1. a presentation for [INSERT EVENT/ORGANIZATION] [INSERT DATE] [INSERT PRESENTER NAMES/ORGS]

2. Make Tobacco Your Priority! Objectives Understand the burden of tobacco on Alaskans Learn how systems change increases positive outcomes in healthcare settings Learn about the Tobacco Prevention and Control Program and its partners’ effort to create a 100% tobacco-free Alaska (Mission 100) Identify how Mission 100 can help your organization reduce tobacco use 2

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4. 4 [INSERT LOCAL PHOTO OR OTHER LOCAL- BASED CONTENT IF DESIRED]

5. THE BURDEN OF TOBACCO ON ALASKANS Reviewing the Data 5

6. Reducing Tobacco Use Saves Lives 6 Adult Smoking Prevalence, 1996 - 2012 Source: Alaska Tobacco Facts, 2014; BRFSS, 1996-2012

7. Preventing Youth Initiation of Tobacco Use Saves Lives 7 Youth Smoking Prevalence, 1995 - 2013 Source: Alaska Tobacco Facts, 2014; YRBS, 1995-2013

8. Reducing Tobacco Use Saves Lives … and Money 8 Findings from the Alaska Tobacco Prevention and Control Program Source: Alaska Tobacco Prevention and Control Program Annual Report, FY 2012

9. Impacts of Tobacco Use 9 Source: Alaska Tobacco Facts, 2014; Alaska Bureau of Vital Statistics, 2011 Alaska Deaths Due to Selected Causes, 2011

10. The Cost of Tobacco Use 10 Source: Alaska Tobacco Prevention and Control Program Annual Report, FY 2012 How much does tobacco cost Alaska each year? Costs of Tobacco Use Tobacco Revenue Investment in Prevention

11. More Work to Be Done 11 Source: Alaska Tobacco Facts, 2014; BRFSS, 2012 Tobacco-Related Disparities: Certain Populations Have Higher Prevalence

12. [insert local data if available] 12 [See TPC’s website for local data] Regional Profiles (scroll down to Regional Profiles) http://dhss.alaska.gov/dph/chronic/pages/tobacco/default.aspx Region Specific Data http://dhss.alaska.gov/dph/Chronic/Pages/Tobacco/regional.aspx [Title of chart or table] Source: [source of data]

13. ALASKA TOBACCO PREVENTION AND CONTROL How a Comprehensive Program Reduces the Burden of Tobacco 13

14. The Alaska Tobacco Prevention and Control Program Vision For All Alaskans to Live Healthy and Tobacco-free Lives! 14

15. TPC Program Goals Four goals guide a comprehensive program: 1.Prevent initiation of tobacco use 2.Help tobacco users quit their addiction 3.Eliminate exposure to secondhand smoke 4.Eliminate tobacco-related health disparities among population groups, including: –Alaska Native People –People of Low Socioeconomic Status (SES) –Young Adults –Pregnant Women 15

16. Addressing Tobacco Use: Public Health Model 16

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18. ADDRESSING TOBACCO USE THROUGH HEALTHCARE SYSTEMS CHANGE How healthcare providers can help people quit tobacco and prevent others from becoming addicted 18

19. Helping Alaskans Quit For Life Alaska’s healthcare providers play a critical role in helping people quit tobacco. At least 70% of smokers see a physician annually Advising a tobacco user to quit increases the odds of quitting successfully Healthcare providers with the right tools (protocols, resources and billing incentives) can make an impact on all patients who use tobacco. Tobacco cessation counseling and medication are safe, effective and reimbursable by Medicaid, Medicare, and most health plans 19

20. Tobacco Cessation and Prevention Promotes Healthier Alaskans Reducing tobacco use in healthcare settings: Improves patient, staff and public health One of the most cost-effective clinical preventive services Integral part of the reforms of the Affordable Care Act: Essential Benefits and Meaningful Use Important quality measure for the Joint Commission, GPRA, and HRSA Increasingly reimbursable 20

21. Healthcare Systems Change Healthcare systems change to address tobacco dependence has three goals: Make it easy to help clients quit tobacco Prevent others from ever starting to use tobacco Protect everyone on the campus (patients, staff and visitors) from the harms of secondhand smoke All health organizations in Alaska have the opportunity to implement best practices and utilize available resources for tobacco cessation and prevention. 21

22. Clinical Practice Guidelines for Treating Tobacco Use and Dependence Ask, Advise, Refer and Document in electronic health records (EHR) The right pharmacotherapy and counseling Consistent reimbursement for eligible services 22

23. Best Practices for Addressing Tobacco Use Ask, Advise, Refer (AAR) Document (in EHR) Tobacco-free campus policy Pharmocotherapy and counseling services Billing and reimbursement 23

24. Brief Interventions Can Make a Difference 70% of smokers want to quit 3 in 5 current smokers have attempted to quit in the last 12 months Quit attempts among Alaska Native smokers increased from 59% (2001) to 65% (2010) Providers can significantly increase patients’ likelihood of quitting with a Brief Intervention (Ask, Advise, Refer) 24

25. Defining Ask, Advise, Refer Ask | Ask about tobacco use at every visit Advise | Conduct a brief 3 minute intervention Refer | Refer to cessation resources for more intensive treatment 25

26. ASK Screening –Type and use patterns –Every patient, every visit Beyond the Basics: Interventions –“Are you still using tobacco?” –“You were chewing/smoking last time you were here, are you still using tobacco?” –“We noted that you smoke a pack a day, is that still true?”

27. ASK: Motivation to Quit Initial Visit “What are your feelings about quitting tobacco?” “How do you think attempting to quit would go for you?” “What lifestyle changes might you need to make if you decided to quit?” “What would be the hardest thing about quitting tobacco?” Follow-up Visits “You were thinking about quitting last time we saw you, what are your feelings about quitting today?” “Did you try to quit since we saw you last?”

28. ADVISE Whether coming in to remove a fishhook, an inhaler refill or a pre-operative visit, advise the patient to quit tobacco. Make it personal –What motivates them to quit? –Ask open-ended questions –Help patients find reasons to quit 28

29. REFER Be direct! Ensure clients know their options Make the referral –Local / in-house cessation program –Alaska’s Tobacco Quit Line –Online resources –Fax referral (Quit Line reaches out to client) –Electronic referral through EHR 29

30. Free counseling and medication –Fax or electronic referral includes update to referring provider after 30 days –Clients can call on their own at any time –Scheduled follow-up calls from Quit Coach –Text to Quit: receive SMS messages from Coach –Includes Nicotine Replacement Therapy (NRT) –Expanded services available for pregnant women 30% of QL callers reported success at 30 days REFER: Alaska’s Tobacco Quit Line 30

31. 31 Alaska Quit Line Coaches are Part of the Patient’s Medical Team Quit Coaches are trained to assist Alaskans in quitting tobacco “They were helpful. They called consistently. They did not judge. They were there to listen and give advice. ”

32. 32 Treatment Model Diagram

33. Training: AK Brief Intervention A web-based training to educate healthcare providers on the brief tobacco intervention, local and statewide resources, and Alaska’s Tobacco Quit Line AAR Brief Tobacco Intervention (Ask, Advise, Refer) Collaborative effort specific to Alaska akbriefintervention.org

34. Document: EHR Simple steps can be introduced effectively into the clinical workflow to support quitting –Document patient’s tobacco use –Document counseling and interventions provided –Document the referral Make it easy: use prompts for providers to follow, in as few clicks as possible Electronic referrals to the Quit Line can be integrated into the workflow 34

35. Documentation in EHR Produces Positive Results Electronic health record-based interventions can lead to significant reduction in tobacco use Prompts for providers to Ask, Advise, Refer will improve cessation treatment outcomes With EHR, providers routinely reach high levels of identification and intervention (>80%) EHR Documentation helps increase reimbursement for cessation services 35

36. TherapyOdds Ratio vs Placebo† Nicotine gum1.5 Nicotine patch1.9 Nicotine inhaler2.5 Nicotine nasal spray2.7 Nicotine lozenge (2 mg/4 mg)‡1.96 / 2.76 Bupropion SR2.1 Varenicline‡3.68 * Table is adapted from multiple studies † All arms, including placebo, included behavioral counseling. ‡ Continuous abstinence rates. Pharmacotherapy and Counseling Combined Increases Success 36 Efficacy of Smoking Cessation Pharmacotherapies vs Placebo at 6 Months*

37. Evidence-Based Treatment Approaches for Tobacco FDA-approved medications –Medications to treat withdrawal symptoms –Options to match individual needs of patient Varenicline / Chantix Buproprion / Wellbutrin Nicotine Replacement Therapy (NRT) –Gum –Patches –Lozenges Pharmacotherapies used in combination Source: PHS Clinical Practice Guidelines, 2008 Update

38. Evidence-Based Treatment Approach Counseling and coaching programs –Tailored to the needs of the patient –Support to adjust to no longer smoking or chewing Education Coping strategies Support –Multiple communication formats (person to person, telephone, texting/SMS, digital)

39. More Payment Options for Cessation Services An Essential Health Benefit –The Affordable Care Act requires private insurance to cover tobacco cessation treatment as of Oct. 2014 –Medicaid reimburses for interventions provided by qualified providers Alaska Division of Behavioral Health clarified Medicaid coverage for funded organizations –Behavioral Health specialists at all levels can provide Medicaid-reimbursable cessation counseling 39

40. MAKING CHANGE A REALITY: HOW YOUR ORGANIZATION CAN BENEFIT The case for investing in health care systems change to address tobacco use and dependence 40

41. Systems Change Complements Quality Improvement Efforts Implementing systems for treating tobacco use can catalyze other improvements. Works well with and reinforces the patient centered medical home model An opportunity for integrating primary and behavioral health care Works with quality improvement measures and efforts already in place 41

42. Sites that achieve systems change experienced a 40% greater reduction in smoking prevalence within their patient population (13.6% reduction vs. 9.7% reduction) Quitting smoking can lower total health care costs within 2 years, and by 10%+ in 3 years Employee cessation program expenditures can be fully offset by health care savings within three years ($144 to $804 per smoker) 42 Systems Change Helps Patients, Staff, and the Bottom Line

43. How Are Alaska Organizations Doing? Baseline Survey (2012) In Alaska, most medical professionals in the surveyed organizations are asking their patients about tobacco use, but more could be advising patients to quit and referring to cessation services. 43 * Survey results from Spring 2012

44. 44 Treatment quality assurance (QA) measures and electronic health records (EHRs) being used more, but there is opportunity to improve. * Survey results from Spring 2012 How Are Alaska Organizations Doing? Baseline Survey (2012)

45. In Alaska, around half of organizations have comprehensive tobacco-free campus policies 56% of Community Health Centers (CHCs) 47% of Tribal Health Organizations (THOs) 42% of Hospitals Smoking and tobacco use by patients, staff, and visitors are not allowed indoors or outdoors at all sites and at all times Let’s make it 100%! 45 * Survey results from Spring 2012 How Are Alaska Organizations Doing? Baseline Survey (2012)

46. Making Change: Where to Start? Make it easy –for medical teams to ask, advise, and refer –to document and refer within a patient’s EHR –to prescribe the right medications –to refer to counseling Establish a change team in your organization Conduct a return on investment (ROI) to determine the value of providing in-house cessation for patients and staff Integrate tobacco cessation into patients’ care plans Provide cessation services and bill for reimbursements your organization is entitled to Look for local partners in primary care, behavioral health to support systems change 46

47. The Mission 100 team can help you integrate clinical best practices into your health system.

48. Mission 100 Services 48 Informational + Cessation Materials Systems change manual Fact sheets Case studies Quit Line materials Cessation + Clinical Workflow Assistance Ask, Advise, Refer Document AAR Quit Line Fax Referral Return on Investment Analyses Billing & Reimbursement Policy Assistance Tobacco-Free Campus Policy Implementation & Enforcement Provider Trainings Brief Intervention Quit Line + Fax Referral Billing/Reimbursement Medications

49. Questions or comments? Thank you! www.mission100alaska.org www.mission100alaska.org Insert presenter’s name and contact info (email and/or phone) for followup