A simple, systematic, step-by-step approach for addressing tobacco use in primary care settings

3. A simple, systematic, step-by-step approach for addressing tobacco use in primary care settings THE MODEL

4. THE ‘OTTAWA MODEL’ FOR SMOKING CESSATION • Identification • Documentation • Treatment • Counselling • Pharmacotherapy • Follow-up support for 2 months

5. HISTORY AND SUCCESS University of Ottawa Heart Institute (2002) INPATIENT Hospital Settings (2006) OUTPATIENT Specialty Clinics (2008-2010) PRIMARY CARE Pilot Program (2009-2010) PRIMARY CARE RCT (2012-2013) PRIMARY CARE Expansion Project (2010-2013) PRIMARY CARE CHC Project (2012-2015)

6. Central Ottawa Family Health Organization The Ottawa Hospital Academic FHT (Riverside) OMSC PRIMARY CARENETWORK 51 Partner FHTs, FHNs, CHCs 148 Clinics in 11 LHINS 630 MDs 120 NPs 260 RNs 30 Pharmacists Serving: 680,000 rostered patients 102,000 smokers 1.8 million visits/year Westend Family Care Clinic FHT Sandy Hill Community Health Centre Greenboro Family Medicine Centre Arnprior FHT The Ottawa Hospital Academic FHT (Civic) West Champlain FHT Rideau FHT Petawawa Centennial FHT University of Ottawa Health Services FHT Family First FHT Montfort Academic FHT Blue Sky Family Health Team Connexion FHT Bancroft Family Health Team Clarence Rockland FHT Manotick Medical Centre Whitewater Bromely CHC Rainbow Valley CHC North Renfrew FHT Shemilt Clinic Trent Hills Family Health Team West Carleton FHT Lakelands Family Health Team Upper Grand Family Health Team Ottawa Valley Family Health Team East Wellington FHT Guelph Family Health Team St. Lawrence Medical Centre East GTA Hamiltion Family Health Team Lower Outaouais FHT Two Rivers Family Health Team CPHC - Community Family Health Team Northumberland FHT New Vision FHT Prince Edward Family Health Team Upper Canada Family Health Team Wise Elephant Family Health Team Sharbot Lake Family Health Team Athens District Family Health Team Credit Valley Family Health Team Queen's Family Health Team Loyalist FHT  Thamesview Family Health Team Beamsville Med Centre FHT Maple Family Health Team West Durham Family Health Team Kingston FHT

7. TASK FORCE BINDER Slides Baseline Assessment Sample Provider and Patient Tools Prescribing and Titration Reference Sheets Sample Training Materials

8. Role of the Task Force • Provide input and leadership/ regular meetings • Inform adaptation of the OMSC to your FHTs needs • Engaging your professional discipline in program rollout activities • Developing a supportive organizational culture • Monitoring program progress • Troubleshooting • Facilitating sustainability activities

9. OMSC FACILITATOR • Member of your FHT OMSC task force • Expert resource to your clinic • Facilitate training of staff • Coordinate data collection activities • Support planning activities • Troubleshooting

10. Smoking Cessation “The single, most powerful, preventive intervention in clinical practice.” Woolf SH. JAMA 1999;282(24):2358-65.

11. A POWERFUL INTERVENTION Source: Woolf 1999 . The need for perspective in medicine. JAMA 282; 24:2358-65.

12. WHAT WE KNOW…. 60%of Smokers intend to quit1 43% will attempt to quit1 4-7%will be successful2-3 Source: (1) CTUMS. Canadian Tobacco Use Monitoring Survey Report. 2007. (2) Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. 2008. (3) Zhu S., Melcer T, Sun J, et al. Smoking cessation with and without assistance: a population- based analysis. Am J Prev Med 2000; 18:305-311.

13. Evidence-based Treatments can Dramatically Enhance Patient Success with Quitting Combining medication with brief advice or behavioural therapy increases continuous abstinence up to 6 times. Adapted from Hughes JR. CA Cancer J Clin. 2000; 50(3):143-51.

14. THE 3As: ASK, ADVISE, ACT ASK AND DOCUMENT Include tobacco use question as one of the patient’s vital signs Have you used any form of tobacco in the last 7 days? ADVISE AND REFER Provide strong, personalized, non-judgmental advice to quit with offer of support ACT For Patient who is READY TO QUIT:QUIT PLAN VISIT • Strategic counselling• Pharmacotherapy Follow-up 1:1/Group (Clinic/STOP-camh) Automated Follow-up Support:: -Smokers Helpline -University of Ottawa Heart Institute

15. OMSC PRIMARY CARE PRACTICE TOOL KIT Tobacco Use Survey Consult Form Your Quit Smoking Plan Quit Smoking Follow-up Program and Patient Management System

16. Pilot OMSC Primary Care 15% 3-fold Increase

17. A STEP-BY-STEP PLAN FOR INTRODUCING THE OMSC INTO YOUR CLINIC SETTING

18. FACILITATION ACTIVITIES

19. PHASE 3: PLAN TOBACCO CONTROL PROTOCOL UOHI team works with Task Force to establish interdisciplinary roles and responsibilities and to create a clinic-specific patient flow sheet. Tools will be available to facilitate efficient integration (includes automated Smoker’s Follow-up System) Tools can be adapted for use within EMR/medical flow chart system.

20. PHASE 4: TRAINING Overview of OMSC Information Sessions - For administrative and clinical leads; delivered by UOHI team - Overview of program and activities CME Event-For physicians, nurses, allied health professionals delivered by Project Team Clinical Lead - Protocol; information on pharmacotherapy Smoking Cessation Counsellor Training -Specialized training workshop on educating and assisting patients who want to quit and arranging for follow-up.

21. PHASE 5: PROGRAM IMPLEMENTATION • Following training, OMSC protocol will be implemented. • Phased implementation can be established if required. • One-month audit and QI Cycle. • UOHI team to assist Task Force in finding resources for smooth program transition and execution.

22. PHASE 5: MEASURING SUCCESS: OMSC AT THE X FHT Period 2011 97% 76% 62% 50%* 40% 31% Smoking Status of each patient Strong Personalized Advise to Quit Completed Quit Plan Visit for Smoker’s Ready to Quit

23. PHASE 6: POST ASSESSMENT & ONGOING QI • Project team conducts follow-up evaluation • Internal site audits encouraged to ensure protocol is being implemented as intended • Task Force and clinicians are provided with quarterly feedback on program effectiveness.

24. IVR SYSTEM REPORTSClinic Summary Evaluation Report

25. PHASE 7: SUSTAINING QUALITY PROGRAM DELIVERY • Address any areas requiring attention, implement quality improvement plans. • Identify opportunities for ongoing education, provision of targeted feedback to patients and clinicians. • Sharing results, both internally and externally, is vital during this phase!

26. OMSC IN PRIMARY CARE IN ACTION

27. System for Identifying and Documenting Smoking Status of all Patients THE NEW 5th VITAL SIGN ASK: TOBACCO USE QUESTIONS: • “Have you used any form of tobacco in the past 7 days?” • “Have you used any form of tobacco in the past?”

28. ADVISE & ASSESS HEALTH PROFESSIONAL’S ADVICE Clear Strong Personalized Offer of Support “Unambiguous & Non-Judgmental” • ASSESS READINESS TO QUIT • “Are you willing to work with me to set a quit date in the next month?” • Not Ready →Provide Self-Help • Ready →Develop Quit Plan

29. Patient Quit Plan

30. TOBACCO USE SURVEY Time saver Identify smokers Assess readiness Counselling prompts Smoking history Barriers/motivators

31. ASSIST & ARRANGE

32. SMOKER’S FOLLOW-UP PROGRAM Integrated Voice Recognition (IVR)

33. Telephone or E-mail Follow-up during first 2 months Patients who schedule Quit Plan Live Call 7 days before Quit Date Automated Check-in Calls at 3,14, 30 & 60 days Patient will be contacted bySmoking Cessation Specialist if: Low Confidence, Struggling, Relapsed Patient can call Smoking Cessation Specialist 7am to 7pm OMSC and SHL now provide integrated support Follow-up CounsellingSmoker’s Follow-up Program

34. Relapse Prevention

35. Training and Communication Plan • CME Event • For physicians, nurses, allied health professionals delivered by Project Team Clinical Lead • Protocol; information on pharmacotherapy • Smoking Cessation Counsellor Training • Specialized training workshop on educating and assisting patients who want to quit and arranging for follow-up • Individual Site Lunch and Learn Sessions • Held at individual sites to share the protocol with all staff who may not have been involved in either of the above training sessions. Provider Overview

36. Breakout Session • SWOT Analysis • Review of current Smoking Cessation Practices and Clinic Flow • Beginning to plan your clinic’s Tobacco Control Protocol

37. Needs Assessment Current Activity / Supports Lessons Learned Important Considerations (SWOT)

38. Considerations

39. Planning Tobacco Control Care Map/Protocol

40. Performance Targets

41. CLINIC TRAINING PLAN

42. CLINIC COMMUNICATION PLAN

43. 3 Billing Codes for Smoking Cessation Initial discussion with patient re: smoking cessation (E079) Smoking cessation follow-up visit (K039) Bonus Code for FHG, FHN, FHTs, FHOs (Q042A)