Brief Tobacco Cessation Counseling For physicians and other providers and healthcare professionals to use in clinical practice

1
Brief Tobacco Cessation Counseling For
physicians and other providers and healthcare
professionals to use in clinical practice

• June 2009
• Tobacco Prevention Control Branch
• Division of Public Health, DHHS

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Tobacco Use

• The number one preventable cause of death in the
  United States and North Carolina

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Efficacy of Physician Advice to Quit

• Abstinence Rate
• No advice 7.9
• Physician Advice 10.2
• Patients expect healthcare providers to ask about
  tobacco use and advise them to quit
• Source Treating Tobacco Use and Dependence,
  USDHHS, Public Health Service, 2000

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Cessation What Works

• Behavioral support
• Treats the psychological and habit aspects
• Pharmacotherapy
• Treats nicotine addiction
• Works best when combined

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http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use.pdf
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The 5As of Tobacco Cessation

• Treating Tobacco Use and Dependence Clinical
  Practice Guidelines 2008 Update - U.S.
  Department of Health and Human Services, Public
  Health Service
• A brief evidence-based tobacco cessation
  intervention

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The 5As of Tobacco Cessation

• Ask about tobacco use
• Advise patient to quit
• Refer (1-800-QUIT-NOW or local prgm)
• Assess readiness to quit
• Assist in quit attempt
• Arrange follow-up

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Ask

• Ask about tobacco use at every visit
• Systematically identify all tobacco users
• Make identification/documentation a vital sign
• Create a universal identification system
  (stickers, computer reminders, etc.)

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Create a Reminder System

• Include tobacco use in other medical / dental
  advice
• Use an identification system
• Stamp, Sticker, EMR

Tobacco Use and Exposure Tobacco Use (circle
one) Current Former Never Secondhand
Smoke Exposure YES NO Tobacco use is the
single most preventable cause of death in the US.
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Advise

• Clear, Strong, Personalized
• Quitting smoking ...
• ...is the single best thing you can do for
  your health
• ...will reduce your risk of
• Employ the teachable moment
• Link visit findings with advice.

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Assess

• Willingness to make quit attempt in next 30 days
• I want to quit NOT I need to quit

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Examples

• Very specific reasons to quit smoking
• I want to quit smoking so I can go shopping
  without stopping 10 times.
• I want to quit smoking so I will not have a
  stroke like my dad.
• I want to quit smoking so my dogs will not get
  emphysema. (real quote)
• I want to quit so I wont smell like an ashtray

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Stages of Change

• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance

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5Rs for Patients Not Ready To Make a Quit Attempt

• Relevance
• Risks
• Rewards
• Roadblocks
• Repetition

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Assist

• Develop a quit plan
• STAR
• - Set a quit date (within 2 weeks)
• - Tell family, friends, coworkers
• - Anticipate challenges to quitting
• - Remove tobacco products from
• environment

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Arrange

• Schedule follow-up
• in person
• via telephone
• NC Tobacco Use Quitline
• 4 visits/calls is evidence based
• Congratulate progress/success
• Identify problems/anticipate challenges
• Evaluate pharmacotherapy use/problems

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Help for the busy practice.
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Health Care Providers Quick Intervention

• ASK about tobacco use
• ADVISE to quit
• REFER to NC Tobacco Use Quitline, Become An Ex,
  other resource
• PRESCRIBE as appropriate

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REFER

• Quitline information to all
• Consider fax referral
• Patients ready to quit within 30 days
• Consider cessation medications
• Provide Quitline number to all patients, even
  those not ready to quit
• Other resources such as BecomeAnEx
• Follow-up at next/every visit

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North Carolina Tobacco Use Quitline

• 1-800-QUIT-NOW (1-800-784-8669)
• 8a.m. 3 a.m., 7 days a week Toll-free
  Confidential
• All North Carolinians - youth and adult
• Proactive Quit coaches can call tobacco users
  back upon request, or make 1st call
• Fax referral
• Multiple language Quit Coaches
• Administered by Tobacco Prevention and Control
  Branch
• Funded by NC Division of Public Health, NC
  Health and Wellness Trust Fund

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Quitline can Assess, Assist, Arrange

• Quit coach helps set Quit Date, and
• Develop quit plan
• Make follow-up calls
• Discuss pharmacotherapy
• Mail targeted resources
• Patients can call the Quitline anytime

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Fax Referral to Quitline Helps With

• Referral to effective cessation services
• Providers limited time and resources
• The burden of patient initiating services
• NOTE Provider referral to a cessation program is
  associated with higher rates of participation
  than simply telling patients they should stop
  using tobacco

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(No Transcript)
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NC Tobacco Use Quitline Fax Referral Flow
Chart
Take patients vital signs ask about tobacco
use.
Advise to quit.
Is the patient ready to quit?
Give patient cessation resources 1-800-QUIT-NOW
(1-800-784-8669), www.becomeanex.org, or other
resource.
NO
YES
INTERVENE Offer cessation medications if
indicated, Quitline , fax referral option
Does patient want a quit coach to call them?
Give patient cessation resources 1-800-QUIT-NOW
(1-800-784-8669), www.becomeanex.org, or other
resource.
NO
YES
Complete fax referral consent form fax to
Quitline.
The Quitline will make at least 5 attempts to
call the patient.
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How Fax Referral Works

• Patient has been identified as a tobacco user
• Patient educated on services of Quitline
• Patient wants to quit tobacco use within 30 days
• Patient would like a quit coach to call at
  time/date they select
• HCP completes Provider Information, including
  Hospital-Clinic Name, Contact Name and Number.
• Patient completes Patient Information and signs
  form, providing consent for HCP to release
  information
• Quitline can provide Fax Referral Outcomes
  Report
• Accepted Services, Refused Services, Not Reached
• Quitline will begin contact attempts to enroll
  patient in program based on time and date
  provided by patient.

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Quitline Outcomes Report

• Tool to follow patient progress with your advice
  to quit / utilize Quitline services
• Most useful in clinic setting with dedicated fax
  machine/staff to retrieve reports
• Outcomes Report information includes
• Accepted services
• Declined services
• Unreachable

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For more patient cessation resources, view
Cessation Resources PPT at www.tobaccopreventio
nandcontrol.ncdhhs.gov
www.becomeanex.org
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Counseling Coverage in NC

• Medicaid added two CPT codes Jan. 1, 2009
• 99406 3-10 minutes
• 99407 gt 10 minutes
• May be billed the same day as an E/M or Health
  Check visit
• Use ICD-9 Code 305.1 (tobacco abuse)
• Unbundled can use a second ICD-9 code
• Medicare, BCBSNC, and State Health Plan also
  reimburse these codes

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Who Can Bill Medicaid for Tobacco Cessation
Counseling?

• In addition to physicians, nurse practitioners,
  and health departments, these codes can be billed
  incident to the physician by the following
  professional specialties
• Licensed psychologists and psychological
  associates
• Licensed clinical social workers
• Licensed professional counselors
• Licensed marriage and family counselors
• Certified nurse practitioners
• Certified clinical nurse specialists
• Licensed clinical addictions specialists or
• Certified clinical supervisors

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Medicaid Coverage for Counseling

• For more information see Medicaid Bulletins
• Jan 2009 http//www.dhhs.state.nc.us/dma/bulletin
  .htm
• Oct.2008 http//www.ncdhhs.gov/dma/bulletin/1008b
  ulletin.htm

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More Cessation Counseling Reimbursement Codes

• 99401-04 - 15-60 minutes (dedicated visit)
• 99354 can be added to regular visit (must
  document counseling)
• 99411 is used for group counseling (per
  participant)
• MD, PA or FNP on premises, must talk to group
• RN (etc.) may facilitate session

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Helpful Web Sites and Links

• www.tobaccopreventionandcontrol.ncdhhs.gov/cessati
  on
• www.tobaccopreventionandcontrol.ncdhhs.gov/FaxForm
  .pdf
• www.QuitLineNC.com
• www.QuitNowNC.org

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Learning More / CE Options

• Counseling for Change An On-line Tobacco
  Cessation Course - Northwest AHEC
• Contact Nedra Edwards Hines
• 336-713-7727 nedwards_at_wfubmc.edu
• 20 fee for course credits free to view
• Medscape Treating Tobacco Use and Dependence
• http//www.medscape.com/viewarticle/570604
• Free
• Approved for 1hour CE
• AMA PRA Category 1 Credit(s)
• Requires registration to Medscape
• TobaccoFreePatients.com
• http//www1.tobaccofreepatients.com/TopicReq?
• Based on NCI educational program
• Available free for study and review
• 15 per credit hour / letter of completion

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A Guide for Counseling Women Who Smoke
For more information on the Womens Health and
Tobacco Use Program, contact Judy Ruffin
Judy.ruffin_at_ncmail.net 919-707-5712
The Guide is available on the Division of Public
Health / Womens Health Branch webpage
http//whb.ncpublichealth.com/provPart/pubmanbro.h
tmtop
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Take-Home Message for Health Care Providers

• Brief cessation counseling is effective
• Longer cessation counseling is more effective
• Pharmacotherapy can double quit rates
• Pharmacotherapy should be offered to all
• - few exceptions
• Evidence-based resources are available

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You only have two minutes

• Ask every everyone about tobacco use
• Advise to quit with a clear, strong, personalized
  message
• Refer to
• NC Tobacco Use Quitline
• 1-800-QUIT-NOW (1-800-784-8669)
• Other resources as appropriate
• Prescribe
• For information on more cessation resources and
  medications visit www.tobaccopreventionandcontr
  ol.ncdhhs.gov

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Tobacco Prevention and Control BranchDivision of
Public HealthNorth Carolina Department of Health
and Human Services Main Ph 919-707-5400Fax
919-870-4844

• www.tobaccopreventionandcontrol.ncdhhs.gov