1. Addressing Tobacco Control In Dental Networks Eric E. Stafne, D.D.S., M.S.D. Director Tobacco Cessation Program University of MN School of Dentistry Shelley Steen, M.S. HealthPartners, Center for Health Promotion

2. Addressing Tobacco Control in Physician & Dental Networks  Grant from: Alliance of Community Health Plans and the Robert Wood Johnson Foundation  6 HMO’s throughout the country  HealthPartners was the only dental network

3. Why dentistry should be involved with tobacco dependence treatment  Tobacco use is a significant risk factor for oral cancers, periodontal diseases and other oral conditions  There is impaired wound healing and less-favorable clinical outcomes for periodontal therapy and dental implants in smokers vs. nonsmokers

4. Dental Office Interventions  Dental office team members  emphasize prevention  have educating & motivating skills  see patients on a regular basis for fairly long appointments And are therefore ideal settings to encourage, support, assist and follow-up their tobacco users to help them through the stages of change Dental hygienists play a key role in an office program

5. Purpose   To implement system changes to include routine brief tobacco cessation interventions using the 5 A’s (through training of the dental office team)   To increase referral patterns to resources for tobacco cessation and increase the use of pharmacotherapy

6. Project Environment HealthPartners Dental Network Number and Affiliation of Dental Clinics Across the system, the total number of dental providers includes: 206 dentists 300 dental hygienists 150 dental assistants.

7. Project Approach   Pilot project implemented:   4 staff model clinics (HPDG)   4 contracted clinics (Park Dental)   Intervention   Provider trainings (entire office team)   Ongoing clinic support   weekly e-newsletter (sharing data)   quarterly staff meetings   new staff training

8. Project Approach   Evaluation   Baseline and post-training (12 Months) staff surveys   Chart reviews for documentation of 5A’s   Dental coding data review   ADA 1320 code   HP I1321 code   HPDG perio risk assessment codes   Park 0007 code   Pharmacy prescriptions written and filled   Referrals and enrollment to   HealthPartners Partners for Better Health (PBH) Phone Line

9. Office Team Training Curriculum  First 2 hour session:  Introductions  Why dentistry should be involved  risks of tobacco use (general & oral effects)  benefits of a tobacco-free lifestyle  Nicotine addiction – the mechanism involved  Stages of change – determines type of intervention  Cessation techniques – successful interactions

10. Office Team Training Curriculum  First 2 hour session:  The 5 A’s  use of 5 A’s stickers on patient progress notes  follow-up stickers and call reminder index cards  Changes in clinic flow  must fit into clinic routine  roles and expectations of the dental team

11. Office Team Training Curriculum  First 2 hour session:  Resources and referrals  Telephone-based tobacco counseling  Pharmacotherapy – start brief overview  Patient scenario – role play  examples of scripting

12. Office Team Training Curriculum  Second 2 hour session:  Pharmacotherapy  when and how to suggest various options  insurance coverage  Patient interactions  low key, nonjudgmental, sensitive, respectful  Patient scenarios  role play patients in various stages of change  walk through process using clinic forms and codes

13. Provider Survey Results Knowledge and Practices of Behavior Change and “5-A’s” in Tobacco Cessation % ** * * * * = p<0.05 - HPDG # = p <0.05 - Park Dental # # # # # #

14. Provider Survey Results Documentation of Tobacco Status % * # # * = p<0.05 - HPDG # = p <0.05 - Park Dental

15. Current Use of Types of Tobacco Cessation Resources Baseline to 12 Months % * # * = p<0.05 - HPDG # = p <0.05 - Park Dental # # # #

16. Training

22. Program Impact HPDG   Survey Results   Knowledge and awareness improvement   Increase in tobacco status documentation   Increase in use of telephone-based counseling as a tobacco cessation resource   Coding Data and Referral Data Results   Coding improvement using ADA and HPDG codes   Improvement in risk assessment coding   Improvement in referrals to the phone line   Pharmacy Data Review   Increase in prescriptions written and filled   Chart Review Data   Difficult to interpret – may be related to new 5-A’s chart form

23. Program Impact Park Dental   Survey Results   Significant increase in knowledge of 5A’s, except for Ask   May indicate an increase in follow-up for already identified patients   Significant increase in use of health history form (with addition of tobacco status)   Increase in use of 5-A’s form   Significant increase in use of tobacco cessation resources (phone line & pharmacotherapy)

24. Lessons Learned   Importance of clinic buy-in with leadership involvement   Importance of agreement on project processes, work plans, and data collection   Responsibility and accountability for doing work   Importance of role clarification   Medication prescribing practices   Dealing with time limitations   Limitations—what’s doable at the time of the visit?