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Case Study: Tobacco Prevention, Cessation, and Treatment Integration

Union Hospital’s Lugar Center for Rural Health joined the Indiana Hospital Association’s Health Systems Change Partnership project funded by the Indiana Department of Health (project timeline was October 1, 2020 – June 30, 2021) to improve the processes and protocols around addressing tobacco prevention and cessation. As a quality improvement process, Union Hospital ensured the use of a strategic planning framework by going through the steps of ASSESSMENT, CAPACITY, PLANNING, IMPLEMENTING, and eventually, EVALUATION. Through the assessment stage of this quality improvement project, several areas were discovered where alignment could be beneficial to allow small changes to improve outcomes.

  • The Orthopedics service line has been working on joint replacement surgery workflows as part of a pursuit for HFAP certification. Orthopedic Surgery random audit of 40 patients showed that 32/40 (80%) of those patients who had surgery were current tobacco users. By strengthening their pre-op protocols, addressing tobacco use status with a workflow process created a standardized approach to addressing tobacco use and abstaining prior to surgery.

  • It was discovered, approximately 400 pregnant women who use tobacco products (17% annually) are within Union Hospital patient population. Therefore, additional TTS (Tobacco Treatment Specialists) education was provided to The Healthy Babies Initiative staff consisting of Community Health Workers and Navigators to revitalize motivation and change behaviors.

  • It was identified, The Neuroscience Service line implemented tobacco screening in year 2019 within the pain management department prior to procedures, consisting of one NP. Volumes are decreasing. It was explained at one point, there was a tobacco use severity tool in the Union Health EHR that allowed tracking of compliance to continually motivate behavior change. Currently, when patients are referred to the state “Quit Line” resource, follow-up is nearly non-existent for any referring provider.

  • There are no inpatient (IP) physician Cerner EHR prompts to assist tobacco using patients with cessation while IP, although we know that 960/4528 inpatients were prescribed nicotine replacement therapy (NRT) while in the hospital (21%).

  • It was identified through the National Cardiac Registry, 70/240 (29%) of Union Hospital (open heart surgery) patients were active smokers while in the hospital.

  • The 2018 Community Health Needs Assessment identified tobacco use as a priority health concern for the Union Healthy System.

Union Hospital’s Cerner EHR includes tobacco status screening within the social history assessment section. It allows an electronic nicotine delivery system to place a “Smoker” identification on the problem list and the patient after visit summary. The barrier is after management as there is no current electronic mechanism for tracking. After patients are referred to resources, treatment follow through is difficult to manage with the current EHR workflow.

There were small stages of change during this case study that improved the advisement to quit tobacco use. At the start of the project, there were no patient advisement standards or protocols for cessation within the pre-op and post-op patient encounters. Mapping this step for providers was established as a required part of the orthopedic joint replacement and pain management workflow, see diagram. Clinical staff are now trained to assess, assist, and arrange.

In addition to the Heathy Start community health worker, navigators, neuroscience pain management nurse practitioner, and orthopedic navigator additional staff within their departments are utilizing the standardized education process to assist in communicating with clients ready to quit smoking. The increased capacity to assess, assist, and arrange tobacco cessation support for patients was further enhanced with Union Health’s Medicare patient care team involvement and pharmacy resources, including NRT resources. Supplies were given immediately to the patient seen face-to-face in the clinic with regular oversight to consistently manage. Asking patients if they are “motivated to quit” is planned as a new emphasis in the clinical staff assessment. All responses are documented in the EHR. In addition, a report captures responses to the “motivated to quit” question so that assistance and arrangement of supportive services can occur. Common assessment questions include:

  1. Assess current smoking/tobacco use behavior, severity of nicotine addiction, and past quit attempts

  2. Scaling Questions: Motivation, Confidence, Importance

  3. Assess reasons for change

  4. Assess for strengths and alternative coping strategies

The role of existing community health workers and navigators evolved into more staff educator’s vs patient educators, as the level of competency is the only requirement to give education. The Lugar Center for Rural Health has always been committed to providing their navigators and community health workers a certification curriculum to include smoking cessation. An additional level of Tobacco Treatment Specialist Certification Training was added to the curriculum to allow the next steps for an additional certification. In addition, the orthopedic service line has added this assistance step into their workflow:

One barrier to aiding for cessation management is due to the cost of nicotine replacement therapies (NRT). The population health pharmacy program grant was utilized until June 2021 that helped cover cost of NRTs. There are currently no options for free or reduced products. Union is hoping to approach its’ Community Benefit Program to see if patient expense for NRT can be covered by the hospital. In addition, while Union Hospital does have 2 to 3 pulmonary rehab staff trained as “Freedom From Smoking” class facilitators, participation has been historically low. With the electronic integration of Indiana Tobacco Quitline referrals not supporting operations and referring provider needs, there is opportunity to reduce the communication barrier.

Patients within the Healthy Start Program benefitted a great deal from the “Baby & Me Tobacco Free program with 63 referrals. Access to Union Pharmacy NRT during this study helped 29/63 obtain immediate help. Lessons learned during the study for longevity purposes include:

  • Embracing smoking cessation across the organization and from all leadership levels.

  • The need to address tobacco cessation at multiple touch points in the patient’s journey.

  • Changing the mindset of tobacco cessation as a choice vs an evidenced-based medical intervention to improve the health and well-being of our patients.

  • All providers need to be engaged to follow standardized processes.


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