Let’s move to systems-change and some
discussion of the valuable role of quitlines in encouraging and supporting health-systems
change. To open up this discussion, NAQC asked Todd Hill, LiCSW, LADC, Cessation
Program Manager for the Vermont Department of Health and the Vice Chair of the
Multi-State Collaborative for Health Systems Change Executive Committee for his
thoughts on the
important role quitlines play in health-systems change efforts.
A good illustration of
how quitlines have contributed to systems change within healthcare is demonstrated
in how they have become a valued additional option for healthcare providers that
are providing the 5 A’s to address tobacco use and dependence (Ask, Advise,
Assess, Assist, Arrange). This integration is often promoted or implemented as the
now familiar 2 A’s and an R (Ask, Advise, Refer).
As a respected and
trusted "R” quitlines step in and provide an effective, evidence-based
treatment. The ready availability of quitlines to healthcare providers may lead
not only to an increased volume of referrals but also to increased downstream
interventions by providers. As Mike Cummings mentioned in his March 11, 2012 NAQC
blog post, "Quitlines have a huge potential to contribute to population-based
tobacco control efforts, but this potential has not been effectively exploited
Tobacco Control Programs
and their quitline partners will rely, in part, upon increased activity in the
form of referrals from the healthcare community to effectively expand reach. There
are case studies that demonstrate small scale healthcare/quitline integration
effectiveness however, in talking with Tobacco Control Program colleagues from
around the country, it seems that low rates of provider referral remains a huge
issue just as it did when I entered Tobacco Control in 2004.
Here in Vermont, according to
our last Adult Tobacco Survey (2010), 36% of smokers who visited their doctor
in the past 12 months were given a specific recommendation on how to address
their tobacco dependence. While this is up from the pre-Vermont Tobacco Control
Program baseline of 21%, I think that we can all agree that this still falls
short of where it needs to be.
The early work done
to integrate quitlines into healthcare has resulted in sustained improvements in
healthcare practice. Identification of tobacco users became a required measure
for providers for CMS Stage I – Meaningful Use. As more practices participate
in CMS incentive programs and as Meaningful Use evolves, provider interventions
are likely to increase and there is greater opportunity to increase referrals
With Meaningful Use the
next frontier for quitlines will come with the incorporation of referrals into
electronic health records. Quitlines cannot continue to rely upon a paper fax
system to remain relevant. Tobacco Control Programs and their quitline partners
are undertaking some initiatives that evolve beyond paper referrals, but the
confusing and sometimes daunting world of electronic health records can make
this process difficult. The solutions are not apparent.
We have to accept the
fact that electronic health records do not now come "out of the box” with ability
to interface with a state tobacco control program’s quitline. Can a universal
solution to electronically integrate electronic health records with quitlines
be found that allows for a bi-directional flow of data? Quiltines will need to
continue to push for an agenda where the treatment of tobacco dependence is
included in healthcare. The role of electronic health records can become a
significant integration point.
This remains only part
the story, as a full integration will not occur unless the providers themselves
are motivated to address tobacco use and supported by clinical and electronic
systems and performance goals. The quitline community must also keep up a
vigilant fight (as touched on in other blog posts) to ensure that there is
adequate funding for quitlines to provide services for those that are referred.
Thank you so much, Todd. What ever will we do
without you? Yes, that’s right…Todd is leaving the tobacco control world to
take an exciting position within Vermont’s
Medicaid agency to develop better systems to treat opiate-addicted Vermonters. We
wish Todd all the best and thank him so much for all of the wisdom he has
shared with NAQC members over the past 8 years!
By the way – what is the role of your quitline
in encouraging or supporting health-systems change? How is this role changing?