smoking cessation improvement in sfhn primary care, 2015-16 19... · smoking cessation improvement...

Smoking Cessation Improvement in SFHN Primary Care, 2015-16

• David Silven, PhD, Supervising Psychologist, SFHN Primary Care Behavioral Health

• Ellen Chen, MD, Director of Quality, SFHN Primary Care

Why smoking assessment and counselling in primary care?• Tobacco use is a leading cause of preventable death*

• Tobacco dependence is a chronic condition*

• Repeated interventions and multiple attempts to quit needed

• Primary care provider and care team can influence decision to quit

SFHN Primary Care:

• High risk populations

• Tobacco use among top 10 diagnoses

• 2009 SFGH study using blood testing of ED pts:

• >40% of ED pts were heavy tobacco users

• 14% were tobacco users

• Opportunity:

• Average almost 3 medical visits/yr & high patient satisfaction with providers *Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department

of Health and Human Services. Public Health Service. May 2008. < http://www.tcln.org/cessation/pdfs/treating_tobacco_use08.pdf >**Kaiser State Health Facts: California: Diabetes. < http://www.statehealthfacts.org/profileind.jsp?sub=22&rgn=6&cat=2 >

http://www.tcln.org/cessation/pdfs/treating_tobacco_use08.pdf

http://www.statehealthfacts.org/profileind.jsp?sub=22&rgn=6&cat=2

Individual clinician efforts to assess, counsel, refer

Assess & Documentat every visit

Counsel & Refer

Connect with cessation services

2014-15

2015-16

2009

2010-13

Progression of SFHN Primary Care smoking cessation efforts

21%

51%

38% 34% 34% 33%26% 24% 23%

19% 17% 16% 14% 13% 13% 11% 9%1%

0

2000

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12000

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30%

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100%

% of patients age 18+ with a medical visit in past 24 months at each clinic who were identified as current smokers, Dec 2015

11,373 current smokers in SFHN Primary Care

Quality Improvement (QI) focus in 2015

In 2014, only 48% of patients identified as current smokers seen in SFHN Primary Care were referred to smoking cessation counseling.

• Set goal for 2015: Increase the percentage of referrals to 58%

• Engaged Quality Improvement representatives from all primary care clinics

• Included all members of the PC care team in screening for smoking, counselling, and referrals for cessation

• Trained Behavioral Assistants (BAs) to counsel patients to quit

• Reminded teams to refer smokers to BAs at daily team huddles

• Collaborated with CHEP to begin developing a joint strategy

o Engaged the QI representatives

o Included all members of the Primary Care care team

o Trained Behavioral Assistants (BAs) to counsel to quit

o BAs reminded teams at staff huddles

o Collaborated with CHEP

EQUIPMENT & TOOLS

PROVIDERS AND OTHER STAFF PATIENTS

Pt doesn’t have the time to stay to talk with a BA after the PCP visit

Pt doesn’t want to quit or feel pressured to quit

Staff member is unclear as to who makes the referral to the BA

Staff asks pt if s/he wants to “quit” or to talk to someone about “quitting”

Not having a registry of current smokers to cue the referral

Uncertainty about whether to use a paper or electronic referral

Low number

of smokers

referred to the

BAsBA isn’t available at the time or inadequate level of BA staffing

MEA feels s/he doesn’t have time to make the referral

PROCESSES

Pt doesn’t know the BA & is uncomfortable talking to a stranger

Difficult to arrange referral to BA before PCP visit

Uncertainty about whether to recommend smoking referral for pts with multiple BA referral needs

Uncertainty about whether ptmust see PCP before referral to BA

It’s unclear how to document in eCWa smoking cessation referral to a BA

Staff lack confidence in BAs’ counseling skills




o BAs reminded teamsat staff huddles


PCP identifies current smoker MEA identifies current smoker

YES: Warm hand-off to BA

NO: PCP/MEA offers info about smoking, and if appropriate, info about 1-800-NO-BUTTS

and stop smoking classes

YESBA begins assessment/

intervention

NOBA offers info about 1-800-NO-BUTTS and if appropriate, info about stop smoking classes;

offers return appointment; makes reminder call

“Your doctor would like you to meet briefly today with one of our staff to get more information about smoking. Would it be okay with you if I introduce you to that person now?”

“Are you able to stay for 15-20 minutes to talk with me now?”




o BAs reminded teams at staff huddles


Precontemplation Not thinking of quitting smoking.

Contemplation Thinking of quitting smoking,

but not ready to make any changes.

Preparation Actively thinking about

changing smoking patterns. May have taken steps

towards quitting.

Action Not currently smoking. Quit within the past 6

months.

Maintenance Not currently smoking.

Quit more than 6 months ago.

Stages of Change and Motivational Interviewing






Standard “script” for staff:

“Your doctor would like you to meet briefly today with one of our staff to get more information about smoking. Would it be okay with you if I introduce you to that person now?”






Areas being explored for joint strategy:

• Increase tobacco cessation referrals to the BAs

• Enhance skills of BAs in providing tobacco cessation counseling

• Improve referrals to community resources for tobacco cessation counseling

0%

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Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15

Smoking Cessation Referrals

Baseline: 47.7%Goal: 58%Current: 75.4% (11,371)

SFHN Primary Care2015 Quality Council GoalsMaximum & Minimum

0%

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80%

100%

Dec Feb Apr Jun Aug Oct Dec

CMHC

Current:Baseline:Goal:

80% Total (727)42.7%51%


52% Total (50)

44%52%

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40%

60%

80%

100%


CHC


93% Total (569)

92.3%93%

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80%

100%


CPHC


89% Total (308)

60.2%66%

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80%

100%


CSC


53% Total (1257)

21.4%33%

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80%

100%


FHC


84% Total (1185)52.7%60%

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GMC


95% Total (960)

70.5%75%

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MHHC


96% Total (577)

90.6%92%

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OPHC


90% Total (515)81.0%84%

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100%


SAFHC


96% Total (657)81.3%84%

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80%

100%


PHHC


81% Total (1306)65.7%71%

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100%


SEHC0%

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TWUHC


59% Total (2041)11.9%25%

December 2015: successful effort to screen for smoking and refer all smokers for smoking cessation counselling

• 55,134 active patients age 18 or older

• 44,929 or 81.5% with smoking status assessed/documented in past one year

• Among current smokers, 8,571 or 75.4% were referred to tobacco cessation services in the past two years: exceeded goal of referring 58% of smokers

2016: taking smoking cessation efforts to the next level

• Continue to monitor the percentage of smokers referred to smoking cessation counseling

• Monitor the percentage of smokers who actually receivesmoking cessation counseling (Mandated by new statewide PRIME program)

• Identify core competencies for providing smoking cessation counseling, and assess BAs’ attainment of those competencies

Primary CareTrue North & Driver Metrics

Strategic Theme Quality Safety Equity Care Experience Develop PeopleFinancial

Sustainability

SFHNTrue North Outcomes(DRAFT)

• Appropriate utilization

• Preventive care

• Zero patient harm

• Zero workplace injuries

• BAAHI initiative• REAL/SOGI data

• Likelihood to recommend

• Timely access

• Staff engagement (Gallup)

• HR measures TBD

• Meets budget• Productivity

Primary CareTrue North

Metrics

2016-2018

• Improve population health through timely preventive care and chronic condition management

• Improve timely coordination of care to prevent high risk events

• Reduce health disparities

• Increase workforce diversity strategically through standard work and HR processes

• Increase number of patients with positive response to CG-CAHPS "would you recommend" question

• Improve workforce engagement, as measured by the Gallup engagement score

• Increase annual revenue

Primary Care (or True North)

Driver Metrics (PCDM)

2016

Unlocked notes

CG CAHPS likelihood to recommend

TNAA (Non-

Urgent)

No Monthly

Data

HTN BP Control /

Racial Disparities

7 Day Post-Discharge Follow Up

HTN BP Control

Smoking Cessation

Fluoride Varnish

Questions?

smoking cessation improvement in sfhn primary care, 2015-16 19... · smoking cessation improvement...

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