Nancy Rigotti, MD Integrating Quitlines with Health Care Systems: A Case Study at Partners HealthCare System, Boston, MA USA 10/10/2011

- 2 - Why link Quitlines with Health Care Systems?  Quitlines need an inexpensive way to promote their services to the public and generate steady call volume  Health care systems need to a way to link smokers to evidence-based accessible treatment  Solution: Have health care providers refer to quitlines  Passive referral (MD gives out QL number) – low yield  Active referral (example: QuitWorks in Massachusetts)  Fax referral (or electronic referral) from office to quitline  Quitline proactively calls smoker to offer counseling (+ medication)  Quitline provides feedback to physician about result - 2 -

- 3 - Linking Quitlines with Health Care Systems  Challenge : Connect smoker from office to quitline  Quitlines reach <= 60% of smokers referred by fax  Only some of the smokers reached accept telephone counseling  Feedback of unsuccessful results to MD discourages more referrals  Solution?  Do quitline enrollment at point of care (office, hospital) - 3 -

- 4 - Case Study: Partners Health Care System  Large integrated health care delivery system  Boston, Massachusetts, USA  6 hospitals affiliated with Harvard Medical School (Massachusetts General Hospital, Brigham and Women’s Hospital, 4 community hospitals)  Network of over 1100 primary care physicians (PCPs)  Multiple private (commercial) and public (Medicare, Medicaid) insurers  Linked by an electronic medical record - 4 -

- 5 - Partners Tobacco Task Force  Created in 2005 by High Performance Medicine (quality improvement department)  Stimulus: Low scores on quality of care measure  % of smokers hospitalized with pneumonia, MI, or CHF whose hospital charts document stop smoking advice or counseling  Charge to Task Force:  Fix the problem  Improve quality of our care for tobacco users across the system - 5 -

- 6 - PHS Tobacco Treatment Task Force Goals  Every patient coming to the health care system (office or hospital) has smoking status reliably identified and recorded in an electronic information system  Every smoker seen is routinely given advice to quit, offered as much cost-effective assistance (medication and referral to behavioral support) as he/she will accept, and linked to community resources  Care is offered proactively to the population of smokers  Care is coordinated across settings and over time  Outcomes are routinely monitored, reported & improved - 6 -

- 7 - Partners Model for Tobacco Treatment  Tobacco dependence = chronic disease  Apply tools used to manage chronic diseases  Coordinate and manage care across sites and over time  Hospital inpatients (with transition to post-discharge care)  Outpatient visits (primary care)  Population-based  Strategy - Pilot test innovative strategies for each site of care - 7 -

- 8 - Partners Tobacco Treatment Model Components  Hospital inpatients  Outpatient visits  Population management - 8 -

- 9 - PHS Model for Inpatient Smokers Step 1: Routine smoking status ID at admission Step 3: Tobacco treatment counselor visit Step 3: Tobacco treatment counselor visit  In an electronic database  Generates a list of newly admitted smokers Step 4: Arrange post- discharge care  Assess medication need, interest in quitting  Offer counseling assistance to prompt quit attempt  Arranged by tobacco treatment counselor  Fax-referral to MA Quitline (free counseling)  Recommend med for discharge med list Step 2: Brief advice by care team Step 2: Brief advice by care team  Booklet put on every bed by housekeeping  MD/RN give quit advice  MD orders NRT Free telephone counseling (MA Quitline) + Medication rx + Hand off to PCP Free telephone counseling (MA Quitline) + Medication rx + Hand off to PCP  PROBLEM Few patients actually got linked to counseling or medication Inpatient Outpatient Aim 1: Treat nicotine withdrawal in inpatients Aim 2: Help smokers to stay quit after discharge

Strategies to sustain treatment after discharge Connect to counseling support after discharge Interactive voice response (IVR) system to reinforce quitting, identify smokers who want or need counseling or are not using medication Increase use of medication after discharge Give free 30-day sample at discharge to remove barrier to starting immediately

Sample of IVR Script - Day 14 call Currently: A counselor calls every smoker who requests a call New idea: Connect a smoker directly from IVR to Quitline

Helping HAND Study : Post-discharge care coordination Improving tobacco treatment delivery after discharge (RC1 HL099668) Outcomes assessed at 1, 3, and 6-month follow-up  Tobacco abstinence at 1, 3, 6 months  Use of tobacco treatment (counseling or medication)  Cost effectiveness (cost/quit)  Hospital readmissions 330 MGH Smokers seen by TTS Randomize Standard Care N=165 Extended Care* N=165 * Extended Care = 5 IVR calls (3, 14, 30, 60, 90 days after discharge) with counselor call-back option + 30 days of free medication of patient’s choice at discharge (refillable x 2)

Partners Tobacco Treatment Model Components  Hospital inpatients  Outpatient visits  Population management

PHS Care Management Model for Outpatients Population Management (Direct to Smoker Study) Goal Reach patients before illness starts Supplement effort of, reduce burden on PCPs Piloted in 1 health center Population Management (Direct to Smoker Study) Goal Reach patients before illness starts Supplement effort of, reduce burden on PCPs Piloted in 1 health center At Office Visits Goal Support brief advice or counseling by PCP at an office visit Piloted in 2 health centers At Office Visits Goal Support brief advice or counseling by PCP at an office visit Piloted in 2 health centers Common component = Tobacco Treatment Coordinator (TTC)  Manages care, coordinates smokers with providers and community resources

System for outpatient visits: Build into the PCP’s workflow “1-click referral” to Tobacco Treatment Coordinator (TTC)  PCP uses electronic health record to refer smoker to TTC  TTC calls smoker to do brief assessment, counseling, and referral to community resources (Quitline, local programs)  TTC gives feedback to PCP via , electronic record

Adopted by 2 health centers Evaluation: Feb 1, 2010-July 1, of 29 MDs used it 135 (29%) of 466 referred smokers were connected to treatment Utilization and Results of the 1-click EHR referral

Focus Groups of Physicians  What they liked  Having a way to continue their efforts  Fit into their work flow  They thought that the program should continue  What they did not like  Many patients referred were not reached or did not use service  They didn’t know who the Tobacco Coordinator was  What helped  One practice director spontaneously send his doctors their numbers of referrals each month; this set up an informal competition and generated more referrals  Our conclusion: promising approach

Partners Tobacco Treatment Model Components  Hospital inpatients  Outpatient visits  Population management

A Population-based Strategy  Supplement office-based systems with population-based approach  Reach smokers before they get sick  Reduce burden on busy PCPs  Make treatment barrier-free (no cost, no visits)  Medication  Mail free nicotine replacement (NRT) for up to 8 weeks  Counseling  Free phone call with Tobacco Coordinator  Fax referral to state quitline that offers free proactive telephone counseling for smoking cessation

Adult current tobacco smokers with their PCP at Revere Health Center Randomize Standard Care 1 letter recommending that they discuss quitting with MD Free Treatment Offer 3 mailed letters offering consultation with tobacco coordinator, referral to quitline, free nicotine patch x 8 wks Outcomes assessed at 3-month follow-up Use of tobacco treatment (counseling or pharmacotherapy) * Made quit attempt Tobacco abstinence (past 7 days, past 30 days) Cost effectiveness (cost/quit) Direct to Smoker Outreach Study * Primary outcome

INTERVENTION GROUP: 413 smokers mailed treatment offer and eligible (Receive 3 monthly letters) 43 (10.4%) respond to offer 42 (98%) request nicotine patch 41 pass medical screen and sent NRT 30 (70%) request referral to counseling Direct to Smoker Study: Results of Offer Is a 10% response to an offer of free treatment a success? State quitlines reach an average of 1.9% of smokers in their states each year (usually without the offer of free medication). With a free NRT promotion, MA and NY Quitlines reached 10% of smokers

Direct-To-Smoker (DTS) Results Patient Response To Offer  43 (10.3%) of 413 smokers in the DTS group accepted the treatment offer  42 (98%) requested NRT; 30 (70%) were referred to counseling 3-Month Follow-Up Control N=177 Intervention N=413 Used any tobacco treatment13 (7.3%)60 (14.5%)* Any counseling2 (1.1%)7 (1.7%) Any medication12 (6.8%)55 (13.3%)* Nicotine Replacement Therapy7 (3.9%)48 (11.6%)* Bupropion or varenicline7 (3.9%)15 (3.6%) Tobacco abstinence past 7 days2 (1.1%)22 (5.3%)* Tobacco abstinence past 30 days1 (0.6%)17 (4.1%)* Cost Effectiveness  $464 Estimated marginal cost per 7-day quit at 3 months * P <.05 in multiple logistic regression model adjusted for age, sex, race, insurance, CHD, diabetes

Direct-To-Smoker (DTS) Conclusion  A population-based outreach offering free tobacco treatment to smokers in a health center is:  Feasible  Cost-effective  A way to increase the reach of treatment (primarily pharmacotherapy) in a population  A promising way to increase short-term quit rates In press, Am. J. Prev. Med.

Next steps  Combine the components into a coordinated whole  Embed tobacco treatment into new models of care redesign  Primary care innovation  Care of high-risk, high-cost patients

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