Helping our Neighbor Webinar Series Lending a Helping Hand: Implementing HUD s Smoke-Free Public Housing Rule

Transcription

1 Helping our Neighbor Webinar Series Lending a Helping Hand: Implementing HUD s Smoke-Free Public Housing Rule Presented by: Tobacco Prevention and Control Branch N.C. Division of Public Health

2 Joining the Audio TO USE YOUR COMPUTER'S AUDIO: When the webinar begins, you will be connected to audio using your computer's microphone and speakers (VoIP). A headset is recommended. --OR-- TO USE YOUR TELEPHONE: If you prefer to use your phone, you must select "Use Telephone" after joining the webinar and call in using the numbers below. +1 (562) Access Code: Audio PIN: Shown after joining the webinar

3 Housekeeping All participants are automatically muted. To ask a question please type your question in the question box. Questions will be answered at the end. If you are joining via phone ONLY, you will not be able to ask questions. Please us any questions you have after the webinar. During the question and answer session at the end, please click the Raise Hand button to indicate that you would like to speak.

4 Purpose Brings you: Evidence-based and culturally relevant strategies to assist with smoke-free public housing implementation Tools that are supported by the: Tobacco Prevention and Control Branch Office of Minority Health and Health Disparities HUD NAATPN Local Health Departments and other partners Is intended for: Local Health Departments, health educators, public health, partners

5 Helping our Neighbor Webinar Series

6 Register! April 24-25, 2017 In-person Train-the-Trainer on Supporting Smoke-Free Public Housing Mecklenburg County Health Department Including Site Visit to Charlotte Housing Authority

7 Overview November 2015: HUD proposed a rule to make all public housing smoke-free November 30, 2016: HUD Secretary Julian Castro announced that public housing developments in the U.S. will be required to provide a smoke-free environment for their residents February 3, 2017: HUD announced the Instituting Smoke-Free Public Housing Rule is now effective July 30, 2018: PHAs must fully implement the smokefree policy

8 Prohibits smoking of lit tobacco products within 25 ft. of buildings Cigarettes Cigars Pipe tobacco Hookah tobacco, water pipes

9 Basic Requirements of the Rule Applies to all housing types, including single family Allows for further restrictions (e.g., buffer around playgrounds, restrict smoking to designated outdoor areas, property-wide smoke-free policy) PHAs required to document policies in their annual plans (includes plans for resident engagement, public meetings). The prohibition would be written into tenants leases either through an amendment or at the annual lease renewal.

10 Help improve the health of more than 2 million public housing residents Impact the more than 940,000 units that are currently not smoke-free, including more than 500,000 units inhabited by elderly individuals

11 The Final Rule Does Not Cover Housing units in mixed finance developments Privately owned, federally subsidized multifamily housing (i.e., referred to as Project-based Section 8 housing) Electronic cigarettes Public housing authorities may find it beneficial to include e-cigarettes in their individual smoke-free policies.

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13 Local Health Departments Can Assist with Policy Change Help train housing staff Provide an information session to residents on the health impacts of secondhand smoke Discuss the benefits of a smokefree policy Provide information on QuitlineNC Possibly provide on-site quit tobacco classes and other resources to help residents quit smoking Assist with compliance issues

14 Secondhand Smoke is Dangerous Exposure to SHS increases the risk of: Heart disease and increased blood pressure Lung cancer and emphysema Bronchitis and pneumonia Frequency and severity of asthma Sudden Infant Death Syndrome 38,000-65,000 deaths a year in the US are caused by SHS

15 Tobacco smoke moves through buildings via Air ducts and vents, Gaps in walls, floors, ceilings, and Mechanical chases

16 Thirdhand Smoke is a Health Risk Children are particularly at risk for damage from thirdhand smoke

17 E-cigarette Aerosol Heavy Metals Nicotine Fine Particulate Other Compounds Volatile Organic Compound Image Courtesy of Brian King, PhD, MPH, Deputy Director for Research Translation, Office on Smoking and Health, CDC

18 Save Maintenance Costs Turning over a smoking unit can cost two to seven times more than turning over a smoke-free unit

19 Prevent Fires Smoking in the home is the leading cause of residential fire deaths

20 Smoke-Free Housing Attracts Renters: It s What Renters Want

21 2 Karen Caldwell David Willard Northampton Camden Alleghany Rockingham Gates Currituck Ashe Surry Warren Stokes Caswell Person Vance Hertford Pasquotank Halifax Mitchell Watauga Wilkes Granville Perquimans Yadkin Forsyth Orange Avery Guilford Franklin Bertie Chowan Yancey Caldwell Alexander Davie Alamance Durham Nash Madison Edgecombe Washington Burke Iredell Martin Dare Buncombe Davidson Wake Tyrrell Tyrell Haywood McDowell Catawba Randolph Chatham Wilson Swain Rowan Pitt Beaufort Graham Rutherford Lincoln Johnston Hyde Jackson Henderson Lee Greene Cabarrus Gaston Stanly Moore Harnett Cherokee Macon Transylvania Polk Cleveland Wayne Lenoir Montgomery Craven Clay Mecklenburg Pamlico Cumberland Union Anson Richmond Sampson Jones Hoke Duplin Scotland Carteret Onslow Robeson Bladen Pender 1 Tobin Lee tobin@mountainwise.org Tobacco Prevention and Control Branch (TPCB) Funding Regions Carleen Crawford Carleen.Crawford@mecklenburgcountync.gov 5 Mary Gillett David.Willard@apphealth.com Catherine.Mulvihill@wakegov.com mgillett@myguilford.com Lead Counties 6 Ashley Curtice acurtice@co.cumberland.nc.us 7 Michelle Mulvihill Columbus Brunswick New Hanover 9 Lisa Phillips Lisa.Phillips@arhs-nc.org 10 Allyson Smith allyson.smith@pittcountync.gov 1. Macon County Public Health 2. Rutherford-Polk-McDowell District Health Department 3. Appalachian District Health Department 4. Mecklenburg County Health Department 5. Guilford County Department of Health and Human Services, Public Health Division 6. Cumberland County Public Health Department 7. Wake County Human Services 8. Robeson County Department of Public Health 9. Albemarle Regional Health Services 10. Pitt County Health Department 8 Ernest Watts ernest.watts@hth.co.robeson.nc.us

22 Lending a Helping Hand: Implementing HUD s Smoke-Free Public Housing Rule Helping our Neighbor Webinar Series : The SPIRIT of Motivational Interviewing: Fostering Collaboration and Support April 7, 2017 Tamara Atkinson, MSW, LCSW

23 Objectives Review health and economic benefits of smoke-free housing policies with a focus on the impacts of tobacco use and secondhand smoke exposure among public housing residents and individuals with mental illness and substance use disorders (SUD); Discuss how to use motivational interviewing to foster collaboration and support during resident listening sessions and meetings in which people s voices are heard and health equity is promoted; and Demonstrate how best to support public housing residents and staff during this transition in a way that helps avoid roadblocks to engagement; and

24 Why are smoke-free policies beneficial? HUD s Proposed Rule

25 Perspectives Second Hand Smoke Smoke- Free Public Housing Behavioral Health Cost Savings

26 Behavioral Health

27 Health Disparity A health disparity exists amongst individuals with behavioral health disorders (mental illness and substance use disorder) who use tobacco. Approximately 25% of adults in the U.S. have some form of mental illness or substance use disorder, and these adults consume almost 40% of all cigarettes smoked by adults (SAMHSA, 2013).

28 Health Disparity The rate of tobacco use among people with a substance use disorder or mental illness is 94% higher than among adults without these disorders. People with mental illnesses and addictions smoke nearly half of all cigarettes produced, yet are only half as likely as other smokers to quit. Anti-smoking efforts have not been directed toward people with mental illnesses as they have toward the general population.

29 Which is True? When it comes to people with mental illness and substance use disorder, A. They are not interested in quitting. B. They cannot quit. C. Quitting interferes with recovery from mental illness or addictions. D. Tobacco is not as harmful as other substances. E. Tobacco is necessary for self-medication, and tobacco cessation would be too stressful. F. Tobacco cessation efforts might prevent treatment of other addictions. G. None of the above.

30 Question Do you view the addiction to nicotine in the same way you view the addiction to other addictive substances like alcohol, opioids use, or cocaine? 1. Yes 2. No

31 Myths Myths about tobacco use among people with mental illness and substance abuse problems persist, including: They are not interested in quitting. They cannot quit. Quitting interferes with recovery from mental illness or addictions. Tobacco is not as harmful as other substances. Tobacco is necessary for self-medication, and tobacco cessation would be too stressful. Tobacco cessation efforts might prevent treatment of other addictions (CDC, 2015)

32 Debunking the Myth SUD patients want to quit tobacco use. With careful monitoring, delivering smoking cessation interventions does not interfere with treatments for mental illness and can cooccur with behavioral health treatment. Among people with mental illnesses who received treatment in the past year, 37% quit smoking. Concurrent treatment increased the likelihood of long term abstinence by 25% compared to patients who received SUD treatment only (Prochaska, Delucchi, & Hall,2004), (Martin et al., 2016).

33 A Matter of Fact SUD patients who smoke find it difficult to quit and are often less successful. Reported barriers to smoking cessation including nicotine withdrawal and confidence in their ability to quit (Martin et al, 2016). People with mental illness are more likely to have stressful living conditions, have low annual household income, and lack access to health insurance, health care, and help quitting. All of these factors make it more challenging to quit (SAMHSA, 2013; SAMHSA, 2014).

34 Question Do you have a different opinion about people who have mental illness compared to those who have a substance use disorder? 1. Yes 2. No

35 Implicit Bias Courtesy of Lecretia Hoffman

36 Health Effects People with mental illness or substance use disorders die about 5 years earlier than those without these disorders; many of these deaths are caused by smoking cigarettes. The most common causes of death among people with mental illness are heart disease, cancer, and lung disease, which can all be caused by smoking. Drug users who smoke cigarettes are four times more likely to die prematurely than those who do not smoke. Nicotine has mood-altering effects that can temporarily mask the negative symptoms of mental illness, putting people with mental illness at higher risk for cigarette use and nicotine addiction. Tobacco smoke can interact with and inhibit the effectiveness of certain medications taken by mental health and substance abuse patients.

37 What local health departments can do to help

38 Help Prepare for a Change Meet with administration and managers, before conducting any tenant meetings or activities. Be sure you are on the same page Discuss a timeline and their process for adopting a lease addendum or rule change Stress transparency and respect

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40 Implicit Bias Courtesy of Lecretia Hoffman

41 Help Prepare for a Change Engage residents Conduct a resident survey Conduct a listening session (to learn about their opinions, fears, culture of the property and to advise the process. Help facilitate resident meetings where the housing managers explain policy Provide cessation support and resources for residents and staff

42 Help Staff Prepare for a Change Consider your policy options 100% smoke-free campus? Perimeter greater than 25 foot minimum required by rule? Smoking only allowed in designated areas? Determine your exact language. Do you ban e-cigarettes and/or all smoking materials (marijuana, hookah, cigars) along with traditional cigarettes? No grandfathering or rolling leases Provide plenty of advance notice 3-6 months at the minimum Proactive communication plan

43 QuitlineNC Services as of June 1, 2016 Web only (can register and interact with quit coach) Commercial Insured (on a private Health Plan) One counseling call Medicare Four counseling calls Two weeks nicotine patches - free Medicaid Four counseling calls Two weeks nicotine patches - free Uninsured Four counseling calls Eight weeks of nicotine patches - free 10 call protocol for pregnant women Texting (add-on service for registered callers) Spanish Speaking Dejelo-Ya Open 24 hrs/day, 7 days/week. Can call in between counseling sessions for added support

44 Implicit Bias Courtesy of Lecretia Hoffman

45 The Spirit of Motivational Interviewing

46 Motivational Interviewing Basics

47 Motivational Interviewing Defined Motivational Interviewing (MI) is a collaborative, goal oriented style of communication with particular attention to language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person s own reasons for change within an atmosphere of acceptance and compassion.

48 What is Motivational Interviewing MI is a collaborative partnership that honors and respects other s autonomy, seeking to understand the person s internal frame of reference (Miller & Rollnick, 2013). MI is a style of being with people, an integration of particular clinical skills to foster motivation for change (Miller & Rollnick, 2013). Ideally, clients should be voicing the reasons for change.

49 What Motivational Interviewing is Not? It is not a technique, an easily used gimmick to tuck away in one s toolbox. It is not just being nice to people! There is an intentional, strategic movement toward one or more goals

50 Motivational Interviewing Basics-Principles Expressing Empathy Developing Discrepancies Rolling with Discord (formally resistance) Supporting Self Efficacy

51 Implicit Bias Courtesy of Lecretia Hoffman

52 How Relevant is Motivational Interviewing in Public Housing?

53 Tobacco Cessation Study in Public Housing Part of a group-randomized comparison controlled smoking cessation trial Smokers residing in low-income public housing developments Smokers smoked at least 10 cigarettes a day Participants were not required to quit smoking to enroll in trial

54 Tobacco Cessation Study in Public Housing Hypothesis #1: The use of MI Spirit would be associated with high engagement and a strong working alliance between counselors and residents. Hypothesis #2: The use of MI consistent behaviors ( open ended questions, affirming, reflecting, and summarizing) would be positively associated with resident engagement and working alliance whereas MI inconsistent behaviors ( confronting and warning) would be negatively associated with resident engagement and working alliance.

55 Tobacco Cessation Study in Public Housing Study Results: MI Spirit demonstrated a significant and positive relationship with both working alliance and resident engagement Reduced resistance Clients were more engaged and cooperative Confrontational style (aggressive, hostile, and controlling) was less effective Any rupture in the alliance may manifest in low levels of engagement and evoke resistance MI Spirit alone cannot eliminate the impact of resident readiness or environmental factors on working alliance Boardman, T., Catley, D., Grobe, J.E., Little, T.D., & Ahluwalia, J.S. (2006). Using motivational interviewing with smokers: Do therapist behaviors relate to engagement and therapeutic alliance? Journal of Substance Abuse Treatment, 31,

56 Another Study Organizational culture plays an important role in the willingness of workers to adopt and properly implement MI. The business side of public housing may cause property managers and staff to maintain emotional distance and judgements that favor the bottom line Creates a barrier to engagement May reduce institutional leverage/support for staff to be trained and use MI Recommendation: Attaining buy-in from all staff and stakeholders across organizational boundaries is vital to the utilization of MI Important for Health Educators to model MI adherent behavior when working with residents and public housing staff Important for Health Educators to have a clear understanding of their roles and that of public housing staff van den Berk-Clark, C., Patterson, D., Ramsey, A. (2015). Motivational Interviewing in permanent supportive housing: The role of organizational culture. Administration and Policy in Mental Health, 42(4),

57 SPIRIT of Motivational Interviewing Collaboration Acceptance MI Spirit Compassion Evocation

58 Motivational Interviewing Basics- Techniques Open-ended questions Summarizing Affirming Reflective Listening

59 SPIRIT of Motivational Interviewing Collaboration Acceptance MI Spirit Compassion Evocation

60 Collaboration An active collaboration among experts- helper and client; Dancing rather than wrestling- not overpowering and pinning; MI is not tricking, manipulating or steering people to change; and Strengths based versus deficit based. Your purpose is to understand the life before you, to see the world through this person s eyes rather than imposing your own vision (Miller & Rollnick, p. 16, 2013).

61 Acceptance Profound acceptance to what the client brings- Carl Rogers - Unconditional Positive Regard

62 62 Compassion Deliberate commitment to pursue the welfare and best interests of the client

63 Evocation Probing questions, in a strengths based manner, to find what is needed for change

64 Readiness Ruler Activity Ask: On a scale of 1-10 with 1 being not interested in quitting and 10 being ready to quit today, how ready are you to quit smoking in the next 30 days?

65 Three Areas of Change Importance Confidence Commitment

66 SPIRIT of Motivational Interviewing Without the underlying spirit, MI becomes a cynical trick, a way of trying to manipulate people into doing what they don t want to do a battle of the wits in which the goal is to outsmart the adversary. (Miller & Rollnick, 2013, p.14)

67 Spirit of MI- Partnership An active collaboration among experts- helper and client; Dancing rather than wrestling- not overpowering and pinning; MI is not tricking, manipulating or steering people to change; and Strengths based versus deficit based.

68 Engagement

69 Three Aspects of Engagement Establishment of a trusting and mutually respectful working relationship; Agreement on treatment goals; and Collaboration on mutually negotiated tasks to reach treatment goals.

70 Engagement: Questions the Resident May Ask Do I feel respected by the Health Educator? Does he/she listen and understand me? Do I trust this person? Do I have a say in what happens in this consultation? Am I being offered options rather than a one size fits all approach? Does he/she negotiate with rather than dictate to me?

71 Engagement: Questions the Health Educator Should Ask How comfortable is this person in talking to me? How supportive and helpful am I being? Do I understand this person s perspective and concerns? How comfortable do I feel in this conversation? Does this feel like a collaborative relationship?

72 Implicit Bias Courtesy of Lecretia Hoffman

73 Roadblocks to Engagement Ordering, directing Warning, threatening Giving advice, making suggestions, providing solutions Persuading with logic, arguing, lecturing Moralizing, preaching Judging, criticizing, blaming Agreeing, approving, praising Shaming, ridiculing, name calling Interpreting, analyzing Reasoning, sympathizing Questioning, probing Withdrawing, distracting, humoring, changing the subject

74 Roadblocks to Engagement Consider your interaction with clients. Are there any roadblocks? What might be the hardest roadblock to overcome? Why? What might be the easiest? Why?

75 Roadblocks to Engagement Which roadblock to engagement gives you the most trouble? A. Ordering, directing B. Warning, threatening C. Giving advice, making suggestions, providing solutions D. Persuading with logic, arguing, lecturing E. None of the Above 75

76 Roadblocks to Engagement Which roadblock to engagement gives you the most trouble? A. Moralizing, preaching B. Judging, criticizing, blaming C. Agreeing, approving, praising D. Shaming, ridiculing, name calling E. None of the Above 76

77 Roadblocks to Engagement Which roadblock to engagement gives you the most trouble? A. Interpreting, analyzing B. Reasoning, sympathizing C. Questioning, probing D. Withdrawing, distracting, humoring, changing the subject E. None of the Above 77

78 Implicit Bias Courtesy of Lecretia Hoffman

79 Disengagement- Traps to Avoid The Assessment Trap Sets the expectation of an active expert and a passive resident. Affords little opportunity for people to explore their own motivation and to offer change talk. The Expert Trap Sets up an uneven power relationship An expert role does not work well when personal change is needed Avoid the righting reflex

80 Disengagement- Traps to Avoid The Premature Focus Trap Problem: Focusing before engaging, trying to solve the problem before establishing a working collaboration and negotiated common goals. The trap is persistence to talk about your own conception of the problem without listening to the residents broader concern Recommendation: Start where the resident s concerns are, listening to their stories, and get a broader understanding of their life situation.

81 81 Disengagement- Traps to Avoid The Labeling Trap A specific form of the premature focus trap. You want to focus on a particular problem, and you call it (or the resident) by name. Diagnostic and behavior labeling included. Recommendation: De-emphasize labeling If the resident brings up the label- use a combination of reflection and reframing

82 Disengagement- Traps to Avoid The Blaming Trap Time and energy about who to blame or whose fault the problem is. If not dealt with properly, time and energy can be wasted on needless defensiveness. Recommendation: Render blame irrelevant within the counseling context ( usually done by reflecting and reframing).

83 83 Disengagement- Traps to Avoid The Chat Trap Chatter that has insufficient direction to the conversation. Not very helpful beyond modest occasions.

84 84 The Ineffective Physician

85 85 The Effective Physician

86 Core Skills

87 Core Skills Speaking to a man in your language speaks to his head, but speaking to a man in his language speaks to his heart. -Nelson Mandela

88 MI Core Skills- OARS Open Ended Questions Affirmations Reflective Listening Summaries

89 Implicit Bias Courtesy of Lecretia Hoffman

90 MI Resource

91 OARS

92 MI Core Skills- Reflections The first step: listen carefully and think reflectively. Think in terms of hypothesis. The second step: try out your guess by reflecting back what you think you heard. It is like asking, Do you mean.? without putting your words in question form.

93 MI Core Skills- Reflections LEVEL OF REFLECTIONS Repeating simply repeating what someone has just said. Rephrasing rephrase what a person has just said with a few word substitutions that may slightly change the emphasis. Paraphrasing fairly major restatement of what the person has said and inferring the meaning of what was said. Reflecting feeling Achieves the deepest level of reflection- not just content, but the feeling or emotion underneath what the person is saying.

94 MI Core Skills- Simple Reflections Simple Reflection- restating what the client said without adding anything additional. CLIENT: She is driving me crazy trying to get me to quit. COUNSELOR: Her methods are really bothering you.

95 MI Core Skills- Amplified Reflections Amplified Reflection- Reflect back what the person said in a slightly amplified or exaggerated form. CAUTION: make sure to do it genuinely. Any hint of sarcasm may be seen as unempathetic. CLIENT: All my friends smoke cigarettes and I don t see myself giving it up. COUNSELOR: So, you re likely to keep smoking forever.

96 MI Core Skills- Double Sided Reflections Double-Sided Reflection- Conveys empathy and captures both sides of a person s ambivalence. In using these, you can reflect back both the pros and cons of change that the client has said or at least hinted. Typically, the two sides are joined by the phrase, on the other hand. Summarizes as well as demonstrates you heard the client. Provides the opportunity to bring together discrepant statements.

97 MI Core Skills- Double Sided Reflections CLIENT: It would stink to have to lose my housing over a dumb policy because I ve been smoking, but no way do I want to quit smoking just because that s hanging over my head. COUNSELOR: On the one hand, you value your housing because it allows you to live comfortably, but on the other hand, you also like how smoking eases your stress.

98 Reflections

99 Giving Information

100 Giving Information: Elicit-Provide-Elicit Elicit Ask permission Clarify information needs and gaps Provide Prioritize Be clear Support autonomy Don t prescribe client s response Elicit Ask for the client s interpretation, understanding, or response

101 Common Pitfalls Offering Advice Self- Disclosure Common Pitfalls

102 Change Talk Preparatory= Desire Ability Reason Need

103 Evoking Change Talk Use core skills- OARS Using the importance ruler Querying extremes Looking back Looking forward Exploring goals and values

104 Change Talk

105 Additional Tools from the CCNC MI Guide

106 Additional Tools

107 Decisional Balance

108 Additional Tools

109 Questions??

110 Thank you! Please complete the survey