Tobacco Treatment at Partners Health Care: An Update

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Tobacco Treatment at Partners Health Care An
Update

• Nancy Rigotti, MD
• Patricia Reid Ponte, RN, DNSc, FAAN

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PARTNERS TOBACCO TREATMENT TASKFORCE
Established February 2005 Sponsors High
Performance Medicine III / CNO Liz Mort and
Jeanette Ives Erickson Co-chairs Nancy Rigotti
and Pat Reid Ponte Members
Rohit Ahuja Jeffrey Arnold Judy Balboni Ellen
Bennett Patti Brita Rossi Mary Ellen
Chambers Kathleen Codair Mary Cooley Susan
DeCristofaro
Ann-Marie Duffy Jonathan Einbinder Joy
Feeney Judith Flynn Marlene Freely Ann
Furey Pragati Ghimire-Aryal Maureen Herget Joanna
Hilgenberg
Jennifer Kelley Karen Maney Bruce Mattus Nancy
McCleary Elyse Park Sue Regan Michele Reyen Anne
Richmond Joanne Rowley
Patricia St. Pierre Melinda Sanchez Louise
Schneider Sandra Skinner Anne Thorndike Cecilia
Vieira Cheryl Williams Jonathan Winickoff
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THE VISION An Ideal Tobacco Treatment System

• Every patient coming to PHS hospital or office
  has smoking status reliably identified and
  captured in an electronic information system.
• Every smoker seen at a PHS hospital or office is
  routinely given advice to quit, offered
  cost-effective assistance (medication and
  referral to behavioral support), and linked to
  appropriate community resources.
• Public private payers reimburse for counseling
  meds
• Outcomes are routinely monitored and improved.
• Care is offered proactively to the population
  (DTS)

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ORIGINAL CHALLENGE Fix a Problem!
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THE ORIGINAL CHALLENGE Fix a Problem!
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FY08 PHS TOBACCO TREATMENT TASK FORCE GOALS

• Achieve 90th ile performance on Smoking
  Cessation National Hospital Quality Measures
• Achieve pay-for-performance (P4P) targets
• Continue development of a population-based
  strategy to improve treatment of tobacco use
  across Partners (inpatient and outpatient)

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Strategy to Reach FY08 Goals

• Inpatient
• Start a Hospital Champions group
• Ann Furey (BWH), Bruce Mattus (FH), Michele Reyen
  (MGH), Sandy Skinner
  (NSMC)
• Share strategies, best practices standardize
  data collection systems
• Outpatient
• Complete test of LMR Tobacco Module (CEASCE)
  (adults)
• Advocate for LMR Secondhand Smoke Module
  (pediatrics)
• Both
• Start to build a registry of smokers at PHS/PCHI
• Think about population management

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FY08 TOBACCO TASK FORCE ACCOMPLISHMENTSThe red
is almost gone
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FY08 TOBACCO TASK FORCE PLANACCOMPLISHMENTSInpa
tients

• We improved processes of care
• Did we improve outcomes?
• How many of our admitted smokers are reached?

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Smokers seen in the past year
Total across all hospitals 12,162
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Adult admissions in past year
Total Hospital Admissions 134,327
?
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Percent of admitted smokers seen
Assuming 15 of admitted patients are smokers
250?
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FY08 TOBACCO TASK FORCE PLANInpatients

• We improved processes of care
• Did we improve outcomes?
• What are our smoking cessation rates?
• MGH does routine follow-up at 2 weeks and 3
  months
• How can we collect this data cost-effectively?

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Interactive Voice Response System

• Automated telephone call system
• Makes calls to patients after discharge
• Assess smoking status
• Assess use of treatment services after discharge
• Assess need for additional support
• Piloted at MGH - Oct 2007-July 2008
• Team Sue Regan, Michele Reyen, Abby Lockhart,
  Sharon Shenhav, Ann Richards, Nate Cobb,
  counselors, Nancy Rigotti

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Interactive Voice Response System

• Pilot Study
• gt800 inpatients seen by MGH counselor - Oct
  2007-July 2008
• ½ get usual care
• Human calls at 2 weeks and 3 months to assess
  outcomes
• ½ get IVR system
• 4 IVR calls (3, 7, 14, 30 days after discharge)
  3 mo f/u human call
• Study Questions
• Will our patients answer IVR calls?
• How often do smokers request additional
  counseling?
• What are the quit rates?
• Results this afternoon

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New Inpatient Project in progress

• What is the true prevalence of smoking among
  patients admitted to MGH?
• How completely and accurately is it recorded in
  chart?
• Collected 1000 bloods left over after admission
  tests done (random 40 sample of adult
  admissions, June-July 2008)
• To be analyzed at UCSF for cotinine (nicotine
  metabolite)
• gt15 ng/ml smoker
• 0.05 15 ng/ml secondhand smoke exposure
• lt0.05 mg/ml nonsmoker with no secondhand smoke
  exposure
• Chart review what smoking status is documented
  in chart?

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FY08 TOBACCO TASK FORCE PLAN Outpatients

• LMR Tobacco Module study (CEASCE)
• CEASCE team
• Jeff Linder, Jennifer Haas, Jennifer Kelley,
  Louise Schneider, Susan Regan, Phyllis
  Brawarsky, Nancy Rigotti

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Identifies patient as a smoker
Reminds physician to address smoking
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FY08 TOBACCO TASK FORCE PLAN Outpatients

• Completed LMR Tobacco Module study
• 26 primary care practices affiliated with BWH and
  MGH
• Tested for 9 months (Dec. 19, 2006-Sept. 30,
  2007)
• Data analysis completed
• Results stay tuned (next presentation)
• CEASCE team
• Jeff Linder, Jennifer Haas, Jennifer Kelley,
  Louise Schneider, Susan Regan, Phyllis
  Brawarsky, Nancy Rigotti

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FY08 TOBACCO TASK FORCE PLANOutpatients

• LMR Second Hand Smoke Module
• Pediatric practices
• Implemented spring 2008
• Analysis underway
• Early results this afternoon (Cecilia Vieira)
• Team Cecilia Vieira, Jonathan Winickoff

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FY08 TOBACCO TASK FORCE PLANPartners Tobacco
Registry

• Goal Integrate inpatient and outpatient smoking
  information from all PHS entities into a single
  source
• Status In process of retrieving and testing all
  available smoking data elements from the five
  hospitals
• Quality Data Management team is working on
  Smoking Database design

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FY09 PHS TOBACCO TREATMENT TASK FORCE GOALS
(draft)

• Achieve 90th ile performance on Smoking
  Cessation National Hospital Quality Measures
• Continue integration across tobacco programs
• Develop population management model for tobacco
  treatment (inpatient and outpatient)
• Lay groundwork for P4P tobacco measure
• Promote smoke-free campuses how big a priority?

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FY09 TOBACCO TASK FORCE PLANInpatients

• Standardize data collection systems
• Extend IVR to collect outcome data beyond MGH?
• Requires specific level of data collection
  capacity at each hospital

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FY09 TOBACCO TASK FORCE PLANOutpatients

• Implement simpler version of CEASCE in LMR
• Existing smoking icon and reminder.
• Build 1-click electronic referral to Partners
  tobacco coordinator, accessible from LMR smoker
  icon.
• Add smoking status to flow sheet so that medical
  assistants can enter smoking status when checking
  in patients, thereby offloading PCPs

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Population ManagementTobacco Care Coordination
Tobacco Coordinator electronic data systems

• Care for outpatients
• Care for hospital patients after discharge
• Contact smokers directly (using Registry)

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PHS Central Tobacco Cessation Model
Inpatient
Outpatient
H
H
H
H
H
TOBACCO REGISTRY
Acute Care Documentation
LMR
PHS Hospitals
OnCall
GE Centricity
Ask to LMR CCC Build this IS connection
Central Tobacco Coordinator
IVR
PHS Smokers
Hospital Based Programs (in-person counseling)
MA QuitLine
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The PHS Tobacco Treatment Coordinator will

• Be the counselor on the other end of the LMR
  1-click referral button
• Contact patients by phone/email to coordinate
  treatment
• Initiate warm transfer to Mass Quitline
• Describe, facilitate start of a cessation
  medication
• Follow those who start meds (esp varenicline) to
  monitor safety issues?
• Provide feedback to referring physician
• Add patients to the registry and document actions
  in LMR
• Support inpatient follow up if/when IVR expands
  beyond MGH

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FY09 TOBACCO TASK FORCE PLANPromote cessation
medication use?

• Could encourage smokers to try to quit
• Could improve cessation rates from counseling
• PHS has purchased some NRT patches to give away
  (2 week starter kits)
• How shall we use them?
• Population contact patients via registry
• Outpatients via PCPs tobacco coordinator offers
• Inpatients offer at discharge to those willing
  to quit

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Potential Tobacco P4P Measure

• Measure
• of patients in panel who have smoking status
  documented in a coded (not text) field
• Method LMR and GE data analysis (easy to
  measure)
• Current status 20.2(1)
• Goal Eventual gt95 (?)
• Year 1 small improvement over existing rate

(1) All patients (age gt/ 18) with LMR data in
QDW, with gt/ 1 visit between 5/1/07 and 4/30/08
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Smoke-free Campuses

• New project idea coming from Hospital Champions,
  Residents, Nurses
• Spreading nationwide and locally
• Hear U Mass Med Centers experience today
• How big a priority is it for the Task Force?
• Who is willing to lead it and make it happen?

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Welcome Sara Lehrhoff

• Please join me in welcoming Sara.
• Sara is joining HPM Team 3 as the new Project
  Manager.

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FORMAT FOR THE REST OF THE DAY

• CEASCE LMR Study Outcomes
• Break
• Scientific Update
• Strategies for Dealing with Difficult Patients
• Lunch
• Interactive Voice Response Technology
• Secondhand Smoke Exposure in LMR
• Smoke Free Campuses
• Wrap up/Thank you

• 945 1005
• 1005 1015
• 1015 1045
• 1045 1200
• 1200 100
• 100 120
• 120 140
• 140 225
• 225 230

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Bottom Line

• Weve done a great job!
• But, we are not done.
• We have only just begun