Tobacco Cessation Efforts Denver Health

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Tobacco Cessation Efforts Denver Health Raymond Estacio, MD, FACP General Internal Medicine Westside Adult Clinic Associated Medical Director for ACS QI and Research Denver

1 Tobacco Cessation Efforts Denver Health Raymond Estacio, MD, FACP General Internal Medicine Westside Adult Clinic Associated Medical Director for ACS QI and Research Denver Health Director of Community Health Colorado Prevention Center Associate Professor University of Colorado, Department of Medicine Board Member Colorado State Board of Health

3 Smoking Cessation: Organizational Priority Denver Public Health o Has been leader in initiating and implementing programs at Denver Health o Community Strategic Pillar o Decrease prevalence of smoking o Decrease second hand exposure Organizational Pillar o Ambulatory Care Services o Emergency Department o Inpatient

4 Denver Health s Smoke-Free Campus Policy Announcement by CEO Our employees, patients and visitors health always comes first Denver Health must take a proactive role in addressing the impact of smoking and tobacco use. By role modeling as a community and not smoking while at work, we are showing our commitment to keeping our employees, patients and visitors as healthy as possible. Before we can ask patients and visitors to follow our policy, we need to do this ourselves.

5 Tobacco Cessation Workgroup Multidisciplinary: Family Medicine, General Internal Medicine, Denver Public Health, Inpatient Provider, Operation Coordinators, Data and Analytic Team, IT (Epic) Monthly meetings Activities o Metric development Communications Training/Implementation Monitoring and reporting o Intervention development Communications Training/Implementation Monitoring and reporting

6 Tobacco Smoking and Second Hand Smoke Exposure Prevalence Data represent the last tobacco use / second hand smoke exposure status documeted in LCR for all patients seen in the year prior to the Year-end Date. Tobacco use = cigarette, cigar/pipe, chew and/or electronic cigarette use among patients >= 18 years old. Smoking = cigarette smoking only among patients >=18 years old. Second Hand Smoke Exposure = exposure among patients <= 17 years old w ho don't themselves smoke cigarettes/cigars/pipes.

7 Systems changes

8 Patient Handouts

9 Implementation Process Created an algorithm Created Educational materials Educated providers and clinics with minute trainings.

10 Monitoring Process: AAR Are Medical Assistants asking?

11 Tobacco Cessation Intervention: Provider Focus Denominator: Patients >=18 years old who smoke cigarettes Had at least 1 visit in the past month in Ambulatory Care Services (ACS), Inpatient/ED, Denver Public Health (ID/AIDS clinic), or OBHS Had at least one other visit in the previous 12 months Numerator: number of patients in the denominator who had at least 1 tobacco cessation intervention, provided by any care provider in any area, in the 6 months prior their last visit. Tobacco cessation interventions included: Quitline referral Tobacco Cessation Clinic referral placed or visit attended Tobacco counselling On a medication for tobacco cessation for any length of time during the 6-month look-back period Referral to text messaging program Provided patient educational materials specific to cessation

Monitoring Process: Tobacco Intervention Team Approach Example using a patient who was seen by 2 different providers in reporting period. Illustrates the team-based approach.

12 Monitoring Process: Tobacco Intervention Team Approach Example using a patient who was seen by 2 different providers in reporting period. Illustrates the team-based approach. POPULATION Take last visit date with each ACS Provider where they had a recorded smoking history: Look back 6 months for evidence of a smoking intervention* given by any provider. MRN 1 smoker Mar 5, 2015 Prov#2 Start: Feb 1, 2015 Start: Jul 1, 2015 MRN 1 smoker July 7, 2015 Prov#1 Intervention: Mar 5, 2015 PASS for Provider 1 All patients seen by ACS Providers in 6-month reporting period who had >= 2 visits in past year in ACS and who were >= 19 at end of reporting period. MRN 1 smoker Aug 3, 2015 Prov#1 MRN 1 no data Aug 22, 2015 Prov#2 PROVIDER 1 End: Aug 3, 2015 Intervention: Mar 5, 2015 Start: Jun 8, 2015 For the ACS rollup measure, this patient would PASS since they passed for at least one provider. MRN 1 smoker Sep 10, 2015 Prov#2 FAIL for Provider 2 MRN 1 smoker Dec 8, 2015 Prov#2 PROVIDER 2 End: Dec 8, 2015 MRN 1 former Dec 15, 2015 Prov#2 End: Dec 31, 2015 *SMOKING INTERVENTIONS Cessation Medications Tobacco counseling Tobacco Cessation Clinic (TCC) Referral Quitline Referral iquit Text Messaging Program HOW IT IS MEASURED IN EPIC Epic Medication list includes a medication used for tobacco cessation SmartText Documentation Referral Order SmartText Documentation SmartText Documentation

13 Then came a new EHR: Epic The focus was to develop a process that transferred our pre-epic work o Multiple, multiple meetings with Epic Analysts o Competing priorities for changes made it challenging Re-training staff on the new process Tobacco Cession Intervention AAR (ongoing) Modify monitoring process

14 Monitoring Process: Ask Cigarette Smoking (visit level)

15 Monitoring Process: Tobacco Intervention Team Approach Numerator Denominator Percent %

16 Monitoring Process: Tobacco Intervention Department Level Sub-group Numerator Denominator Percent Trend ACS % DH PAV H INFECTDISEASE % DH PAV K OBHS % IP/ED % Note: numerators and denominators at the clinic-level cannot be summed to calculate the sub-group percentage. If a patient has been seen in multiple clinics they will be included in each clinic's denominator, but only once in the sub-group-level denominator.

Monitoring Process: Tobacco Intervention Clinic Level Ambulatory Care Services LOWRY REFUGEE DH PAV E PULM OP Webb LOP Derm DH PAV G ADULT DH PAV E PALL CARE Webb LOP Podiatry DH PAV B INFECDISEASE

17 Monitoring Process: Tobacco Intervention Clinic Level Ambulatory Care Services LOWRY REFUGEE DH PAV E PULM OP Webb LOP Derm DH PAV G ADULT DH PAV E PALL CARE Webb LOP Podiatry DH PAV B INFECDISEASE DH PAV G INTENSIVE OP DH PAV D CARDIO OP WESTSIDE ADULT DH PAV E GI/HEP OP DH PAV E NEPHRO OP DH PAV D SURGERY DH PAV G GERIATRICS SOUTHWEST URGENT CARE DH PAV G LEVELONE PHYS MHCD ADULT Percent 100.0% 85.0% 83.3% 77.3% 75.0% 75.0% 69.2% 69.0% 66.7% 62.9% 61.2% 58.3% 55.8% 55.6% 55.5% 52.4% 52.3% Trend

18 Monitoring Process: Tobacco Intervention Provider Level

19 Monitoring Process Second Hand Smoke Exposure (Peds): Ask Percent of ACS visits for non-smoking patients 0-17 y where SHS exposure was verified 1. The tobacco use field was set to "Passive Smoke Exposure - Never Smoker" AND 2. Tobacco history was 'marked as reviewed' in the Rooming Activity

20 Monitoring Process Second Hand Smoke Exposure (Peds): Advise Percent of ACS visits among cigarette smokers >=11 years where advice to quit was given ('Offered Resources' in Rooming Tab marked as 'yes')

21 Tobacco Smoking and Second Hand Smoke Exposure Prevalence Tobacco Smoking and Second Hand Smoke Exposure Prevalence Data represent the last tobacco smoking / second hand smoke exposure status for empanelled patients in the year prior to the Year-end Date. Tobacco smoking is among patients >= 18 years old. Second hand smoke exposure is among patients <= 17 years old w ho don't themselves use tobacco.

22 Denver Health Tobacco Cessation Efforts Multi-year process! Organizational support and engagement Leadership priority Multidisciplinary team to monitor and address issues Listen to feedback from clinic level Data Need to monitor! Good data Provide solutions

Quit Rates of New York State Smokers

Quit Rates of New York State Smokers Sara M. Abrams, MPH Data Manager NYS Smokers Quitline Sara.Abrams@roswellpark.org September 6, 20 Presentation Outline Basic Quitline Service How Quit Rates are defined