Smking Cessatin Imprvement in SFHN Primary Care, 2015-16 David Silven, PhD, Supervising Psychlgist, SFHN Primary Care Behaviral Health Ellen Chen, MD, Directr f Quality, SFHN Primary Care
Why smking assessment and cunselling in primary care? Tbacc use is a leading cause f preventable death* Tbacc dependence is a chrnic cnditin* Repeated interventins and multiple attempts t quit needed Primary care prvider and care team can influence decisin t quit SFHN Primary Care: High risk ppulatins Tbacc use amng tp 10 diagnses 2009 SFGH study using bld testing f ED pts: >4 f ED pts were heavy tbacc users 14% were tbacc users Opprtunity: Average almst 3 medical visits/yr & high patient satisfactin with prviders *Fire MC, Jaén CR, Baker TB, et al. Treating Tbacc Use and Dependence: 2008 Update. Clinical Practice Guideline. Rckville, MD: U.S. Department f Health and Human Services. Public Health Service. May 2008. < http://www.tcln.rg/cessatin/pdfs/treating_tbacc_use08.pdf > **Kaiser State Health Facts: Califrnia: Diabetes. < http://www.statehealthfacts.rg/prfileind.jsp?sub=22&rgn=6&cat=2 >
Prgressin f SFHN Primary Care smking cessatin effrts 2014-15 2015-16 2009 2010-13 Individual clinician effrts t assess, cunsel, refer Assess & Dcument at every visit Cunsel & Refer Cnnect with cessatin services
10 9 8 7 6 5 4 3 2 1 21% % f patients age 18+ with a medical visit in past 24 mnths at each clinic wh were identified as current smkers, Dec 2015 51% 38% 34% 34% 33% 26% 24% 23% 11,373 current smkers in SFHN Primary Care 19% 17% 16% 14% 13% 13% 11% 9% 1% 12 10 80 60 40 20 0
Quality Imprvement (QI) fcus in 2015 In 2014, nly 48% f patients identified as current smkers seen in SFHN Primary Care were referred t smking cessatin cunseling. Set gal fr 2015: Increase the percentage f referrals t 58% Engaged Quality Imprvement representatives frm all primary care clinics Included all members f the PC care team in screening fr smking, cunselling, and referrals fr cessatin Trained Behaviral Assistants (BAs) t cunsel patients t quit Reminded teams t refer smkers t BAs at daily team huddles Cllabrated with CHEP t begin develping a jint strategy
Engaged the QI representatives Staff asks pt if s/he wants t quit r t talk t smene abut quitting PROVIDERS AND OTHER STAFF Pt desn t want t quit r feel pressured t quit PATIENTS Included all members f the Primary Care care team Trained Behaviral Assistants (BAs) t cunsel t quit Uncertainty abut whether t recmmend smking referral fr pts with multiple BA referral needs Staff member is unclear as t wh makes the referral t the BA Staff lack cnfidence in BAs cunseling skills BA isn t available at the time r inadequate level f BA staffing Pt desn t knw the BA & is uncmfrtable talking t a stranger Pt desn t have the time t stay t talk with a BA after the PCP visit It s unclear hw t dcument in ecw a smking cessatin referral t a BA Lw number f smkers referred t the BAs BAs reminded teams at staff huddles Cllabrated with CHEP Uncertainty abut whether pt must see PCP befre referral t BA MEA feels s/he desn t have time t make the referral Difficult t arrange referral t BA befre PCP visit Nt having a registry f current smkers t cue the referral Uncertainty abut whether t use a paper r electrnic referral PROCESSES EQUIPMENT & TOOLS
Engaged the QI representatives Included all members f the Primary Care care team Trained Behaviral Assistants (BAs) t cunsel t quit BAs reminded teams at staff huddles Cllabrated with CHEP PCP identifies current smker YES: Warm hand-ff t BA YES BA begins assessment/ interventin MEA identifies current smker Yur dctr wuld like yu t meet briefly tday with ne f ur staff t get mre infrmatin abut smking. Wuld it be kay with yu if I intrduce yu t that persn nw? Are yu able t stay fr 15-20 minutes t talk with me nw? NO: PCP/MEA ffers inf abut smking, and if apprpriate, inf abut 1-800-NO-BUTTS and stp smking classes NO BA ffers inf abut 1-800-NO-BUTTS and if apprpriate, inf abut stp smking classes; ffers return appintment; makes reminder call
Engaged the QI representatives Included all members f the Primary Care care team Trained Behaviral Assistants (BAs) t cunsel t quit BAs reminded teams at staff huddles Cllabrated with CHEP Stages f Change and Mtivatinal Interviewing Maintenance Nt currently smking. Quit mre than 6 mnths ag. Actin Nt currently smking. Quit within the past 6 mnths. Precntemplatin Nt thinking f quitting smking. Cntemplatin Thinking f quitting smking, but nt ready t make any changes. Preparatin Actively thinking abut changing smking patterns. May have taken steps twards quitting.
Engaged the QI representatives Included all members f the Primary Care care team Trained Behaviral Assistants (BAs) t cunsel t quit BAs reminded teams at staff huddles Cllabrated with CHEP Standard script fr staff: Yur dctr wuld like yu t meet briefly tday with ne f ur staff t get mre infrmatin abut smking. Wuld it be kay with yu if I intrduce yu t that persn nw?
Engaged the QI representatives Included all members f the Primary Care care team Trained Behaviral Assistants (BAs) t cunsel t quit BAs reminded teams at staff huddles Cllabrated with CHEP Areas being explred fr jint strategy: Increase tbacc cessatin referrals t the BAs Enhance skills f BAs in prviding tbacc cessatin cunseling Imprve referrals t cmmunity resurces fr tbacc cessatin cunseling
10 8 6 4 2 Smking Cessatin Referrals Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nv-15 SFHN Primary Care 2015 Quality Cuncil Gals Maximum & Minimum 47.7% Gal: 58% 75.4% (11,371)
10 10 10 10 8 8 8 8 6 6 6 6 4 4 8 Ttal (727) 2 42.7% 2 Gal: 51% CMHC Dec Feb Apr Jun Aug Oct Dec Gal: 52% Ttal (50) 44% 52% CHC Dec Feb Apr Jun Aug Oct Dec 4 2 Gal: 93% Ttal (569) 92.3% 93% CPHC Dec Feb Apr Jun Aug Oct Dec 4 2 Gal: 89% Ttal (308) 60.2% 66% CSC Dec Feb Apr Jun Aug Oct Dec 10 8 Gal: 53% Ttal (1257) 21.4% 33% 10 8 10 8 10 8 6 6 6 6 4 4 84% Ttal 2 2 (1185) 52.7% FHC Gal: 6 GMC Dec Feb Apr Jun Aug Oct Dec Dec Feb Apr Jun Aug Oct Dec 4 2 Gal: 95% Ttal (960) 70.5% 75% MHHC Dec Feb Apr Jun Aug Oct Dec 4 2 Gal: 96% Ttal (577) 90.6% 92% OPHC Dec Feb Apr Jun Aug Oct Dec 10 8 6 4 2 Gal: 59% Ttal (2041) 11.9% 25% TWUHC 10 8 6 4 2 Gal: 96% Ttal (657) 81.3% 84% PHHC Dec Feb Apr Jun Aug Oct Dec Dec Feb Apr Jun Aug Oct Dec 10 8 6 4 2 Gal: 9 Ttal (515) 81. 84% SAFHC Dec Feb Apr Jun Aug Oct Dec 10 8 6 4 2 Gal: 81% Ttal (1306) 65.7% 71% SEHC Dec Feb Apr Jun Aug Oct Dec
December 2015: successful effrt t screen fr smking and refer all smkers fr smking cessatin cunselling 55,134 active patients age 18 r lder 44,929 r 81.5% with smking status assessed/dcumented in past ne year Amng current smkers, 8,571 r 75.4% were referred t tbacc cessatin services in the past tw years: exceeded gal f referring 58% f smkers
2016: taking smking cessatin effrts t the next level Cntinue t mnitr the percentage f smkers referred t smking cessatin cunseling Mnitr the percentage f smkers wh actually receive smking cessatin cunseling (Mandated by new statewide PRIME prgram) Identify cre cmpetencies fr prviding smking cessatin cunseling, and assess BAs attainment f thse cmpetencies
Strategic Theme Quality Safety Equity Care Experience Develp Peple SFHN True Nrth Outcmes (DRAFT) Primary Care True Nrth Metrics 2016-2018 Primary Care (r True Nrth) Driver Metrics (PCDM) 2016 Apprpriate utilizatin Preventive care Imprve ppulatin health thrugh timely preventive care and chrnic cnditin management HTN BP Cntrl Fluride Varnish Smking Cessatin Zer patient harm Zer wrkplace injuries Imprve timely crdinatin f care t prevent high risk events 7 Day Pst- Discharge Fllw Up BAAHI initiative REAL/SOGI data Reduce health disparities Increase wrkfrce diversity strategically thrugh standard wrk and HR prcesses HTN BP Cntrl / Racial Disparities Likelihd t recmmend Timely access Increase number f patients with psitive respnse t CG-CAHPS "wuld yu recmmend" questin CG CAHPS likelihd t recmmend TNAA (Nn- Urgent) Primary Care True Nrth & Driver Metrics Staff engagement (Gallup) HR measures TBD Imprve wrkfrce engagement, as measured by the Gallup engagement scre N Mnthly Data Financial Sustainability Meets budget Prductivity Increase annual revenue Unlcked ntes
Questins?