{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,19]],"date-time":"2026-09-19T21:16:17Z","timestamp":1789852577162,"version":"4.0.1"},"reference-count":46,"publisher":"SAGE Publications","issue":"4","license":[{"start":{"date-parts":[[2021,10,1]],"date-time":"2021-10-01T00:00:00Z","timestamp":1633046400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Substance Abuse"],"published-print":{"date-parts":[[2021,10]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Hub and spoke systems (HSS) are increasingly promoted as a systems-level intervention to expand access to medication for opioid use disorders (MOUD), particularly in rural areas with limited treatment options. The HSS model consists of sub-systems in which \u201chubs\u201d deliver specialized expertise to a regional network of office-based opioid treatment (OBOT) providers in \u201cspokes,\u201d who together create a continuum of acute and chronic care. Yet, little is known about system-level factors (e.g., system structure, financing) that influence HSS implementation and sustainability in rural areas.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec sec-type=\"methods\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      For this case study, we conducted semi-structured interviews with substance use disorder treatment providers (\n                      <jats:italic toggle=\"yes\">N<\/jats:italic>\n                      \u2009=\u200926) and system-level stakeholders (\n                      <jats:italic toggle=\"yes\">N<\/jats:italic>\n                      \u2009=\u200916) in five rural HSS sub-systems throughout one state. We undertook iterative textual analysis of interview transcripts, identifying and coding themes related to key implementation constructs associated with the Exploration, Preparation, Implementation and Sustainability (EPIS) framework.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec sec-type=\"results\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>California policy-makers adopted HSS to expand rural access to opioid treatment programs (OTPs, i.e., providers of methadone and other medications for opioid use disorder). However, stakeholders questioned the model's fit for rural regions featuring few established OTPs that could function as hubs and critiqued its treatment-focused approach, felt to sideline harm reduction service providers. Contracts to serve rural regions were awarded entirely to for-profit methadone providers, contributing to stigma and distrust among many buprenorphine providers whose organizations were later recruited as spokes. While hubs offered financial resources enabling some spokes to expand MOUD, the needs of spokes varied considerably. Relationships between hubs and spokes to facilitate the care continuum under HSS were restricted by limited behavioral health resources and the large distances characterizing rural California.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec sec-type=\"conclusions\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>This case study reveals how rural contextual factors such as geography and behavioral healthcare resource availability can dramatically influence differential HSS implementation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1080\/08897077.2020.1846149","type":"journal-article","created":{"date-parts":[[2020,12,7]],"date-time":"2020-12-07T23:21:05Z","timestamp":1607383265000},"page":"716-725","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":27,"title":["System-level factors shaping the implementation of \u201chub and spoke\u201d systems to expand MOUD in rural areas"],"prefix":"10.1177","volume":"42","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3661-2458","authenticated-orcid":false,"given":"Claire","family":"Snell-Rood","sequence":"first","affiliation":[{"name":"University of California Berkeley School of Public Health, Berkeley, California, USA;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cathleen","family":"Willging","sequence":"additional","affiliation":[{"name":"Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, Albuquerque, New Mexico, USA;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Showalter","sequence":"additional","affiliation":[{"name":"Department of Sociology, University of California Berkeley, Berkeley, California, USA;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hannah","family":"Peters","sequence":"additional","affiliation":[{"name":"University of California Berkeley School of Public Health, Berkeley, California, USA;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robin A.","family":"Pollini","sequence":"additional","affiliation":[{"name":"West Virginia University School of Public Health, Morgantown, West Virginia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2021,10,1]]},"reference":[{"key":"e_1_3_4_2_2","unstructured":"Center for Behavioral Health Statistics and Quality. 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