STOP with FHTs: Building Capacity to
Deliver Smoking Cessation Programming
in Family Health Teams
Carolyn Peters, STOP Program Coordinator, CAMH
Canadian Collaborative Mental Health Care Conference –
June 20th
2014
+ Presenter Disclosures
• Presenters: Carolyn Peters
• Relationships with Commercial Interests: Not applicable• Disclosure of Commercial Support: No commercial support• Mitigating Potential Bias: Not applicable
+ Need for Smoking Cessation Programming
Percentage of Canadians (15+ y.o.) who smoke (1965-2012)1,2
0
10
20
30
40
50
60
1965
1975
1979
1985
1990
1996
2001
2004
2007
2010
Year
%
1.Health Canada. CTUMS Smoking Prevalence1999‐2012. 2.Physicians for a Smoke Free Canada (2012) Smoking Prevalence Fact Sheet.
+ Need for Smoking Cessation Programming
• 55% of smokers want to quit in next 6 months1
• Nicotine Replacement Therapy doubles chances of quitting
• Cost is a barrier to medication use for 27% of Ontario smokers 1
• 59% would use nicotine replacement therapy if offered for free2
1.Health Canada. CTUMS 2012.2.Cunningham, JA & Selby PL (2008) CMAJ. 179(2):145‐146.
+ Rationale for STOP with FHTs• Primary care practitioners are ideally
positioned to intervene and treat smokers who want to quit
• Practitioner barriers to implementing best practices for smoking cessation interventions:
• Time (42%)/ Capacity• Confidence in ability (22%) or knowledge
(16%)• Cost of medication for patients (24%)
5
Reid et al, 2012; Vogt et al, 2005; Gross et al, 2008
+ Government ActionIn Feb 2011, new program by Ontario Government
proposed to:
i)
make free Nicotine Replacement Therapy (NRT) in combination with counseling, available to
patients of Ontario Family Health Teams (FHTs)
ii)
build capacity among FHT practitioners to provide evidence‐based treatments to their
patients.
6
+ Taking a Collaborative ApproachThe College of Family Physicians of Canada note that
successful collaborative projects in Canada have
i)
Better clinical outcomes
ii)
More efficient use of resources
iii)
Enhanced experience of seeking and receiving care
7
+ What is Collaborative Care?Collaborative care is care that is delivered by providers
from different specialties, disciplines, or sectors working together to offer complementary services or mutual
support.
Best practices for a successful model of collaboration include:
i)
Effective Communication
ii)
Consultation
iii)
Coordination
iv)
Integration
8
+ What are Challenges to a Collaborative Care Model?
Potential barriers to implementing collaborative partnerships:
i)
Fundingii)
Remuneration
iii)
Time constraintsiv)
Clarity around documentation requirements
v)
Views that collaborative care is not relevant to practice
vi)
Culture of some health services that may not be prepared for collaborative practice
vii)
Geographic disparities that can make access to resources challenging
9
+ Next Steps1. Invitation and Capacity Assessment
Invitation sent out to all Ontario Family Health Teams (FHTs) to gauge interest and
current capacity to implement program
2. Program Development and Implementation
Program developed to increase capacity within Family Health Teams and provide evidence‐based treatment to help FHT
patients quit smoking
10
+ Engagement Process
11
March 2011:
Individual snapshots sent to FHTs about theirreadiness to implement programNotification that CAMH is coordinating site
Ministrycontact
CAMHcontact
Feb 2011:
MHPS emailed invitation to all 170 Ontario FHTs
122 FHTs (65%) responded indicating interest
April 2011:
CAMH contacted FHTs with next steps(contract process, training opportunities etc)
An additional 16 FHTs have become operational
since Feb 2011.
An additional 39 FHTs contacted CAMH
expressing interest between Feb 2011‐May 2014
(Total respondents = 168/186 = 90%)
+ Capacity Assessment Results
12
% of FHTs that:have practitioners interested in receiving training in smoking cessation
85%
have a locked space available for NRT storage
95%
0
5
10
15
20
25
30
35
0 1 2 to 3 4 to 5 >5
# of trained staff
Number of staff formally trained in
delivering smoking cessation
interventions
% of respo
nden
ts
+ Capacity Assessment Results
Current implementation of best practices
13
% of FHTs that:actively track smokers’ progress
56%
have an organized smoking cessation program
58%
collect patient quit rates 31%
When are smokers asked if
they are ready to quit?
0
20
40
60
80
100
AnnualHealthExam
Every Visit If pat ientasks for
help quit ting
If symptomsare
smoking-related
Other
% of respo
nden
ts
+ Advisory Group
• Representatives from all stakeholder organizations to discuss goals, progress
and outcomes:
• Ontario Government• CAMH• Ontario Tobacco Research Unit• Professional Bodies• Healthcare organizations• Non‐profit organizations with an
interest in tobacco control
14
+ STOP with Family Health Teams Program
15
Enhance Practitioner
CapacityFacilitate Knowledge
Exchange
Increase Patient Access to
Evidence‐Based Treatment
Comprehensive,
evidence‐based
smoking cessation
treatmentprogram
patient
knowledge brokerpractitioner
designed to address barriers to implementing best practices
+ Building capacity to deliver tobacco dependence intervention
In‐person
(classroom) Online Condensed Webinars
TEACH Courses
+ Enhance Practitioner Capacity
Accredited training opportunities
3‐5 day in‐person course
3‐module online course
monthly 1‐hour ‘lunch and learn’ webinars
Non‐physician practitioners encouraged to get trained so that they
can implement STOP program
+ TEACH TrainingsCommunity of Practice Q & A Webinar Series
The 2013/2014 webinar series focused on various topics
in tobacco dependence treatment in a Question &
Answer format.
Topics include:•Pharmacotherapy: Nicotine Replacement Therapy and
Prescription Medications•Tobacco Interventions for Pregnant and Post‐partum women•Tobacco Interventions for Patients with Mental Health Issues•Psychosocial Interventions•The Highly Complex Client: Issues and Interventions•Tobacco Interventions for Patients with Concurrent Addictions
+ Building capacity at FHTs
Number of practitioners from
FHTs
In‐person TEACH core course 187
Online course (1) 57
FTI trainings (online) 195
Lunch and Learn webinars 384
TEACH trainings received
+ Increase Patient Access to Evidence‐Based Treatment
Cost‐free Nicotine Replacement Therapy (NRT)
20
IndividualizedTitrated to effectCombination NRTMax 4 weeks/visit;26 weeks/year
patch gum inhaler lozenge
Pre‐assembled kitMonotherapy5‐week treatment
and/or
+ Client Flow for Individualized Treatment Option
Visit agency/
practitioner for X
reason
Smoking
Cessation
Visit
Group optionOne visit
5‐week kit of NRT
dispensed
Individual optionInitial visit
NRT dispensed
Subsequent visits
NRT refill
Follow‐up at 3, 6, 9 and 12 months
E‐mail, Telephone
1. Intervention Form2. NRT dispensing log
1. Intervention Form2. NRT dispensing log
1.
Follow‐up Survey
Clients A Clients BSelf‐referral/ Responding to
advertisement
1. Consent Form
2. Baseline
Questionnaire
+ Increase Patient Access to Evidence‐Based Treatment
NRT provided with free behavioural support provided by nursing and/or allied health staff
22
Multi‐sessionOne‐on‐one
Intensive counselling
One‐sessionGroupPsychoeducation
+ Facilitate Knowledge Exchange
• Bi‐weekly teleconferences for FHT implementers to discuss successes and
challenges
• Evaluation
Patient
Practitioner
Organization
• Feedback reports
23
+ Achievements: Enhanced Practitioner Capacity
More than 450 FHT practitioners have completed the University of Toronto‐
and CME‐accredited TEACH Core
Course or abbreviated Fundamentals of Tobacco Interventions Course between May 2011‐May 2013
+ Achievements: Increased Patient Access to Cost‐Free Medication
• 134 FHTs in all 14 LHINs are implementing the program to date
• 70% of all Ontario FHTs currently offering cost‐free NRT
and counselling support
• Over
33,000
FHT participants enrolled to date
+ Table Discussion
Experiences of collaborative care at your practices
‐What works? Share any success stories.‐What challenges have you experienced?
+ Preliminary Participant Baseline Characteristics
0
10
20
30
40
50
60
Male No HighSchoolDiploma
Householdincome
<$40,000
Mental HealthDx
Depression Anxiety BipolarDisorder
Schizophrenia
Baseline Patient Characteristics
% o
f par
ticip
ants
Mean age: 50 years old
July 2011 to May 30, 2014
+ Preliminary Participant Baseline Characteristics
0
10
20
30
40
50
0 1 to 2 3+
% P
artic
ipan
ts
39%
41%
12%
8%
Within 5 mins
6 to 30 mins
31 to 60 mins
60+ mins
Mean cigarette consumption (daily smokers): 20 cigarettes per day
Time to First CigaretteSerious Quit Attempts in Past Year
July 2011 to May 30, 2014
+ Preliminary 3m, 6m and 12m Follow‐up Data
0
10
20
30
40
3m 6m 12m
3 months 6 months
Quit Rates:
# CPD for daily smokers:
14 15 16
% who have quit for 24 hours (among those still smoking)
58 60 63
Among SurveyRespondents
12 months
July 2011 to October 2013
+ Achievements: Knowledge Exchange Facilitated
30
• 81 practitioner teleconferences held
(June 2011 to June 11, 2014)
• Produced and sent out feedback reports
• Developing a reporting feature on online portal for real‐time access to
results
+ Challenges: Enhancing Practitioner Capacity
• Patient demand exceeding staff resources
• Consistently making smoking cessation priority
31
+ Challenges: Increasing Patient Access to Cost‐ free Medication
• Systematic identification of all smokers at all FHTs
• Systematic referral of patients at all FHTs
• Access to other smoking cessation medications
32
+ Challenges: Facilitating Knowledge Exchange
• Some FHTs not participating in KE activities
• Challenging to reach patients for follow‐ups
33
+ Evaluation
OTRU Formative Evaluation
34
+ Improved Provision of Smoking Cessation by FHTs since Baseline
Integration of STOP into daily practice
OTRU Formative Evaluation of the STOP with FHTs Program from September 2011 to March 2013
+ Perceived Facilitators to the Delivery of the STOP Program
OTRU Formative Evaluation of the STOP with FHTs Program from September 2011 to March 2013
+ Perceived Barriers to the Delivery of the STOP Program
OTRU Formative Evaluation of the STOP with FHTs Program from September 2011 to March 2013
+ Formative Evaluation Helped to Improve Program Delivery
OTRU Formative Evaluation of the STOP with FHTs Program from September 2011 to March 2013
• Evaluation served the learning and accountability needs of the STOP program
team
• Reporting back to partnering FHTs
• Development of an online portal for electronic
documentation of STOP enrollees
• Feedback loop is integral to the continued success of the STOP program
+ Practitioner Experience
39
‐
St. Michael’s Hospital Family Health Team
+ SMH FHT Baseline Statistics
All FHTs(n=30,123)
St. Michael’s Hospital FHT (n=286)
No Mental Illness Any Mental Illness No Mental Illness Any Mental Illness
CPD at baseline (mean) 19.79 20.90a 19.31 22.40a
Self‐reported
mental health
diagnosis
All FHTs(n=30,123)
%
St. Michael’s Hospital FHT(n=286)
%
Anxiety 32.7 42.9Depression 38.0 46.3Bipolar Disorder 4.8 11.2Schizophrenia 2.2 6.5
a. p<0.05 at 95% level
Time to first
cigarette
All FHTs(n=30,123)
%
St. Michael’s Hospital FHT(n=286)
%
Within 5 minutes 39.8 53.36 to 30 minutes 40.3 32.931 to 60 minutes 12.0 8.9More than 60 minutes 7.9 4.9
+ Experiences from St. Michael’s Hospital FHT
41
Building capacity for smoking cessation
- Increased training and knowledge
- Increased referrals to STOP
- KE with other STOP implementers and STOP staff has improved delivery of program
Dealing with challenges
- Recruited additional staff to be TEACH trained
- Added SW trained in addictions
- Expanded hours of service
- Addition of workshop
- KE sessions summaries are disseminated through SMH FHT monthly team meetings
Improved Capacity in Other Areas of Practice
- Increased confidence among non-physician practitioners
- Increased support and training for managing patients with COPD
- Concepts for motivational interviewing being used in other Chronic Disease State management
+ SMH FHT Follow‐Up Results
All FHTs St. Michael’s Hospital FHT
No Mental
Illness (%)
Any Mental
Illness(%)
No Mental
Illness (%)
Any Mental
Illness(%)
Quit Rate 3m 41.1 32.0a 21.4 24.6
Quit Rate 6m 39.8 30.3
a 32.3 32.6
a. p<0.05 at 95% level
Have utilized the key components of the collaborative model to deliver a successful program: Communication, Consultation, Coordination and Integration
+ Review of Barriers
Has STOP been successful in overcoming potential barriers to implementing a collaborative partnership?
i)
Fundingii)
Remuneration
iii)
Time constraintsiv)
Clarity around documentation requirements
v)
Views that collaborative care is not relevant to practice
vi)
Culture of some health services that may not be prepared for collaborative practice
vii)
Geographic disparities that can make access to resources challenging
43
+ Table Discussion
How would you develop a collaborative model for treating a patient with
concurrent disorders for smoking cessation in a 26 week program of no
cost NRT?
+ Take Home Message
45
•
Family Health Teams can be engaged in implementing more comprehensive smoking cessation treatment programs if
barriers are addressed
•
Similar model can be used for other preventative treatment programs in primary care.
↑ evidence‐based
treatment + more
sustainable smoking
cessation programs
Provision of free NRT+ Increasing capacity to treat+ Encouraging knowledge exchange
+ Acknowledgements
Funding and Support generously provided by the Ontario Ministry of Health and Long Term Care – Health Promotion
Division as part of the Smoke‐Free Ontario Strategy
CAMH Nicotine Dependence Service (NDS) Leadership Team and the entire STOP team:
Scientists• Laurie Zawertailo (co‐investigator)• Dolly Baliunas
Research Coordinators • Ryan Ting‐A‐Kee• Erin Cameron• Dmytro Pavlov• Andra Ragusila
Research Analysts•Bianca Filoteo•Camyl Gatchalian•Jessica Farber•Laura Martinez•Rackell Levin •Mathangee Lingam•Salaha Zaheer•Virginia Ittig Deland•Henry Cowan•Binh Tam Le
Most of all, the dedicated implementers at all participating Ontario Family Health Teams
+ CAMH Nicotine Dependence Service Team
