Best Practices: What weve tried and where we are headed'

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Best Practices What weve tried and where we are
headed.

• CAPT Larry Williams Great Lakes
• CDR Joe McQuade Jacksonville
• LCDR Dan Seidensticker San Diego

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Great Lakes

• One-on-One
• Pharmacy
• REACH
• Corpsmen training

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One-on-One

• Clinical setting
• Patients can call, walk-in, be scheduled
• Providers receive training in cessation
• http//www.medscape.com/viewprogram/8840
• Patients are followed at two week intervals
  except for Chantix
• Residents receive cessation training

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Pharmacy Walk up and quit
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REACH

• Reinforcing Education to Achieve Health
• 2 weeks before graduation from Recruit training
• Covers being tobacco free, oral and general
  health, benefits, sexual health, and alcohol

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Corps School

• Basic tobacco education
• Informs newest corpsmen how to discuss tobacco
  issues with patients
• Encourages the teachable moment

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Tobacco Cessation at One Year...at-a Glance

• Naval Hospital Jacksonville
• BUMED Pilot Study March 2007- March 2008

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Consults to Tobacco Cessation Averaged 5.6 per
month 2005-2006. Averaged 154.5 consults per
month 2007-2008.
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Who are sending these consults? From 1 March
2007 to 1 March 2008.
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Pharmacy Costs NRT 11.72/7 days // Generic
bupropion 12.90/30 tabs // Chantix 1.14/tab.
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A Seamless Garment

• RN working on the floor are briefed on our
  program, provided tobacco cessation folders.
• MIU has advertising, posters in every room, their
  nursing staff briefed on our tobacco cessation
  program.
• Labor Deck has posters in exam rooms, in hallway
  advertising our program.

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A stitch in time does save nineHow to get your
patients the nine core preventive measures they
need.

• Breast Cancer Mammogram / see letter in chcs-1
  ptrm.
• Cervical Cancer PAP /see letter in chcs-1 ptrm.
• Colon Cancer Colonoscopy, Flex Sig, BE / see
  letter in chcs-1 ptrm.
• Depression See letter in chcs-1 ptrm / CONSULT
  FPC DEPRESSION for follow on care with RN /
  mental health counselor.
• Asthma See letter in chcs-1 ptrm / CONSULT FPC
  ASTHMA for follow on care with RN.
• Obesity Follow on care with CONSULT WELLNESS
  CENTER, NUTRITIONIST.
• Tobacco Use Consult to TOBACCO CESSATION NHJ
  for Wellness Center behavioral therapy, SMOKE
  Tobacco Cessation for follow on care with RN /
  see letter in chcs-1 fp.
• Hypertension / Hyperlipidemia CONSULT WELLNESS
  for group class /see letter in chcs-1 for
  diabetic hyperlipid patient follow up ptrm.
• Diabetes CONSULT to FPC DIABETES for RN follow
  on care / screening letter in chcs fp /
  pre-visit letter in chcs-1 ptrm / diabetes lipid
  letter in chcs-1 ptrm.

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Intern Year 2006-2007Tobacco Cessation Consults
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• Tobacco Cessation Chart Chit.
• Clipped onto all outpatient charts. Meant to
  grab the attention of our providers.

• Tobacco Cessation

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Tobacco and Pregnancy

• BUMED position statement calls for weighing the
  risks vs the benefits for use of bupropion, NRT,
  CHANTIX during pregnancy.
• Recent evidence showed 12 of pregnant women in
  America smoke. Simple messages to quit for your
  baby may be too simplistic. Recommendations are
  to screen pregnant smokers for mental health
  disorders and initiate therapy for depression.
• Pregnant smokers were about three times as likely
  to have a mental health disorder as pregnant
  non-smokers.

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Diabetic patients should be a target.

• Smoking doubles the risk of developing diabetes.
• ADA position statement places major emphasis on
  cessation therapy for all diabetics.

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How to Code Tobacco Cessation

• 305.1 Nicotine Dependence
• New! CPT/ HCPCS
• G0375 3-10 minutes of cessation counseling
• G0376 gt 10 minutes of cessation counseling
• G0375 RVU 0.24
• G0376 RVU 0.48

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Tobacco Quit-lines work.

• Recent data showed that providing smokers a
  telephone line or email site to follow up with
  improved their chances of quitting and remaining
  smoke free.
• 542-9389. Terry Botkin RN.

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A seamless garment Intervention at every portal
of entry.

• Outpatient. Consistency Counts!
• Inpatient. A Teachable Moment.
• Procedures. A captive audience.
• Surgery Pre Op.
• Pre- and Post deployment.
• Dental.
• SARP. Recent evidence points to better outcomes
  with treatment of both addictions simultaneously.
• OB care. Major impact on Mom and Baby.

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Tobacco Cessation Inpatient Protocol
Naval Hospital Jacksonville BUMED Pilot
Program 2007

• Goal To make tobacco cessation therapy as
  accessible as possible to all our patients. Make
  it as easy to get help quitting use of tobacco
  products as it is to buy a pack of cigarettes at
  the NEX.
• Heres how you can help
• ASK every patient admitted to the floor,
  Do you smoke? Do you use any tobacco products?
  Do you want to quit?
• ACT by providing every inpatient smoker or
  dipper at admission a copy of the Tobacco
  Cessation folder. This contains useful
  information for the patient on how to access quit
  smoking help here at NAS Jax.
• __________________________________________________
  ____
• Consider consult to SMOKE TOBACCO CESSATION
  to follow up patient medications and provide
  feedback to the patient as they try to quit.
• Consider consult to TOBACCO CESSATION NHJ to
  enroll the patient in classes at the WELLNESS
  CENTER.
• Zyban, Nicotine replacement (patches, gum,
  lozenge), and CHANTIX are available to help our
  patients.
• __________________________________________________
  ____
• Any questions can be referred
  to RN Terry Botkin at 542-9389.
• Quitting tobacco may be the hardest thing a user
  may ever have to do. Were here to help.

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Group Medical Visits

• Naval Medical Center, San Diego

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Effects of Clinician Interventions
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Group Medical Visit

• Multi-disciplinary clinic to make tobacco
  cessation easier for both patients and providers
• Designed to get physicians involved in tobacco
  cessation
• Cardiology, Pulmonary, Internal Medicine, Health
  and Wellness all participating
• Advertising flyers, business cards, word of mouth

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The Clinic

• 1545-1600 Patients Walk-in
• Complete demographic/medical background sheet,
  congregate in conference room
• 1600-1615 Interactive didactic lecture
• 6 series lecture schedule covering CAD, pulmonary
  dz, cancer, myths, miscellaneous issues
• 1615-1645 Group discussion
• Usually 5-6 physicians in the conference room
  along with the patients
• 1645-1700
• pts meet individually with physician

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Group Dynamics

• Pts in various stages of Tobacco Cessation
• Various age ranges, more retirees than active
  duty
• Patients on home O2, referred for cardiac
  transplant, s/p CVA and MI, and in motor scooters
  that are gt 3 months tobacco free
• Patients share short term benefits, struggles
• Patients congratulated for their successes
• Behavioral modification techniques, lifestyle
  adjustment discussed

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Individual Counseling

• Pts devise individual plan with a physician
• Wellbutrin
• Nicotine patch
• Varenicicline rarely
• Usually have 8-10 physicians participate
• Everyone has been done by 1710 (even the day we
  had 31 pts)
• Avg wait at pharmacy 20-30 minutes
• Meds are formulary without restriction

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Results

• Feb 21 2007 5 patients seen
• Feb 21 2008 291 pts seen total
• 35 cessation rate at 6 months
• A similar clinic in GITMO established
• Over 45 different physicians have seen pts
• Multiple sub-specialties have given lectures
• ENT, CT surgery, nephrology, cardiology,
  pulmonary, IM, neurology, Dental, Heme-onc

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Problems

• Manpower intensive to be efficient
• Coding
• Follow-up calls

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Benefits

• Very efficient format
• Easy referral for physicians
• Easy access for patients
• Exposes many physicians to tobacco cessation
• Takes the mystery away from tobacco cessation
• Highly satisfying