Mayo Clinic Nicotine Dependence Center:

A Working Model in a Medical Center

ATTUD Inaugural MeetingDecember 13, 2003

Lowell C. Dale MD

Nicotine Dependence Center Education Program Director

Kay M. Eberman MS

Nicotine Dependence Center Education Program Coordinator

Mayo Clinic practice sites

Scottsdale, Arizona

Rochester, Minnesota

Jacksonville, Florida

Mayo Program:Background

• Smoke free facilities 1987

• “Smoking Cessation Center” 1988

Mayo Clinic Nicotine Dependence Center

Vision and Mission

• Vision statement: “The best is where we begin”

• Mission: “To promote tobacco-free living through an integrated program of intervention services, education, and research”

• Full concept of the treatment program. • Providing choices of treatment to meet

different levels of addiction and individual needs.

• Providing program branches for practice, research, education

System Changes

• Smoke free buildings and campus

• Department of Medicine support

• Human Resources Policy: compliance a condition of employment

• Employee Benefit Package: Full Coverage of all of our services and medications

• Easy referral: ordered like any other test

• “Open Access”: The “teachable moment”

System Changes

• Counselors go to the patient• Outpatient area of referring physician• Hospital bedside

• Educational Efforts• Resident education (8 hours)• Medical student curriculum• Grand rounds, committee meetings, etc• Nursing in-services

• Research• Study recruitment• Press releases

Basic service design: Partnership

PATIENT

PHYSICIANCOUNSELOR

Mayo NDC Current Profile: Branches of Service

• Research Program: • Areas of investigation include treatment methods,

adolescents, family and support persons, medications• Separate staff and funding

• Education Program (Training Health Care Providers) • NIH Grant funding for 2001 - 2006. • Internal Mayo education: medical residents and fellows,

nurses, respiratory therapy students, medical students• External education: medical systems, conferences

• Community Outreach: Mayo Outreach to Students & Teachers

• Treatment Program

Target Population

• Mayo patients who are using/ have used tobacco• Outpatients• Hospitalized patients

• Self-referred for treatment of tobacco use

• Local patients: majority within 50 miles

• Average age: 50 years

• <10% Mayo employees/dependents

• <1% teens

The Referral Base

• Mayo medical community (80%)

• Self referral (15%)

• Other (5%)•Regional Practices•NDC Research Program•Other medical groups and hospitals•Community: public health, dental offices,

health clubs•Internet, media

Role of Medical Staff

• Leadership, vision

• Medical management of the center

• Medical back up for patients as needed (review medical conditions, medication advice, write prescriptions)

• Research: Primary Investigators

• Education: NDC staff, other professionals

NDC Staffing

• Counselor responsibilities• Provide patient care

• Maintain records, paper and computerized

• Provide lectures for patients

• Provide information for MDs, other medical staff

• Train new staff

• Take part in NDC education program

Components of Care

• Individualized

• Alliance with patient: a helping relationship

• Counseling rather than teaching

Foundation for Treatment Model • Chemical Dependence Concepts

• Behavioral Change Techniques

• Pharmacologic Therapy

• Relapse Prevention

Ending Tobacco Use: Process of Change

• Ending tobacco use may take years

• Relapse is common

• Health care provider facilitates the process of positive change

• Understanding the process of behavior change helps tailor initial intervention

• Forming a motivational partnership enhances the possibility of positive change

Consultation/Assessment

• Basic service

• Counselor meets with patient

• 45 - 60 minutes

• Majority of patients seen face to face one time only

Tools for the Consultation/Assessment Session• Assessment forms

• Treatment interview

• Carbon monoxide measurement

• Treatment planning

• Medication planning

• Self help materials

• Relapse prevention system

ServicesOptions for service: • outpatient consultation • hospital consultation• on going counseling • intensive individual program • group program• residential treatment • telephone counseling (Quitline) • support group • Nicotine Anonymous

Outcome Evaluation

• Stop rates measured at 6 months

• Telephone interviews

• “Intent-to-Treat” Analysis

• 7 day point prevalence tobacco use status

• 22% - 45% stop rate

• Rate is higher with more intensive treatment

Financial

• Outpatient services are billed to insurance and/or the patient

• Hospital services are not billed directly, but can be considered in room rate adjustments

Insurance Coverage• Medicaid/Medical Assistance

• Coverage varies from state to state• May cover face to face counseling,

medications

• Private insurance

• Varied between and within companies• Call the 800# for information

• Telephone Quitlines

• Many states and third party payers offer a tobacco quitline at no charge

Billing Codes

• CPT Codes with a possible fit for outpatient services:• Preventive Medicine codes: 99401 -

99412• Health and Behavior assessment

codes: 96150-96155• Psychiatric dx codes: 90805 - 90809

• ICD-9 diagnostic code: Tobacco use disorder 305.1

Determining Coding

• Health and Behavior Assessment codes for tobacco dependence tx are recognized by Medicare

• However, Medicare carriers will determine whether or not to cover the cost

• Best method of determining the codes to use: work with revenue recognition expert or medicare expert

Summary of Clinical Service

• Individualized counseling service provided within medical setting: the teachable moment

• Timely - same day service or within 24 - 48 hours of medical visit

• Brief focused counseling service, long follow up

• Choices of services following first visit

• Addiction basis for treatment approaches

• Use motivational and models for change

• Use tools of behavior change, medications, and relapse prevention

Summary• Mayo program: integrated into medical setting,

uses partnership, trained counselors, service options, faced many challenges

• Basic components of treatment: chemical dependence/chronic disease, behavior change, pharmacotherapy, relapse prevention

• Counseling strategies for intensive interventions include models for behavior change and motivational interviewing

• This type of service can be used in other settings

Opportunities for Growth

• JCAHO

• Enhanced Relapse Prevention

•Work-site Programs

• Educational Efforts• Internally• State• National