Promoting brief cessation interventions in hospitals – 6/3/10

Q: The Georgia Tobacco Use Prevention Program would like some suggestions for promoting brief cessation counseling in hospitals and hospital systems. Can states share tips on getting buy-in from hospital administrators and staff? Who were your champions? What worked and what did not work? Do states have any examples of training materials to share? Any and all suggestions would be appreciated.

A:

  1. California: The California Diabetes Program, in collaboration with the California Smokers’ Helpline, California Tobacco Control Program and the Smoking Cessation Leadership Center, has been working to increase calls to the Helpline via referral by health care providers using the Ask Advise Refer intervention.
     
    Part of our focus has been to increase knowledge among health care providers (MD’s, RN’s, RD’s CDE’s, Pharmacists, MAs, etc) about the devastating effects tobacco use has on chronic disease (most specifically diabetes). Health care providers learn about how quitting smoking can improve health outcomes (this is important for many health systems that use a pay for performance incentive). We also provide education on “Ask Advise Refer” and how Quitlines function. During the past six years we have seen an increase in referrals by health care providers to the Helpline that surpasses referrals due to media. Health care providers are a sustainable referral source.
     
    The “Do you cAARd?” Task Force has been one of our champions. We have been working with the statewide “Do you cAARd?” task force of diabetes educators (RNs, RDs, Pharmacists’, and MD’s), who work in hospitals and health systems and provide training and pocket guides on AAR to their colleagues. This peer-to-peer campaign has been extremely successful in increasing awareness and use of the Helpline. Diabetes educators play a key role in helping patients learn to manage their diabetes and improve their health. Using the brief AAR smoking cessation intervention and referring to the Helpline with a “California Smokers’ Helpline Goldcard” fits perfectly into their practice.
     
    The task force helped to develop a health care provider pocket guide and an educational program that is now online. Please visit the tobacco cessation online continuing education program at www.caldiabetes.org (linked is an announcement of the program). This resource also provides many other tools that may assist you in your cessation efforts.
     
    These passionate volunteers are currently working on an AAR training for medical assistants and community health workers. One educator (a clinical nurse specialist) is piloting the integration of AAR into their health system’s electronic medical records (EMR) with automated fax referral to the Helpline.
     
    We piloted a manual proactive fax referral – but it was very resource intensive for busy clinics. Clinicians prefer using the AAR intervention and providing a “Helpline Goldcard.”
     
    The Smoking Cessation Leadership Center provides excellent tools and resources for working with health care providers.
     
  2. Indiana: Indiana Tobacco Prevention and Cessation has initiated a number of interventions designed to improve cessation systems in the health care setting including hospitals. Ideas include:
     
    • A Preferred Provider Network to be used in tandem with our Indiana Tobacco Quitline. We sign up health care providers so that we can begin to communicate with them and conduct outreach to them around the Quitline.
       
    • Grand rounds and presentations in hospitals. These briefly touch on the tobacco use problem and then go into detail on how to address this in the broadest, most effective way (enroll as a preferred provider and begin fax referring immediately). We show them that in about three minutes they can get the ball rolling to unlimited one-on-one support for their patients from our excellent QuitLine. We identify physicians to conduct the presentation on tobacco use to provide the peer-to-peer outreach, and then ITPC staff and local partners provide the training on the Quitline and Fax Referrals to the Quitline.
       
    • A grant with the Indiana Rural Health Association to assist us with building relationships with Critical Access Hospitals and Rural Health Clinics to implement training and outreach around the Indiana Tobacco Quitline and the Preferred Provider Network.

    3. Click here for more information.

  3. Massachusetts: The Multi-State Cessation Collaborative is a network of nineteen state-level tobacco control programs working to advance tobacco interventions in healthcare at the state level and to advance changes at the national level; here is a summary describing this group. On their website, you will find several reports that may be helpful: Improving Health Care Systems to Reduce Tobacco Use: Lessons Learned from States, and Case Studies. Also attached is a comparison table of the case studies. You could contact any of the states whose work may be of interest to you.
     
    You may be interested in the Collaborative's October 2010 Conference: Multi-State Collaborative for Health Systems Change 2010 Conference.
     
  4. Michigan: In our webinar series last year, one of our presenters - Laura Van Heest (of Saint Mary's Health Care) - did a PowerPoint presentation that contains information similar to what Georgia is requesting.
     
  5. Nevada: Nevada has worked with general providers directly. The quitline has a general pamphlet referral, where the provider discusses the benefits of cessation, and if the person is interested in quitting they give them a pamphlet on the quitline and encourage them to call. This has received a more positive response and increased call volume to the state quitline than a hospital or provider making a formal referral to the quitline by faxing in their information.

    Blue Cross Blue Shield of Idaho Foundation was working on this very thing and had developed materials for it. Here is their contact information:
     
    Blue Cross of Idaho Foundation for Health, Inc.
    P.O. Box 8419
    Boise, ID 83707-2419
    Phone: (208) 387-6817
    Toll-Free: (866) 482-2252
    info@bcidahofoundation.org
     
  6. New Hampshire: The Multi-State Cessation Collaborative has some excellent resources for these efforts, and so does the Center for Studying Health System Change (HSC). These are good places to start.
     
    New Hampshire receives no state dollars, so all funds are CDC-based for any tobacco control activities; therefore media campaigns are out of the question.
     
    The New Hampshire Tobacco Prevention and Control Program gives presentations at any and all Chronic Disease (Diabetes, Asthma, Breast and Cervical Cancer) events sponsored by the state and hand out copies of the 2008 Public Health Service Guidelines.
     
    In the past, the New Hampshire Tobacco Prevention and Control Program issued Requests for Proposals that contract with a system for a systems change. We had great success with the largest medical center with a small amount of money because the release of the RFP coincided with the Senior Management taking on a Pay for Performance quality improvement initiative around tobacco use.
     
    At the same time, the medical school affiliated with this medical center and the community health center all bought into this quality improvement initiative. In this case, all the stars aligned.
     
    In another case, we have used ARRA funding to contract with the Network of affiliated community health centers that utilize the same electronic medical record system.
     
    Using the "Quality Improvement Project" header, we have buy-in from the senior management of the network and will conduct Grand Rounds for all the medical directors, doctors, and mid-levels with free education credits offered. This peer-to-peer training has been shown to be more effective than trying to do "lunch and learns" with staff and not having the buy-in of the senior management.
     
  7. New York: The New York State DOH Tobacco Control Program funds nineteen Cessation Center contractors whose primary deliverable is to implement systems to support tobacco dependence treatment into health care. These contractors have worked with most of the hospitals in New York State, and there are many types of activities that we have used to implement treatment into the hospital setting. Briefly, piggy-backing onto the Joint Commission's performance measures is a big incentive for hospitals to implement treatment. Especially now, when the Joint Commission is strengthening their measures, hospitals should be very receptive to the idea. We have also worked with hospitals to implement the fax to quit program which follows up discharged patients who were identified as smokers.
     
    Ideally, the primary person you would want to contact at the hospital setting is the CEO. Getting buy-in from the top helps quite a bit. But even if you don't get buy-in from the top, finding a champion at the site can work as well. Use of the New York State Department of Health name gets the attention of hospital administrators.
     
  8. Oklahoma (response from Tobacco Cessation Systems Initiative, Oklahoma Hospital Association):  Your request has been forwarded to us from the Oklahoma State Department of Health, Tobacco Use Prevention Service with whom we work closely.
     
    The Oklahoma Hospital Association was awarded a grant from the Oklahoma Tobacco Settlement Trust Fund that is specifically designed to work with Oklahoma hospitals in implementing the evidence-based Clinical Practice Guidelines for hospitalized patients. Our goal is to implement systemic changes that will be sustainable at the patient care level.
     
    About ten months ago, we began to work with Integris Health, the largest system of hospitals in Oklahoma. Integris currently operates fourteen hospitals in Oklahoma, with three in the Oklahoma City metro area and a fourth under construction. We are beginning our pilot with these three so that we can fine-tune the implementation process, and then eventually roll out to the others. These three hospitals range from very large (577 beds) to small (44 beds), which will give us experience in different size settings and with demographic populations that vary somewhat. Together they serve 40,654 patients annually and have 1,067 beds, but even within Baptist Hospital, the largest, we will begin to implement by department.
     
    The past ten months have been spent laying the groundwork and building support with top Integris corporate leaders as well as administrative and clinical leadership of each hospital. We have had numerous meetings and presentations before reaching the actual planning of the implementation itself. In fact, today, we just had our first “roll up your sleeves” meeting with staff to begin the planning of the initial implementation at Integris Baptist Hospital.
     
  9. Virginia: 1) Getting buy-in from administration and staff:
    In Virginia, we partnered with our state's Quality Improvement Organization (QIO). The Centers for Medicare and Medicaid Services funds a QIO for every state; to locate your state's QIO, click here, and scroll down to the link for the QIO Directory. Our QIO was working with a majority of acute care hospitals to assist them in developing resources/protocols, etc., for meeting various JCAHO/CMS core measures. Since several included a "smoking cessation" measure, we participated in their Collaborative meetings (held quarterly) and provided: education/training about the 5As, materials (e.g., quitline cards and posters), and information on other sources of free or low-cost resources. We also offered phone consultations and onsite trainings to hospitals wanting additional assistance.
     
    Most of the hospital staff at these meetings were quality improvement departments, attending because they had a need to improve compliance for the various measures in order to avoid reduction in Medicare reimbursement. The hospitals even had to pay a small fee to join the Collaborative. So there was already buy-in from them (and administration) to work on numerous clinical protocols. Buy-in to implement brief cessation was accomplished by providing ready-to-use resources (they didn't have to spend time looking into what worked or developing a training curriculum or locating affordable materials, etc.) that they could easily implement and which would help them not only quickly improve their compliance rate for the smoking cessation measure but also be effective in reducing tobacco use - all factors that were important to them.
     
    2) Who the champions were:
    The QI staff were very motivated to improve the smoking cessation measure, as it was usually one of those for which they had the lowest rates and they were encouraged by finding out we were offering so many resources at no cost. Other staff who tended to be champions were the respiratory therapists and cardiac care department clinicians. Virtually every hospital implemented their brief cessation protocol with all patients (not just Medicare-insured and not just those with an AMI, heart failure or pneumonia diagnosis).
     
    3) What did not work:
    Providing onsite clinician training seemed like a good idea but actually did not work well because it allowed the hospital to rely on someone from the outside coming in to train staff. This led to a failure to integrate training on brief cessation into the hospital's usual clinician education protocols. It also resulted in unmet needs when, for example, some nurses were not able to attend the training because they were not at work that shift or were out on the floor or when the training was not as helpful as it could have been because it was not tailored enough to some unique factor specific to a facility. Including training on the 5Rs was not very successful either because time allowed for the education by the hospital (and even at the Collaborative meetings) was insufficient to adequately train clinicians who were not very familiar with motivational interventions and who barely had time to do the 5As with patients motivated to quit.
     
    4) What worked:
    Providing training on the 5As to staff from over 35 hospitals all at the same time (during the Collaborative meetings) worked well and was very efficient. Providing a display table of free/low-cost materials and information on where to get them was very popular and used a lot. Providing technical assistance to the hospitals (at the meetings and by phone) as they developed procedures and forms helped ensure that as many of the A’s as possible would be accomplished (i.e., patients would be asked smoking status, advised to quit and provided with a resource to assist them with a plan if they were interested or, if not, at least have information on the quitline in case they became interested later). Offering to do onsite consultations to assist hospitals in developing their own clinician training resources instead of doing the training ourselves also worked much better because we were able to help them tailor the education more effectively (e.g., if a hospital already had an internal continuing education system for clinicians where they took courses online as it suited their schedule and then the system automatically provided confirmation of completion, we were able to help the hospital identify the most appropriate online courses for their nurses or RTs or clinic staff, etc., so they could add that to the menu of education options).
     
    5) Examples of training materials:
    Three presentations are attached (two with handouts); the last presentation we did was a webinar in WebEx:

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