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Addressing Tobacco in Behavioral Health Settings


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August 2014 Webinar Slides

August 2014 Webinar Slides

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  • 1. Addressing Tobacco in Behavioral Health Environments Understanding the new DHHS Requirements and Best Practices
  • 2. Welcome Webinar Logistics: • All participants will be muted throughout the webinar. • Questions will be answered at the end of the presentation. You may ask a question or send a comment at any time by entering it in the “question” box of the task box. • The webinar will be recorded and archived at: • A post-test will be sent at the end of the webinar, after completion participants will receive a certificate of webinar attendance by email.
  • 3. Agenda and Presenters Agenda: ► Welcome ► Background ► Why Address Tobacco ► DHHS Contract Language ► Tips for Addressing Tobacco ► Resources ► Questions Presenters: ► Lindsay Gannon, MCD Public Health ► Andy Finch, Maine Center for Disease Control ► Leticia Huttman, Maine Office of Substance Abuse and Mental Health Services ► Sarah Mayberry, Breathe Easy Coalition of Maine
  • 4. Community Transformation Grant (CTG) ► The US Centers for Disease Control and Prevention awarded $103 million in Community Transformation Grants in 2011 to 610 states and communities to serve approximately 120 million Americans. ► In September 2011, the Maine Center for Disease Control and Prevention was one of 36 states awarded a Community Transformation Grant. ► Maine’s award was $1.3 million per year for three years ($1 per resident for each year) with the majority of funding going to 9 Public Health Districts. ► The goal of this grant is to promote the health and well-being of Maine residents in regard to obesity, tobacco and heart health.
  • 5. Goals of CTG ► Maximize health impact through prevention. ► Advance health equity and reduce health disparities. ► Use and expand the evidence-base for local policy, environmental and infrastructure changes that improve health.
  • 6. State Level CTG Tobacco Objectives ► Tobacco-free living: ► Protect people from secondhand smoke. ► Increase access to evidence-based tobacco treatment. ► Implement state level systems changes that aim to protect people served through DHHS agencies or their contractors from secondhand smoke. ► Increase the number of persons from disparate populations who are assessed, referred, and provided evidence-based tobacco treatment.
  • 7. State Level Partners ► CTG Management Team ► CTG Behavioral Health Work Group:  Multiple agencies working together towards Maine’s healthy transformation: o Maine Center for Disease Control and Prevention o Office of Substance Abuse and Mental Health Services o Office of Child and Family Services o Partnership for a Tobacco-Free Maine o Breathe Easy Coalition of Maine o MaineHealth Center for Tobacco Independence o Project Integrate
  • 8. CTG Behavioral Health Work Group ► Work Group will promote best practices and policies designed to increase the number of residential treatment sites that are 100% smoke-free, and to increase the incorporation of evidence-based tobacco treatment into Behavioral Health services. ► Conduct survey of all agencies and provide training opportunities. ► Develop language that addresses tobacco specifically for behavioral health contracts. ► Provide resources to provide to assist in changes.
  • 9. Work Group Outcomes ► In Spring 2013, Maine’s Behavioral Health Agencies and Sites were surveyed to gather information on their current status of policies and practices regarding tobacco use. ► Introduction letter from three DHHS directors sent out 2 weeks in advance. ► Survey gathered information on the current status of policies and practices in Maine’s behavioral health agencies and sites relative to tobacco use. ► The Center for Tobacco Independence hosted two tobacco intervention basic skills trainings with a special focus on behavioral health in August and September 2013. ► As a follow up to the survey and free basic skills trainings – CTI conducted 55 separate clinical outreach sessions to CTG Sites (per request).
  • 10. Work Group Outcomes ► CTG State Behavioral Health Work Group developed language to address both secondhand smoke and tobacco treatment. ► As of July 1, 2014, language is in place and will cover all contracted BH agencies, including the new Behavioral Health Home Organization contracts. ► Implementation resources and toolkit completed with the Breathe Easy Coalition to support changes in policy and practice, which will be supported by additional resources and technical assistance.
  • 11. Why Address Tobacco? It’s Simple: Tobacco remains the leading cause of preventable death in the United States. 480,000 Deaths per Year in the United States.* *Campaign for Tobacco-Free Kids
  • 12. Tobacco is a Public Health Problem ►Premature Death. ►Increased Disability. ►Enormous Costs to Individuals and their Families. ►Enormous Monetary Costs to Society.
  • 13. Increasing population impact Increasing individual effort needed
  • 14. Tobacco Use and Behavioral Health ► People with serious mental illnesses are now dying at least 25 years earlier than the general population.  88% of the deaths and 83% of premature years of life lost in people with serious mental illness are due to “natural causes:” • Cardiovascular Disease • Diabetes • Respiratory Diseases • Infectious Diseases ► Increased morbidity and mortality are largely due to treatable medical conditions that are caused by modifiable risk factors such as smoking, obesity, substance abuse, and inadequate access to medical care. Parks, J., Svendsen, D., Singer, P. & Foti, M.E., Morbidity and Mortality in People with Serious Mental Illness, National Association of State Mental Health Program Directors, Medical Directors Council ( 2006)
  • 15. Tobacco Use and Behavioral Health ► While smoking rates in the general population are declining, smoking rates for those with mental disorders continue to be twice that of the general population. Lasser, et al. Smoking and mental illness: A population-based prevalence study (2000)
  • 16. Statistics to Consider ► 44% of cigarettes in the US are smoked by people with a serious mental illness. ► 75% of smokers have a past or current problem with mental illness or addiction. ► 27% - the percentage of an average monthly budget spent on cigarettes by people on public assistance. ► 1.5% - the proportion of patients seeing an outpatient psychiatrist who receive treatment for tobacco addition. Sources: JAMA; National Comorbidity Study; National Association of State Mental Health Program Directors; Tobacco Control; American Journal of Addiction
  • 17. Myths vs. Opportunities Tobacco Treatment and Behavioral Health Populations
  • 18. Myths vs. Opportunities Myth #1: Tobacco dependence is less harmful than other additions. ► Those with alcohol, drug and/or other behavioral health diagnosis are more likely to die from their tobacco use than from their other co-occurring conditions. 1. Hser, Y. I., McCarthy, W. J., & Anglin, M. D. (1994). Tobacco use as a distal predictor of mortality among long-term narcotics addicts. Preventive Medicine, 23, 61–69.
  • 19. Myths vs. Opportunities There is greater mortality from tobacco use than from alcohol, illicit drugs, HIV, suicide, homicide, and motor vehicle accidents combined.
  • 20. Myths vs. Opportunities Myth #2: Recovery from other addictions should come first. ► Studies of smoking and alcohol treatment indicate that concurrent treatment does not jeopardize abstinence from alcohol and other non-nicotine drugs. 3. Prochaska, Delucchi, & Hall. (2004). A Meta-Analysis of Smoking Cessation Interventions With Individuals in Substance Abuse Treatment or Recovery. Journal of Consulting and Clinical Psychology, 2004, Vol. 72, No. 6, 1144–1156
  • 21. Myths vs. Opportunities Myth #3: Tobacco use is just a bad habit that people can address on their own. ► As with other addictions, tobacco dependence is a chronic relapsing condition often requiring multiple, assisted quit attempts before long-term abstinence is achieved. ► A combination of behavioral counseling and use of approved tobacco treatment medications have been found to significantly increase quit rates. 4. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service. May 2008
  • 22. Myths vs. Opportunities Myth #4: Persons with mental illness and substance abuse disorders do not want to quit smoking or they’ve given up enough. Why take away their last pleasure? ► Roughly 70% of all tobacco users want to quit. Roughly 50% will make at least one quit attempt each year. This population should be afforded the same opportunity and encouragement to quit tobacco as any other segment of the population. ► People who achieve abstinence from tobacco report greater satisfaction in their lives. Recovery from tobacco dependence can ease financial burden, improve health, strengthen relationships and potentiate other positive life changes. • 4. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service. May 2008 • 5. L. Shahab & R West, “Do ex-smokers report feeling happier following cessation? Evidence from a cross-sectional survey”, Nicotine Tob Res. 2009 May;11(5):553-7.
  • 23. Myths vs. Opportunities Myth #5: Quitting tobacco is too stressful for someone whose mental health status is already fragile. ► Studies have demonstrated that individuals with psychiatric disorders can be aided in quitting smoking without threat to their mental health recovery. ► People who use tobacco use found to experience more stress than non- users. ► Experiences in psychiatric hospitals have demonstrated that tobacco-free hospitals have resulted in fewer instances of seclusion and incidences of restraint as well as reduction in coercion and threats among patients and staff. 6. Prochaska, J., “Failure to Treat Tobacco Use in Mental Health and Addiction Treatment Settings: A Form of Harm Reduction?”. Drug Alcohol Depend. 2010 August 1; 110(3): 177–182. 7. Parrot, A.C. “Does Cigarette Smoking Cause Stress?”, American Psychologist, Vol 54(10), Oct 1999, 817-820. 8. Tobacco-Free Living in Psychiatric Settings: A Best-Practices Toolkit Promoting Wellness and Recovery, 2007
  • 24. Supporting Wellness by Taking Steps to Address Tobacco Treatment in Mental Health and Substance Abuse Services.
  • 25. New Rider E Contract Requirements being added as contracts are renewed. All agencies providing Mental Health or Substance Abuse Services under this agreement shall have a current written tobacco policy addressing: ► Inclusion of tobacco assessment and need for treatment in all plans of care; ► Annual screening of individuals receiving MH/SA services for tobacco use and dependence using best practice assessment protocols, tools, and procedures; ► Referral of individuals receiving MH/SA services to evidence-based tobacco cessation treatment; and ► Use of tobacco in agency facilities, on agency property, and at all locations in which services are delivered. At a minimum, these policies shall comply with state tobacco laws (MSRA 22 §1580 A and §1541-1550). These policies shall be reviewed annually with all staff and updated as necessary. Updates shall be submitted to the DHHS program administrator upon update.
  • 26. Changes to Tobacco Cessation Services in MaineCare Rule
  • 27. Tobacco Cessation Services Effective August 1, 2014, there were a number of substantial changes to MaineCare coverage of tobacco cessation services. These changes result from a combination of state and federal legislation (LD 386, An Act to Reduce Tobacco-Related Illness and Lower Health Care Costs in MaineCare, and the Affordable Care Act, respectively) promoting access to these benefits. MaineCare providers should be aware of these changes and of increased member eligibility for tobacco cessation products and services. As of August 1, 2014, tobacco cessation pharmacological products, including patches, inhalers, sprays, gum, lozenges, and oral medications, will be available to all MaineCare members, as well as to participants in Maine’s Drugs for the Elderly (DEL) program. No co- payments may be collected for these products, and no annual or lifetime limitations will be imposed. Effective August 1, 2014, those annual limits will be eliminated, and the service will be reimbursable for all members.
  • 28. Tobacco Cessation Services Prior to August 1, 2014, tobacco cessation counseling was reimbursable for some members up to a limit of three sessions per year. The following sections of the MaineCare Benefits Manual will be updated to eliminate the limitations:  Section 9, Indian Health Services;  Section 31, Federally Qualified Health Centers;  Section 90, Physician Services;  Section 103, Rural Health Centers; and,  Section 25, Dental Services (one per year) Effective August 1, 2014, in addition to full coverage of tobacco cessation products, MaineCare will now cover tobacco cessation counseling for all MaineCare members. Tobacco cessation counseling will now be covered under Section 65, Behavioral Health Services. No co-payments or other cost- sharing may be imposed on these services. There will no longer be limitations placed on the number of annual tobacco cessation counseling sessions available to MaineCare members.
  • 29. Tobacco Cessation Services The following codes may be used:  S9453: Smoking cessation classes, non-physician provider (Section 9, Indian Health Services; Section 31, Federally Qualified Health Centers; and Section 103, Rural Health Clinics);  99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than three (3) minutes and up to 10 minutes (Section 90, Physician Services; Section 65, Behavioral Health Services);  99407: Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (Section 90, Physician Services; Section 65, Behavioral Health Services);  99411: Preventive medicine, group counseling; 30 minutes (Section 65, Behavioral Health Services);  99412: Preventive medicine, group counseling; 60 minutes (Section 65, Behavioral Health Services); and,  D1320: Tobacco Counseling for the Control and Prevention of Oral Disease (Section 25, Dental Services) Please call Provider Services with questions at: 1-866-690-5585.
  • 30. Notice of MaineCare Reimbursement Methodology Change AGENCY: Department of Health and Human Services, Office of MaineCare Services AFFECTED SERVICES: Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 65, Behavioral Health Services NATURE OF PROPOSED CHANGES: The Department seeks to add tobacco cessation counseling as a covered service with the following four Current Procedural Terminology (CPT) codes: 99406 (smoking and tobacco use cessation counseling; individual, greater than 3 minutes up to 10 minutes), 99407 (smoking and tobacco use cessation counseling; individual, greater than 10 minutes), 99411 (preventive medicine, group counseling; 30 minutes) and 99412 (preventive medicine, group counseling; 60 minutes). The above change has a retroactive application with an effective date of August 1, 2014, authorized under 22 MRSA Sec. 42(8). The Department will hold a hearing for the proposed rulemaking and will be publishing a notice which includes information on the hearing date and location. Rates for CPT codes 99406 ($8.67), 99407 ($16.81), 99411 ($11.54) and 99412 ($15.04) are based on 70% of the 2009 Medicare rate.
  • 31. Notice of MaineCare Reimbursement Methodology Change REASON FOR PROPOSED CHANGES: In accordance with 22 MRSA §3174-WW, which requires that comprehensive tobacco cessation treatment be covered for all MaineCare members over the age of eighteen and those who are pregnant, tobacco cessation counseling services are being added to Section 65, Behavioral Health Services. This proposed change seeks to cover tobacco cessation treatment for all members, regardless of age who wish to cease the use of tobacco. ESTIMATE OF ANY EXPECTED INCREASE OR DECREASE IN ANNUAL AGGREGATE EXPENDITURES: The Department anticipates that this rulemaking will not have a measureable impact on expenditures. ACCESS TO PROPOSED CHANGES AND COMMENTS TO PROPOSED CHANGES: The public may review the proposed methodology changes and written comments at any Maine DHHS office in every Maine County. To find out where the Maine DHHS offices are, call 1-800-452-1926. For a fee, a paper copy of the rule may be requested by calling (207) 624-4050. CONTACT INFORMATION FOR RECEIPT OF COMMENTS: Elizabeth S. Bradshaw AGENCY NAME: Office of MaineCare Services ADDRESS: 242 State Street, 11 State House Station Augusta, Maine 04333-0011 TELEPHONE: (207) 624-4054 FAX: (207) 287-1864 TTY: 711 Maine Relay (Deaf or Hard of Hearing)
  • 32. Best Practices for Addressing Tobacco
  • 33. Tobacco Policy Adoption Creation of 100% tobacco-free environment policies will: ► Build on Maine’s comprehensive smoke-free laws to address all tobacco products. ► Change the social norm of tobacco products. ► Encourage and support tobacco-free lifestyles. ► Reduce exposure to secondhand smoke.
  • 34. Best Practice Tobacco-Free Policies Definition of a 100% tobacco-free campus: ► An environment/facility policy that addresses smoking and the use of all tobacco products, including but not limited to cigarettes, cigars, pipes, chew, snuff, snus, electronic cigarettes and other nicotine delivery devices that are not FDA approved for tobacco treatment. Integrated Tobacco Screening and Treatment into Practice: ► Asking clients on intake if they are a tobacco user, addressing tobacco use in existing treatment plan and referral to evidence-based tobacco treatment. Supporting Employees Who Want to Quit: ► Offering tobacco treatment benefits to employees who are interested in quitting, including counseling and NRT.
  • 35. Best Practice Guides
  • 36. Resources & Organizations to Help You Address Tobacco
  • 37. Policy and Treatment Support Organizations MeCDC Healthy Maine Partnerships Breathe Easy Coalition Center for Tobacco Independence
  • 38. Support Tobacco Policy Change ► Tobacco Policy Toolkit – Coming Soon! ► Template Policies and information: health ► Technical Assistance from BEC and Healthy Maine Partnerships
  • 39. Additional Free Policy Training Supports ► Tobacco-Free Behavioral Health Summits ► September 16th and 18th ► Register at: ► Brewer: 1024621/Copy-Of-Behavioral-Health-Summit-Bangor ► Portland: 1024605/Behavioral-Health-Summit-Portland
  • 40. Tobacco Treatment Training Supports ► MaineHealth Center for Tobacco Independence provides: ► Tobacco Treatment Trainings  Basic Skills and Intensive Tobacco Treatment ► Clinical Outreach Sessions ► More information: ► Become a Certified Tobacco Treatment Specialist:  A professional who possesses the skills, knowledge and training to provide effective, evidence-based interventions for tobacco independence. 
  • 41. Free Quit Resources ► Order free materials at:
  • 42. Questions? THANK YOU FOR PARTICIPATING! ► Please complete the post-test at: