Tobacco Cessation Efforts

Denver Health

Raymond Estacio, MD, FACPGeneral Internal Medicine

Westside Adult Clinic

Associated Medical Director for ACS QI and Research

Denver Health

Director of Community Health

Colorado Prevention Center

Associate Professor

University of Colorado, Department of Medicine

Board Member

Colorado State Board of Health

Smoking Cessation: Organizational

Priority

• Denver Public Health o Has been leader in initiating and implementing

programs at Denver Healtho Community Strategic Pillar

o Decrease prevalence of smokingo Decrease second hand exposure

• Organizational Pillar o Ambulatory Care Serviceso Emergency Departmento Inpatient

Denver Health’s Smoke-Free

Campus Policy

Announcement by CEO • Our employees, patients and visitors’ health always comes first…

Denver Health must take a proactive role in addressing the impact of smoking and tobacco use.

• By role modeling as a community and not smoking while at work, we are showing our commitment to keeping our employees, patients and visitors as healthy as possible.

• Before we can ask patients and visitors to follow our policy, we need to do this ourselves.

Tobacco Cessation Workgroup

• Multidisciplinary: Family Medicine, General Internal Medicine, Denver Public Health, Inpatient Provider, Operation Coordinators, Data and Analytic Team, IT (Epic)

• Monthly meetings• Activities

o Metric development ▪ Communications▪ Training/Implementation▪ Monitoring and reporting

o Intervention development▪ Communications▪ Training/Implementation▪ Monitoring and reporting

Tobacco Smoking and Second Hand Smoke Exposure Prevalence

Data represent the last tobacco use / second hand smoke exposure status documeted in LCR for all patients seen in the year prior to the Year-end Date.

• Tobacco use = cigarette, cigar/pipe, chew and/or electronic cigarette use among patients >= 18 years old.

• Smoking = cigarette smoking only among patients >=18 years old.

• Second Hand Smoke Exposure = exposure among patients <= 17 years old w ho don't themselves smoke cigarettes/cigars/pipes.

Systems changes

Patient Handouts

Implementation Process

• Created an algorithm

• Created Educational materials

• Educated providers and clinics with 15 – 30 minute trainings.

Monitoring Process: AAR

Are Medical Assistants asking?

Tobacco Cessation Intervention:

Provider Focus

Denominator:• Patients >=18 years old who smoke cigarettes• Had at least 1 visit in the past month in Ambulatory Care Services

(ACS), Inpatient/ED, Denver Public Health (ID/AIDS clinic), or OBHS• Had at least one other visit in the previous 12 months

Numerator: number of patients in the denominator who had at least 1 tobacco cessation intervention, provided by any care provider in any area, in the 6 months prior their last visit. Tobacco cessation interventions included:• Quitline referral • Tobacco Cessation Clinic referral placed or visit attended• Tobacco counselling• On a medication for tobacco cessation for any length of time during

the 6-month look-back period • Referral to text messaging program• Provided patient educational materials specific to cessation

Monitoring Process: Tobacco Intervention

“Team Approach”

Example using a patient who was seen by 2 different providers in reporting period. Illustrates the team-based approach.

Intervention: Mar 5, 2015

Start: Jun 8, 2015

End: Dec 8, 2015

FAIL for Provider 2

Start: Jul 1, 2015

All patients seen by ACS Providers in 6-month reporting period who had >= 2 visits in past year in ACS and who were >= 19 at end of reporting period.

End: Dec 31, 2015

MRN 1 smoker Mar 5, 2015 Prov#2

MRN 1 smoker July 7, 2015 Prov#1

MRN 1 smoker Aug 3, 2015 Prov#1

MRN 1 no data Aug 22, 2015 Prov#2

MRN 1 smoker Sep 10, 2015 Prov#2

MRN 1 smoker Dec 8, 2015 Prov#2

MRN 1 former Dec 15, 2015 Prov#2

Start: Feb 1, 2015

Intervention: Mar 5, 2015

End: Aug 3, 2015

Take last visit date with each ACS Provider where they had a recorded smoking history:

Look back 6 months for evidence of a smoking intervention* given by any provider.

PASS for Provider 1

PROVIDER 1

POPULATION

PROVIDER 2

*SMOKING INTERVENTIONS HOW IT IS MEASURED IN EPIC Cessation Medications Epic Medication list includes a medication used for tobacco cessation Tobacco counseling SmartText Documentation Tobacco Cessation Clinic (TCC) Referral Referral Order Quitline Referral SmartText Documentation iQUIT Text Messaging Program SmartText Documentation

For the ACS rollup measure, this patient

would PASS since they passed for at least one provider.

Then came a new EHR: Epic

• The focus was to develop a process that transferred our pre-Epic worko Multiple, multiple meetings with Epic

Analystso Competing priorities for changes made it

challenging• Re-training staff on the new process

• Tobacco Cession Intervention• AAR (ongoing)

• Modify monitoring process

Monitoring Process: Ask Cigarette

Smoking (visit level)

Monitoring Process: Tobacco Intervention

“Team Approach”

Numerator

2741 5659 48.4%

Denominator Percent

Monitoring Process: Tobacco Intervention

Department Level

Note: numerators and denominators at the cl inic-level cannot be summed to ca lculate the sub-group percentage. If a patient

has been seen in multiple cl inics they wi l l be included in each cl inic's denominator, but only once in the sub-group-level

denominator.

IP/ED 650 1208 53.8%

DH PAV K OBHS 87 153 56.9%

DH PAV H INFECTDISEASE 107 214 50.0%

ACS 2214 4618 47.9%

Sub-group Numerator Denominator Percent Trend

Monitoring Process: Tobacco Intervention

Clinic Level

Percent

100.0%

85.0%

83.3%

77.3%

75.0%

75.0%

69.2%

69.0%

66.7%

62.9%

61.2%

58.3%

55.8%

55.6%

55.5%

52.4%

52.3%

DH PAV G LEVELONE PHYS

MHCD ADULT

DH PAV D SURGERY

DH PAV G GERIATRICS

SOUTHWEST URGENT CARE

WESTSIDE ADULT

DH PAV E GI/HEP OP

DH PAV E NEPHRO OP

DH PAV B INFECDISEASE

DH PAV G INTENSIVE OP

DH PAV D CARDIO OP

DH PAV G ADULT

DH PAV E PALL CARE

Webb LOP Podiatry

LOWRY REFUGEE

DH PAV E PULM OP

Webb LOP Derm

Ambulatory Care Services Trend

Monitoring Process: Tobacco Intervention

Provider Level

Monitoring Process Second Hand Smoke

Exposure (Peds): Ask

Percent of ACS visits for non-smoking patients 0-17 y where SHS exposure was verified

1. The tobacco use field was set to "Passive Smoke Exposure - Never Smoker"

AND2. Tobacco history was 'marked as reviewed' in the Rooming Activity

Monitoring Process Second Hand Smoke

Exposure (Peds): Advise

Percent of ACS visits among cigarette smokers >=11 years where advice to quit was

given ('Offered Resources' in Rooming Tab marked as 'yes')

Tobacco Smoking and Second Hand Smoke Exposure Prevalence

Data represent the last tobacco smoking / second hand smoke exposure status for empanelled patients in the year prior to the Year-end Date.

• Tobacco smoking is among patients >= 18 years old.

• Second hand smoke exposure is among patients <= 17 years old w ho don't themselves use tobacco.

Tobacco Smoking and Second Hand Smoke Exposure Prevalence

Denver Health Tobacco Cessation Efforts

• Multi-year process!

• Organizational support and engagement

• Leadership priority

• Multidisciplinary team to monitor and address

issues

• Listen to feedback from clinic level

• Data

• Need to monitor!

• Good data

• Provide solutions