Grant ID 044920/St. Francis Medical Center/Vida Sana QUITS

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St. Francis Medical Center Vida Sana Quality Interventions to Transition Smokers

“Vida Sana QUITS”

Proposal to Smoking Cessation Leadership Center at UCSF and

Pfizer Medical Education Group

October 18, 2012

All required fields completed online in the Pfizer Grant Management system

i.

Table of Contents

B. Table of Contents .......................................................................................... i

C. Primary Investigator Information ............................................................... 1

D. Proposal ...................................................................................................... 2

1. Overall Aim and Objectives ..................................................................... 2

2. Current Assessment of Need in Target Area .......................................... 5

3. Technical Approach ................................................................................. 7

4. Evaluation Design .................................................................................. 10

E. Detailed Workplan .................................................................................... 11

F. Detailed Budget ........................................................................................ 14

G. Organizational Detail ................................................................................ 15

I. Letters of Commitment ............................................................................. 17

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C. Primary Investigator (PI)

Mary Lynne Knighten, MSN, RN, PN, NEA-BC, DNP(c) has taken a critical leadership role in the pursuit of a healthy, smoke-free environment in Southeast Los Angeles and at St. Francis Medical Center. She developed the concept of Vida Sana QUITS and will act as the Primary Investigator for its duration.

Ms. Knighten is a nurse executive with more than twenty years of progressive management experience in leading patient care operations, developing staff, hospital and community-based healthcare programs, developing clinical programs, improving patient satisfaction and quality outcomes, identifying cost efficiencies, controlling budgets, and ensuring regulatory compliance for major medical centers and teaching hospitals. An established expert in patient and family centered care, Ms. Knighten has a demonstrated ability to create a participative management culture while maintaining strict oversight, keeping managers accountable for delivery of patient care.

As Senior Director of Patient Experience and Care Delivery at St. Francis Medical Center, Ms. Knighten is responsible for all aspects of the patient experience and implementation of a patient and family centered model of care delivery. Currently, Ms. Knighten has administrative responsibility for the Behavioral Health Service Line, the Skilled Nursing Facility, Palliative Care, the Education Department, Decedent Affairs and the Advocacy Office. During her tenure at SFMC, Ms. Knighten improved sepsis mortality by developing leadership skills in direct care nurses to drive change from the front-line using the improvement model – contributing to a national award from QUEST Premier from improving quality core measures; facilitated implementation of over 50 PFCC strategies; improved HCAHPS overall rating of hospital 9/10 Top Box score by four percentage points in eighteen months, doubling the national average of 2 percentage points; and, led Behavioral Health Services as the only service line to gain market share in the past two years.

In 2011, Ms. Knighten was awarded a grant and in-kind support totaling $20,000 from LACDPH for the L.A. Pioneers smoke-free project. The success of that endeavor was, to large extent, the impetus for the design of the Vida Sana QUITS project. As PI for the project Ms. Knighten will manage the resources of the project—including staff and financial resources—will plan and control the project activities and will oversee all communications with regards to Vida Sana QUITS. Specifically, Ms. Knighten will supervise the clinician/health educator in developing the projects

Contact information:

infrastructure, monitor healthcare staff to ensure that the project is conducted in accordance with the terms of the grant agreement, and report project progress toward meeting the objectives outlined in the grant proposal.

Mary Lynne Knighten, MSN, RN, PN, NEA-BC, DNP(c) Senior Director, Patient Experience and Care Delivery, St. Francis Medical Center 3630 East Imperial Highway, Lynwood, CA 90262 Phone: (310) 900-8593; Fax: (310) 900-8880 MaryLynneKnighten@dochs.org

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D. Proposal 1. Overall Aim & Objectives:The overall aim of the Vida Sana QUITS (QUality Interventions to Transition Smokers) Project is to improve clinical outcomes by training health professionals and community health promoters how to apply proven smoking cessation strategies in a culturally competent manner utilizing discipline and population specific curriculum. Involving staff at the hospital and the Vida Sana Initiatives—SFMC’s flagship community benefit effort—the project builds on the success of the Los Angeles (L.A.) County Pioneer Smoking Cessation project (LA Pioneers).

LA Pioneers developed a train-the-trainer smoking cessation curriculum that was shown to be highly successful in motivating community members to change their attitudes and ultimately their habits around tobacco use. Vida Sana Initiatives is a multi-faceted effort to improve community health among low-income, underserved populations through health promotion, disease prevention, and management of chronic conditions. Vida Sana QUITS will develop a new curriculum by applying concepts of the Pioneer Project curriculum while providing an approach that is more tailored toward the specific communities and healthcare disciplines that will ultimately benefit from the proposed interventions. The new curriculum developed will be both discipline specific—applicable to health professionals practicing in various professional healthcare practitioners—and population specific—accounting for differences in socio-economic and cultural factors, educational attainment and health literacy as well as whether the individual in question is an inpatient or a community member seeking services at a community based program offered by the hospital. Ultimately Vida Sana QUITS will create a curriculum that can be effectively utilized by everyone from primary care providers to community health workers (promotoras) and mental health professionals and that respond to the specific circumstances of their audience.

The current evidence-based curriculum consists of training around six topic areas including 1) Healthy Behaviors; 2) The Truth about Tobacco; 3) Changing Behaviors; 4) Coping with Cravings; 5) Managing Stress; and 6) Planning Ahead. Specific didactical information on smoking cessation is augmented by information on the role of the health worker within the smoking cessation/motivation process. The new curriculum will include modifications that will allow health practitioners to customize interaction with their patients so that the message delivered is appropriate to the socio-economic and cultural circumstances and health literacy level of the recipient. In addition, the new curriculum will incorporate a comprehensive list of strategies and will show which strategies and which combination of approaches is most effective with individuals from specific socio-economic or cultural backgrounds. The curriculum will teach healthcare providers to employ interview techniques designed to elicit accurate information about smoking habits—overcoming the stigma that has historically been shown to prevent full disclosure of tobacco use.

Once completed, the Vida Sana QUITS curriculum will be used to train a core group of St. Francis Medical Center (SFMC) health professionals engaged in direct patient care either at the hospital or through Vida Sana Initiatives. Trainees—including physicians, direct-care nurses,

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parish nurses, promotoras, patient family advisors, respiratory therapists and mental health professionals (social workers, PET Team members)—will then use that training to provide culturally and linguistically appropriate smoking cessation interventions to people in various locations including the hospital itself, community centers and churches. The interventions provided will run the gamut from providing passive education, information and basic messaging that builds awareness of the dangers of tobacco use to offering more intensive lifestyle intervention workshops and support groups along with nicotine replacement therapy.

Project goals include the following: 1. Develop the programmatic and capacity infrastructure of SFMC (including training,

implementation, marketing and evaluation) to provide initial and ongoing training of healthcare professionals who teach smoking cessation strategies to patients and the community.

2. Utilize the evidence-based Train-the-Trainer modules from L.A. Pioneers Smoke-Free Project to create a new, culturally and linguistically appropriate, discipline and population specific methodology around smoking cessation intervention.

3. Train a cadre of health professionals in various disciplines to effectively offer smoking cessation intervention along a continuum of intensity levels—from raising awareness to providing pharmacological intervention in tandem with behavioral modification strategies.

4. Newly trained healthcare workers in community settings will provide community members with information on tobacco use, introducing smoking cessation strategies and techniques.

5. Newly trained healthcare workers in community settings will provide support groups to provide more substantive support for smokers who have resolved to quit or cut back and/or for smokers who are in the process of quitting.

6. Newly trained healthcare workers at the hospital will have a greater range of strategies at their disposal to address smoking cessation with patients including motivational interviewing, pharmacological intervention, and the ability to refer to smoking cessation support activities available through Vida Sana Initiatives.

7. Develop a refresher/review course for the newly trained healthcare workers designed specifically for post-grant award continuity.

8. Evaluate the effectiveness of the infrastructure development, the training activities, retooling the curriculum, and the effectiveness of the delivery mechanism.

SFMC will achieve these goals by successfully executing the following objectives:

• Produce a discipline and population-specific Vida Sana QUITS curriculum for use by hospital and community-based healthcare personnel associated with St. Francis Medical Center and Vida Sana Initiatives within six months of funding.

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• Provide approximately 80 to 120 health professionals over the grant period including physicians (approximately 40), direct-care nurses (approximately 40), parish nurses (approximately 4), respiratory therapists (approximately 7), promotoras (approximately 8), mental health professionals (approximately 20), and patient family advisors (approximately 5) with training in how to deliver culturally appropriate smoking cessation strategies as measured by Vida Sana QUITS sign-in sheets and feedback surveys.

• Provide a total of two (2) Continuing Medical Education courses, ten (10) direct trainings, and four (4) refresher courses using the new Vida Sana QUITS curriculum to accommodate the schedules and training needs of the healthcare professionals served through the project.

• Provide a minimum of 65 support groups with an average weekly attendance of 5 to 10 individuals as evidenced by sign in sheets and feedback/survey forms collected.

• Provide smoking cessation messaging reaching approximately 2,000 community members over the grant period via healthcare personnel engaged in Vida Sana Initiatives community health promotion programs and mobile health van as evidenced by participant tracking sheets and class rosters.

• Provide a minimum of 1,000 hospital in-patients with interventions and/or smoking cessation messages and support at the hospital by healthcare personnel trained through Vida Sana QUITS as evidenced by self-reporting by healthcare professionals.

The impact of this project on the community served will be as follows:

1) The community will benefit from consistent and culturally appropriate messaging on tobacco use and smoking cessation methods available that are delivered through several health and wellness initiatives available through the hospital;

2) A measurable increase in self-reported smoking cessation based on SFMC’s proven track record in various health promotion initiatives of delivering culturally and linguistically appropriate interventions;

3) A greater awareness among healthcare professionals, across disciplines, of proven methodologies to help patients and community members in their smoking cessation strategies; and;

4) Improved accuracy of information gathered by teaching trainees to use motivational interviewing and the educational teach

back method to elicit accurate information from socio-economically and ethnically diverse clients, creating the reciprocal information sharing necessary to initiate and maintain a change in behavior.

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2. Current Assessment of Need in Target Area:Vida Sana QUITS builds on two efforts—the L.A. County Pioneers Smoking Cessation Project discussed in Section 1 and SFMC’s proven, hospital-based, smoking cessation strategies that reduced smoking rates among participating patients–by adapting components of those interventions and incorporating motivational interviewing and other strategies to create a curriculum that can be effectively utilized by various health professionals to respond to the circumstances and health literacy level of specific audiences. SFMC has a smoking protocol in place, collects data on smoking at community wellness and health screening events in addition to hospital admissions, and provides passive smoking cessation education in the form of written and verbal material.

Smoking cessation strategies implemented in SFMC’s Outpatient Psychiatric Services program, for example, resulted in 50% of patients who smoked either quitting or reducing their nicotine intake.

Baseline Data

Smoking is the leading cause of preventable morbidity and mortality in the United States1. The general decline in smoking rates that was observed in the U.S. between 1970 and the year 2000 has stalled. Between 2005 and 2009 the National Health Interview Survey found that smoking rates across the nation remained constant. Although residents in the Western U.S. smoke at lower rates than in other areas of the country, numerous and significant risk factors for smoking—low income, low educational attainment and large numbers of recent immigrants2

The highest cigarette smoking burden in 2009 was on residents living below the federal poverty level and those whose educational attainment was low

—are prevalent in the communities served by SFMC.

3. In 2009, 20.6% of adults in the U.S. were current smokers (defined as smoking every day or some days) including nearly 24% of men and 18% of women4. People who live in poverty, however, smoke at significantly higher rates than their more affluent counterparts. Estimates from the 2009 National Health Interview Survey and the 2009 Behavioral Risk Factor Surveillance System indicate that 31% of adults living at or below the federal poverty level and 28.5% of adults with less than a high school diploma were current smokers (compared with just 5.6% of residents with a graduate degree5

Southeast Los Angeles Community Data

). Finally, recent data show that immigrant populations also experience a higher than average smoking rate of 21.6%.

Income in SFMC’s service area is markedly lower than the national and countywide averages. Twenty-eight percent of families in Service Planning Area (SPA) 6 and 14% in SPA 7 live at or below 100% of the Federal Poverty Level and, in the nine communities where most SFMC patients reside, the poverty rate is significantly higher than the county averages. Fully 24% of

1 Vital Signs: Current Cigarette Smoking Among Adults Aged 18 years [and older]—United States 2009. Morbidity and Mortality Weekly Report. The Centers for Disease Control and Prevention. September 10, 2010 / 59(35);1135-1140 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5935a3.htm 2 Ibid. 3 Vital Signs: Current Cigarette Smoking Among Adults Aged 18 years [and older]—United States 2009. Morbidity and Mortality Weekly Report. The Centers for Disease Control and Prevention. September 10, 2010 / 59(35);1135-1140 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5935a3.htm. 4 Ibid. 5 Ibid.

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residents in Lynwood; 28% in Compton, 22% in Paramount, 25% in Huntington Park, 24% in Cudahy, 24% in Bell, 11% in Downey, 19% in South Gate, 25% in Maywood, and 27% in Bell Gardens6 live below the federal poverty level7. It is important to note that the high cost of living in Los Angeles County places additional strain on low-income families. According to the Public Policy Institute of California, when cost of living is factored into the equation, the poverty rate in Los Angeles County jumps from 15% to 26%8

Research, and our own community data, shows that low-income residents of Southeast Los Angeles tend to have low educational attainment—another risk factor associated with high rates of smoking. In Maywood, 42% of residents have less than a 9

.

th

Arguably the most important social determinant of health status other than poverty is insurance status. Los Angeles County had the largest number of uninsured residents in the state with 2.7 million children and adults—fully 28.9% of the population experiencing some period of being uninsured in 2009.

grade education, followed by Bell Gardens 41%, Cudahy 38%, Bell 36.5%, Huntington Park 35%, South Gate 33%, Lynwood 29%, Paramount 26%, Compton 24.5%, and Downey 12.5%. Our communities have a high concentration of households where Spanish is the primary language. In Huntington Park, Spanish is the primary language in 93% of households followed by 92% of households in Bell Gardens, 91% in Maywood, 90% in Cudahy, 87% in South Gate, 86% in Bell, 79% in Lynwood, 71% in Paramount, 59% in Compton and 58% in Downey.

9 The Kaiser Commission on Medicaid and the Uninsured found that individuals living below the poverty level are at the highest risk of being uninsured and comprise more than 40% of the uninsured.10

SFMC Patient & Community Program Participant Data

Uninsured and underserved populations also utilize emergency health services for non-emergency conditions at a higher rate than their insured counterparts and experience a greater degree of difficulty in accessing preventative care—resulting in barriers that prevent these populations from having access to the latest information and advice from health professionals. The Vida Sana QUITS program addresses this by bringing smoking cessation messages into the community.

In 2010, only 5% of the 20,313 patients admitted to SFMC acknowledged that they were current smokers on their admission forms. In 2011, the “My Life Check” questionnaire administered to participants in our community-based Vida Sana program revealed that 6% of participants reported being current smokers and an additional 5% reported having quit smoking greater than 12 months prior. Given the prevalence of smoking among poor, uneducated and immigrant populations, and given the large concentration of such residents in SFMC’s service

6 U.S. Census Bureau State and County Quickfacts. Retrieved online at: http://quickfacts.census.gov/qfd/states/06/0646492.html. 7 U.S. Census Bureau State and County Quickfacts. Retrieved online at: http://quickfacts.census.gov/qfd/states/06/0646492.html. 8 PPIC calculations using U.S. Census Bureau, Current Population Survey, Annual Demographics Files for trends, and American Community Survey (2006) for racial/ethnic, child, county, and working-poor statistics. 9 St. Francis Medical Center. Building Healthier Communities: Community Benefit Programs FY 2010 Update. St. Francis Medical Center, Lynwood, CA. page 14. 10 Five Facts About the Uninsured. Kaiser Commission on Medicaid and the Uninsured. September 2010. Retrieved online at: http://www.kff.org/uninsured/upload/7806-03.pdf.

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area; SFMC is confident in asserting that the smoking rate is likely much higher than reported by the target population.

In addition to data provided through questionnaires and hospital admission forms, SFMC has assessed the current need for smoking cessation interventions by conducting a review of published literature, consulting the Community Needs Assessment conducted by the hospital each year, and by reviewing feedback from front-line personnel including community health workers engaged in health promotion activities at SFMC. According to a recent report entitled Cigarette Smoking in Los Angeles County: Local Data to Inform Tobacco Policy

The prevalence of underreporting cigarette smoking in our communities—principally immigrant or ethnic minority populations—speaks to the stigma associated with smoking in these communities. The stigma and a reluctance to “give answers that the patient believes the interviewer does not want to hear,” makes the delivery of smoking-cessation strategies more challenging. In addition, many individuals deny the smoking label, even though they may infrequently use cigarettes at social events, while consuming alcohol, or other specific times. Many liquor stores sell single cigarettes for those “occasional” smokers. The use of motivational interviewing by all healthcare disciplines will delve into this often-forgotten area of tobacco use. Training healthcare professionals to apply smoking cessation strategies that will overcome the stigma and other barriers to eliciting accurate feedback addresses a clear gap in practice at SFMC and in the Vida Sana program.

(June 2010) produced by the Office of Health Assessment and Epidemiology at the County of Los Angeles Public Health Department, nearly 115,000 smokers reside in Southeast Los Angeles. SFMC’s 2010 Community Needs Assessment showed that 19.7% of residents in the primary service area (SPA 6) were smokers—a far greater number than in any other SPA in L.A. County. Given the risk factors for smoking in the service area, the logical assumption would be that SFMC patients would smoke at rates that far surpass the rates reported. Yet epidemiological data analysis of patient information gathered on admissions, and interviews with community-based and direct care staff indicates that there is significant underreporting of smoking prevalence among SFMC patients.

3. Technical Approach, Intervention Design and Methods:Development of Infrastructure

Vida Sana QUITS will enable SFMC to build its capacity to provide smoking cessation strategies by amassing a comprehensive listing of area resources, training healthcare workers, and creating smoking cessation materials that are appropriate for all disciplines and populations/audiences. This project will also build capacity by addressing the lack of appropriate, relevant training of healthcare professionals that has resulted in significant underreporting of tobacco usage in underserved community. At the core of a successful implementation of Vida Sana QUITS is the development of a population and discipline specific smoking cessation curriculum. The project infrastructure and curriculum development will be spearheaded by the Program Manager. The implementation methods that will be used will include didactic instructional techniques delivered in a hospital setting; community based intervention delivered by community health workers in trusted community sites; and hospital based interventions delivered at SFMC’s main facility.

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Didactic Instructional Techniques (or Training the Trainers): Vida Sana QUITS will combine cultural and linguistically appropriate motivational interviewing with the modules and implementation package obtained during the L.A. Pioneers outreach associated with Project TRUST (Tobacco Reduction Using Effective Strategies and Teamwork). The goal of Project TRUST is to reduce tobacco use in high-risk communities across the country through policy, systems and environmental change interventions. The goal of motivational interviewing is to elicit and strengthen motivation for change through a patient/person-centered approach.

Motivational interviewing focuses on exploring and resolving ambivalence about change by centering on the individual’s capacity to alter patterns of destructive or addictive behavior. The technique affirms the values, outlook and cultural norms of the person being interviewed and uses that as the basis for strengthening the person’s willingness and motivation to modify behavior. Vida Sana QUITS will teach motivational interviewing in conjunction with the train-the-trainer Project TRUST curriculum to both hospital staff and community health workers. This technique will open the door for other strategies and interventions—from pharmacological intervention to support groups and educational classes—to be presented by the healthcare workers and hopefully adopted by the recipient.

Community-Based Intervention: SFMC firmly believes that reaching our communities with health information, especially preventative, is key to promoting life-long wellness and disease prevention. SFMC administers several successful, community programs that utilize promotoras and Parish Nurses as community-based health educators, to influence life-style behaviors and reduce physical and behavioral risk factors for disease. Studies show that the use of community health educators can be highly effective in low-income, ethnically diverse populations. One policy paper commissioned by The California Endowment in 2008 found that “Because of the relationship they [promotoras] have with their community, they are particularly effective at reaching Latinos and other unserved and underserved families and individuals. They can help address multiple barriers to accessing services, such as those related to transportation, availability, culture, language, stigma, and mistrust11

11 Rhett-Mariscal, PhD. Promotores in Mental Health in California and the Prevention and Early Intervention Component of the MHSA. Funded by The California Endowment and prepared by the Center for Multicultural Development at the California Institute for Mental Health, November 2008. Retrieved 10/12/12 at: http://www.cimh.org/LinkClick.aspx?fileticket=Qw5mqcEahTI%3D&tabid=568

. Results of the “Move More” initiative in the Vida Sana program, an exercise component, are measured with the aid of a custom built database for designed for statistical analysis. Outcome data showed 35% of the adults improved their physical activity 3 to 5 days per week following health promotion intervention and 18% of children improved their physical activity 3 to 5 days per week following health promotion intervention. Results of the “Eat Smart” intervention, focused on healthy food choices, demonstrated that 67% of adults and 78% of children increased their consumption of ≥ 4 servings of fruits and vegetables per day following nutritional education and personal health counseling. Often times, community members regard the promotoras and parish nurses as medical authorities since they have little contact with physicians other than through a hospital

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admission. These programs are clearly effective in changing perception and behavior among the target population and SFMC is confident that the strategy will prove equally as effective in reducing smoking.

Community Health Workers: Promotoras and parish nurses work in the community and therefore have different opportunities to address smoking. Motivational interviewing is an excellent fit with SFMC’s utilization of community-based health professionals and community health promoters (promotoras). Engaging community members in health promotion is a strategy that has proven to be exceptionally effective in reaching underserved and diverse ethnic groups. These personnel are able to quickly establish rapport with clients, building on a previously established sense of trust. These relationships are often the key to the success of smoking cessation efforts, particularly in underserved communities like SPA 6 where SFMC is located. Training these professionals to address smoking cessation through motivational interviewing, education, anti-smoking messaging and support groups gives them a broad array of tools with which to empower and inform residents, creating a greater aptitude for medical consumerism around smoking cessation.

Interventions provided by community health workers will include individual outreach touches, support groups, educational classes that include messages on smoking cessation and carbon monoxide monitoring, and outreach touches provided through the mobile health unit.

Hospital-Based Intervention: Smoking cessation training for physicians, direct-care nurses and patient family advisors respiratory therapists and mental health professionals (social workers, PET Team members) at the hospital will focus on how to use motivational interviewing to initiate conversations about smoking that will elicit honest information and set the stage for change. Staff will be trained on various pharmacological interventions that have been shown to increase the efficacy of smoking cessation strategies including the Nicotine Replacement protocol that is already in place at SFMC. Patients will receive multiple “touches” at the hospital, from staff at various levels and in different specialty areas—creating an atmosphere that de-stigmatizes smoking in an effort to motivate behavioral changes. Hospital patients will have access to pharmacological intervention, information and referrals to the community based smoking cessation efforts available through Vida Sana QUITS including support groups and educational classes. Vida Sana QUITS will establish sufficient skill levels in healthcare professionals across several disciplines to enable them to provide culturally competent smoking cessation interventions to individuals and groups.

A crucial component to sustaining the project’s momentum over the long term is development of follow-up training sessions to reinforce the principles and methods taught during the initial grant period. These “refresher” courses will be provided on a quarterly basis after the grant period. Since the lion’s share of the funding request will be used for infrastructure development, we anticipate that the infrastructure growth will be sufficient to fully integrate the training into the routine training of healthcare workers at SFMC (Physician committees, Department Meetings, community program meetings, etc.) which will provide longevity for the activities without requiring significant additional financial resources.

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4. Evaluation Design:Smoking rates, understanding of the consequences of smoking, number of cigarettes typically smoked, interest in quitting and other specifics will be measured via pre- and post-test survey instrument for hospital patients and community members. Individuals involved in more intensive support and intervention will have their self-reporting of cessation successes confirmed through monitoring individual carbon-monoxide levels at the Vida Sana QUITS support meetings. Participants will be queried one month post-intervention and again at six months to measure sustainability of smoking cessation strategies. Patient Activation Measures surveys for monitoring smoking cessation will be created from our custom built National Health Foundation software and administered to participants.

The efficacy of the training itself will be measured via pre- and post-training surveys that will gauge health personnel knowledge and attitudes as well as willingness to adopt the new strategies. Surveys will also seek to measure engagement (e.g. determine their most recent efforts to discourage smoking, and how they engaged the patient or community member). Changes in behaviors will be tracked over the course of the project using follow-up surveys as well as feedback collected at refresher courses. Data collected from Vida Sana QUITS will be evaluated by the Principal Investigator with the assistance of an outside evaluator such as Clinical Care Extenders from COPE Health Solutions or National Health Foundation. Because of the project’s reliance on an outside evaluator, the evaluation process is not fully developed. However, it is anticipated that at a minimum the program evaluation will show the following outcomes:

• An estimated 25% of participants who participate in intensive smoking cessation intervention strategies including motivational interviewing, pharmacological interventions, and weekly educational classes or support groups will have quit smoking or reduced nicotine intake as demonstrated by surveys collected and by carbon monoxide monitoring conducted at weekly classes/groups.

• An estimated 75% of healthcare personnel trained will report an improved confidence in their ability to effectively deliver proven educational interventions on smoking cessation as demonstrated by pre- and post- training surveys.

• An estimated 75% of healthcare professionals will report increases in the number of messages delivered by healthcare professionals when compared to control group results.

Community members and patients participating in ongoing activities will be asked to complete a brief survey each time they access information or services. The survey will include:

• Number of cigarettes used daily;

• Carbon monoxide level measured;

• Medications used;

• Whether the participant has quit smoking or has a quit date in mind;

• Whether the participant has cut down on smoking; and

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• What particular strategy they find to be most helpful.

The Program Manager will work with hospital staff to recruit a control group of healthcare professionals who have not received the training to act as a control group. This group will be queried on a quarterly basis to determine how many patients self-report tobacco use to the non-trained healthcare personnel, how many smoking cessation messages are delivered, and how many smoking cessation interventions (pharmacological or referrals to support groups) are provided. This control group will commit to providing quarterly updates on smoking cessation intervention and messaging activities for a one year period.

Because SFMC has a smoking cessation protocol already in place, we anticipate a high rate of target audience engagement and follow through. Because the overall number of healthcare professionals trained is relatively small within each discipline, we anticipate that the providers who volunteer to undergo the training will be those who experience significant self-motivation to follow through on the opportunities presented by the training.

Once the infrastructure is developed for ongoing training of healthcare professionals, it will be quite simple to use a “plug and play” approach with any future healthcare professionals. Smoking cessation techniques will be incorporated into other health promotion activities within the Vida Sana Initiatives, making the delivery of services part of their ongoing program. Additionally, there may be an opportunity to bill Medicare for beneficiaries who attend outpatient smoking cessations groups.

This project is an excellent candidate for dissemination. The Train-the-Trainer curriculum already exists, and SFMC is well versed in evaluating program results and creating report documents. SFMC will make a full accounting of the project to the grantor, the steps taken, challenges encountered, and overall success available to other hospitals within the Daughters of Charity System, Ascension Health System, and via partnership with L.A. County Pioneers agencies, ACNL, Hospital Association of Southern California and other key stakeholders.

E. Detailed Work Plan and Deliverables Schedule: Please see attached work plan.

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St. Francis Medical Center

Vida Sana QUITS Work Plan

Goal/Dollar Amount Key Activities and Deliverables Time Frame

Infrastructure Build / $39,500

1. Project is funded. 2. Primary Investigator will schedule an initial team meeting with the Program Manager, the

Director of Vida Sana and other personnel to outline action plan activities, grant objectives and reporting requirements.

3. Initiate curriculum modification to include discipline and population specific training modules and create materials that are appropriate for all disciplines and populations/audiences—creating a tailored Vida Sana QUITS curriculum.

4. Incorporate Motivational Interviewing (MI) into the curriculum to help strengthen motivation for change in the target population.

5. Determine how to address the cultural and other barriers that contribute to significant underreporting in underserved communities and incorporate strategies to address the issue.

6. Develop a refresher/review course for the newly trained healthcare workers designed to provide follow-up support and additional learning.

7. Create a comprehensive guide to area resources for smoking cessation and create bilingual and online editions of the guide.

8. Create evaluation/feedback surveys for dissemination to trainees and community members to collect baseline data for future evaluation.

9. Provide Project TRUST and Motivational Interviewing techniques as part of the Vida Sana QUITS curriculum to all program staff in preparation for training healthcare personnel.

December 2012 – May 2013

Training / $12,000

1. Recruit healthcare personnel including physicians, direct-care nurses, parish nurses, promotoras, patient family advisors, respiratory therapists and mental health professionals (social workers, PET Team members to participate in the training.

2. Schedule and conduct ten (10) training sessions for 80 to 120 healthcare personnel over the grant period and collect evaluation and feedback data.

April 2013 – May 2013

Implementation / $15,000

1. Trained personnel will use MI techniques outlined in the training to elicit accurate information about smoking activities from community members.

2. Personnel will use discipline and demographic specific interventions to address tobacco use

June 2013 – December 2014

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Goal/Dollar Amount Key Activities and Deliverables Time Frame

among hospital patients and community members by offering pharmacological intervention, education, information, and referrals to classes and support groups.

3. Provide a minimum of 65 support group/smoking cessation classes with an average attendance of 5 to 10 individuals.

4. Provide 2,000 community members with smoking cessation messaging and information offered in community sites and through the Vida Sana mobile health van in Southeast Los Angeles.

5. Healthcare personnel trained through Vida Sana QUITS will provide a minimum of 1,000 hospital inpatients with educational information and/or smoking cessation messages at the hospital.

Evaluation / $7,060

1. Evaluate the effectiveness of the infrastructure development process by conducting a 360 degree type of review processes for personnel, collecting feedback from attendees in the trainings, and the completion of key deliverables including the discipline and demographic specific Vida Sana QUITS curriculum, the comprehensive resource guide, the refresher/review curriculum, and feedback collection and service tracking instruments.

2. Track number of healthcare professionals participating in the training classes and use their feedback and pre-and post-test surveys to assess the effectiveness of the curriculum and areas for improvement.

3. Track number of classes and/or support groups provided to the community and how many participants attend; use feedback from participants to assess the effectiveness of the curriculum and areas for improvement—particularly in terms of improvements in the accuracy of reporting of smoking activity.

4. Track the number of community members receiving smoking cessation interventions, the type and intensity of the intervention utilized and the effectiveness of each based on pre-and post-test survey instruments and monitoring individual carbon-monoxide levels.

September 2013 – December 2014

Identify Dissemination Strategies / $1,500

1. The Principal Investigator and Program Manager will identify appropriate avenues and timeframe for the dissemination of the lessons learned in the proposed program to various entities possibly including (but not limited to) hospitals within the Daughters of Charity System, Ascension Health System, and via partnership with L.A. County Pioneers agencies, ACNL, Hospital Association of Southern California and other key stakeholders.

January 2014 – December 2014

Final Grant Progress Report / $500

2. Using data amassed through the evaluation procedures, create a final grant report outlining the project methods, success, challenges and outcomes.

December 2014

Grant ID 044920/St. Francis Medical Center/Vida Sana QUITS Page 14

F. Detailed Budget: St. Francis Medical Center requests a total award of $76,560 for the Vida Sana QUITS project to be expended as follows: $8,000 Program Director/Principal Investigator

This stipend will cover a portion of the time and expertise committed to the Vida Sana QUITS project by Principal Investigator Mary Lynne Knighten.

$39,500 Program Manager/Clinician/Health educator

This line item will provide funding to support the staff costs associated with building SFMC’s infrastructure and training capacity. These costs include salary for the program manager position and for a Clinician/Health Educator in addition to ancillary costs associated with creating a new curriculum and a refresher curriculum.

$12,000 Classes

This line item covers all costs associated with classes provided to healthcare professionals and to the community including curriculum reproduction, materials, refreshments, stipends for promotoras and various incidental expenses.

$2,000 Promotional materials

This includes materials associated with community-based classes, support groups, outreach and various survey instruments.

$2,000 Physician Education

This covers costs associated with the CME specifically for physicians.

$3,500 Database Functionality

This line item will enable SFMC to upgrade its current VSI tracking database to accommodate the new patient population to be measured—providing immeasurable benefit in terms of tracking and evaluation.

$2,500 Incentives to encourage smokers to quit.

SFMC’s experience in providing community programs shows that the socio-economic status of the population served makes incentives an effective method of motivating a change in behavior and encourages participants to “show up” for the intervention.

$7,060 Evaluation

Approximately 10% of the total budget cost has been budgeted for evaluation.

$76,560 Total

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G. Organizational Detail: 1. Leadership and Organizational Capability: Established in 1945, St. Francis Medical Center (SFMC) is one of the largest private Disproportionate Share Hospitals in the nation and the only comprehensive, non-profit health care institution serving Southeast Los Angeles. Located in Lynwood, SFMC is one of six hospitals that make up the Daughters of Charity Health System (DOCHS) in California—a regional healthcare system of hospitals and care centers spanning the California coast from the Bay Area to Los Angeles. DOCHS sponsors are the Daughters of Charity of St Vincent de Paul who, for more than 370 years, have been serving the sick and the poor through healing ministries around the world.

SFMC’s Mission reflects the Daughters’ guiding principle—to serve the sick and the poor. No ill or injured man, woman, or child is ever turned away because of the inability to pay for needed care. The Vision of the organization is to be a values-driven, integrated healthcare delivery system that promotes the development of the human person, the preservation of health, and the well-being of the community.

St. Francis Medical Center provides a full range of diagnostic and treatment services, operating a 384-bed acute care hospital; four community-based health clinics; the largest and busiest private emergency trauma center in Los Angeles County; a Family Life Center and state-of-the-art Neonatal Intensive Care Center;

SFMC’s wide-array of services include:

Centers of Excellence in Heart and Vascular Medicine and Obstetrics; and a growing school-linked health program.

• Behavioral Health Services • Bioethics Program • Children’s Counseling Center • Community Clinics • Emergency & Trauma Services • Heart and Vascular Center • Health & Workplace Safety • Imaging Services • Industrial & Occupational Medicine

• Intensive Care/Critical Care Unit • Outreach Programs • Pastoral and Spiritual Care Services • Radiation Oncology • Rehabilitation Services • Skilled Nursing Facility • Sweet Beginnings in Our Family Life Center • Wound Care Center

Meeting the health needs of the one million Southeast Los Angeles residents who reside in SFMC’s service area requires a multi-pronged approach to service provision. In addition to direct medical care, SFMC provides a broad array of community service programs that represent a continuum of care for disenfranchised populations. The hospital’s philanthropic endeavors focus on nurturing healthy children and families, building self-sufficiency, and achieving excellence for facilities and technology with the ultimate goal of enhancing the health of our community. To this end, the organization operates the Health Benefits Resource Center (HBRC), the St. Francis Career College (SFCC), community health fairs and screenings, Children’s Counseling Center, and programs for seniors and homeless families.

All of SFMC’s programs exist to meet the needs of low-income and underserved community members and are created in collaboration with myriad community organizations and

Grant ID 044920/St. Francis Medical Center/Vida Sana QUITS Page 16

stakeholders—partnerships that allow the hospital to reach people in the places where they live, work and play.

2. Staff Capacity:

If SFMC is awarded the opportunity to implement Vida Sana QUITS, Outpatient Psychiatric Services Manager Ms. Catherine Wulfensmith will act as Program Manager. She will oversee all aspects of infrastructure development and, under the guidance of the Principal Investigator, will create the new curriculum, guide and materials, and smoothly integrate Vida Sana QUITS into the context of the hospital’s behavioral modification efforts as a whole. Ms. Wulfensmith has a keen understanding and awareness of the importance of incorporating SFMC’s Mission—serving the sick and the poor—into all areas of service and will develop this program with an eye for furthering the Mission.

Ms. Wulfensmith is highly committed to managing Vida Sana QUITS and has a proven track record of successfully implementing new programs, providing education and training to professionals in various disciplines, and creating messaging specific to the health literacy level of the community served. Ms. Wulfensmith has designed and implemented population specific programs at hospitals throughout Los Angeles County, has extensive experience in training, managing and supervising employees, and has implemented several successful programs from initial concept to fruition. In particular, Ms. Wulfensmith successfully launched a project that resulted in a significant reduction of smoking among patients recovering from mental illness and/or addiction; patients who, on average, have significantly higher smoking rates than any other segment of the population.

3. Biographical Sketches of Key Project Staff Members: Ms. Catherine Wulfensmith, a licensed Marriage and Family Therapist and health educator who successfully implemented a smoking cessation program for SFMC’s mental health patients, will act as the Program Manager for this effort. Ms. Wulfensmith received a B.A. in Psychology from Nyack College and her Master of Arts in Marriage and Family Therapy from Azusa Pacific University. In her tenure as the Outpatient Psychiatric Services Manager at SFMC, Ms. Wulfensmith has rewritten and organized all departmental policies and procedures, developed educational and guidance materials, started a women’s process group and implemented policies to facilitate patient growth. Her professional presentations include “Structured smoking cessation groups for patients in the Outpatient Psychiatric Services unit,” “Introversion vs. Isolation in Recovery,” and many others.

Ms. Pamela Carmona, the Healthy Communities Initiative (HCI) health educator, will provide support and additional culturally competent training for the project. She holds a California State Teaching Credential, a Master of Public Health and has been in health education for over 15 years. Ms. Carmona is CPR certified, knows the community well and is committed to delivering health and social services to disenfranchised populations in SFMC’s service area.

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I. Letter(s) of Commitment: Please see attached letters of commitment. J. Submission: Proposal submitted online via the Pfizer Medical Education Group website: www.pfizermededgrants.com.