proactive referrals: increasing cessation recruitment by building collaborations

Arizona Department of Health Services - Tobacco Education and Prevention

Program

Proactive Referrals: Proactive Referrals: Increasing Cessation Increasing Cessation Recruitment by Building Recruitment by Building CollaborationsCollaborationsPamela Powers, MPH; Robert Leischow, MPH; Mary Gilles, MD; Pamela Powers, MPH; Robert Leischow, MPH; Mary Gilles, MD;

Rebecca Ruiz-McGill; Amy Dye; Rebecca Ruiz-McGill; Amy Dye; Susan Larsen; James Ranger-Moore, Ph.D.Susan Larsen; James Ranger-Moore, Ph.D.

Network for Information and Counseling - Arizona Smokers’ Helpline Network for Information and Counseling - Arizona Smokers’ Helpline Mel & Enid Zuckerman Arizona College of Public Health Mel & Enid Zuckerman Arizona College of Public Health

National Conference on Tobacco or HealthNational Conference on Tobacco or HealthBoston, Mass., Dec. 11, 2003Boston, Mass., Dec. 11, 2003


Program

Tobacco Control in Tobacco Control in ArizonaArizona Comprehensive system funded by tobacco Comprehensive system funded by tobacco

tax ($1.18)tax ($1.18)– 15 Community-based tobacco control projects 15 Community-based tobacco control projects

– 11 Tribal Projects11 Tribal Projects

– Statewide Services: Helpline, Information Statewide Services: Helpline, Information Technology and Internet Services, Training and TA, Technology and Internet Services, Training and TA, Policy Tracking, Media, EvaluationPolicy Tracking, Media, Evaluation

Visit Visit www.TEPP.orgwww.TEPP.org for additional details for additional details


Program

Arizona Smokers’ Arizona Smokers’ HelplineHelpline Created in 1995 at the University of ArizonaCreated in 1995 at the University of Arizona Funded by ADHS/TEPP to provide: Funded by ADHS/TEPP to provide:

– Bilingual proactive telephone counselingBilingual proactive telephone counseling– Bilingual mailed self-help publicationsBilingual mailed self-help publications– Information and referral to local servicesInformation and referral to local services– Reduced cost for NRT or ZybanReduced cost for NRT or Zyban– Pre-recorded voicemail and FAX quit tipsPre-recorded voicemail and FAX quit tips– Cessation technical assistanceCessation technical assistance– www.ASHLine.orgwww.ASHLine.org with interactive with interactive

decision-making tools and E-mail decision-making tools and E-mail


Program

Levels of Service Based Levels of Service Based Upon Client ChoiceUpon Client Choice Questions OnlyQuestions Only Information OnlyInformation Only Information and ReferralInformation and Referral CounselingCounseling Currently QuitCurrently Quit Calling for AnotherCalling for Another

– Friend or relativeFriend or relative

– Healthcare providerHealthcare provider

– Human ResourcesHuman Resources


Program

Statewide Recruitment Statewide Recruitment EffortsEfforts

Traditional Paid AdvertisingTraditional Paid Advertising

FY 98-99, FY 99-00, FY 00-01FY 98-99, FY 99-00, FY 00-01


Program

Paid AdvertisingPaid Advertising– TelevisionTelevision

– RadioRadio

– NewspaperNewspaper

ReferralsReferrals– Friends, family, former clientsFriends, family, former clients

– Community-based tobacco projectsCommunity-based tobacco projects

– Healthcare providers, WorksitesHealthcare providers, Worksites

– Community EventsCommunity Events

What motivates people What motivates people to seek quit-tobacco to seek quit-tobacco services? services?

Interruption Marketing

Permission Marketing

–BillboardsBillboards

–Telephone bookTelephone book


Program

Multiple TV Ad Multiple TV Ad CampaignsCampaigns

Effective TV advertising increased Helpline calls from 500/quarter to 500/week


Program

Statewide Recruitment Statewide Recruitment EffortsEfforts

Budget Cuts Brought Changes in StrategyBudget Cuts Brought Changes in Strategy

Promoting ReferralsPromoting Referrals

FY 01-02, FY 02-03 FY 01-02, FY 02-03


Program

Public Relations & Public Relations & OutreachOutreach Public RelationsPublic Relations

– News and feature story placement News and feature story placement

– Guest appearances on radio and TV talk showsGuest appearances on radio and TV talk shows

– Speakers’ BureausSpeakers’ Bureaus

– Newsletters and trade publicationsNewsletters and trade publications

– SponsorshipsSponsorships

– Listserv promotionsListserv promotions

OutreachOutreach– Targeted initiatives with specific groupsTargeted initiatives with specific groups

– Direct mail incentives to referring agenciesDirect mail incentives to referring agencies


Program

Proactive Referral Proactive Referral NetworksNetworks

Community projectsCommunity projects– Pilot project: referrals Pilot project: referrals

from Mohave County from Mohave County make up 68% of the make up 68% of the proactive community proactive community referrals (FY 01-02)referrals (FY 01-02)

WIC clinicsWIC clinics– Pilot project: recruitment Pilot project: recruitment

from Mohave County WIC from Mohave County WIC increased 340% in 3 increased 340% in 3 quartersquarters


Program

ProactiveProactiveReferralReferral

Outside agency Outside agency conducts brief conducts brief interventionintervention

Gains client Gains client consent for consent for Helpline callHelpline call

Faxes referral to Faxes referral to HelplineHelpline

Helpline calls, Helpline calls, recruits client into recruits client into services, doesservices, doesintake formintake form

FAX TO: Arizona Smokers’ Helpline 1-877-908-8181 Toll-free fax number

FROM: (Stamp or write in your contact information here)

Client Consent and Personal Information Section: I understand that the Arizona Smokers’ Helpline will be contacting me with quit tobacco information, community referrals and/or counseling. My participation is voluntary. I understand that any information I provide will be kept confidential. I give the Helpline and the referring agency or physician permission to discuss my quit status.

_________________________________________ ___________________________________________ Client’s Name (please print) Client or Guardian’s Signature Verbal consent received ___________________________________________ Person obtaining verbal consent (sign and print) ___/___/___ Client Date of Birth Best time to call client: _________________________________________ Client’s Address 8am to 12pm 12pm to 5pm _________________________________ 5pm to 8:30pm Specific: _________________________________ Spanish Speaker English Speaker (_______)________________________________ Phone: home work other

Referring Agency Section: Please CHECK ALL THAT APPLY for Client: Adult Youth Youth Diversion Pregnant/post-partum WIC

Intra-Agency Section: If your agency is receiving a proactive referral, please track the client contact information below, and fax this form back to the agency that sent you this fax: __________________________ (referring agency’s fax number)

Attempt Date Time Result

1 Reached, accepted services Reached, declined services Not reached



Comments ____________________________________________________________________________________________________

ARIZONA SMOKERS’ HELPLINE TOBACCO EDUCATION AND PREVENTION PROGRAM PROACTIVE REFERRAL FAX Proactive Proactive

ReferralsReferrals


Program

Proactive Referral Proactive Referral System: System: Vision & GoalsVision & Goals Vision:Vision:

– To create a uniform manner in which to refer clients To create a uniform manner in which to refer clients to free, research-based, quit-tobacco services.to free, research-based, quit-tobacco services.

Goals:Goals:– Increase access to services statewideIncrease access to services statewide

– Increase cessation recruitment statewideIncrease cessation recruitment statewide

– Build relationships with healthcare practitioners Build relationships with healthcare practitioners (HCPs)(HCPs)

– Build relationships with Women, Infant, and Build relationships with Women, Infant, and Children clinics (WIC)Children clinics (WIC)


Program

Proactive Referral Proactive Referral System: System: Vision & GoalsVision & Goals Goals (continued):Goals (continued):

– Increase awareness of tobacco tax-funded servicesIncrease awareness of tobacco tax-funded services

– Create system changes within healthcareCreate system changes within healthcare

– Provide a mechanism for evaluation of productivity Provide a mechanism for evaluation of productivity and cost effectiveness of training and referral systemand cost effectiveness of training and referral system

– Decrease the prevalence of tobacco useDecrease the prevalence of tobacco use


Program

Smokers’ Helpline: Smokers’ Helpline: Referral HubReferral Hub


Program

Healthcare Provider Healthcare Provider OutreachOutreach


Program

Provider Advice to QuitProvider Advice to Quit

Most Americans see doctor annuallyMost Americans see doctor annually Physician advice to quit is a powerful Physician advice to quit is a powerful

motivator-- even advice as brief as 3 motivator-- even advice as brief as 3 minutes can make a differenceminutes can make a difference

5 “A’s”: every office visit, every patient5 “A’s”: every office visit, every patient– AskAsk if patient smokesif patient smokes– AssessAssess readiness to quit readiness to quit– AdviseAdvise to quit to quit– AssistAssist in quitting/finding servicesin quitting/finding services– ArrangeArrange for cessation services for cessation services


Program

Healthcare Provider Healthcare Provider OutreachOutreach Give healthcare providers the tools they Give healthcare providers the tools they

need on an ongoing basis need on an ongoing basis – Basic cessation intervention training (5As)Basic cessation intervention training (5As)– Collateral materials for waiting roomCollateral materials for waiting room– Strategies to change systems (chart Strategies to change systems (chart

stickers, referral forms, NRT benefits, free stickers, referral forms, NRT benefits, free cessation services, training, incentives)cessation services, training, incentives)

– Outcome results per referralOutcome results per referral


Program

Healthcare Provider Healthcare Provider OutreachOutreach Distribute aggregate client data to MCOsDistribute aggregate client data to MCOs Mail tailored packets MCO clientsMail tailored packets MCO clients Mail thank-you letters, incentives, and Mail thank-you letters, incentives, and

publications to referring HCPspublications to referring HCPs


Program

Recruitment ResultsRecruitment Results

Are healthcare providers using the Are healthcare providers using the proactive referral system?proactive referral system?

Have changes in recruitment strategies Have changes in recruitment strategies influenced client characteristics?influenced client characteristics?


Program

Recruitment StrategiesRecruitment StrategiesHelpline Client Comparisons: Recruitment Strategies

76.1% 77.6%

67.9%

37.7%

28.3%

21.6%25.6%

45.3%

78.5%

87.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FY 98-99 FY 99-00 FY 00-01 FY 01-02 FY 02-03

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Traditional Paid Advertising Referrals + Self-Help


Program

Who calls the Helpline?Who calls the Helpline?FY 98-99 Quantity

FY 98-99 Percent

FY 99-00 Quantity

FY 99-00 Percent

FY 00-01 Quantity

FY 00-01 Percent

FY 01-02 Quantity

FY 01-02 Percent

FY 02-03 Quantity*

FY 02-03 Percent

Total New Clients 6831 100.0% 6691 100.0% 5164 100.0% 3738 100.0% 2743 100.0%GenderMale 3132 45.8% 3064 45.8% 2403 46.5% 1505 40.3% 907 38.0%Female 3699 54.2% 3627 54.2% 2761 53.5% 2227 59.6% 1462 61.2%Counseling StatusInformation and Referral 5448 79.8% 5109 76.4% 2210 42.8% 1363 36.5% 865 31.5%Counseling 1383 20.2% 1582 23.6% 2954 57.2% 2375 63.5% 1706 62.2%Pregnancy StatusSelf-Identified Pregnant 215 3.1% 166 2.5% 108 2.1% 69 1.8% 43 1.8%WIC StatusWIC 242 3.5% 296 4.4% 231 4.5% 278 7.4% 149 6.2%Health InsuranceYes, Insurance 4260 62.4% 3886 58.1% 2986 57.8% 2590 69.3% 1871 78.3%No, Insurance 1658 24.3% 1839 27.5% 1634 31.6% 799 21.4% 412 17.2%Refused, Missing 97 1.4% 73 1.1% 127 2.5% 321 8.6% 106 4.4%EthnicityAfrican-American 240 3.5% 162 2.4% 97 1.9% 110 2.9% 86 3.6%Asian-American 40 0.6% 38 0.6% 44 0.9% 20 0.5% 11 0.5%White-Caucasian 5025 73.6% 4495 67.2% 3270 63.3% 2828 75.7% 1886 78.9%All Hispanic 653 9.6% 1595 23.8% 1549 30.0% 550 14.7% 378 15.8%Native American 65 1.0% 58 0.9% 43 0.8% 44 1.2% 20 0.8%Mixed Race 25 1.0%Other 159 2.3% 137 2.0% 50 1.0% 40 1.1% 219 9.2%No Response 649 9.5% 206 3.1% 111 2.2% 146 3.9% 73 3.1%Call LanguageEnglish 6650 97.4% 5538 82.8% 3978 77.0% 3463 92.6% 2219 92.9%Spanish 181 2.6% 1144 17.1% 1186 23.0% 275 7.4% 170 7.1%

Total Telephone Calls 11575 11622 10086 7781 7226Total Client E-mails 77 165 117 462 733


Program

Helpline Recruitment Helpline Recruitment SourcesSourcesFY 98-99

QuantityFY 98-99 Percent

FY 99-00 Quantity

FY 99-00 Percent

FY 00-01 Quantity

FY 00-01 Percent

FY 01-02 Quantity

FY 01-02 Percent

FY 02-03 Quantity*

FY 02-03 Percent

Total Client Contacts 6831 100.0% 6691 100.0% 5164 100.0% 3738 100.0% 2743 100.0%How did you hear about the Helpline? Television 4182 61.2% 4143 61.9% 2348 45.7% 406 10.9% 182 7.6%Radio 840 12.3% 721 10.8% 798 15.5% 492 13.2% 111 4.6%Newspaper 61 0.9% 79 1.2% 56 1.1% 137 3.7% 192 8.0%Billboard 74 1.1% 81 1.2% 91 1.8% 187 5.0% 43 1.8%Telephone Book 42 0.6% 166 2.5% 211 4.1% 186 5.0% 148 6.2%Traditional Paid Advertising 5199 76.1% 5190 77.6% 3504 67.9% 1408 37.7% 676 28.3%Health Ins. Provider ** 100 1.9% 85 2.3% 75 3.1%Physician 502 7.3% 560 8.4% 306 5.9% 236 6.3% 293 12.3%Dentist 4 0.1% 4 0.1% 10 0.2% 8 0.2% 9 0.4%Pharmacist 11 0.2% 5 0.1% 14 0.3% 7 0.2% 7 5.5%Printed Material 269 3.9% 156 2.3% 191 3.7% 196 5.2% 131 5.5%Web Page 13 0.2% 27 0.4% 40 0.8% 41 1.1% 37 1.5%Local Project *** 316 6.1% 632 16.9% 258 10.8%

Voucher Program 158 3.1% 423 11.3% 177 7.4%Friends and Family *** 419 8.1% 467 12.5% 261 10.9%Former Client Referred*** 53 1.4% 36 1.5%Was Former Client*** 284 7.6% 290 12.1%Eval Callback Team 66 1.8% 204 8.5%Community Event *** 8 0.2% 60 1.6% 23 1.0%WIC Clinic *** 64 1.2% 134 3.6% 38 1.6%University *** 17 0.3% 9 0.2% 6 0.3%

ASU 1 0.0% 0 0.0% 1 0.0%NAU 0 0.0% 0 0.0% 0 0.0%UA 16 0.3% 9 0.2% 5 0.2%

Workplace*** 15 0.6%Child's School*** 1 0.0%Community College*** 1 0.0%Church/Temple/Mosque/Clergy*** 1 0.0%Youth Diversion **** 105 2.0% 59 1.6% 37 1.4%Other 675 9.9% 958 14.3% 575 11.1% 165 4.4% 179 6.9%Referrals + Self-Help 1474 21.6% 1710 25.6% 2340 45.3% 2934 78.5% 2085 87.3%


Program

Referral ResultsReferral ResultsPassive Referrals to Helpline

38

143

181

119

98

16

59

75

4733

4 6 10 7 3

19

98

5567 69

0

50

100

150

200

Q1 02-03 Q2 02-03 Q3 02-03 Q4 02-03 Q1 03-04

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Passive Total LP WIC HCP WIC Referral Program is pilot (not statewide).

Total Passive Referrals to Date: 638Local Project: 243 (38%)WIC: 31 (5%)HCP: 371 (58%)


Program

Referral ResultsReferral ResultsProactive Referrals to Helpline

10

89

116 114

189

10

48

123

34

6 4 3 3

35

100108

152

0

50

100

150

200

Q1 02-03 Q2 02-03 Q3 02-03 Q4 02-03 Q1 03-04

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Proactive Total LP WIC HCP Total Proactive Referrals to Date: 779Local Project: 94 (12.1%)WIC: 21 (2.7%%)HCP: 565 (72.5%)

WIC Referral Program is pilot (not statewide).


Program

Referral ResultsReferral Results

Healthcare providers (HCPs) are more likely Healthcare providers (HCPs) are more likely to use proactive referral system than county to use proactive referral system than county health departmentshealth departments

Although Speakers’ Bureau training and Although Speakers’ Bureau training and other outreach activities have reached other outreach activities have reached hundreds of HCPs, only a core group uses hundreds of HCPs, only a core group uses the system. (113 HCPs of 2,555 in database)the system. (113 HCPs of 2,555 in database)

Acceptance of proactive referral system Acceptance of proactive referral system continues to growcontinues to grow


Program

ServicesServicesHelpline Client Comparisons: Service Choice

79.8%76.4%

42.8%

36.5%

31.5%

20.2%23.6%

57.2%

63.5% 62.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FY 98-99 FY 99-00 FY 00-01 FY 01-02 FY 02-03

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Information and Referral Counseling


Program

Call LanguageCall LanguageHelpline Client Comparisons: Call Language

6,650

5,538

3,978

3,463

2,219

181

1,144 1,186

275 170

6,8316,691

5,164

3,738

2,389

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

5,500

6,000

6,500

7,000

FY 98-99 FY 99-00 FY 00-01 FY 01-02 FY 02-03

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English Spanish Total Clients

97.4%

2.6%

82.8%

17.1%

77%

23%

92.6%

92.9%

7.4% 7.1%


Program

Hispanic EthnicityHispanic EthnicityHelpline Client Comparisons: Hispanic Ethnicity

5,025

4,495

3,270

2,828

1,889

653

1,595 1,549

550378

6,8316,691

5,164

3,738

2,389

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

5500

6000

6500

7000

FY 98-99 FY 99-00 FY 00-01 FY 01-02 FY 02-03

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White-Caucasian All Hispanic Total Clients

73.6%

9.6%

67.2%

23.8%

63.3%

30%

75.7%

14.7%

78.9%

15.8%


Program

Health InsuranceHealth InsuranceHelpline Client Comparisons: Health Insurance Status

62.4%

58.1% 57.8%

69.3%

78.3%

24.3%27.5%

31.6%

21.4%17.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FY 98-99 FY 99-00 FY 00-01 FY 01-02 FY 02-03

Per

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Yes, Insurance No, Insurance


Program

GenderGenderHelpline Client Comparisons: Gender

45.8% 45.8% 46.5%

40.3%38.0%

54.2% 54.2% 53.5%

59.6% 61.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FY 98-99 FY 99-00 FY 00-01 FY 01-02 FY 02-03

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Male Female


Program

Future AnalysesFuture Analyses

Further investigate changes in clientele Further investigate changes in clientele and recruitment (i.e., age, pregnancy and recruitment (i.e., age, pregnancy status, WIC status, education)status, WIC status, education)

Track and evaluate proactive referralsTrack and evaluate proactive referrals– What are the most productive referral sources?What are the most productive referral sources?

– How can the process be changes to increase How can the process be changes to increase recruitment of low SES clients?recruitment of low SES clients?

How with discounted NRT provision How with discounted NRT provision change recruitment in the future?change recruitment in the future?


Program

Arizona Smokers’ Arizona Smokers’ HelplineHelpline

1-800-55-66-2221-800-55-66-222For cessation counseling:For cessation counseling:

www.ASHLine.orgwww.ASHLine.org

For additional evaluation information:For additional evaluation information:

www.TEPP.org/evaluationwww.TEPP.org/evaluation

Mel & Enid Zuckerman Arizona College of Public HealthTucson, Arizona

proactive referrals: increasing cessation recruitment by building collaborations

Documents

quittobacco services

helpline callfaxes referral

prevalence of tobacco

referral systemdecrease

internet services

arizonacomprehensive

recruits client

mohave county wic