Smoking Cessation Clinical Pathway (SCCP) Project:

A new approach Deepali Gupta Senior Pharmacist and Metro South SCCP Project Lead Natalie Davis Metro South SCCP Project Officer (Community Addiction and Mental Health) .

Overview

• Intro: Smoking in Australia

• Metro South Smoking Cessation Clinical Pathway Project overview

• The QIP C opportunity and MSAMHS

• Evidence based smoking cessation strategies (the Bittoun Algorithm)

Metro South HHS

• Servicing Brisbane south side, Logan, Redlands and a portion of the Scenic Rim.

• Servicing 25% of the QLD population • 5 hospitals & 14 community centres

Smoking rates in Australia

1991

24%

[1] National Drug Strategy Household Survey 2016

However… Smoking rates by groups

Adapted from: https://makesmokinghistory.org.au/

12.2%

32%

43%

70%

84%

93%

General population

Mental illness

Aboriginal People

Schizophrenia

Homeless People

AOD

Schizoaffective disorder or

People with AOD / mental health concerns:

• Are more likely to die from smoking related disease than the mental health or other drug concern [2, 3].

• Want to quit but likely need more support and more NRT [4].

• Are less likely to be offered help [2]. (HP beliefs, skill, lack of time?)

• Can really benefit from brief, repeated, non-judgmental interventions by health professionals like you! [4, 5].

We also know that smoking cessation..

does not negatively impact substance use treatment outcomes [3]

– “..smoking cessation interventions during addictions treatment appeared to enhance rather than compromise long-term sobriety” (2004 Meta-analysis, 19 RCTs) [6]

is associated with improved mental health [7]

– “Smoking cessation is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke” (2014 Systematic review & Meta-analysis of 26 studies) [7].

Often leads to a reduction in the dose of medications

required for certain mental health conditions

Smoking Cessation Clinical Pathway

• An evidence based brief intervention tool based on the 5 A’s. – Ask (screen for smoking status) – Assess (nicotine addiction) – Advise (to quit smoking) – Assist (access pharmacotherapy) – Arrange (follow up / referral)

As the story unfolds….

Source: Dr Ashley Webb

[8]

[9]

Healthcare provider negative beliefs

Slide credit: Dr Henry Marshall, MHCC forum 2017.

Past audits (2013, 2014) in health services showed:

• Poor use and uptake of Nicotine Replacement Therapies • No standardised process for assessment and care of hospitalised

smokers

.

A disconnect in smoking assessment and patient care in hospitals

Low uptake of Smoking Cessation pathway:

The Pathway for hospitalised smokers was developed and endorsed by the State Wide Respiratory Clinical Network in 2012; however the uptake was low due to lack of an implementation strategy.

Metro South SCCP Project • Key Metro South initiative since January 2015 • QLD government smoke-free initiative

QIP-B Oral Health - July 2016

QIP-C Community Mental Health - July 2017

QIP-A Inpatients - Nov 2014

2015 2016 2017 2018

By increasing use of the Smoking Cessation Clinical Pathway in Metro South Health, we aimed to:

– Improve the care and support provided to smokers by: • increasing delivery of evidence based treatment for nicotine

dependence • encouraging quit attempts for inpatients / outpatients • increasing utilisation of Quitline and other support services

– Achieve Queensland Health Quality Improvement Payments

(QIP) targets to ensure continued focus on smoking cessation.

Aims of this innovation

1. Employment of project officers, supported by a steering committee , reporting to Metro South Executive

2. Promotion of the pathway and the pharmacist and nurse led Nicotine Replacement Therapy

3. Setting up a project website and media strategy

4. Input into the new Integrated electronic medical record system

5. Education from commencement (e-module and in-services)

6. Support to clinical areas where smokers are highly prevalent – Mental Health, Maternity, Aboriginal and Torres Strait Islanders & Oral Health

7. Support to other HHS’s and input to the Statewide Respiratory Clinical Network

Activities (key message: smoking is a chronic relapsing disease)

Empowered staff: Pharmacist and nurse initiated NRT for inpatients

Empowered patients

E-Learning module

2295

Rewards

33,907 recorded in-patient encounters where smoking cessation was discussed since January 2015

Number of patients receiving SCCP continues to increase

1. Multidisciplinary Involvement in smoking assessment and care planning (91% were Pharmacy and Nursing staff)

2. Increased utilisation/offers of Nicotine Replacement Therapy (NRT) - NRT offers nearly tripled - 57% (from 32% to

89%)

Patient care outcomes

• Referrals nearly tripled

– 2014 255

– 2015 751

– 2016 1330

• Metro South is the highest HHS referrer in Qld

Source: Statewide Quitline report November 2015

Increased Quitline Referrals

• Project officers known to local teams

• Executive endorsement

• Multiple strategies- education, involvement in technology enhancement and resource development

• Measurement – scorecards, reporting

• Communication – presentations, reports website, newsletters and awards

• Passion!

Lessons learned – success factors

MT

“….As a smoker, I have been judged on many occasions as a lower form of human, but not one of your staff made me feel bad in any way. They were all professional and caring people….”

Smoking Cessation in Metro South Addiction

and Mental Health Services

MS Addiction and Mental Health Services

• 10 Academic Clinical Units (ACUs)

- Inpatient - Psychosis - Older Adult

- Consultation Liaison - Mood - Addiction Services

- Resource & Access Services - Rehabilitation

- Transcultural Mental Health - Child and Youth

• Approx 40 community based teams.

$1m across Qld

Screening & brief intervention

for smokers

6monthly targets (OSE, 18&over)

Recorded in CIMHA

QIPC 1st July

Quality Improvement Payment for SmokeFree Community Mental Health

QIP C Stake-

holders

Executive, Team

Leaders

Consumers

Staff members

MHIMS

Quitline

MHCC

Where to begin?

Consultation – gather support and info • Executive Sponsor

• ACU Meetings / Team Leader Forum

• Request feedback – face-to-face or online survey

– Challenges? – How to best communicate? – What resources did they need?

• Provide regular project updates to Exec

Staff Training

• 27 x in-services delivered to teams – (approx 200 MSAMHS staff members trained in

use of SCCP (using 5As to deliver smoking brief intervention).

– ‘Quit Now, Ask Me How’ badges popular

• Which teams? Include all teams (regardless of “in-scope”)

• Who? Include all staff – SCCP is a multidisciplinary tool

• Positive evaluation results – 116 responses, anonymous feedback

Info Session Location Answered: 116 Skipped: 0

Brief smoking intervention is relevant to my role

I feel confident to ask consumers if they wish to quit smoking

I feel confident that I can complete the SCCP

95% agree or strongly agree

95% agree or strongly agree

96% agree or strongly agree

A network of Smoking Cessation Champions

• 35 team champions - In-services, flyer, promotion

• ‘Support Crew’ shirts

• Bi-monthly meetings, email updates, training opportunities

Clinician Resources: Find here: MS SCCP QHEPS page

Clinician Resources: Find here: MS SCCP QHEPS page

Clinician Resources Find here: MS SCCP QHEPS page

Consumer resources Find them here: MS SCCP QHEPS page

Team Feedback Reports

Training opportunities: promote, encourage, provide

Metro North & Metro South ½ day Smoking Cessation

Workshops – 2018

Thurs 22nd Feb - Logan Central

Thurs 26 April The Prince Charles Hospital

Tues 24th July - PA Hospital

Thurs 25 October The Prince Charles Hospital

Email for more info

MSH_SmokingCessation@health.qld.gov.au

Professor Renee Bittoun

3-day Nicotine Addiction and Smoking Cessation Course

Email the Woolcock Institute to request information about upcoming course dates info@woolcock.org.au

MS Addiction Services

• Medical Officers prescribe quit smoking pharmacotherapy

• Senior Pharmacist trained in smoking cessation

• Smokerlyzers used in all main clinics

• Preventative Team – active in community and developing resources

• Search ‘quit smoking assistance’ on QHEPS to view resources.

Smoking Status - CHIMS

• Smoking Status function now added to CHIMS. • Reporting available • Quick Reference Guide available from CHIMS

To conclude.. what’s been working well?

Strong support from Exec level

Get as many people on board as possible (champions, communicate regularly)

Feedback and updates (team feedback reports, Exec updates)

Share info – training opportunities!

Find ways to reward champions (training, forums, Quitline visit, recognition)

Listen and respond (i.e. develop resources)

Include everyone –smoking cessation is everyone’s business.

We are off to a good start but there is still so much more to do to ensure ongoing progress and future sustainability.

Quick tips for delivering smoking cessation interventions

IF STILL SMOKING and on NRT?

Excerpt from QH smoking cessation clinical pathway v-5; 2016

Is smoking/nicotine addiction a chronic disease OR lifestyle choice?

• Dependence on nicotine develops quickly • Prone to relapses and remissions • Repeated quit attempts often required before

achieving long-term abstinence • Complex process • Psychosocial, biological and genetic factors • Smokers have lost control of their behaviour

[10]

“Make Every Contact Count”

Ready to quit/staying quit

• Explain importance of medications to quit

• Written resources • Organise a PBS

prescription • Referral to specialist

support – If not available, Quitline

plus weekly review in clinic until satisfied improvement

– CO Monitoring

Unwilling / unable to quit

• Continue to discuss smoking at each contact

• Harm reduction – Discuss relative safety of

nicotine • CO Monitoring • Use smoking cessation as

adjunct treatment for depression and anxiety – involve psych.

Tips and Tricks

• Smokers need higher doses of: – Medications (Clozapine, Olanzapine) monitor/refer – Caffeine halve – Alcohol halve

• Stopping tobacco but continuing cannabis = formula for relapse treat both.

• Breakfast / exercise reduces cravings

• Combinations work better than alone – More intensive treatment – Behavioural assistance weekly review

Key Messages

• Nicotine addiction is a complex chronic disease state that is prone to relapses

• Dispel myths with sufficient education and ongoing review

• Majority of smokers want to quit smoking, it is the responsibility of the multidisciplinary health care team to offer support.

• One size does not fit all tailor your advice to your patient. Don’t undertreat nicotine withdrawals!

48

Thank you for listening

Deepali Gupta - Senior Pharmacist & SCCP Project Lead – 07 3176 4866 Natalie Davis - SCCP Metro South Project Officer – 0408 553 956

Sources 1. National Drug Strategy Household Survey 2016

2. http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-12-smoking-and-mental-health#x2

3. Smoking cessation in people with alcohol and other drug problems, Volume 45, No.8, August 2016 Pages 569-573

4. Review of randomised control trials - *Stead L., Bergson G., Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2008; (2): CD000165

5. Efficacy of Initiating Tobacco Dependence Treatment in Inpatient Psychiatry: A Randomized Controlled Trial, Judith J. Prochaska, PhD, MPH, Stephen E. Hall, MD, Kevin Delucchi, PhD, and Sharon M. Hall, PhD

6. A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. J Consult Clin Psychol. 2004 Dec;72(6):1144-56. Prochaska JJ1, Delucchi K, Hall SM.

7. Change in mental health after smoking cessation: systematic review and meta-analysis BMJ 2014

8. http://ash.org/join-me-ash-support-global-action-against-tobacco/

9. Australian Institute of Health and Welfare, 2017

10. Supporting smoking cessation: a guide for health professionals. Melbourne: The Royal Australian College of General Practitioners, 2011 [Updated July 2014].