AAFP Office Champions Leading Tobacco Cessation in FQHCs Family Health Centers of Georgia, Inc. Theresa Jacobs, M.D. , FAAFP Niambi Lavender, Medical Assistant 5/19/14

Disclosure The American Academy of Family Physicians (AAFP) Office Champions Tobacco Cessation Federally Qualified Health Center (FQHC) Project was funded by Pfizer Inc, in collaboration with the Smoking Cessation Leadership Center (SCLC) The AAFP Office Champions project has been implemented in 120 practices including family medicine practices, residency programs, and FQHCs. Office Champions began with the 2011 Office Champions Tobacco Cessation Pilot Project and the Office Champions Tobacco Cessation National Dissemination Project in 2012.

AAFP Office Champions Tobacco Cessation Project AAFP recruited FQHCs to participate in the Office Champions Tobacco Cessation Project. An FQHC is a non-profit private or public entity that serves medically underserved populations and/or areas In 2013, the AAFP recruited FQHC’s to participate in the Office Champions Project. The 13 month project goals were to support a tobacco-free culture, increase the number of patients asked about tobacco status (Ask) and increase tobacco cessation assistance documentation (Act).

What is Office Champions? A team-focused quality improvement model that incorporates practical, proven strategies: Develop an implementation plan Provide training and improve staff collaboration Initiate systems changes Increase patient engagement Evaluate results (chart reviews and surveys)

AAFP Tobacco Cessation Resources http://www.aafp.org/patient-care/public-health/tobacco-cessation/ask-act.html In addition to resources offered as seen above, tobacco cessation assistance was documented that included motivational interviewing, group visits, and offering evidenced based nicotine replacement therapy medications.

Burden of Tobacco Use The annual burden of smoking-attributable mortality in the U.S. is currently estimated to be 480,000. Millions more are living with smoking-related diseases The picture above is of Terrie Hall, one of the people featured in the CDCs Tips Campaign from former smokers ad campaign. She died at 53 from cancer that she fought bravely for 13 years. She inspired many smokers to quit with her videos by describing how her grandchildren never heard her actual voice, and how smoking robbed her of her health. According to the 2014 U.S. Surgeon General’s Report, in the last 50 years the smoking rate has been cut in half (from 43% in 1965 to 18% in 2012). Progress has been made, but we still fall short. References U.S. Department of Health and Human Services. Health Consequences of Smoking—50 years of Progress: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. http://www.cdc.gov/tobacco/campaign/tips/stories/terrie.html

National Uniform Data System & Office Champions Outcomes The chart above is a comparison of the National Uniform Data System 2011-2012 and the Office Champions Outcomes from the 2013 Office Champions Tobacco Cessation FQHC Project that included 22 FQHC participants. Tobacco Use Screening Percent of patients for whom documentation demonstrates that patients were queried about their tobacco use one or more times during their most recent visit. Tobacco Intervention Percent of patients 18 and over who were identified as users of any and all forms of tobacco who received tobacco use intervention (cessation counseling and/or pharmacological intervention). Office Champions has success rates that are higher than the national average in the areas of both tobacco use screening and tobacco use intervention. The results of the 2013 Office Champions Project are in the final report. This model has consistently shown positive health outcomes and serves as a powerful and sustainable intervention. Office and Physician Champions working in various roles and settings provided leadership in implementing changes to create a tobacco-free culture. The AAFP’s Office Champions model and team-based approach is essential to making clinic systems changes. Reference UDS Performance Measures, 2012. Harris, Jeanita.

Who We Are Family Health Centers of Georgia, Inc. (FHCGA) began providing comprehensive preventive healthcare in 1976.There are eight locations in Fulton and Cobb counties. Healthcare services include medical, behavioral health, and dental care Family Health Centers of Georgia (Formerly West End Medical Centers) provided healthcare to 22,477 patients in 2012.

Behavioral Health Services FHCGA has a licensed clinical social worker on staff that counsels patients, as needed. All patients 13 and older are screened for depression and referred to behavioral health for in-house counseling Barriers consist of the stigma of seeing a counselor being equated to mental instability. Even though the visit costs are based on the patient’s income, this is also a barrier. Desired improvements/modifications to current system: Include having a psychiatrist on staff to prescribe any behavioral medications as needed and to work directly with the licensed clinical social worker. Additional counseling staff should include a social worker and an additional licensed clinical social worker in an effort to treat more patients.

Behavioral Health & Tobacco Cessation More that 1 in 3 adults (36%) with a mental illness smoke cigarettes, compared with about 1 in 5 adults (21%) with no mental illness The most common behavioral health issues linked to nicotine dependence at FHCGA is stress, depression, and anxiety The most common behavioral health issues linked to nicotine dependence at the FHCGA is stress, depression, and anxiety. Once the behavioral issues are identified, the Physician Champion refers the patient to a Behavioral Health Counselor. In addition, an anti-depressant drug that works for reducing the cessation of tobacco may be prescribed. Reference National Center for Chronic Disease Prevention and Health Promotion. National Survey on Drug Use and Health. 2009-2011. Adults ages 18 or older

Clinical Environment More than 40% of FQHC patients use tobacco, double the national prevalence rate Health disparities that impact the FHCGA community are: race, low socioeconomic status, lack of insurance, low education levels, and unemployment FHCGA is a community health center with a primary care program that has been delivering services for over 30 years. Overall, FHCGA serves a targeted medically underserved population of more than 21,000 yearly. The patient demographic is roughly 94% non-Hispanic blacks, 3% non-Hispanic white, 2% Hispanic/Latino and 1% Asian. The payor mix is roughly 40% Medicaid, 44% uninsured, 12% private insured and 4% medicare. Health disparities include lower socioeconomic status, lack of insurance, unemployment, tobacco use and education all impact the community. There are also high rates of hypertension, diabetes, and tobacco use within the population. Reference FQHC Tobacco Cessation Project Tobacco Free Mississippi. http://www.mphca.com/resources/Tobacco AAFP Addendum Fact Sheet 2013: Federally Qualified Health Centers.

Office Champion & Physician Champion Role Provide health education to patients Help develop cessation plans based on health risks Monitored patient progress Physician Champion Identify cessation modality Refer patient to behavioral health counseling Provide patients with treatment options FHCGA was selected as a participant in AAFP’s Office Champions FQHC Tobacco Cessation Project.   The Office Champion, Physician Champion, and supportive staff did the following: Completed the Office Champions training program, attended a teleconference, reviewed the practice manual, presented an overview of the Office Champions Project to their practice’s physicians and staff to a staff meeting in April 2013. Also part of the project was to complete a pre- and post-project chart review of 20 randomly selected patient charts, following the parameters distributed during the course of the project. FHCGA implemented systems changes to better integrate tobacco cessation activities into daily office routines and participated in all phases of program evaluation, including the final evaluation survey at the end of the project. Other duties specific to FHCGA are listed above:

Team Approach In order for Office Champions to be successful, the practice team must collaborate to meet the common goal of achieving a tobacco-free culture Effective communication Staff buy-in Office & Physician Champions sharing a leadership role

Systems Changes The AAFP Office Champions FQHC project was instrumental in improving clinical practice patterns at FHCGA. The goal was to incorporate cessation into routine workflow and reduce smoking prevalence by 10-20% A large number of the patient population of tobacco users were hypertensive, diabetic, and obese.

1) Implementation Plan: Referrals Patients were referred to behavioral health counselors, case managers, social workers, health educators, and quitlines as needed. In addition, the head pharmacist is a tobacco cessation treatment specialist The implementation plan at FHCGA consisted of three parts: Referrals, Communication/Education, and Marketing Behavioral health counselors and others were responsible for providing counseling sessions for tobacco users.

2) Implementation Plan: Staff Communication/Education Several health education classes were made available to patients. Workshops offered included the Office Champion as a speaker and offered a table to display with AAFP’s Ask and Act patient education materials and resources to promote tobacco cessation ***Led by Physicians, Office Champion, Nurses, Receptionists, Health Education Counselors Staff communication and education was increased to provide patients with individualized support. FHCGA provided 6 and 12 month follow-up calls, patient surveys, and staff surveys. (Progress was monitored by class attendance, and follow-up calls.)

3) Implementation Plan: Marketing AAFP’s Ask and Act resources including patient education materials, flyers, posters, lapel pins, newsletters, etc. helped to encourage a culture of tobacco cessation Marketing plan also includes distributing flyers throughout the community to encourage individuals to promote FHCGA’s tobacco cessation program

Tobacco Cessation 2013 rates at FHCGA 1,133 patients were enrolled in the tobacco cessation program, 30% of the patients enrolled have reduced cigarettes intake to less than 5 per day, 20% of patients no longer smoke

Challenges The barriers that were identified while implementing the changes: Finding affordable medication for the patients on an individual basis Working on prior authorization from the insurance companies to use approved medications Patients that have relapse due to life changes

Successes! FHCGA has initiated a comprehensive tobacco cessation program because tobacco use screening and intervention is extremely effective in both cost and health outcomes Why is Office Champions a success for Family Health Centers of Georgia? This project has made a powerful impact on the patient population and has reduced tobacco rates. By making systems changes using the Office Champions model, this can also potentially help decrease long term morbidity and mortality rates. The ultimate goal is to reduce the % of smokers by applying the five A’s: Ask, Advise, Assess, Assist & Arrange. *Add a personal story, if possible

Patient Centered Medical Home FHCGA, whose framework is based on the Patient Centered Medical Home (PCMH), has incorporated tobacco cessation into the workflow The changes made are sustainable, and now are part of the system to support a tobacco-free culture Part of the routine workflow for FHCGA is morning huddles, report card rating system, and continuing to strive towards NCQA accreditation. Mention PCMH Level 3

Achieving Goals By participating in AAFP’s Office Champions project, FHCGA achieved its goal to incorporate cessation into routine workflow and reduced smokers by 10-20%. For more information on Ask and Act and final report results visit: www.aafp.org/askandact/officechampions http://www.aafp.org/dam/AAFP/documents/patient_care/tobacco/office-champions-final-report-2013.pdf FHCGA has achieved the goal to reduce smoking prevalence by 20% and will continue its successful comprehensive tobacco cessation program!

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Thank You! Questions ? Theresa Jacobs, M.D., FAAFP trjacobs1@yahoo.com Niambi Lavender, Medical Assistant nlavender@att.net Christy Alexander, MPH American Academy of Family Physicians Project Specialist TempPR@aafp.org 913-906-6000 x 3140 Q and A session