Systems Change Strategies To Address Commercial Tobacco Treatment Progress Of Apple Tree Dental The 2017 Minnesota Tobacco Control Conference January 26, 2017 St. Paul, MN
Efforts Made Possible By A Health Systems Change Grant Presentation prepared by Dr. Teresa E Johnson, DDS, MS, MPH, DABSCD There are no other disclosures indicated, nor any conflicts of interest.
1 About Apple Tree Dental
In our 31st Year! Apple Tree’s mission is to improve the oral health of all people, including those with special access needs who face barriers to care.
Six Minnesota Centers 130 Community Sites • Low-income children and their families • Adults with disabilities • Elders in long-term care • Urban and rural communities
2014 MN Adult Smoking Distribution • West Central MN = 16.7% • Metro Area = 13.6% • Southeastern MN = 13.0% • South Central MN = 12.8% Southwest MN = 13.8% Northwest MN = 15.5% Central MN = 17.0% Northeast MN = 18.3%
Three-Way 2 School Organizational and Group Home Staff Nursing Facility Partnerships Assisted Living 3 1 On-Site 1. Center for Dental Health Center for Hygienist- • Clinic Designed for Special Care Dental Health Dentist Teams • Care Coordination Center
Cloud-Based Electronic Health Record Apple Tree has entered into Phase II meaningful use with our customized EHR
2 Our Health Systems Change Initiatives
Tobacco Cessation Planning Team • One representative from each Center for Dental Health - Five Hygienists, and one Advanced Dental Therapist • Leadership representatives - Dr. Michael Helgeson, Karen Engstrom, Brenda Prosa, Mary Larkin, Dr. Teresa E. Johnson
Grant Objectives • Integrate tobacco dependence diagnosis and patient education and referral processes using our EHR • Modify our EHR to go beyond only reporting smoking status • Implement quality improvement processes to monitor and improve tobacco cessation efforts
Goals & Means • Goals ‣ Foster a reduction in tobacco utilization among patients ‣ Improve our ability to assess patients’ tobacco use and their interest in quitting, provide patient education, & offer referrals ‣ Staff “buy - in” • Means ‣ Staff education and encouragement – leadership-driven to achieve “buy - in” ‣ Develop an Integration Plan and Standard Operating Procedures (SOPs) ‣ Request EHR program changes tailored to our SOPs ‣ Pilot testing, staff training, and launching our systems change program ‣ Community Outreach Survey
Progress Made To Date • Developed SOPs and staff and patient education materials • Open Dental v16.2 (EHR) integrated our tobacco assessment and intervention documentation needs • Center Reps pilot tested the SOPs & EHR changes; SOP modifications made • Staff Education (four-hour training) - May 2016 • Monitoring Staff Compliance of the SOPs (ongoing) • Tweaked the SOPs & provided additional staff training (Oct.-Nov. 2016) • Community outreach initiatives (Fall 2016 to present)
3 Apple Tree’s Standard Operating Procedures
Intent Of Our SOPs • Facilitate ATD staff education • Achieve consistency among ATD clinical staff • Serve as a resource/guide • Clearly explain: ‣ what ATD dental health professionals will and will not do ‣ how patients will be screened and what questions to ask them ‣ how to provide patient education ‣ when and how to offer patients a tobacco cessation referral ‣ how data will be recorded in our EHR ‣ the patient follow-up process
Emphasis On Team Work Team Work is critical for the success of our health systems change program!
Forms Used For Our SOPs • Tobacco Cessation Patient Encounter Flow Chart ‣ Used by our dental health professionals to: - master the 5A’s model - develop our communication and education approach - learn how to document pertinent tobacco use data in our EHR • Tobacco Users Guide: Health Effects & Benefits to Quitting ‣ An educational tool • Tobacco Users Guide: Online Resources & Informative Links ‣ An educational resource and a referral option for patients
5 A’s Model for Tobacco Cessation • All patients age 13 years and older are assessed for tobacco use at their first visit and all future recall visits. - Ask patient’s about tobacco use - Advise patients to quit (patient education) - Assess patients’ interest in quitting tobacco use now (1 - 10 readiness ruler) - Assist those ready to make a quit attempt now (RR > 8) - Referral to “Call It Quits” or - Referral to a MD or - On-line Resources (to make a quit attempt on their own) - Arrange for patient follow-up for those patients choosing to make a quit attempt
Our SOPs Do Not Include • Questioning of patients about e-cigarettes • Cessation counseling to patients by our dental healthcare team • Prescribing NRT medications
EHR Enhancements • Duration of tobacco use (approximate start date is entered, then the years & months are automatically calculated) • Document the forms/referrals given to tobacco users • Record the readiness to quit tobacco use today (scale 1- 10) • Record the referral intervention that tobacco users choose • Record when tobacco users decline referral interventions • Assist with patient follow-up at future appointments
4 A closer look at our Forms
Tobacco Cessation Patient Encounter Flow Chart Multifunctional: ‣ a script to use in communicating with patients ‣ directions on how to document tobacco use data into the EHR ‣ prompts when to provide educational handouts and or referrals Two Versions of the Flow Chart
Tobacco Users Guide: Health Effects & Benefits to Quitting
Tobacco & The Mouth
Tobacco Users Guide: Online Resources & Informative Links
4 Community Partners
Outreach Efforts • Contact our community partners (where we provide on-site dental services) • Inquire about their tobacco cessation efforts for residents/clients • Inform partners about our systems change strategies to address patients’ commercial tobacco use • Is there interest in learning more about our patient education materials?
Community Partners Surveyed By Phone 1. Do you allow residents/clients/staff to use tobacco products on site? Y or N 2. Do you have designated places for smokers? Y or N 3. Where are your designated smoking locations/spaces? a. None (no designated smoking area) b. Outdoors c. Indoors d. Outdoors and indoors 4. Approximately what percentage of your residents use tobacco? ________ 5. Have you implemented a tobacco cessation program? Y or N 6. Do you routinely ask your residents who use tobacco if they are interested in quitting? Y or N
Preliminary Outreach Data As of January 11, 2017 Data from 86 of 100 Outreach Facilities 1. Do you allow residents/clients/staff to use tobacco products on site? Y = 52% N = 48% 2. Do you have designated places for smokers? Y = 66% N = 34% 3. Where are your designated smoking locations/spaces? None = 29% Outdoors = 64% Indoors = ? Outdoors and indoors = 6% (1% not answered) 4. Approximately what percentage of your residents use tobacco? 0% = 49% <5% = 11% 5%-<10% = 12% 10%-<25% = 7% 25% = 17% 35% = 1% 50% = 1% ? = 2% 5. Have you implemented a tobacco cessation program? Y = 31% N = 69% 6. Do you routinely ask your residents who use tobacco if they are interested in quitting? Y = 23% N = 77%
Face To Face Meetings With Two Community Partners After asking the first six questions (previous slide,) a ATD Center Representative from the Tobacco Cessation Planning Team takes a few moments to describe Apple Tree Dental’s tobacco cessation efforts and review our custom made patient education form. Then asks: 7. How we can support one another in our efforts to reduce tobacco use among our mutual patients/residents? 8. Are there any steps we can take to achieve consistency with the messages we are both giving our mutual patients/residents about tobacco use?
6 Quality Monitoring
EHR Monitoring Data May 27, 2016 - December 31, 2016 EHR ACTIVITY TOTALS Number of Patient Assessments Entered 6,362 Number of Tobacco Users 1,584 Percentage of Tobacco Users 25% Total Number of Referrals Made 188 Number of Call It Quits Referrals (% of referrals) 123 (65%) Number of MD Referrals (% of referrals) 27 (14%) Number of Online-Resources Referrals (% of referrals) 38 (20%) Number of Tobacco Cessation Follow-ups Completed 27 Number of Tobacco Cessation Failures Recorded 12 Number of Tobacco Cessation Successes Recorded 0 Note: Data includes anticipated staff recording errors or omissions
Thank You! www.appletreedental.org
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