11
If They Won’t Come to If They Won’t Come to You…You…
Reaching the Hard to ReachReaching the Hard to Reach
““Infiltrating the Systems”Infiltrating the Systems”
Catherine Suiter, M.Ed.Catherine Suiter, M.Ed. Statewide Tobacco Cessation CoordinatorStatewide Tobacco Cessation Coordinator
Vermont Association of Hospitals and Health SystemsVermont Association of Hospitals and Health Systems
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The SystemsThe SystemsHospitalsHospitals
Outpatient ClinicsOutpatient ClinicsThe WorkplaceThe Workplace
33
Vermont Vermont Cessation Cessation ProgramProgram
Clinically based programClinically based program Local Tobacco CoordinatorLocal Tobacco Coordinator
•At all 14 hospitals in the state including At all 14 hospitals in the state including VAVA
•Provides local classes and 1-1 counselingProvides local classes and 1-1 counseling Provides access to free or low cost NRTProvides access to free or low cost NRT
Vermont Quit LineVermont Quit Line
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Cessation SystemCessation System
LAKE CHAMPLAIN
EDEN
STOWE
JAYDERBY
MILTON
RIPTON
LOWELL
PERU
FAIRFIELD
TROY
LEWIS
DANVILLE
NEWBURY
GROTON
IRA
HIGHGATE
DANBY
ESSEX
CHESTER
BETHEL
JAMAICA
CHITTENDEN
CABOT
DORSET
ORWELL
RUPERT
BARTON
CALAIS
BARNET
POWNAL
PAWLET
BENSON
CONCORD
CORINTH
CAMBRIDGE
BOLTON
BRIGHTON
LINCOLN
HALIFAX
TOPSHAM
BARNARD
WINHALL
SWANTON
BRISTOL
VICTORY
DOVER
BURKE
LYNDON
ALBANY
NORTON
PEACHAM
BERLIN
SUTTON
WARREN
ADDISON
JOHNSON
FAIRFAX
ELMORE
AVERILL
SHARON
ROCHESTER
GRANBY
NORWICH
GLOVER
GRANVILLE
READING
UNDERHILL
ORANGE
STRATTON
FERDINAND
WALDEN
MENDON
HOLLAND
RANDOLPH
FRANKLIN
PLYMOUTH
RICHFORD
DUXBURY
ENOSBURG
GEORGIA
LUDLOW
NEWARK
BRIDPORT CHELSEA
HARTFORD
HARTLAND
KIRBY
POULTNEY
THETFORD
ROXBURY
SHELDON
POMFRET
ALBURG
NEWFANE
BRANDON
GRAFTON
WESTON
RYEGATE
CANAAN
WOLCOTT
JERICHO
PITTSFORD
KILLINGTON
MONTGOMERY
IRASBURG
SANDGATE
GUILFORD
FERRISBURG
WOODFORD
FAYSTON
WATERBURY
HANCOCK
BERKSHIRE
TUNBRIDGE
ROYALTON
SHOREHAM
SPRINGFIELD
STRAFFORD
VERSHIRE
STAMFORD
FLETCHER
MORRISTOWNHARDWICK
MORGAN
LUNENBURG
MONKTON
ARLINGTON
NORTHFIELD
NEW HAVEN
MARLBORO
CASTLETON
WHEELOCK
MIDDLESEX
WESTFIELD
WESTFORD
CHARLOTTE
BRAINTREE
WELLS
CAVENDISH
SHREWSBURY
HYDE PARK
PUTNEY
WOODSTOCK
BRIDGEWATER
MARSHFIELDHINESBURG
MOUNT HOLLY
MORETOWN
TOWNSHEND
BROOKFIELD
SUNDERLAND
STARKSBORO
WESTMORE
STOCKBRIDGE
WOODBURY
BENNINGTON
BAKERSFIELD
WESTMINSTER
SHAFTSBURY
BLOOMFIELD
WILMINGTON
GLASTENBURY
ROCKINGHAM
WATERFORD
MIDDLEBURY
WHITINGHAM
WALLINGFORD
WORCESTER
MANCHESTER
GUILDHALL
RICHMOND
MOUNT TABOR
EAST HAVEN
LEMINGTON
SHEFFIELDCRAFTSBURY
HUNTINGTON
CHARLESTON
ANDOVER
BELVIDERE
READSBORO
WILLISTON
WASHINGTON
GREENSBORO
TINMOUTH
BRADFORD
NEWPORT TOWN
COLCHESTER
WINDHAM
MAIDSTONE
WEATHERSFIELD
WILLIAMSTOWN
SOMERSET
FAIRLEE
GOSHEN
SALISBURY
CLARENDON
CORNWALL
COVENTRY
LONDONDERRY
ST. JOHNSBURY
WARDSBORO
VERNON
SUDBURY
BARRE TOWN
BRATTLEBORO
ST. ALBANS TOWN
WAITSFIELD
SHELBURNE
BRUNSWICK
WINDSOR
DUMMERSTON
HUBBARDTON
WEST HAVEN
PANTON
LEICESTER
PLAINFIELD
BROWNINGTON
PITTSFIELD
EAST MONTPELIER
RUTLAND TOWN
SEARSBURG
WHITING
FAIR HAVEN
WEST FAIRLEE
WEST WINDSOR
ATHENS
WEYBRIDGE
GRAND ISLE WATERVILLE
AVERY'S GORE
WEST RUTLAND
SOUTH HERO
STANNARD
BROOKLINE
MIDDLETOWN SPRINGS
SO. BURLINGTON
WALTHAM
BURLINGTON
MONTPELIER
PROCTOR
LANDGROVE
WARREN'S GORE
ISLE LA MOTTE
RUTLAND CITY
NORTH HERONEWPORT CITY
BALTIMORE
BUELS GORE BARRE CITY
ST. GEORGE
VERGENNES
WARNER'S GRANT
WINOOSKI
ST. ALBANS CITY
ProposedHospital Service Areas (HSAs)
Based on 1997-2001 DataInpatient Dischargeswith Acute Diagnoses
Out of State Reassigned
Geographic AreasBarre
Bennington
Brattleboro
Burlington
Middlebury
Morrisville
Newport
Randolph
Rutland
St. Albans
St. Johnsbury
Springfield
White River Jct.
5/17/04
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Snapshots of VermontSnapshots of Vermont Population Population 613,000613,000 25%25% in Burlington in Burlington
areaarea Outside the cityOutside the city
Very ruralVery rural 44 people /sq. mile44 people /sq. mile
Geography and Geography and weather impede travelweather impede travel
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Snapshots of VermontSnapshots of Vermont Fours years into programFours years into program 6500 clients6500 clients 12,000 NRT coupons 12,000 NRT coupons
distributeddistributed Smoking prevalence Smoking prevalence
dropped from 22.4 to dropped from 22.4 to 19.5%19.5%
17% Quit Rate at one year17% Quit Rate at one year
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More SnapshotsMore SnapshotsClientsClients March March
20022002March March 20052005
DisabledDisabled 7%7% 13%13%
<HS graduate<HS graduate 12%12% 15%15%
Co-occurring Co-occurring medical DXmedical DX
44%44% 60%60%
UninsuredUninsured 12%12% 22%22%
Join classesJoin classes 52%52% 29%29%
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The Hard to ReachThe Hard to Reach ““We have plucked the low We have plucked the low
hanging fruit”hanging fruit” If they do not come to us, we If they do not come to us, we
will go to themwill go to them In hospitalsIn hospitals In clinicsIn clinics In the work placeIn the work place
99
Nicotine Intervention in the Nicotine Intervention in the Hospitalized PatientHospitalized Patient
Mary Anne Riley, RRTMary Anne Riley, RRTNicotine Cessation Coordinator, Nicotine Cessation Coordinator,
Springfield HospitalSpringfield Hospital
1010
The Facts:The Facts:70% of current smokers want to quit.
Smokers rate physician’s advice as incentive to quit smoking
““The influence your role as a health care provider carries in helping The influence your role as a health care provider carries in helping smokers quit cannot be overstated. A clinician’s advice to quit smokers quit cannot be overstated. A clinician’s advice to quit improves success in maintaining abstinence. With the addition of a improves success in maintaining abstinence. With the addition of a few minutes of counseling, the success rate doubles “ few minutes of counseling, the success rate doubles “
U.S. Public Health Service (2000)U.S. Public Health Service (2000)
1111
How do you find these How do you find these patients?patients?
Develop a system to identify current smokers admitted to
ER ICU PRE-OP MEDICAL/SURGICAL MATERNITY PSYCHIATRY DISCHARGE PLANNING
Develop a flow sheet or charting system to document initial visit and follow-up visits – make it accessible to other members of the patient’s care team.
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Nicotine consult to the Nicotine consult to the cessation coordinator, or cessation coordinator, or department in charge of department in charge of providing this service.providing this service.
NRT orderNRT order
Educate staff, physicians, Educate staff, physicians, and anyone who may and anyone who may initiate a consult.initiate a consult.
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What do you say?What do you say? Do they want to quit ?Do they want to quit ?
Provide the 5 A’sProvide the 5 A’s
Are they only interested in help to control Are they only interested in help to control their cravings while in the hospital? their cravings while in the hospital? Provide the 5 R’sProvide the 5 R’s
NO PREACHING ALLOWED! NO PREACHING ALLOWED! Just talk to them and find our how you can Just talk to them and find our how you can
help by help by listening.listening.
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what do you say what do you say continued…continued…
THE 5 A’sTHE 5 A’s ASKASK ADVISEADVISE ASSESSASSESS ASSISTASSIST ARRANGEARRANGE
THE 5 R’sTHE 5 R’s RELEVANCERELEVANCE RISKSRISKS REWARDSREWARDS ROADBLOCKSROADBLOCKS REPETITIONREPETITION
or…
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Provide feedback to their statements, Provide feedback to their statements, concerns, or possible barriers to success.concerns, or possible barriers to success.
NRT- what is available in the hospital NRT- what is available in the hospital setting. setting.
Ask open-ended questions rather than Ask open-ended questions rather than “yes” or “no” ones. “yes” or “no” ones.
Provide written education if requested, Provide written education if requested, at least leave a contact phone number at least leave a contact phone number and cessation class information for and cessation class information for follow-up after discharge.follow-up after discharge.
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Treating Tobacco Use and Treating Tobacco Use and Dependence as a Chronic Dependence as a Chronic
Disease:Disease:Developing Office-Based Developing Office-Based
SystemsSystems
Evelyn Sikorski, CSW, CEAP, TTSEvelyn Sikorski, CSW, CEAP, TTSFletcher Allen Health Care - Burlington VTFletcher Allen Health Care - Burlington VT
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Cessation CounselingCessation CounselingPrimary Care SettingPrimary Care Setting
Provide motivational interview to Provide motivational interview to patients after advice to quit patients after advice to quit
Evening appointments for Evening appointments for individuals and couplesindividuals and couples
Model intervention with physician Model intervention with physician to increase skill setto increase skill set
Stock readiness literature and Stock readiness literature and posters for exam roomsposters for exam rooms
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Recognizing and Applying Best Recognizing and Applying Best Practice GuidelinesPractice Guidelines
Tobacco dependence is itself a disease and Tobacco dependence is itself a disease and not simply a risk factornot simply a risk factor
Tobacco use and dependence is a chronic Tobacco use and dependence is a chronic diseasedisease
Tobacco use and dependence can be Tobacco use and dependence can be treated effectivelytreated effectively
Local resources exist to assist current Local resources exist to assist current tobacco userstobacco users
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STEPS to create an effective STEPS to create an effective IDENTIFICATION systemIDENTIFICATION system Identify key partners (AHEC)Identify key partners (AHEC) Organize a team and designate a leaderOrganize a team and designate a leader Conduct a self-assessment of the current Conduct a self-assessment of the current
tobacco treatment systemtobacco treatment system Develop a site specific planDevelop a site specific plan Implement a system to address tobacco Implement a system to address tobacco
cessationcessation
2020
Referral PadsReferral Pads
2121
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Infiltrating the WorksiteInfiltrating the Worksite
Jamie Balch, MSNJamie Balch, MSNNorthwestern Medical Center, St. Albans, Northwestern Medical Center, St. Albans,
VermontVermont
2323
Building WithinBuilding Within Local ResourcesLocal Resources
Local PartnersLocal Partners Local ProvidersLocal Providers Local EmployersLocal Employers
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Cardiovascular Health Cardiovascular Health Improvement ProgramImprovement Program
Evidenced Based Screening ProgramEvidenced Based Screening Program Outcome drivenOutcome driven ReplicableReplicable Successful!Successful!
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CHIP CHIP Screening Screening
ReportReport
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Worksite PilotWorksite Pilot Selling the ideaSelling the idea FundingFunding ImplementationImplementation EvaluationEvaluation Success and ObstaclesSuccess and Obstacles From hereFrom here
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from here…from here… Broader ImplementationBroader Implementation
Community SitesCommunity Sites Worksite MarketingWorksite Marketing
• Links to local chronic disease initiativesLinks to local chronic disease initiatives Statewide Initiatives Statewide Initiatives
• Ladies First/Wise womanLadies First/Wise woman• Networking with additional service Networking with additional service
areasareas• Working toward a broader registryWorking toward a broader registry
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More Opportunities to “Infiltrate”More Opportunities to “Infiltrate” Inpatient settingsInpatient settings
Nursing homesNursing homes StaffStaff
ClinicsClinics Planned Planned
ParenthoodParenthood Free clinicsFree clinics
WorksiteWorksite Food shelfFood shelf Salvation ArmySalvation Army Urban Urban
ministriesministries
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Remaining GapsRemaining Gaps
18- 24 year olds18- 24 year olds
Pregnant womenPregnant women
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Questions?Questions?