Integrating Tobacco Cessation Tools and Practices within Behavioral Health Settings

Transcription

1 Integrating Tobacco Cessation Tools and Practices within Behavioral Health Settings Tuesday, June 23 rd, 2015 Jim Pavlik, MA Mike Luxemburger, BSW, CTTS Linda Hurley, MA, CAGS, SCDCS, CCJP Carolyn James, BA

2 Welcome! Shelina D. Foderingham MPH MSW Director of Practice Improvement Project Director, National Behavioral Health Network for Tobacco & Cancer Control National Council for Behavioral Health Margaret A. Jaco MSSW Policy Associate Project Manager, National Behavioral Health Network for Tobacco & Cancer Control National Council for Behavioral Health

3 Housekeeping Technical Difficulties? Call Citrix Tech Support at

4 Jointly funded by CDC s Office on Smoking & Health & Division of Cancer Prevention & Control Provides resources and tools to help organizations reduce tobacco use and cancer among people with mental illness and addictions 1 of 8 CDC National Networks to eliminate cancer and tobacco disparities in priority populations Visit and Join Today! Free Access to Toolkits, training opportunities, virtual communities and other resources Webinars & Presentations State Strategy Sessions Community of Practice #BHtheChange

5 Congratulations to Community of Practice participating organizations! American Samoa Community Cancer Coalition Arapahoe/Douglas Mental Health Network CODAC, Inc. (dba CODAC Behavioral Healthcare) Coleman Professional Services CommuniCare, Inc. Credo Community Center for the Treatment of Addictions, Inc. Mirror, Inc. Northern Lakes Community Mental Health Pittsburgh Mercy Health System Way Station, Inc. 4

6 Webinar Agenda Overview Tobacco Use in At-Risk Populations Cessation Outcomes Integration of Care Evidence-Based Interventions Sustainability Real-World Implementation Pittsburgh Mercy Health System CODAC Behavioral Healthcare Question & Answer 5

7 Guest Speaker #1 Jim Pavlik, MA Program and Policy Analyst, Behavioral Health & Wellness Program

8 Tobacco Cessation Integrating Tobacco Cessation Tools & Practices within Behavioral Health Settings

9 Better Health The Triple Aim Better Quality Lower Cost BHWP

10 What is killing the majority of us is not infectious disease, but our chronic and modifiable behaviors BHWP

11 Behavioral Causes of Death in U.S BHWP

12 Trends in U.S. Adult Smoking % of adults are current smokers Men Women BHWP

13 Health Disparities General Population Rate of Use of Tobacco Products: 21.3% Population Behavioral Health HIV/AIDS Diagnosis Homeless (or at risk) Justice Involved Rates of Use Compared to General Population 2-3 times higher 2-3 times higher Nearly 4 times higher 3 times higher 2015 BHWP

14 Smoking Cessation Outcomes Smoking cessation is associated with: depression, anxiety, and stress positive mood and quality of life compared with continuing to smoke The effect size seems as large for those with psychiatric disorders as those without The effect sizes are equal or larger than those of antidepressant treatment for mood and anxiety disorders Taylor et al, BHWP

15 Tobacco Cessation Interventions Integration into Daily Practice

16 Integration is the New Norm Mental health and addictions Across healthcare sectors Integrated care & health homes Public health Quitlines Community integration Chronic care Diagnoses/ codes EHRs & performance measurement BHWP

17 What Do We Mean by Integration? Tobacco Cessation Services and Supports are: A crucial part of an organization-wide Tobacco Free policy Offered to clients and staff Are a part of a broader commitment to general wellness Are consistently applied Are designed with sustainability in mind BHWP

18 Chronic Care Model BHWP

19 Tobacco Cessation Interventions Evidence-Based Interventions

20 Tobacco Dependence Has Two Parts Tobacco dependence is a 2-part problem Physical The addiction to nicotine Treatment Behavior The habit of using tobacco Treatment Medications for cessation Behavior change program Treatment should address both the addiction and the habit. Courtesy of the University of California, San Francisco BHWP

21 Cessation Rates Across Interventions Treatment Format Abstinence Rate Unaided 4-7% Self-help 11-14% Quitline 11-15% Individual counseling 15-19% Group counseling 12-16% Medication alone 22% Medication/Counseling 25-30% BHWP

22 Tobacco Cessation Medications The only medications approved by the Food and Drug Administration (FDA) for tobacco cessation are: Nicotine gum Nicotine lozenge Nicotine patch Nicotine nasal spray Nicotine inhaler Bupropion SR tablets Varenicline tablets BHWP

23 Tobacco Free Group (or Individual Counseling) Session A: Creating a Plan Session B: Healthy Behaviors Session C: The Truth about Tobacco Session D: Changing Behaviors Session E: Coping with Cravings Session F: Maintaining Change *Groups are typically 90 minutes BHWP

24 Tobacco Cessation Interventions: The 5 A s and 2A s & R Models The 5 A s: Ask Advise Assess Assist Arrange BHWP

25 Advice Can Improve Chances of Quitting Estimated abstinence at 5+ months No clinician Compared to people who smoke who do not get help from a clinician, those who get help are times as likely to successfully quit for 5 or more months. Self-help material 1.7 Nonphysician clinician Type of Clinician 2.2 Physician clinician BHWP

26 ANTIPSYCHOTICS ANTIDEPRESSANTS MOOD STABLIZERS ANXIOLYTICS OTHERS Medications Known or Suspected To Have Their Levels Affected by Smoking and Smoking Cessation Chlorpromazine (Thorazine) Clozapine (Clozaril) Fluphenazine (Permitil) Haloperidol (Haldol) Mesoridazine (Serentil) Amitriptyline (Elavil) Clomipramine (Anafranil) Desipramine (Norpramin) Doxepin (Sinequan) Duloxetine (Cymbalta) Carbamazepine (Tegretol) Alprazolam (Xanax) Diazepam (Valium) Acetaminophen Caffeine Heparin Insulin Rasagiline (Azilect) Olanzapine (Zyprexa) Thiothixene (Navane) Trifluoperazine (Stelazine) Ziprasidone (Geodon) Fluvoxamine (Luvox) Imipramine (Tofranil) Mirtazapine (Remeron) Nortriptyline (Pamelor) Trazodone (Desyrel) Lorazepam (Ativan) Oxazepam (Serax) Riluzole (Rilutek) Ropinirole (Requip) Tacrine Warfarin BHWP

27 Detailed Guidance for Priority Populations BHWP

28 Tobacco Cessation Interventions Sustainability

29 Individual Coverage Status Yes Coverage Third Party Military Insured Medicaid Medicare No Self-Paid BHWP

30 State Medicaid Program Coverage of Tobacco Dependence Treatments Source: kff.org/medicaid/state-indicator/cessation-treatment-under-medicaid BHWP

31 DSM-5 Substance Related and Addictive Disorders There are four tobacco-related disorders: 1 Tobacco Use Disorder 2 Tobacco Withdrawal 3 Other Tobacco-Induced Disorders 4 Unspecified Tobacco- Related Disorder BHWP

32 Billing Diagnosis and Codes Diagnosis &Treatment Codes Tobacco Use Disorder Diagnosis Personal History of Tobacco Use V15.82 Symptomatic Tobacco Use Counsel 3-10 min Symptomatic Tobacco Use Counsel >10 min Asymptomatic Tobacco Use Counsel 3-10 min Asymptomatic Tobacco Use Counsel >10 min G0436 G0437 *Group sessions by a physician, and other qualified individuals S9453 may also reimbursable BHWP

33 Upcoming ICD-10 Codes ICD-10 Codes: F17.2 Nicotine Dependence F17.20 Nicotine dependence, unspecified, F17.21 Nicotine dependence, cigarettes; F17.22 Nicotine dependence, chewing tobacco, F17.29 Nicotine dependence, other tobacco product BHWP

34 Medicare Providers Medicare Part B covers tobacco use treatment multiple times each year. 8 visits per year (4 sessions per attempt) At intermediate (3 to 10 min) or intensive (>10 min) levels Medicare Part D covers cessation medications BHWP

35 Tobacco Cessation Workflow Front Desk/ Admin Clinician/ Medical Assistant (5A s Model) Physician (2A s & R Model) Screening form Verify screening form & complete tobacco use assessment Review screening & tobacco use assessment Post/ place tobacco cessation promotional materials in waiting area Fax quitline referral preauthorizations No Discuss sustaining abstinence and healthy living strategies Peer services/ Patient navigator Current or recent tobacco use Utilize Motivational Interventions to Address Use* Onsite cessation group and/or individual counseling Yes Visual Prompt on Exam Room Door CO Reading Collaborative treatment planning Preauthorizations & referrals Brief counseling* Rx meds** Follow up appointment set within 1 month * 5As algorithm ** Cessation medications protocol Billing Enter interventions into EHR and/or chart BHWP

36 BHWP

37 Rocky Mountain Tobacco Treatment Specialist Certification (RMTTS-C) Program Interactive, 4-day course Effectively treat tobacco dependence in healthcare settings SAVE THE DATE: October 12-15, 2015 in Aurora, Colo. For detailed information visit grams/rmtts-c/ BHWP

38 Behavioral Health & Wellness Program Behavioral Health and Wellness Program BHWP_UCD

39 Guest Speaker #2 Mike Luxemburger, BSW, CTTS Prevention/Intervention Specialist, Pittsburgh Mercy Health System

40 2014 Pittsburgh Mercy Health System

41 TOBACCO CESSATION A typical day in the life of a Pittsburgh Mercy Health System Tobacco Treatment Specialist Meet with individuals/groups in the following setting: Pittsburgh Mercy Family Health Center (PMFHC) Mental Health Residential Sites Community Groups Individuals 2014 Pittsburgh Mercy Health System 40

42 2014 Pittsburgh Mercy Health System 41

43 TOBACCO CESSATION Is it 5 A s or 6????? Ask Advise Assess Assist Arrange 2014 Pittsburgh Mercy Health System 42

44 TOBACCO CESSATION Approach-prior to Ask, to maintain a person centered approach, we never begin an encounter/session talking about tobacco. This is for ALL of our programming-pmfhc, mental health residential sites, and community groups. Build relationships, then Ask questions Pittsburgh Mercy Health System 43

45 PMFHC TOBACCO PROTOCOL 2014 Pittsburgh Mercy Health System 44

46 Asked regardless of location and/or program: Do you smoke? If NO, encounter is complete. How do you like it? How good is it? Is it a habit or an addiction? ASK Why do you think you smoke? Do you want to quit/or reduce? Have you tried to quit previously? If YES, how many attempts? Were any successful and if so, for how long? 2014 Pittsburgh Mercy Health System 45

47 Present the Options: ADVISE Cessation services Quit line Groups Individual FDA Approved Medications Bupropion Chantix Nicotine Replacement Therapies Patch, Gum, Lozenges 2014 Pittsburgh Mercy Health System 46

48 ASSESS Stages of Change Where is the individual at in their quest to quit? Pre-contemplation Contemplation Preparation Action Maintenance 2014 Pittsburgh Mercy Health System 47

49 ASSIST If consumer has acknowledged they are a smoker, but do not wish to quit: They can be provided with a brief Motivational Interview including: Remember! Decisional Balance Worksheet A Written, personalized educational information Reassess at next encounter! 2014 Pittsburgh Mercy Health System 48

50 ASSIST If the consumer has shown interest in smoking cessation: Provide information on NRT, cessation programming, QUITLINE info, Medication, etc. If they are interested in Bupropion SR/Chantix: Cessation staff verify insurance provision and assist consumer in getting prescription Pittsburgh Mercy Health System 49

51 ARRANGE Cessation/PMFHC staff work with consumer on next steps including but not limited to: Individual/group sessions NRT/Medications Reduction/Quit Plan 2014 Pittsburgh Mercy Health System 50

52 LESSONS LEARNED Person Centered Always use Motivational interviewing! If at first you don t succeed Celebrate EVERYTHING! Get everyone involved 2014 Pittsburgh Mercy Health System 51

53 2014 Pittsburgh Mercy Health System

54 Guest Speakers #3 Linda Hurley, MA, CAGS, SCDCS, CCJP Chief Operating Officer/Director of Clinical Services CODAC, Inc. Carolyn James, BA Special Projects/Tobacco Program Coordinator CODAC, Inc.

55 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island CODAC Behavioral Healthcare Tobacco Treatment Services Rhode Island: Model of Care 54

56 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Systems Change USPHS Treating Tobacco Use and Dependence: Clinical Practice Guideline 2008 CODAC Board of Directors Approves Systemic Approach to Embed Tobacco Treatment in Substance Abuse Services: Full adherence to RI Clean Air Act Embed Tobacco Education and Treatment within all CODAC sites Evidence-based interventions including pharmacotherapy Provide annual in-service Basic Skills for Working with Smokers Joint Initiative with RI Department of Health to Affect Statewide Tobacco Policy: RI Council on Tobacco Use 55

57 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Office wide change Action Steps > Include smoking status in vitals at each visit and incorporate in EHR Education & Resources for Promoting Intervention > Provide on-going education and training to all staff > Allocate adequate resources > Measurable Outcomes > Feedback to Staff Dedicated Staff > Clinical Director of Tobacco Treatment Services > CTTS embedded at each site > Coordinate tobacco dependence treatment across all sites > Delineate staff responsibilities > Maintain effective communication and documentation 56

58 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Screening, Intake and Assessment > Basic screening included in EHR Action Steps (con t) > Expanded screening for patients identified as tobacco users > Comprehensive tobacco intake and assessment [Survey Monkey] Providing Evidence-Based Treatment > Identify all tobacco users > Provide full range of treatment options > Dose response relationship > Pharmacotherapy: 7 first line medications Full Insurance Coverage for Counseling & Pharmacotherapy Continues to be a major challenge for providers and patients (Fiore, MC. USPHS Guidelines, Treating Tobacco Use and Dependence, 2008) 57

59 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Training & Staff Development UMass, School of Medicine, Center for Tobacco Treatment Research & Training > Skills and core competencies required for certification > National standard Master level certification of CODAC C-TTS staff in 2010 CODAC Pilot Study and training initiative CODAC one of 15 sites asked to participate in the inaugural Train-thetrainer program developed by UMass, CTTRT, Scholarships provided by RIDOH, funded by CVS, to train and certify staff to be integrated into each CODAC site, 2015 Annual in-service training for all program staff 58

60 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Dedicated Staff Clinical Director for Tobacco Treatment Services 2 Master level CTTS within the agency: > Both staff completed the Train the Trainer program with Umass, School of Medicine, CTTRT Certified Tobacco Treatment Specialist at each CODAC site: > Meet with all patients identified as tobacco users > Facilitate individual and group counseling > Ensure documentation in EHR Integration of tobacco into Health Homes Implementation of Wellness Classes with a focus on tobacco use and dependence Oversight and training to other clinical staff Community outreach: > Coordinate tobacco treatment with local FQHC s > Educate Primary Care Physicians > Collaboration with local hospitals 59

61 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Evidence-Based Best Practices 5A s embedded in service delivery model for all patients Tobacco Screener included in initial Intake & Assessment 3 questions to assess for current or past use More extensive screening tool for patients actively using tobacco Comprehensive tobacco intake in Survey Monkey and completed by the TTS on site Assess for Dependence as well as psychosocial function: CO FTND BDI and BAI 60

62 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Comprehensive Tobacco Screening & Assessment Transtheoretical Model Stages of Change: > All patients staged for readiness to quit > Current tobacco user > Previously used tobacco, 7-day point prevalence > Never used tobacco Comprehensive Tobacco Intake Motivational Interviewing adopted as a best practice agency wide Individual and Group Counseling on site Referrals to QuitWorks-RI 61

63 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Initial Tobacco Screening embedded in patient intake/assessment: 1. Do you currently smoke cigarettes or use tobacco products? > If YES, patient referred to TTS for more comprehensive screener and assessment > If NO, go to Q2 2. Have you ever smoked cigarettes or used tobacco products? > If YES, go to Q3 > If NO, continue with the general intake and assessment 3. What was your quit date? > If Quit Date has been within the past 3 months, TTS will review intake with patient and arrange follow-up for relapse prevention 62

64 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Expanded Tobacco Screening Algorithm (completed by Tobacco Tx Specialist): 1. Do you currently use tobacco products or smoke cigarettes? If YES, go to Q4, If NO, go to Q2 2. Did you ever use tobacco products or smoke cigarettes? If YES, go to Q3, If no END SCREENER and DO NOT COMPLETE TOBACCO INTAKE 3. When did you quit? MM/DD/YYYY > If > 6 months ago, END SCREENER and DO NOT COMPLETE TOBACCO INTAKE > If less < 3 months, GO TO Q8 4. Are you seriously considering quitting in the next 6 months? > If YES, GO TO Q5 > If NO, GO TO Q8 5. Are you seriously considering quitting in the next 30 days? > If YES, GO TO Q6 > If NO, GO TO Q8 6. Have you set a quit date? > If YES, GO TO Q7 > If NO, GO TO Q8 7. What is your quit date? MM/DD/YYYY 8. Would it be okay to have someone follow up with you about your tobacco use? > If YES, Complete Tobacco Intake with TTS and refer to individual and/or group counseling (8 sessions) > If NO, TTS recommends that primary counselor continue to check smoking status with patient at each contact and use an MI approach (5 R s) to assist patient in exploring their tobacco use. 63

65 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Fagerstrom Test for Nicotine Dependence: 1. How soon after you wake do you smoke your first cigarette? > Within 5 minutes 3 points > 6-30 minutes 2 points > minutes 1 point > After 60 minutes 0 points 2. Do you find it difficult to refrain from smoking in places where it is forbidden, e.g., in church, at the library, in the theater, etc? > Yes 1 point > No 0 points 3. Which cigarette would you hate most to give up? > The first one in the morning 1 point > Any other 0 points 4. How many cigarettes do you smoke a day? > 10 or less 0 points > point > points > 31 or more 3 points 5. Do you smoke more frequently during the first hours after waking than during the rest of the day? > Yes 1 point > No 0 points 6. Do you smoke if you are so ill that you are in bed most of the day? > Yes 1 point > No 0 points 64

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67 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Who Recommends: > Role of the CTTS > All 7 first line medications Pharmacotherapy How is appropriate treatment determined: > Comprehensive material provided at intake > Prior quit attempts > Patient choice most important Building collaborations with local health clinics (FQHC), hospitals, and Primary Care Physicians > Memorandum of Agreement > Signed Waivers for follow-up > Seamless referral systems 66

68 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Insurance Mandates for Reimbursement of Tobacco Treatment Rhode Island General Assembly Regulation 14 State Medicaid Medicare Rhode Island Exchange 67

69 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Rhode Island State Quit Line Referrals made for patients after insurance coverage stops Additional support Collaboration for on-going training and staff development 68

70 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Rhode Island Council on Tobacco Use 69

71 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Capacity > Reimbursement > Parity Challenges Conflicting insurance guidelines that limit consumer choice: > Barriers to use of FDA-approved smoking cessation medications Systems > Resistance from staff and administration in behavioral and mental health settings > Residential programs continue to allow smoke breaks for patients > Fear among administrators and clinicians about the negative impact that would result from limiting tobacco use > Maintaining a Harm Reduction approach 70

72 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island Sustainability Developing a direct and more intimate working relationship with the RI Department of Health, Division of Tobacco Control Increasing statewide capacity > Expanded workforce > Reimbursement > Parity Innovative partnerships with other healthcare providers, clinics, hospitals and Federally Funded Health Centers Developing collaboration with Rhode Island EOHHS to influence how behavioral healthcare can be defined in the future 71

73 CODAC Behavioral Healthcare: Tobacco Treatment Services of Rhode Island References: Association for the Treatment of Tobacco Use and Dependence (ATTUD), Disparate Populations Committee, Integrating tobacco treatment within behavioral health. Fiore, MC. Treating Tobacco Use and Dependence: Clinical Practice Guideline, 2008 update. US Department of Health and Human Services Fiore, MC. Et al. The Joint Commission s New Tobacco-Cessation Measures - Will Hospitals do the right thing,? NEJM, March 29, Helping Patients Quit: Implementing the Joint Commission Tobacco Measure Set in Your Hospital. Partnership for Prevention, Action to Quit. NEJM, May 29, 2012 Kalman, D. et al. Addressing tobacco use disorder in smokers in early remission from alcohol dependence: The case for integrating smoking cessation service in substance use disorder treatment programs, Clinical Psychology Review, 2009 McCool, RM, et al. Benefits of and barriers to providing smoking treatment in methadone clinics: Findings from a national study. (2005) The American Journal on Addictions, 14: Prochaska, JJ., et al. A meta-analysis of smoking cessation interventions with Individuals in substance abuse treatment and recovery, Journal of Counseling & Clinical Psychology, 2004, Vol 72, No6, Prochaska, JJ. Failure to treat tobacco use in mental health and addiction treatment settings: A form of harm reduction? (2010) Drug and Alcohol Dependence, 110: Surgeon General Report, 2014 Torrijos,RM & Glantz, SA. The US Public Health Service Treating tobacco use and dependence clinical practice guidelines as a legal standard of care. (2006) Tobacco Control:15:44. Williams, JM. & Ziedonis, D. Addressing tobacco among individuals with a mental illness or an addiction, Addictive Behaviors 29 (2004) Ziedonis, DM et al. Barriers and solutions to addressing tobacco dependence in addiction treatment programs. (2006) Alcohol Research & Health, V29(3):

74 Comments & Questions?

75 Jointly funded by CDC s Office on Smoking & Health & Division of Cancer Prevention & Control Provides resources and tools to help organizations reduce tobacco use and cancer among people with mental illness and addictions 1 of 8 CDC National Networks to eliminate cancer and tobacco disparities in priority populations Visit and Join Today! Free Access to Toolkits, training opportunities, virtual communities and other resources Webinars & Presentations State Strategy Sessions Community of Practice #BHtheChange

76 Thank you for joining us for the Integrating Tobacco Cessation Tools & Practices within Behavioral Health Settings Webinar!