Treating Tobacco Use During Pregnancy and Beyond

Treating Tobacco Use During Pregnancy and Beyond Office-Based Reminder Systems Dr. Monica Scheibmeir Associate Professor School of Nursing University of Kansas Medical Center 4/25/2008 1 4/25/2008 2 The Six Strategies 1. Implement a Tobacco-user identification system in every clinic. 2. Provide education, resources, and feedback to promote provider interventions. 3. Dedicate staff to provide tobacco dependence treatment and assess the delivery of this treatment in staff performance evaluations. 4/25/2008 3 The Six Strategies 4. Include tobacco dependence treatments (both counseling and pharmacotherapy) as paid or covered services for all subscribers or members of health insurance packages. 5. Promote hospital policies that support and provide tobacco dependence services. Reimburse clinicians and specialists for delivery of tobacco dependence treatments and include them among the defined duties of clinicians. 4 6. 4/25/2008 The Six Strategies Implement a Tobacco-user identification system in every clinic Strategies: 1. Flow sheets 2. Stickers/reminder systems 3. Unique history forms 4/25/2008 5 Pregnancy Smoking Cessation Flow Sheet Survey Teachable MomentADVISE •Discussed •Relevance •Risks •Rewards •Roadblocks ASSESreadiness to quit •No interest •Quit later •Ready •Quit< 6 months •Maintenance •Relapse GiveASSIST EvaluateARRANGE Date__/__/__ Initial___ EDC__/__/__ Cig/day___ Set quit date __/__/__ •Counsel •Referral •Booklet •Support •Pharmacotherapy •Quit •Call •Referral to specialist •Follow-up appt. 4/25/2008 6 Vital Sign Stamp Blood Pressure_______________ Pulse_________ Weight________ Temperature________ Respiratory Rate_____ Tobacco Use Current Former Never (circle one) 4/25/2008 7 Smoking History Survey for Pregnant Women o o o o o I have never smoked or have smoked fewer than 100 cigarettes in my life. I stopped smoking before I found out I was pregnant and am not smoking now. I stopped smoking after I found out I was pregnant and I am not smoking now. I smoke some now but have cut down since I found out I was pregnant. I smoke about the same amount now as I did before I found out I was pregnant. 4/25/2008 8 Smoking History Survey for Pregnant Women Household Environment 1. How many smokers do you live with?___ 2. What is the relationship to the above smoker(s) check all that apply partner___ parent___ friend___ other___ 3. Where do they smoke? inside your home___ outside your home___ in the car___ away from home___ other___ 4. Do you allow people to smoke in your home? Yes___ no___ 4/25/2008 9 Smoking History Survey for Pregnant Women 1. 2. 3. 4. 5. How many cigarettes a day did you or do you smoke?____ How many years have you or did you smoke?____ If you smoke, how soon after awakening do you smoke? Where did/you smoke? If you quit, how long has it been since you smoked a cigarette? 10 4/25/2008 The Six Strategies Provide education, resources, and feedback to promote provider interventions. Strategies 1. Chart audit 2. Web-based CEU 3. HEDIS reports (used in managed care contracts) 4/25/2008 11 The Six Strategies Dedicate staff to provide tobacco dependence treatment and assess the delivery of this treatment in staff performance evaluations. Strategies 1. 2. Part of job description for staff Evaluate patient flow—identify staff from flow sheet 4/25/2008 12 Assigning Tasks Tasks Ask Advise Assess Ask patient about smoking Document status Advise patient to quit Assess interest in quitting Assess previous quit attempts Assess barriers to quitting (5 R’s) Help patient set a quit date Provide self-help materials Provide problem-solving information Document status for checking at next visit Follow up by telephone (optional) Send congratulatory letters (optional) Order and keep materials stocked Compile follow-up results Who Where Assist Arrange Administrative support 4/25/2008 13 Sample Office Flow Chart With Whom With Whom New Patient What Happens What Happens Tools Tools Patient exits Tools What Happens 4/25/2008 Gaffney, 2001 14 Sample Office Flow Chart Office staff Ask about smoking New Patient Document smoking status Nurse Practitioner Advise quitting Benefits personalize Handouts, progress note Vital Signs stamp Patient exits Assist with Assist with quitting quitting Flow sheet Yes Assess readiness to No 5 R’s quit 4/25/2008 Gaffney, 2001 15 Implementing a Smoking Cessation Program Step 1. Develop administrative commitment Step 2. Involve staff early Step 3. Assign one coordinator Step 4. Provide training Step 5. Adapt procedures to your setting Step 6. Monitor and provide feedback 4/25/2008 16 Step 1: Develop Administrative Commitment  Include all staff who are responsible for patient care, records, materials, or other aspects of implementation  Review health consequences of smoking  Explain the 5 A’s  Note cost-effectiveness 4/25/2008 17 Step 2: Involve Staff Early  Invite participation  Address concerns  Anticipate problems or barriers  Offer intervention to staff who smoke 4/25/2008 18 Step 3: Assign One Coordinator  One person should oversee implementation to ensure that tasks are not overlooked  The coordinator can     answer questions troubleshoot problems arrange for training monitor implementation 19 4/25/2008 Step 4: Provide Training  5 A’s approach to quitting  5 R’s (when patients don’t want to quit)  Provider and patient resources 4/25/2008 20 Step 5: Adapt Procedures to Your Setting  Assign specific tasks  Assignments depend on size of practice  Additional support and follow-up beyond the 5 A’s depends on staff availability 4/25/2008 21 Step 6: Monitor, Provide Feedback  Are procedures working as intended?  Is staff completing assigned tasks?  Is staff adequately trained?  Is documentation complete and accurate?  Are materials available and being used appropriately? 4/25/2008 22 Resources  American College of Obstetricians and Gynecologists (www.acog.org)  Smoke-Free Families (www.smokefreefamilies.org)  Treating Tobacco Use and Dependence  Agency for Healthcare Research and Quality (www.ahrq.gov) 4/25/2008 23 Questions Dr. Monica Scheibmeir Associate Professor School of Nursing University of Kansas Medical Center 3901 Rainbow Blvd. Kansas City, KS Office: 913-588-1664 Email: mscheibm@kumc.edu 4/25/2008 24