1. MN Clinic Fax Referral Program

2. What is it? The MN Clinic Fax Referral Program allows you to easily refer any of your patients to appropriate tobacco quitline services via a single form. It is FREE for all Minnesotans. The program is sponsored by Call it Quits, a collaboration between seven of Minnesotas major health plans and ClearWay Minnesota.

3. Why phone counseling? Statistics show that fewer than 1 in 20 smokers will be successful in quitting tobacco and staying quit. 1 With tailored phone-based coaching, nearly 1 in 3 will be successful in quitting and staying quit. 2 1 CDC Analysis of data from the 2000 National Health Interview Survey indicated that 4.7% of smokers quit and maintained abstinence for 3-12 months. (CDC. Cigarette Smoking Among Adults – United States, 2000. MMWR. 2002;51:642-645) 2 Free & Clear performance metrics for Blue Cross and Blue Shield of Minnesota, 2006. Based on a 30 day quit rate and a 12 month follow-up.

4. Program Components A series of individually-tailored calls from a quitline coach No limit to the number of calls to quitline coach while enrolled Program materials mailed to each participant Quit Aids (nicotine gum, patch, lozenge) available via direct mail to enrolled participants* * costs vary depending on benefits of the individual

5. Patient visits clinic. Ask patient if he/she uses tobacco. Assess, are they interested in quitting? Assist, offer phone support through quitlines. How it works…

6. Briefly explain about the tobacco quitline services: –Free –Confidential –Increases quitting success –Available regardless of insurance coverage

7. MN Clinic Fax Referral Member agrees to be contacted xJohn Doe How it works… If interested, patient completes consent form. If Electronic Health Record (EHR) is used, verbal consent is documented in record.

8. How it works… Consent form or EHR record is faxed to a single, centralized triage number for all patients regardless of insurance status.

9. Tobacco quitline will contact patient within 3 days. Calls are 15-20 minutes in length and emphasize support and successes. How it works…

10. Your clinic will receive a follow-up fax from the quitline with the referral outcome for your patient records. Reporting will also be available to view your clinic efforts. How it works…

11. THANK YOU Together well make it easier for your patients to take the next step toward becoming tobacco free. If you have questions, please contact your clinic administrator.

12. To Sign Up and Begin Referring Call Kim Winter at (651)662-6879 Visit Center for Prevention website http://www.preventionminnesota.com/ Complete and fax the combination clinic registration and order form to enroll your clinic A unique clinic ID and referral forms will be sent to you