RFAs for institutionalizing PHS clinical practice guidelines – 2/17/06

Q: We would like to release a Request for Applications to institutionalize the US Public Health Service Clinical Practice Guidelines for Tobacco Cessation into health care provider settings and we had the following questions and requests:

1. Have other states released similar RFAs, and if so, can we review them?
2. Who was the target audiences (family physicians, hospitals, etc.) and what type of intervention did you use (training, technical assistance, etc.)?
3. Have other states incorporated secondhand smoke messaging into their cessation interventions? If so, how did they do this?

We also had this larger philosophical question.

1. Is their evidence to support condensing the 5As to a 2As & a R? If so, how many states are currently using this model?

A:

1. Alabama:
    
   1. We have not issued an RFA but we have drafted a policy to implement the 5A's in all health department venues that see patients. The policy is currently under review and includes the Alabama Tobacco Quitline Fax Referral/Patient Consent form. We also offer free 5A's training to any healthcare provider (dentist, family practitioners, etc.) that request training.
   2. The target audience is health department venues that see patients and any other healthcare provider that requests training.
   3. While advising patients to quit, health care providers are trained to advise patients of the health consequences of secondhand smoke as well to those around them. For example: "Exposure to second hand smoke is a cause of lung cancer among nonsmokers. Studies support a causal relationship between exposure to secondhand smoke and coronary heart disease mortality among nonsmokers. Second hand smoke can also trigger asthma attacks among nonsmokers."
   4. We do not have any evidence of this, but the draft policy that is under review uses the Ask, Advise, Refer (using the patient consent/fax referral form) and then Prescribe medication if appropriate.
       
2. New Hampshire: New Hampshire Tobacco Prevention and Control Program (TPCP) has contracted for services to institutionalize the PHSG throughout healthcare systems over the last 3 years and currently has a contract with Dartmouth Hitchcock Medical Center and Medical School for a standardized systems change. Funding dicatates the reach of each initiative.
    
   In 2003 the priority target was women of reproductive age. In 2004 and 2005 the priority target was under and uninsured patients in a NH county with a high prevalence of this population. In 2005 a large provider network requested assistance to train 30 of their 215 providers that referred patients to a large medical center. In order to meet this request, the contractor worked with a staff person at TPCP. Currently, Dartmouth Hitchcock Medical Center and Medical School is under contract to change their entire system, including their Occupational Health Department, to address and document tobacco use status for every in and out patient. This effort includes the Community Health Center where medical Residents volunteer time as part of their residency training. Initially, the contractor created a 1-hour training currilcum for which 1.2 CEUs were offered to each participant. The curriculum is based on: Documented evidence about the harms of secondhand smoke and tobacco use; NH specific data about adult tobacco use; PHSG Treating Tobacco Use and Dependence 5 A's Model; and Stages of Change.
    
   Concurrently, the NH dental professionals were producing a "2 A and Refer"
   protocol for dental hygienists. TPCP has been at the table for discussion about using this condensed version. Michael Fiore, the Chairperson for the PHSG, acknowledges that this model is acceptable. Therefore, PHSG trainings have been revised to reflect that the 5A's Model can be reduced to 2A's and Refer to the NH Smokers' Helpline.
    
   The RFPs issued for each initiative reflects New Hampshire Division of Public Health Services policies and procedures. TPCP will be pleased to share our RFP format with others in the TCN.
    
3. New Jersey: We have moved to the 2As and R model. While we have not done a formal study, physicians and dentists value their time and, if they are taught to trust the R part, they will take this approach. Several short messages can be very effective.
    
4. New York:
    
   1. Yes - Click for more information.
   2. We funded one organization per catchment area to work with health care organizations and providers, generally starting with the larger ones. We did not prioritize type of practice. We provided TA and training.
   3. We have not done this at this point.
   4. We have no evidence, but are generally supportive of the AARP model - ask, advise, refer, prescribe, with referral to the state Quitline, which provides counseling, proactive call back and NRT.
       
5. North Dakota: We did not release an RFA to institutionalize the PHS Guidlines in to healthcare settings, however, through a contract with our Medical School we have them providing healthcare provider education and outreach to our healthcare community. We also required that they have an objective to insitutionalize the PHS Guidelines into the medical school curriculum, which they have done. They are now working on institutionalizing the Guidelines into the residency programs. This includes providing information on the impact of tobacco use on the body, appropriate NRT recommendations and 5As training. Depending on the setting they often recommend use of three As {Ask, Advise, Assist (refer to quitline)}. Our dental community in promoting the use of the 3As as well. Our quitline has been operating since September 2004 and currently 35% of our referrals come from healthcare providers.
    
6. Oregon: Oregon has a vast experience in implementing (embedding) guidelines into health systems. We would be happy to be a resource. Contact Kirsten Aird at 971-673-1053.
    
   For the tobacco guidelines Oregon worked through a partnership between community organizations, public health and health systems to adapt the guidelines to Oregon and to develop a plan for implementing them within health systems. We have the adapted guidelines and implementation kit that we would be happy to share.
    
   For other information: You may want to consider using the collaboratives learning model as a vehicle for your intervention. This is commonly used to implement guidelines for chronic diseases, such as asthma and diabetes, and could work well for prevention. Click for more information on this model. The collaborative is primarily based on the Chronic Care model, which you can learn more about at the Institute for Healthcare Improvement.
    
   Additionally, with the future of health care being heavily dependent upon electronic medical records I would recommend that any contractor be savvy in this area. Full implementation will be most easily achieved through the use of clinical information systems.
    
7. Utah:
    
   1. N/A
   2. The Tobacco and Control Program (TPCP) and Coalition for Tobacco Free Utah (CTFU) worked together to develop a new, standardized packet of materials for health care providers. The TRUTH Network: Treating Tobacco Dependence explains the 5As of tobacco control, available pharmacologic therapies, statewide cessation programs and fax referral to the Utah Tobacco Quit Line. The 5As reminder card and the Public Health Service Guideline summary are also included. Two pamphlets to share with patients accompany the guide, one for orienting patients to the Quit Line (when they fill out a fax referral form) and another to motivate patients who are not ready to quit. (Click to view and print materials from the TRUTH Network). The target audience for these materials are healthcare providers (physicians, nurses, dentists, dental hygienists, pharmacists etc.) The TPCP, the local health departments, and CTFU have been working to implement the distribution plan. Local health departments (LHDs) have been conducting numerous in-person visits with health care clinics. Several LHDs have also been working with local hospitals to implement the recommended systems changes. Additionally, several training sessions have also been conducted by LHDs and other partners.
   3. Yes, we have. For example, the pamphlet (mentioned above) that was developed to motivate patients who are not ready to quit contains the heading, "Stopping tobacco use can prevent harm to yourself and your loved ones. Think about your health and your family." Besides listing the harmful effects of tobacco use for the tobacco user, the pamphlet also lists the harmful effects that secondhand smoke can have on the tobacco user's family.
   4. The LHDs and community partners that distribute the TRUTH Network materials cover all of the 5As when training health care providers. If you have any questions, please contact Marci Nelson at (801) 538-7002.
       
8. West Virginia:
    
   1. WV did an RFA a few years ago for provider training. We could share a current workplan from this effort – contact Bruce Adkins.
   2. Target audience for provider training was any level of healthcare provider/worker who could advise patients who are tobacco users.
   3. WV Division of Tobacco Prevention has collaborated with sister agencies (Cardiovascular Program, Cancer Coalition, and Asthma Program) to combine messages in a statewide billboard and newspaper ad campaign.
   4. Would this not be 'AHRQ's' call (as to whether there is evidence to support condensing the 5A's)?

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