1. Mayo Clinic Nicotine Dependence Center: A Working Model in a Medical Center ATTUD Inaugural Meeting December 13, 2003 Lowell C. Dale MD Nicotine Dependence Center Education Program Director Kay M. Eberman MS Nicotine Dependence Center Education Program Coordinator

2. Mayo Clinic practice sites Scottsdale, Arizona Rochester, Minnesota Jacksonville, Florida

5. Mayo Program:Background Smoke free facilities 1987 Smoking Cessation Center 1988

6. Mayo Clinic Nicotine Dependence Center Vision and Mission Vision statement: The best is where we begin Mission: To promote tobacco-free living through an integrated program of intervention services, education, and research Full concept of the treatment program. Providing choices of treatment to meet different levels of addiction and individual needs. Providing program branches for practice, research, education

7. System Changes Smoke free buildings and campus Department of Medicine support Human Resources Policy: compliance a condition of employment Employee Benefit Package: Full Coverage of all of our services and medications Easy referral: ordered like any other test Open Access: The teachable moment

8. System Changes Counselors go to the patient Outpatient area of referring physician Hospital bedside Educational Efforts Resident education (8 hours) Medical student curriculum Grand rounds, committee meetings, etc Nursing in-services Research Study recruitment Press releases

9. Basic service design: Partnership PATIENT PHYSICIANCOUNSELOR

10. Mayo NDC Current Profile: Branches of Service Research Program: Areas of investigation include treatment methods, adolescents, family and support persons, medications Separate staff and funding Education Program (Training Health Care Providers) NIH Grant funding for 2001 - 2006. Internal Mayo education: medical residents and fellows, nurses, respiratory therapy students, medical students External education: medical systems, conferences Community Outreach: Mayo Outreach to Students & Teachers Treatment Program

11. Target Population Mayo patients who are using/ have used tobacco Outpatients Hospitalized patients Self-referred for treatment of tobacco use Local patients: majority within 50 miles Average age: 50 years <10% Mayo employees/dependents <1% teens

12. The Referral Base Mayo medical community (80%) Self referral (15%) Other (5%) Regional Practices NDC Research Program Other medical groups and hospitals Community: public health, dental offices, health clubs Internet, media

13. Role of Medical Staff Leadership, vision Medical management of the center Medical back up for patients as needed (review medical conditions, medication advice, write prescriptions) Research: Primary Investigators Education: NDC staff, other professionals

14. NDC Staffing Counselor responsibilities Provide patient care Maintain records, paper and computerized Provide lectures for patients Provide information for MDs, other medical staff Train new staff Take part in NDC education program

15. Components of Care Individualized Alliance with patient: a helping relationship Counseling rather than teaching

16. Foundation for Treatment Model Chemical Dependence Concepts Behavioral Change Techniques Pharmacologic Therapy Relapse Prevention

17. Ending Tobacco Use: Process of Change Ending tobacco use may take years Relapse is common Health care provider facilitates the process of positive change Understanding the process of behavior change helps tailor initial intervention Forming a motivational partnership enhances the possibility of positive change

18. Consultation/Assessment Basic service Counselor meets with patient 45 - 60 minutes Majority of patients seen face to face one time only

19. Tools for the Consultation/Assessment Session Assessment forms Treatment interview Carbon monoxide measurement Treatment planning Medication planning Self help materials Relapse prevention system

20. Services Options for service: outpatient consultation hospital consultation on going counseling intensive individual program group program residential treatment telephone counseling (Quitline) support group Nicotine Anonymous

21. Outcome Evaluation Stop rates measured at 6 months Telephone interviews Intent-to-Treat Analysis 7 day point prevalence tobacco use status 22% - 45% stop rate Rate is higher with more intensive treatment

22. Financial Outpatient services are billed to insurance and/or the patient Hospital services are not billed directly, but can be considered in room rate adjustments

23. Insurance Coverage Medicaid/Medical Assistance Coverage varies from state to state May cover face to face counseling, medications Private insurance Varied between and within companies Call the 800# for information Telephone Quitlines Many states and third party payers offer a tobacco quitline at no charge

24. Billing Codes CPT Codes with a possible fit for outpatient services: Preventive Medicine codes: 99401 - 99412 Health and Behavior assessment codes: 96150-96155 Psychiatric dx codes: 90805 - 90809 ICD-9 diagnostic code: Tobacco use disorder 305.1

25. Determining Coding Health and Behavior Assessment codes for tobacco dependence tx are recognized by Medicare However, Medicare carriers will determine whether or not to cover the cost Best method of determining the codes to use: work with revenue recognition expert or medicare expert

26. Summary of Clinical Service Individualized counseling service provided within medical setting: the teachable moment Timely - same day service or within 24 - 48 hours of medical visit Brief focused counseling service, long follow up Choices of services following first visit Addiction basis for treatment approaches Use motivational and models for change Use tools of behavior change, medications, and relapse prevention

27. Summary Mayo program: integrated into medical setting, uses partnership, trained counselors, service options, faced many challenges Basic components of treatment: chemical dependence/chronic disease, behavior change, pharmacotherapy, relapse prevention Counseling strategies for intensive interventions include models for behavior change and motivational interviewing This type of service can be used in other settings

28. Opportunities for Growth JCAHO Enhanced Relapse Prevention Work-site Programs Educational Efforts Internally State National