Summit Session 8 How to Use EHRs and Data to Advance Tobacco Dependence Systems Change. Presented by: June 15, 2017

Transcription

1 Summit 2017 Presented by: Session 8 How to Use EHRs and Data to Advance Tobacco Dependence Systems Change June 15, 2017

2 How to Use EHRs and Data to Advance Tobacco Dependence Systems Change 2017 Minnesota e-health Summit June 15, 2017

3 Overview Overview of Tobacco Use Overview of Health Systems Change Presentations by Grantees Discussion 3

4 Tobacco Use in Minnesota 4

5 Tobacco Use in Minnesota2 Source: Minnesota Adult Tobacco Survey

6 Challenges to Reducing the Rate Low socioeconomic status 1 : 28.6% of adults with less than high school education smoke 24.4% of adults with low incomes smoke Tribal tobacco use 2 : 59% of American Indian adults smoke Source: 1 Minnesota Adult Tobacco Survey 2014; 2 Tribal Tobacco Use Project Survey

7 Prevalence of Commercial Cigarette Smoking, U.S. Adults Population Smoking prevalence (%) African Americans Latinos People with mental illness Asian Americans LGBT Sources: 1 National Health Interview Survey, MMWR, November 13, 2015 / 64(44); National Survey on Drug Use and Health, MMWR, February 8, 2013 / 62(05);

8 What is Health Systems Change A sustainable, integrated solution at the organization level that supports clinicians and health care systems to address tobacco use consistently and effectively. 8

9 Why Health Systems Change? 9

10 Health Systems Change Grants Fiscal Year 2014 Fiscal Year

11 Key Strategies to Facilitate Change Monitor and share feedback Build system level support Capitalize on internal and external priorities Utilize and modify electronic health records Implement new protocols and train staff Utilize a teambased approach 11

12 Utilize Technology and Data Monitor and share feedback Utilize and modify electronic health records Monitor and share feedback 12

13 Case Studies 13

14 Megan Whittet, MPH ClearWay Minnesota SM Senior Cessation Manager

15 Grantee Presentations

16 Tammy Didion

17 The public dissemination of information relating to the grant was made possible by Grant Number IC from ClearWay Minnesota SM and the contents of this information are the sole responsibility of the authors and do not necessarily represent the views of ClearWay Minnesota.

18 Background of HCMC Tobacco Cessation Objectives Workflow Team Based Approach to Tobacco Treatment Successes Challenges Lessons Learned

19 Minnesota's premier Level 1 Adult Trauma Center and Level 1 Pediatric Trauma Center A recognized system of primary care clinics and retail clinics located throughout Hennepin County An essential teaching hospital for doctors who go on to practice throughout the state A safety net hospital providing care for low-income, the uninsured and vulnerable populations

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21 Change the scope of work for rooming staff to ask about tobacco use at an agreed upon frequency level. Create a tobacco cessation smart set for providers to use to appropriately treat tobacco dependence for those who indicate they are ready to quit using tobacco. Register all clinics with Call It Quits. Identify and train clinic and inpatient champions to make appropriate referrals. Work with the identified EPIC support analyst to create an electronic referral to the Call It Quits Program. Train ambulatory and inpatient staff on the tobacco cessation workflow.

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23 1. The MA asks about and documents tobacco use at every visit as part of their standard work. 2. If the patient is a tobacco user, the MA asks if he/she is interested in quitting and documents the patient s response. 3. When the MA documents a patient is interested in quitting, a best practice alert fires alerting the provider to open the Tobacco Cessation Smart Set.

24 Tobacco Use Rooming Questions: 1. Tobacco Use (Current Everyday Smoker, Current Someday Smoker, Former Smoker, Heavy Tobacco Smoker, Light Tobacco Smoker, Never Assessed, Never Smoker, Passive Smoke Exposure Never Smoker, Smoker Current Status Unknown, Unknown if Ever Smoked) Start Date and End Date 2. Type (s) of tobacco used (Cigarettes, Pipe, Cigars, E-Cigarettes) Packs/day Years 3. Counseling Given (Y/N) 4. Smokeless Tobacco (Current User, Former User, Never Used, Unknown). Types (Snuff, Chew) Quit Date

25 Primary care counseling and medication management o Medications o CPT codes o Diagnosis Call it Quits Phone/Text Counseling o Referral can be completed electronically in Epic Behavioral health/psychology consult HCMC Smoking Cessation Clinic Clinical Phar.D. counseling and medication management

26 Utilize and modify electronic health records Found in Communication Management Call it Quits Referral is a tab to select in Communication Management. The provider/support staff is able to use pre populated text to fill out the referral. To fax, the Call it Quits fax number is entered into the recipient field.

27 Developed tobacco cessation workflow that is being implemented across the organization Incorporated MA work in asking tobacco cessation questions in the standard rooming process at every visit Call It Quits Program referral in EHR o 47 ambulatory clinics registered as CiQ

28 Provider education and training Keeping 47 clinics up to date/registered under CiQ It s been challenging to capture the data that will measure the effectiveness of the workflow

29 Establishment of EHR support team early on Establishment of key stakeholder involvement o ACQC o Physician champions Develop a central location for staff to look at and/or refer to information Being flexible in a large dynamic organization Hardwire EHR process

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31 Tobacco Dependence Treatment: A System s Change Approach e-health Summit June 15, 2017 Jill Doberstein, MA, CTTS

32 LANDSCAPE

33 Essentia Health Facilities 67 Clinics 17 Hospitals 13,000 Employees

34 At Essentia Health

35 Our Clinic Patient Population that uses Tobacco: 12% - 31% System-wide Average: 19.04%

36 Initial Funding for Project Launch Work began in May 2015 with a 2-year ClearWay MN Health Systems Change Grant (many smaller scale initiatives prior) Steering Committee formed - has about 20 members representing a multi-disciplinary group with representation from diverse geography (MN, WI and ND) FTE hired August 2015 Tobacco Treatment Integration Specialist

37 GOALS & STRATEGIES

38 Project and System Goals Conduct a Needs Assessment with Pilot Clinics (7 in NE MN) to identify barriers, gaps and opportunities Utilize Clinical Practice Guidelines to guide process and workflow changes, leading to evidence based treatment strategies Improve access and enhance tobacco treatment services system-wide Measure outcomes and conduct program evaluation

39 Key Strategies & Success Factors Champions at the leadership level Utilize Advisory Group to increase buy-in Dedicated staff time/person to coordinate (cheerleader) Partner with Community Health to enhance resources and reach Engage/educate the entire care team Measure and share outcomes (data feedback)

40 Section Meetings Grand Rounds CME Enduring Education Video Weekly Newsletter STAT Clinic Leadership Primary Care Leadership Provider Education

41 Care Team Education Same as above! Rooming staff ask the question/start the conversation Can T-Up and pend referral orders to providers Facilitate warm hand offs with CTTS Update care process and standard work to support clinic staff Monitor standard work & provide coaching when necessary

42 Process Improvement PDSA Cycle Performance Board Team Huddles Reporting Workbench Celebrate Successes!

43 GAME CHANGER

44 Tobacco Treatment Integration 20 EH staff from across all 3 regions and 6 community partners came together in Duluth to complete the Mayo Nicotine Dependence Centers Tobacco Treatment Certification course. The week long training with certification exam was held at the EH - Hermantown Clinic and offered registration at half the cost to employees and ¼ cost to community partners (some full scholarships)

45 Tobacco Treatment Specialist on-site Face to face tobacco treatment counseling offered on-site. From 13 to now 38 clinic and hospital locations!

46 CTTS Integration/Utilization Ancillary Schedules for RN s in Primary Care (20/40 min visit types) EPIC Documentation Tools Referral Order by region and clinic location SmartSet specific to CTTS s Unique toll free Number for EH - TTS Visit Marketing and Patient Education Materials Monthly Connect Calls with EH CTTS + Basecamp Proactive Outreach to Chronic Disease Patients utilizing Healthy Planet

47 Documentation Tools Formed a Data Workgroup early on in the project to help think through and develop the necessary documentation tools Members included IS, IT, Call Center, Quality Outreach, Research and CTTS front line users Data Workgroup has evolved in membership and focus over the 2 year period, but a critical part of the projects success

48 Documentation Tools, cont. CTTS SmartSet Includes: All encounter types: face to face visit, telephone, letter, MyHealth message and communication all with unique Reason for Call/Visit tied to CTTS Initial vs. Follow Up Visit Progress notes, which include Patient Assessment Questionnaire (Fagerstrom Score, Tobacco use history, cessation history plus medications, etc.) CO Screening score Patient Plan which includes items discussed in visit such as, quit date, medications, coping strategies, support system, their WHY, etc. Medications 7 FDA approved meds in all dosing options Level of Service codes for billing specific to CTTS + Diagnosis codes to supplement billing codes Follow Up Section which prints as an AVS and includes next appointment date, reminder for CTTS to follow up (in 2 weeks or on quit date, etc.), patient plan from SmartSet

49 OUTCOMES (USING DISCRETE DATA POINTS IN EPIC TO TRACK AND MEASURE)

50 Clarity Reports : (data is a beautiful thing!)

51 Clarity Reports: (data is a beautiful thing!)

52 6 Month Quit Rates & Patient Satisfaction 12 months of Patient Referral Data 6 months of Follow Up Data from 6 month outreach

53 TARGETED PATIENT OUTREACH

54 MN Community Measures

55 Optimal Diabetic and Vascular Care Outcomes Before & After Outreach Initiative: our total diabetic patient population increased by 274 but our patients non-compliant in the D5 ONLY because of tobacco decreased by 38.

56 Addressing our Employee Tobacco Use Rate Sign Up in March (86 enrolled) Quit for the Month of April Weekly Support Tools & Prizes for Participation $500 Grand Prize Drawing *If Health Partners member - $260 insurance premium credit (TakeCharge) *If MN resident, can sign up for MN QUITPLAN s big QuitCash Challenge - $5,000 Grand Prize

57 NEXT STEPS: INPATIENT

58 Integrating Tobacco Treatment Counseling into Essentia Health s Duluth Hospitals Hospitalization offers smokers a unique opportunity to initiate cessation because hospitals are smoke-free, requiring smokers to abstain temporarily. Hospitalization provides patients with both salient motivation to quit as well as access to tobacco-cessation interventions. A meta-analysis of 50RCT s found that hospital based interventions increased cessation rates by 37% at 6 to 12 month follow up. The two most successful strategies were: 1. Bedside Interventions (counseling + medications) *starting NRT in hospital quit rates by 54% 2. Providing NRT at Discharge (not just a prescription) EH Plans to take this one step further to sustain quit attempts/prevent relapse after discharge: 3. Provide a referral to outpatient CTTS for follow up - ongoing counseling and medication management * Not effective without continued support after discharge

59 Inpatient at SMMC Admission OrderSet to include: Protocol Order Consult Order NRT Order Easy dosing nomogram No Orders Documentation tools being developed for consult with CTTS including discrete data points to track progress and evaluate outcomes

60 CRITICAL SUCCESS FACTORS

61 If you build it, will they come?

62 Lessons Learned! Systems Change, especially in a large system, takes time!!! It takes leadership at all levels far and wide It takes the entire care team to be successful It s a full time gig! Be forward thinking about what data you might want to capture and how to pull it back out Don t reinvent the wheel learn from/share with others Stay grounded and compassionate

63 This is hard work Quitting smoking is the single most important thing you can do to improve your overall health But so incredibly rewarding

64 Closing Slide The public dissemination of information relating to the grant was made possible by Grant Numbers IC and IC from ClearWay Minnesota SM. The contents of this information are the sole responsibility of the authors and do not necessarily represent the views of ClearWay Minnesota. Jill Doberstein, MAPL, CTTS Tobacco Treatment Program Manager System Quality Essentia Health

65 Questions & Discussion

66 Thank you! Connectivity. Equity. Health.