Maine Tobacco HelpLine Fax Referral Promotion

Strategies Sandi Kazura, MD

MaineHealth-Center for Tobacco Independence NAQC Conference – August, 2012

Kansas City, Missouri

Disclosures

Salary support – Partnership for a Tobacco-Free Maine, Maine

CDC

Acknowledgements

Kimberly Harvey, MPH Katherine Ryan, PhD Cori Holt, MBA Dorean Maines, MPA

David Spaulding, BA Alere Wellbeing, Inc. InterMed Best

Practices Committee

Fax Referrals – The Numbers NB: 2012 #s are for first 6 months only!

Maine & Tobacco - Background

Maine Tobacco HelpLine Key Facts

Opened in 2001

Has provided service to 74,000+ tobacco users

Treatment reach has ranged from 1.7 – 6.4% 2011 reach rate = 3.3%

2011 quit rate = 28.1% (7-month, 30-day PP)

Clinical Outreach Development Themes of breadth, depth, focus

Education model Early model Goal: wide reaching dissemination of As

Office systems model Includes traditional CEU But assesses and provides feedback and consultation about office

systems and patient flow procedures to enhance As delivery

Focused messaging “Strive for Five” referrals/month

Flexible offerings – offices are in different “stages” of action

CO Changes, 2007-2011 FY # Ref # Sites Strategy Comments

2007 1051 141 Education; passive referral – encourage pts to call MTHL, handout brochures

Standardized 1-hr CME/CEU; per diem COEs

2008 869 153 Education; passive referral More tailoring of CME to specialty; revision of toolkit – more user friendly

2009 693 201 Education; fax referrals discussed

Toolkits include fax referral form; systems model piloted

2010 940 153 Message change from “refer to the MTHL” to “FAX a referral to the MTHL”

ARRA funding –more success with outpt than hospitals; salaried COEs, added coordinator

2011 1704 191 Proactive referrals emphasized; systems model predominates

Preparing for Meaningful Use needs, e-referrals

Focus the Message Faxing a referral to the MTHL

is one of the best ways to help support your patient's quit attempt. Your support makes a difference.

The fax referral form has been simplified to better accommodate your busy schedule. It is also available electronically and can be emailed if that is more convenient.

The customer’s primary care provider will receive a notification letter from the MTHL when the patient enrolls.

Services Now Offered Education & training

“how” to identify, assess, fax refer

Practice assessment Consultation for improving tobacco treatment Other technical support, e.g. resources for patient

education material

CO Teams Today State-funded

Program Manager – 0.6 FTE Program Coordinator – 1 FTE

Technical support Scheduling Record keeping

Clinical Outreach Educators (COEs) – 1.5 FTE; 3 COEs Background – health-related Masters degree preferred Training – 5 weeks of training prior to field work Field-based outreach, training, assessment, technical assistance

Private – MaineHealth Program Manager - MA; 0.6 FTE Clinical specialist NP; o.7 COE – TTS-C; 0.8 FTE

COE Training Tobacco treatment foundation

PHS Guideline; CDC Action Guide TTS training activities Structured self-study

Observation of MTHL & clinic (face-to-face) Orientation to CO procedures, forms Presentation content and skills Field observations Mock office visit Supported office visits (program manager observes) Solo office visits Ongoing in-service

Updates in tobacco treatment Relevant national and local policy

Evolution of Practice Recruitment

Cold calls to offices Grand Rounds and other professional

presentations Letters from Maine CDC Tobacco Control

Program Manager Grants for specific populations Systems of care recruited, and key

administrators and/or practitioners help to recruit practices

Fax Referrals – The Numbers NB: 2012 #s are for first 6 months only!

All Registered Tobacco Users Method of Entry, CY 2007-2012

Fax Referrals – Disposition, CY 2007 - 2012

Disposition – room for improvement?

Comments Average # referrals/provider – room

to improve How well are providers assessing

readiness to quit? Can we improve engagement once

we have people on the phone? More MI for ambivalence? Stronger orientation to what we

provide Improve flow between registration

and counseling? Are we losing participants because

the MTHL can’t provide NRT to those with MaineCare (Medicaid)?

*estimated #

Quit Outcomes, FY 2011

Follow Up Cohort (N=811)

30 Day PP % 95% CI

Fax Referred 115 33.0 24.4 - 41.6 HA HCP 205 33.2 26.8 - 39.7 All Others 491 24.8 21.0 - 28.6

*p=.04, chi sq

Do fax referred registrants resemble self-referred?

FY12 Fax Referred (N=1,122)

HA HCP (N=1,376)

All Other HL (N=3,846)

Age 18-24 25-34 35-64 65+

5.5% 13.1% 68.6% 12.5%

7.8% 15.7% 63.7% 11.9%

11.1% 20.5% 61.0% 6.8%

Female 56.3% 55.4% 48.9%

Race/Ethnicity White, NH Other Race, NH Hispanic

81.6% 17.3% 1.2%

90.1% 8.7% 1.2%

87.2% 11.3% 1.5%

Education Less than HS High School Beyond HS

12.7% 37.9% 23.6%

17.1% 40.6% 37.4%

10.2% 37.2% 44.2%

Rural Locality 37.4% 43.7% 37.9%

Insurance Status Commercial Uninsured Medicaid Medicare

31.38% 16.1% 38.5% 11.5%

26.7% 24.5% 29.9% 16.0%

28.9% 29.5% 25.4% 9.9%

Illness (CAD, COPD, DM, Asthma) None

One Two 3 or More

49.4% 31.3% 13.9% 5.4%

56.3% 28.8% 11.9% 3.0%

70.3% 21.1% 6.7% 1.9%

HL Service Used General Questions Only Materials Only One Call Program Multiple Call Program

0.9% 2.2% 36.2% 60.7%

2.5% 0.3% 10.9% 86.3%

5.0% 0.4% 10.4% 84.2%

Case Study – InterMed ref. copied with permission from an InterMed in-house presentation

InterMed articulates a primary goal for

tobacco “Provide education, referrals, and medication for

long term abstinence from tobacco use. To assess tobacco independence quit rates* for InterMed patients who currently use or have used tobacco.” • Currently 3,000 or 6% known active smokers. • 15,000 patients with unknown smoking status.

*Successful quit attempt defined as: No tobacco use documented in smoking history for 6 months

InterMed Team Approach ref. InterMed in-house presentation

Utilize your resources: Cheerleader, Business Intelligence, EMR Super-User, Nursing Staff, Administrative Team… empower those around you. (find those with intrinsic motivation).

3 step process… start to finish (keep it simple).

“If you build it, they will come” (find a common ground).

InterMed Timeline, ref. InterMed in-house presentation

Maine Tobacco Hotline and InterMed begin discussions. PDSA style learning

and program starts. Pod – 8-4 and FRFP only

Outreach phone calls to current tobacco user at Foden Road Family Practice

Reports between InterMed and Center for Tobacco Independence go from monthly to weekly. Action plans in EMR with outreach letters and education material.

InterMed Pilot Program initiated; Program involvement with payers,

community groups and internal strategic tobacco specialist

2013

May 2012

January 2012

August 2011

Referral Process – Electronic

InterMed working side by side Patient = MTHL

Initial Phone Call

1 week after encounter #2 – InterMed letter

Call #2 MTHL

Call #4 MTHL

Follow-Up Call #1

1 week after encounter #3 – InterMed phone call

Call#3 MTHL

1 week after initial encounter – InterMed phone call

1-2 days after faxed referral – call from MTHL

6 month after initial referral – OV/fu or phone call

Completed Program

Still Using Tobacco

Able to register again at 6 months*

Tobacco-Free

*follow phone protocol

Consult InterMed –Referral, M THL Consult

Process map for a MTHL referral

INTERMED Pending Declined Services

Already Enrolled

Not Reached

Accepted Services

Current Received

YTD Received

Oct-11 2 1 0 6 10 19 19 Nov-11 7 6 0 13 15 41 60 Dec-11 2 1 0 7 14 24 84 Jan-12 4 5 0 18 19 46 130 Feb-12 2 2 1 8 7 20 150 Mar-12 3 2 0 11 16 32 182 Apr-12 5 3 1 11 14 34 216

YTD Totals 25 20 2 74 95 216

0 5

10 15 20 25 30 35 40 45 50

Accepted Services

Not Reached

Already Enrolled

Declined Services

Pending

InterMed = 6 months Aggregate Referral Information

Challenges

Trust Transition to EMR & e-referrals Geography NRT eligibility & MaineCare Competing priorities in the health care

system Nature of work/staffing Feedback reports

Trust

Practitioners want to know Who we are Quality of our work Will we treat their patients well Will we provide feedback

Some solutions COE relationship building – gets to know practice and

is “face” of MTHL Provide quit outcomes and satisfaction data Assess and communicate feedback needs to MTHL

EMR & E-Referrals Time of change

Practices in different stages of adoption Staff often stressed with work flow changes, learning EMR Costs and training demands with changes to EMR Getting different EMR systems to “talk” with each other

Some solutions COEs getting trained in EMR use Developed HIPAA compliant information transfer procedures Invest $ to help key systems integrate tobacco treatment

modules in EMR, e.g. programmer time

“you can’t get theyah from heyah”

NRT Eligibility

MaineCare (Medicaid) not eligible for MTHL NRT but must get prescription from health care provider, even for OTC NRT

Solution Change to eligibility rules? Cue to provider to prescribe at time of referral

Competing Priorities Re-organization of health care system, accountable care Demands to respond to specific disease conditions EMR roll-outs Reimbursement concerns

Some solutions

COEs need to be familiar with these other demands Creative integration when possible,

e.g. tobacco metrics and meaningful use metrics Work with public health advocates

Nature of Work On-the-road vs in-the-office People-centered vs reporting demands Working with providers and staff who may be feeling

burnout Customer service needs – predictably unpredictable Last minute scheduling changes

Some solutions

Thoughtful interview process – look for job/skills/interest “match” Training and support Coordinator to optimize resources and needs, respond to needs

promptly

Feedback Reports Spelling

Are these all the same practice? Family Health Center of Cumberland, The Family Health Center of

Cumberland, Cumberland Family Health, Family Health Center of Cumburland….

Providers who work for multiple practices/agencies Which practice/agency gets credit?

Maintaining accurate provider databases and linking these to registrant level data

Some solutions Drop-down menu for provider and practice information

Limit who can add to this list Pre-filled, practice specific referral forms E-referrals, e-feedback Contact source when referral form incomplete

Key Points Build trust Match staff skills and personalities to job needs Focus the message Flex intervention to the practice “stage” Integrate “larger system” needs, e.g. meaningful

use documentation Provide practical assistance with problems Provide feedback Engage in quality assessment and improvement

with quitline activities

Questions?