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1 Sustainability of Public Health Programs: The Example of Tobacco Treatment in Massachusetts Community Health Settings Nancy La Pelle, Ph.D. University.

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Presentation on theme: "1 Sustainability of Public Health Programs: The Example of Tobacco Treatment in Massachusetts Community Health Settings Nancy La Pelle, Ph.D. University."— Presentation transcript:

1 1 Sustainability of Public Health Programs: The Example of Tobacco Treatment in Massachusetts Community Health Settings Nancy La Pelle, Ph.D. University of Massachusetts Medical School February 2007 Grant # RO1 CA86282 funded by National Cancer Institute State and Community Tobacco Control Interventions Research Initiative

2 2 Principal Investigator: Judith K. Ockene, PhD UMMS Co-Principal Investigators: Lori Pbert, PhD UMMS Donna Warner, MBA, CAC MDPH Co-Investigators: Nancy La Pelle, PhD UMMS Jane Zapka, ScD UMMS Sarah Reiff-Hekking, PhD UMMS Harriet Robbins, MEd MDPH Project Directors: Denise Jolicoeur, MPH, CHES UMMS Mary Jo White, MS, MPH UMMS

3 3 Sustainability Sustainability contrasts with the notion ofinstitutionalization which implies that a service is continued within the original organizational structure and that it is unchanged Sustainability includes adaptations to scope of services offered, organizational context, and supporting resources

4 4 Massachusetts Tobacco Treatment Policy Study (MASSTTPS) Sustainability Substudy Qualitative comparative case study Sample Massachusetts Tobacco Control Program (MTCP) statewide Smokers Helpline funded by MDPH 77 of 86 defunded community-based tobacco treatment programs - 21 hospitals; 27 community health centers; 9 substance abuse treatment centers; 6 mental health agencies; 14 other agencies

5 5 Data Collection and Analysis Telephone-based key informant interviews with community agency staff (77) In-person interviews with DPH/MTCP staff regarding Smokers Helpline (5) Tape-recorded and transcribed Thematic and relational analysis conducted to idenify strategies used to sustain services

6 6 Results: Essential Strategies for Sustainability When Defunded Redefine Scope of Services: 1.Align services with organizational goals 2.Select acceptable and affordable services Creative Resourcing: 3.Find funding sources for services offered 4.Adjust staffing pattern 5.Assign resources to create demand for services Sustainable Services

7 7 Align Services with Organizational Goals Meet needs of high smoking prevalence populations served Meet needs to provide tobacco treatment to patients with co-morbid conditions Support staff needs to quit at smoke- free sites Dovetail with cessation-related research at the site

8 8 Select Acceptable and Affordable Services Target specific at-risk subpopulations Offer selected services only Reduce availability: hours and sites when/where services are offered

9 9 Find Funding for Services Offered Charge fees Use grant-writing expertise to find other funding Get other entities (departments, collaborators, etc.) to fund, share costs, or provide space Bill as encounter that has insurance coverage

10 10 Adjust Staffing Pattern Reduce tobacco treatment specialist (TTS) staff Find other roles TTS staff can play part-time in other departments Outsource TTS staff Find non-TTS staff resources to provide services

11 11 Assign Resources to Create Demand for Services Create referral system from providers and other departments Educate healthcare providers about services Program staff networks with other community organizations to generate referrals Enlist marketing resources to advertise services

12 12 Sustainability Results After 9 Months Level 1: Non-Sust. Level 2: Low-Sust. Level 3: Mid-Sust. Level 4 : High-Sust. Totals Volume of Prior Services Still Provided 0%5-19%20-49%50-100% Totals 252621577 % of Total # Agencies 33%34%27%7%

13 13 Level 1: 33% Non-Sustaining (Minimal Scope; No Resources) Redefining Scope: 1.Drop tobacco treatment - low priority 2.Refer to other agencies for treatment Creative Resourcing: 3.No funding; Fees not acceptable to clients; No grant-writing resources 4.No staff to deliver services 5.No staff to create demand

14 14 Level 2: 34% Low Sustaining (Restricted Scope; Minimal Resources) Redefining Scope: 1.Serve high prevalence smokers where possible 2.Limited services for specific populations; No nicotine replacement therapy (NRT) unless covered by insurance; Integrate with other treatment services Creative Resourcing: 3.Limited grant-writing resources 4.TTS staff provide fewer sessions at fewer sites; Services provided by interns, volunteers, non- specialists 5.No outreach since not staffed for full service; Internal referral systems not optimized

15 15 Level 3: 27% Mid-Sustaining (Expanding Scope; Expanding Resources) Redefining Scope: 1.Gradually restore services available to all 2.Provide only group services; Provide all previous services except NRT; Provide only phone- or web-based services Creative Resourcing: 3.Seek alternate funding sources/charge fees; Seek collaborators with funding; Seek grants to serve specific ethnic groups; Seek NRT funding source 4.Use contract staff or share staff with other departments; Transfer program to related groups with more resources 5.Emphasize use of internal referral system

16 16 Level 4: High Sustaining (Similar Scope; Similar Resources) Redefining Scope: 1.Continue services to all smokers 2.Continue to offer same level of services as when funded Creative Resourcing: 3.Seek alternate funding sources/charge fees 4.Maintain staff required 5.Provide marketing and outreach support; Encourage internal referrals agency-wide

17 17 Sustainability Results After 9 Months Level 1: Non-Sust. Level 2: Low-Sust. Level 3: Mid-Sust. Level 4 : High-Sust. Totals Volume of Prior Services Still Provided 0%5-19%20-49%50-100% Hospitals 1 (5%)*8 (38%)*9 (43%)* 3 (14%)*21 Community Health Centers 8 (30%)*12 (44%)*6 (22%)*1 (4%)*27 Substance Abuse Treatment Agencies 5 (56%)*3 (33%)v1 (11%)*09 Mental Health Treatment Agencies 1 (17%)*3 (50%)*2 (33%)*06 Other Agency Types 10 (71%)*0 3 (21.5%)* 1 (7.5%)*14 Totals 252621577 % of Total # Agencies 33% 34% 27% 7% * The percentage is of the agency type total

18 18 Sustainability Strategies Key Strategies at Defunding Redefine Scope of Services: Align services with organizational goals Select acceptable and affordable services Creative Resourcing: Find funding sources for services offered Adjust staffing pattern Assign resources to create demand for services Additional Key Strategies at Planning Program design Standard operating routines Capacity building Community board involvement Local institutional support Administrative system support Evaluation

19 19 References Bracht N, Finnegan JR, Rissel C, et al. Community ownership and program continuation following a health demonstration project. Health Ed Research 1994;9(2):243-255. Claquin P. Sustainability of EPI: Utopia or sine qua non condition of child survival. In. Arlington, VA: REACH; 1989. Evashwick C, Ory M. Organizational characteristics of successful innovative health care programs sustained over time. Fam Community Health 2003;26(3):177-93. Goodman RM, Steckler AB. A model for the institutionalization of health promotion programs. Fam Community Health 1989;11(4):63-78. La Pelle N, Zapka J, Ockene JK. Sustainability of Public Health Programs: the Example of Tobacco Treatment in Massachusetts. American Journal of Public Health, Aug 2006, Volume 96: p. 1363-1369. Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of community- based health programs: conceptual frameworks and future directions for research, practice and policy. Health Ed Res 1998;13(1):87-108. Steckler A, Goodman R. How to institutionalize health promotion programs. Am J Health Promot 1989;3:34-44. U.S. Agency for International Development. Maximizing Program Impact and Sustainability: Lessons Learned in Europe and Eurasia 1999. In: Available at: http://usaid.gov/locations/Europe_Eurasia/dem_gov/local_gov/maximpact.ht m. http://usaid.gov/locations/Europe_Eurasia/dem_gov/local_gov/maximpact.ht m U.S. Agency for International Development. Sustainability of Development Programs: A Compendium of Donor Experience. In. Washington, DC; 1998.


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