Access to evidence-based treatment including medication treatment for opioid use disorder (MOUD) remains a global challenge. A wide array of implementation strategies have guided efforts to expand access to MOUD, with most centered around externally facilitated approaches to practice change. While effective, such approaches may be inaccessible to those clinics and systems that lack the resources necessary to partner with an external team, suggesting a need to identify and describe change processes that are internally developed and promoted. Interviews with clinicians and administrators (n = 9) and ethnographic observation of planning meetings (n = 3) revealed how a self-appointed local team developed, established broad support for, and successfully implemented a Primary Care-based Buprenorphine Clinic and E-Consult Service to expand access to MOUD to patients across the health care system. First, national and local policy changes—including altered clinical practice guidelines, performance pay incentives regarding opioid prescribing, and a directive from the VA Central Office increased individual staff and administrators’ perception of the need for change and willingness to invest time and resources. Then, a self-appointed interdisciplinary team utilized cross-clinic meetings and information gathering to identify appropriate, and widely supported, models of care delivery and care consultation. Finally, the team increased staff investment in these change efforts by bringing them into the planning process and encouraging collaborative problem-solving. Processes of care that were tailored to local needs are well-positioned for sustainability over time.