Tobacco Cessation & Nicotine Addiction

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Penelope Sybil Shepherd
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1 Tobacco Cessation & Nicotine Addiction Adam O. Goldstein, MD, MPH Professor & Director Nicotine Dependence Program Department of Family Medicine UNC-Chapel Hill 1

2 Mission UNC Nicotine Dependence Program 1) Provide regional, state and national leadership for comprehensive, tobacco-use treatment services 2) Conduct innovative tobacco policy, prevention and cessation research that can dramatically decrease tobacco use across North Carolina and the U.S Resources

3 NDP Services Aligned with UNC Health Care mission Leading public academic health care system Vertically & horizontally integrated Highly effective and cost-effective Successful- region, state, national Sustainable over time Can generate $$$ to sustain many clinical functions Can save $$$ by alignment with multiple accountability functions Landscape changing dramatically Medicaid, Medicare, Private insurers now covering CDC and IOM tobacco priority national quality improvement

4 NDP-Scope of Services Outpatient NC Cancer Hospital Family Medicine Inpatient Employees Administrative Education Attending, Residents, Nurses, Students training Research Treatment knowledge and practice Community Tobacco-free policy promotion and evaluation 100% TF Hospital Campus nationally Fire-safe cigarette legislation Secondhand smoke elimination public places

5 The 5 A s of Counseling 1. Ask about tobacco use 2. Advise to quit 3. Assess willingness to make a quit attempt 4. Assist in quit attempt 5. Arrange follow-up 5

6 ASK & ASSESS Asking and Assessing vital signs 6

7 Use of Plan to Quit? Assessment Vital Sign 100% increase in documentation of plan to quit assessment (p=.03) Significantly more quit assessment for patients whose tobacco use was documented in vital signs (p=.004) 7

8 Relationship of Assessment & Advise = Cessation Counseling Of patients assessed for plan to quit 51% received at least one counseling step Of patients not assessed for plan to quit 14% received at least one counseling step Significant difference (p<0.001) 8

9 NDP Outpatient Program Growth Family Medicine 30% quit rates 6-12 months 25% reduction 6-12 months Cancer Center Y1 Y2 Y3 New appts F/U appts Support group Phone Calls Total Contacts

10 NDP Cancer Hospital Program Growth 30% quit rates 6-12 months 25% reduction 6-12 months

11 NDP Cancer Hospital Program Growth > 60 Providers referring/involved Serves all clinics in Cancer Hospital Now- based out of Radiation Oncology NDP Consults by Cancer Type Other No Cancer 30 NCCH Provider Involvement with NDP GI GYN GU H&N H&N Lung Breast GU Breast GYN GI 5 0 Other Lung No Cancer

13 UNC Health Care System policy 100% tobacco free on all campus property, including vehicles. Patients who leave campus to smoke may be discharged against medical advice.

NDP Inpatient Counseling Pfizer unrestricted educational grant UNC SOM 09-11 System Changes and Education Performance Improvement, IT,

14 NDP Inpatient Counseling Pfizer unrestricted educational grant UNC SOM System Changes and Education Performance Improvement, IT, Focus Groups, Surveys, Educational interventions Pilot testing >50 consults, 12/10 January, 2011 Full implementation > 100 consults every month

15 Provider Tools Inpatient Cessation Education

16 Identifying patient tobacco use History and physical notes E - chart

17 Nicotine Replacement Order Set 17

18 Ordering a bedside consult 1) Check consult in the Nicotine Replacement Order Set or 18

19 Ordering a bedside consult (cont.) 2) Check Smoking Cessation Consult in CPOE patient care orders Either way, order automatically triggers a page to NDP Tobacco Treatment Specialist 19

20 What happens after consult ordered Consult page goes to Tobacco Treatment Specialist (TTS), who triages requests attempts to see patient before discharge if unable to see patient, sends letter with information about Quitline and NDP Consults may be ordered 24/7. However, bedside visits take place Mon-Fri during work day (8am-5pm) 20

21 What happens after consult ordered Note of TTS visit can be found in WebCIS under Reports, Inpatient Consults. If medication changes are recommended by TTS, nurse may request from resident on duty and/or a phone note is sent to physician who ordered consult 21

22 Assessing need for withdrawal during hospital Increased chances of withdrawal if: smoke 10+ cigarettes per day (cpd) 1 pack=20 cigs first cigarette in morning less than 30 minutes after waking Recognize withdrawal symptoms Agitation Irritability Depression Constipation 22

23 For those who don t want to quit Remind of tobacco-free policy, including discharge if leave campus Order NRT If you change your mind, there are resources to help.

24 NDP- Tobacco-Free Tar Heels Program for Employees

25 NDP- Tobacco-Free Tar Heels Program for Employees

26 Administrative Policy development Policy compliance Tobacco as Vital Signs all outpatient clinics Tracking all healthcare system smokers Outpatient tools Inpatient order sets Inpatient patient education Training of volunteers Training of providers Coding

27 Outpatient systems Carolina Data Warehouse >27,000 smokers (track across every clinic) Critical for UNC Health Care Joint Commission New tobacco measures 2011 ARRA Meaningful use data tobacco Medicare Core Measures New pay for performance incentives PCMH, CCMH, CHN

28 Publicity/Reputation /

29 NDP Staff- Multidisciplinary

30 Patient & Provider Satisfaction Patients (N = 50) Providers (N = 41) It was easy for me to make an appointment 94% Treatment specialists knowledgeable 94% I will recommend NDP 90% Respondents positive about: Kinds of support provided by the TTS (strategies, education, feedback) & Character qualities of the TTS (knowledgeable, friendly, dedicated, nonjudgmental, caring)

31 In addition. UNC Health Care Employee Tobacco Cessation Program Allows UNC to attain CEO Gold Standard UNC Health Care

32 32 Reimbursement

33 Coding/Billing Tobacco Improving Target +++ Private Plans, Medicaid & Medicare Medicare, Private and Medicaid smokers can receive tobacco cessation counseling Annual Benefit- 8 sessions per beneficiary Intermediate session (3-10 minutes) Intensive session (> 10 minutes) Previous Tobacco Coding/Billing UNCHC POOR Charges Revenue Family Medicine 452 $11,800 Medicine 895 $7,900 Heart/vascular 142 $1,113 Neurology 8 $56 Ob-Gyn 3 $53 ENT 5 $84 PM&R 1 $25 ER 1 $23

34 Coding/Billing Potential High Goal is to train providers and increase coding, counseling, billing, revenue

35 Cutting edge cessation measures Meaningful use data JCAHO Measures PCMH 35

36 Meaningful use of EMR Eligible hospitals and eligible providers CORE set: smoking status A user must be able to electronically record, modify, and retrieve the smoking status of a patient. Smoking status types must include: Current every day smoker Current some day smoker Former smoker Never Smoker Smoker, current status unknown Unknown if ever smoked

37 Eligible professional quality measures CORE set: tobacco a. Percentage of patients aged 18 years and older who have been seen for at least 2 office visits who were queried about tobacco use one or more times within 24 months b. Percentage of patients aged 18 years and older identified as tobacco users within the past 24 months and have been seen for at least 2 office visits, who received cessation intervention.

38 38

39 Value added by UNC NDP Maintain effective, comprehensive, sustainable, service UNC Health Care ROI benefits Employee program Total Costs $94,000 Cost per successful quitter < $2000 Annual excess costs smoking UNC Health Care Coding/Billing Clinic program & outcomes Teaching mission UNC Health Care Reputation & Differentiator ARRA Clinical Trials $5.78 million

40 Community Quit Line Presentations Conferences Target Groups At-risk populations Providers Training Reimbursement Leadership Hospital-Based Inpatient consults Visitors Resources A Comprehensive Program for Nicotine Addiction Evaluation Utility Focused Health System Research Teaching Policies Leadership Cessation Classes Medications Telephone Support Self-Help Materials Meaningful use Clinics Outpatient programs Resources

41 Thank you.. tobacco programs are "fundamentally important and should never be discounted because they become the stories of the organization, building its culture, giving the organization meaning.. [and] are "value proposition, or consumer value differentiation. Cheryl Scott Former Group Health CEO/Gates Foundation Advisor Global Health

Meaningful Use - The Basics

Meaningful Use - The Basics Presented by PaperFree Florida 1 Topics Meaningful Use Stage 1 Meaningful Use Barriers: Observations from the field Help and Questions 2 What is Meaningful Use Meaningful Use