11

If They Won’t Come to If They Won’t Come to You…You…

Reaching the Hard to ReachReaching the Hard to Reach

““Infiltrating the Systems”Infiltrating the Systems”

Catherine Suiter, M.Ed.Catherine Suiter, M.Ed. Statewide Tobacco Cessation CoordinatorStatewide Tobacco Cessation Coordinator

Vermont Association of Hospitals and Health SystemsVermont Association of Hospitals and Health Systems

22

The SystemsThe SystemsHospitalsHospitals

Outpatient ClinicsOutpatient ClinicsThe WorkplaceThe Workplace

33

Vermont Vermont Cessation Cessation ProgramProgram

Clinically based programClinically based program Local Tobacco CoordinatorLocal Tobacco Coordinator

•At all 14 hospitals in the state including At all 14 hospitals in the state including VAVA

•Provides local classes and 1-1 counselingProvides local classes and 1-1 counseling Provides access to free or low cost NRTProvides access to free or low cost NRT

Vermont Quit LineVermont Quit Line

44

Cessation SystemCessation System

LAKE CHAMPLAIN

EDEN

STOWE

JAYDERBY

MILTON

RIPTON

LOWELL

PERU

FAIRFIELD

TROY

LEWIS

DANVILLE

NEWBURY

GROTON

IRA

HIGHGATE

DANBY

ESSEX

CHESTER

BETHEL

JAMAICA

CHITTENDEN

CABOT

DORSET

ORWELL

RUPERT

BARTON

CALAIS

BARNET

POWNAL

PAWLET

BENSON

CONCORD

CORINTH

CAMBRIDGE

BOLTON

BRIGHTON

LINCOLN

HALIFAX

TOPSHAM

BARNARD

WINHALL

SWANTON

BRISTOL

VICTORY

DOVER

BURKE

LYNDON

ALBANY

NORTON

PEACHAM

BERLIN

SUTTON

WARREN

ADDISON

JOHNSON

FAIRFAX

ELMORE

AVERILL

SHARON

ROCHESTER

GRANBY

NORWICH

GLOVER

GRANVILLE

READING

UNDERHILL

ORANGE

STRATTON

FERDINAND

WALDEN

MENDON

HOLLAND

RANDOLPH

FRANKLIN

PLYMOUTH

RICHFORD

DUXBURY

ENOSBURG

GEORGIA

LUDLOW

NEWARK

BRIDPORT CHELSEA

HARTFORD

HARTLAND

KIRBY

POULTNEY

THETFORD

ROXBURY

SHELDON

POMFRET

ALBURG

NEWFANE

BRANDON

GRAFTON

WESTON

RYEGATE

CANAAN

WOLCOTT

JERICHO

PITTSFORD

KILLINGTON

MONTGOMERY

IRASBURG

SANDGATE

GUILFORD

FERRISBURG

WOODFORD

FAYSTON

WATERBURY

HANCOCK

BERKSHIRE

TUNBRIDGE

ROYALTON

SHOREHAM

SPRINGFIELD

STRAFFORD

VERSHIRE

STAMFORD

FLETCHER

MORRISTOWNHARDWICK

MORGAN

LUNENBURG

MONKTON

ARLINGTON

NORTHFIELD

NEW HAVEN

MARLBORO

CASTLETON

WHEELOCK

MIDDLESEX

WESTFIELD

WESTFORD

CHARLOTTE

BRAINTREE

WELLS

CAVENDISH

SHREWSBURY

HYDE PARK

PUTNEY

WOODSTOCK

BRIDGEWATER

MARSHFIELDHINESBURG

MOUNT HOLLY

MORETOWN

TOWNSHEND

BROOKFIELD

SUNDERLAND

STARKSBORO

WESTMORE

STOCKBRIDGE

WOODBURY

BENNINGTON

BAKERSFIELD

WESTMINSTER

SHAFTSBURY

BLOOMFIELD

WILMINGTON

GLASTENBURY

ROCKINGHAM

WATERFORD

MIDDLEBURY

WHITINGHAM

WALLINGFORD

WORCESTER

MANCHESTER

GUILDHALL

RICHMOND

MOUNT TABOR

EAST HAVEN

LEMINGTON

SHEFFIELDCRAFTSBURY

HUNTINGTON

CHARLESTON

ANDOVER

BELVIDERE

READSBORO

WILLISTON

WASHINGTON

GREENSBORO

TINMOUTH

BRADFORD

NEWPORT TOWN

COLCHESTER

WINDHAM

MAIDSTONE

WEATHERSFIELD

WILLIAMSTOWN

SOMERSET

FAIRLEE

GOSHEN

SALISBURY

CLARENDON

CORNWALL

COVENTRY

LONDONDERRY

ST. JOHNSBURY

WARDSBORO

VERNON

SUDBURY

BARRE TOWN

BRATTLEBORO

ST. ALBANS TOWN

WAITSFIELD

SHELBURNE

BRUNSWICK

WINDSOR

DUMMERSTON

HUBBARDTON

WEST HAVEN

PANTON

LEICESTER

PLAINFIELD

BROWNINGTON

PITTSFIELD

EAST MONTPELIER

RUTLAND TOWN

SEARSBURG

WHITING

FAIR HAVEN

WEST FAIRLEE

WEST WINDSOR

ATHENS

WEYBRIDGE

GRAND ISLE WATERVILLE

AVERY'S GORE

WEST RUTLAND

SOUTH HERO

STANNARD

BROOKLINE

MIDDLETOWN SPRINGS

SO. BURLINGTON

WALTHAM

BURLINGTON

MONTPELIER

PROCTOR

LANDGROVE

WARREN'S GORE

ISLE LA MOTTE

RUTLAND CITY

NORTH HERONEWPORT CITY

BALTIMORE

BUELS GORE BARRE CITY

ST. GEORGE

VERGENNES

WARNER'S GRANT

WINOOSKI

ST. ALBANS CITY

ProposedHospital Service Areas (HSAs)

Based on 1997-2001 DataInpatient Dischargeswith Acute Diagnoses

Out of State Reassigned

Geographic AreasBarre

Bennington

Brattleboro

Burlington

Middlebury

Morrisville

Newport

Randolph

Rutland

St. Albans

St. Johnsbury

Springfield

White River Jct.

5/17/04

55

Snapshots of VermontSnapshots of Vermont Population Population 613,000613,000 25%25% in Burlington in Burlington

areaarea Outside the cityOutside the city

Very ruralVery rural 44 people /sq. mile44 people /sq. mile

Geography and Geography and weather impede travelweather impede travel

66

Snapshots of VermontSnapshots of Vermont Fours years into programFours years into program 6500 clients6500 clients 12,000 NRT coupons 12,000 NRT coupons

distributeddistributed Smoking prevalence Smoking prevalence

dropped from 22.4 to dropped from 22.4 to 19.5%19.5%

17% Quit Rate at one year17% Quit Rate at one year

77

More SnapshotsMore SnapshotsClientsClients March March

20022002March March 20052005

DisabledDisabled 7%7% 13%13%

<HS graduate<HS graduate 12%12% 15%15%

Co-occurring Co-occurring medical DXmedical DX

44%44% 60%60%

UninsuredUninsured 12%12% 22%22%

Join classesJoin classes 52%52% 29%29%

88

The Hard to ReachThe Hard to Reach ““We have plucked the low We have plucked the low

hanging fruit”hanging fruit” If they do not come to us, we If they do not come to us, we

will go to themwill go to them In hospitalsIn hospitals In clinicsIn clinics In the work placeIn the work place

99

Nicotine Intervention in the Nicotine Intervention in the Hospitalized PatientHospitalized Patient

Mary Anne Riley, RRTMary Anne Riley, RRTNicotine Cessation Coordinator, Nicotine Cessation Coordinator,

Springfield HospitalSpringfield Hospital

1010

The Facts:The Facts:70% of current smokers want to quit.

Smokers rate physician’s advice as incentive to quit smoking

““The influence your role as a health care provider carries in helping The influence your role as a health care provider carries in helping smokers quit cannot be overstated. A clinician’s advice to quit smokers quit cannot be overstated. A clinician’s advice to quit improves success in maintaining abstinence. With the addition of a improves success in maintaining abstinence. With the addition of a few minutes of counseling, the success rate doubles “ few minutes of counseling, the success rate doubles “

U.S. Public Health Service (2000)U.S. Public Health Service (2000)

1111

How do you find these How do you find these patients?patients?

Develop a system to identify current smokers admitted to

ER ICU PRE-OP MEDICAL/SURGICAL MATERNITY PSYCHIATRY DISCHARGE PLANNING

Develop a flow sheet or charting system to document initial visit and follow-up visits – make it accessible to other members of the patient’s care team.

1212

Nicotine consult to the Nicotine consult to the cessation coordinator, or cessation coordinator, or department in charge of department in charge of providing this service.providing this service.

NRT orderNRT order

Educate staff, physicians, Educate staff, physicians, and anyone who may and anyone who may initiate a consult.initiate a consult.

1313

What do you say?What do you say? Do they want to quit ?Do they want to quit ?

Provide the 5 A’sProvide the 5 A’s

Are they only interested in help to control Are they only interested in help to control their cravings while in the hospital? their cravings while in the hospital? Provide the 5 R’sProvide the 5 R’s

NO PREACHING ALLOWED! NO PREACHING ALLOWED! Just talk to them and find our how you can Just talk to them and find our how you can

help by help by listening.listening.

1414

what do you say what do you say continued…continued…

THE 5 A’sTHE 5 A’s ASKASK ADVISEADVISE ASSESSASSESS ASSISTASSIST ARRANGEARRANGE

THE 5 R’sTHE 5 R’s RELEVANCERELEVANCE RISKSRISKS REWARDSREWARDS ROADBLOCKSROADBLOCKS REPETITIONREPETITION

or…

1515

Provide feedback to their statements, Provide feedback to their statements, concerns, or possible barriers to success.concerns, or possible barriers to success.

NRT- what is available in the hospital NRT- what is available in the hospital setting. setting.

Ask open-ended questions rather than Ask open-ended questions rather than “yes” or “no” ones. “yes” or “no” ones.

Provide written education if requested, Provide written education if requested, at least leave a contact phone number at least leave a contact phone number and cessation class information for and cessation class information for follow-up after discharge.follow-up after discharge.

1616

Treating Tobacco Use and Treating Tobacco Use and Dependence as a Chronic Dependence as a Chronic

Disease:Disease:Developing Office-Based Developing Office-Based

SystemsSystems

Evelyn Sikorski, CSW, CEAP, TTSEvelyn Sikorski, CSW, CEAP, TTSFletcher Allen Health Care - Burlington VTFletcher Allen Health Care - Burlington VT

1717

Cessation CounselingCessation CounselingPrimary Care SettingPrimary Care Setting

Provide motivational interview to Provide motivational interview to patients after advice to quit patients after advice to quit

Evening appointments for Evening appointments for individuals and couplesindividuals and couples

Model intervention with physician Model intervention with physician to increase skill setto increase skill set

Stock readiness literature and Stock readiness literature and posters for exam roomsposters for exam rooms

1818

Recognizing and Applying Best Recognizing and Applying Best Practice GuidelinesPractice Guidelines

Tobacco dependence is itself a disease and Tobacco dependence is itself a disease and not simply a risk factornot simply a risk factor

Tobacco use and dependence is a chronic Tobacco use and dependence is a chronic diseasedisease

Tobacco use and dependence can be Tobacco use and dependence can be treated effectivelytreated effectively

Local resources exist to assist current Local resources exist to assist current tobacco userstobacco users

1919

STEPS to create an effective STEPS to create an effective IDENTIFICATION systemIDENTIFICATION system Identify key partners (AHEC)Identify key partners (AHEC) Organize a team and designate a leaderOrganize a team and designate a leader Conduct a self-assessment of the current Conduct a self-assessment of the current

tobacco treatment systemtobacco treatment system Develop a site specific planDevelop a site specific plan Implement a system to address tobacco Implement a system to address tobacco

cessationcessation

2020

Referral PadsReferral Pads

2121

2222

Infiltrating the WorksiteInfiltrating the Worksite

Jamie Balch, MSNJamie Balch, MSNNorthwestern Medical Center, St. Albans, Northwestern Medical Center, St. Albans,

VermontVermont

2323

Building WithinBuilding Within Local ResourcesLocal Resources

Local PartnersLocal Partners Local ProvidersLocal Providers Local EmployersLocal Employers

2424

Cardiovascular Health Cardiovascular Health Improvement ProgramImprovement Program

Evidenced Based Screening ProgramEvidenced Based Screening Program Outcome drivenOutcome driven ReplicableReplicable Successful!Successful!

2525

CHIP CHIP Screening Screening

ReportReport

2626

Worksite PilotWorksite Pilot Selling the ideaSelling the idea FundingFunding ImplementationImplementation EvaluationEvaluation Success and ObstaclesSuccess and Obstacles From hereFrom here

2727

from here…from here… Broader ImplementationBroader Implementation

Community SitesCommunity Sites Worksite MarketingWorksite Marketing

• Links to local chronic disease initiativesLinks to local chronic disease initiatives Statewide Initiatives Statewide Initiatives

• Ladies First/Wise womanLadies First/Wise woman• Networking with additional service Networking with additional service

areasareas• Working toward a broader registryWorking toward a broader registry

2828

More Opportunities to “Infiltrate”More Opportunities to “Infiltrate” Inpatient settingsInpatient settings

Nursing homesNursing homes StaffStaff

ClinicsClinics Planned Planned

ParenthoodParenthood Free clinicsFree clinics

WorksiteWorksite Food shelfFood shelf Salvation ArmySalvation Army Urban Urban

ministriesministries

2929

Remaining GapsRemaining Gaps

18- 24 year olds18- 24 year olds

Pregnant womenPregnant women

3030

Questions?Questions?