With an eye toward improving patient health and conserving resources, University of Colorado Hospital has expanded its smoking cessation program to the outpatient arena.
The outpatient program, which launched last July, focuses for now on patients in the Lung Cancer, Nodule, Pulmonology and COPD clinics, all of which are under the umbrella of UCHealth’s Comprehensive Lung and Breathing Program. The aim is to identify smokers who are open to discussing quitting and connect them with a tobacco treatment specialist (TTS) who can offer immediate and ongoing support with counseling and medications.
Helping patients kick the habit isn’t a nice-to-have, said Allen Wentworth, RT, MEd, director of Respiratory Therapy for UCH. It’s a must for both patients and the hospital.
“The most important thing we can do as providers is to help patients stop smoking,” said Wentworth, who lost his father to smoking-related COPD. “It’s more important than exercise, healthy eating, and good sleeping habits. A robust smoking cessation program in both the inpatient and outpatient areas shows we are walking the walk as a hospital in terms of helping patients move from health care to health.”
The outpatient program also squares with the health care system’s slow but steady tilt toward preventive care, Wentworth added. For example, the Centers for Medicare and Medicaid Services imposes financial penalties on hospitals with excessive 30-day readmission rates for COPD patients.
The ins and outs of cessation
There are some built-in advantages to offering smoking cessation services in the outpatient setting. Physicians can write patients prescriptions for smoking cessation medications, such as Chantix and Wellbutrin, alone or in combination with varieties of nicotine replacement therapy (NRT). Only NRT is available for patients who receive services in the inpatient setting. In addition, because outpatient smoking cessation counseling is “incident to” a physician visit, Medicare will reimburse for the TTS’s time. That’s not the case in the inpatient setting.
Nonetheless, the hospital’s inpatient smoking cessation program, which continues, is the foundation for the outpatient initiative. It launched five years ago on the strength of a package of grants funded by UCH, the University of Colorado School of Medicine and the University of Colorado Cancer Center. The Colorado Department of Public Health and Environment (CDPHE) extended the efforts with a three-year grant that funded the COMITT (Colorado Model of Inpatient Tobacco Treatment) Program.
The CDPHE grant paid for changes in the Epic electronic health record to flag smokers; TTSs who met with them to gauge their interest in quitting; nicotine replacement therapy for those who wanted it; and six months of follow-up support after discharge – again at the patient’s discretion. When the grant ended in 2015, UCH leadership agreed to continue COMITT and fund TTSs.
The COMITT program is firmly entrenched at UCH. The program’s three TTSs provided counseling to 95 percent of tobacco-using patients admitted to the hospital between June 1, 2015 and May 31, 2016, said TTS Kathleen Moreira.
The team is gathering data to assess the program’s success at helping patients stay tobacco-free at one and six months, she said. But Moreira cited a handful of notable COMITT success stories, including a patient who had smoked three packs of cigarettes a day for 40 years. With the help of the program, Moreira said, the patient has been smoke-free for a year and a half. Another with a 30-year, pack-a-day smoking history received assistance from COMITT and celebrates her one-year tobacco-emancipation anniversary this month.
Moreira, a former smoker who quit nearly a decade ago, said simply helping patients open their minds to the possibility of quitting is a vital first step. “Most people need six to 10 tries at quitting before they are successful,” she said.
What’s my motivation?
The outpatient program follows the COMMIT principles, which rely on motivational interviewing techniques designed to help patients identify intrinsic reasons for wanting to quit. Lecturing and scare tactics are not part of the equation, Moreira said. She always offers her services to patients in the clinic, but enters an extended conversation only at their request. She makes it clear at all times that she is there to listen, not to judge.
“I don’t assume anyone wants to quit,” Moreira said. “The idea is to identify a patient’s reasons for smoking, the benefits they find in it, and the barriers to quitting. If they’ve attempted to quit, we talk about what worked and what didn’t. The goal is to help them elicit for themselves the reasons they have for wanting to make an attempt to stay smoke-free. The patient has all the answers. I’m there to allow them to share those and reflect them back to me.”
Moreira offers a unique perspective and set of skills to assist physicians, said Derek Linderman, MD, co-director of the Nodule Clinic at UCH. Linderman said offering help in quitting smoking is “far and away the best thing we can do” for his clinic patients, many of whom have lung cancer. But it’s difficult for a physician to drive the message home convincingly during a busy clinic day and very few have the expertise to delve deeply, Linderman said.
“I can say the usual, ‘You should quit smoking,’” he said. “But that’s an easy thing to say and it’s much more difficult than that. Kathleen brings more expertise in motivating patients and helping them to choose different products to help them quit. She handles the nitty-gritty details of which agents are best, and we write prescriptions based on her recommendations.”
Linderman and clinic co-director Stephen Malkoski, MD, PhD, both said they’ve been surprised at times by the inroads Moreira makes with patients who initially seem uninterested in smoking cessation.
“We do the best we can, but with our time constraints, it’s hard to have a real in-depth conversation,” Linderman said. “Patients see Kathleen and somehow she magically has a 30- to 40-minute discussion. It has turned out to be a great service.”
Having a TTS available in the clinic to speak immediately with a patient dealing with a lung issue greatly improves the chances of success, Malkoski added. “It’s a good teachable moment,” he said.
Keeping touch
Moreira makes at least initial contact with every smoker in the participating clinics. For those who agree, she said she spends several hours each week making follow-up calls, “not to check up but to check in,” as she put it. It’s necessary work to help people kick an addiction “woven into the tapestry of their lives” and consider “a life without cigarettes.”
Wentworth said he hopes soon to add the Transplant Clinic to the fledgling outpatient program. If it can show success in the months ahead, he hopes to bolster TTS coverage: For now, Moreira handles all outpatient clinic visits, devoting roughly two-thirds of her time to the effort.
“In an ideal world,” Wentworth envisions TTSs also being available in the hospital’s primary care clinics for smoking cessation consultations. As of now, the Epic team is engaged in a separate effort to develop an e-referral in the electronic health record to the Colorado Quitline, which is not operated by UCHealth.
“We’d like eventually to have our own call center manned by our employees that individuals struggling with cravings could call into,” Wentworth said, acknowledging that the idea would need to pass budgetary muster to come to fruition.
Whatever the operational and leadership setup, the goal of health care providers is the same, Wentworth said.
“We’re all in the business of getting our patients to quit smoking,” he said. “Ultimately, we need to do that before they become inpatients.”