broader low-threshold program design. Methods From December 2022 to June 2023, semi-structured interviews were conducted with 20 former and current PCARE patients and 6 staff members. We used deductive and inductive coding followed by thematic content analysis to identify themes around treatment experiences and care preferences. Results There were strong preferences among current and former patients for continuing buprenorphine treatment at the PCARE Van. Several themes emerged from the data that explained patient preferences, including both advantages to continuing care at the van (preference for familiarity, feeling respected by the program’s structure and philosophy) and disadvantages to transitioning to a clinic (perceived harms associated with rigid or punitive care models). Staff noted limited program capacity, and patients expressed that if needed, they would transition to a clinic for altruistic reasons. Staff expressed varied perspectives on low-threshold care, emphasizing both larger systems factors, as well as beliefs about individual patient responsibility. Conclusions While many low-threshold care settings are designed as transitional bridge models, this research highlights patient preference for long-term care at low-threshold programs and supports efforts to adapt low-threshold models to be sustainable as longitudinal care.