Regional Training 3 Hours 09 13

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  • We are very limited in time today so am going to be giving a didactic presentation today, but we are available to come to your office to give a interactive presentation with your staff. We have trainers throughout the state that are available.
  • I am not going to speak the physiology of smoking and pregnancy, as to why things happen.
  • Page 58 of CPG
  • Page 58 of CPG
  • The National Health Interview Survey was quoted in the MMWR, November 11, 2005/ vol. 54/ No. 54
  • Patient said she could not quit smoking I would still discuss the 5 R’s. Show her the pages of the (blue) magazine (4) that discusses how babies grow. Tell her “The best thing would be for you to quit smoking but since it is real to me that you are not going to cut down are there any changes you can make right now ?” Clearly suggest she; Quit smoking Cut down Smoke only when a away from the home Smoke outside the house or apartment Smoke in one room only Not smoke while; holding, feeding, bathing or in car with child or baby
  • Your plan may consist of; Ideally for you to do counseling or some sites can refer to an on-site cessation counselor Use the (blue) magazine (pages 8-15) Steps to quitting along with Prenatal Quit Plan Tear off Sheet (30/folder-non pregnant, B-123,manual) Quitline – at a minimum for sites who do not have time to counsel and so not have an on site cessation counselor you can do a quick assist by referring patients to the Quitline Do Quitline slides Bring back for follow-up visit no matter what stage they are in
  • Bring back for follow-up visit no matter what stage they are in
  • A smoking survey that is sent to patients Up until April 2004 only the first four questions were asked Now most clinicians advise, and discuss the 5 A’s intervention and pharmacotherapy
  • Hospital are required to give tobacco education counseling to patients who 2 out the 4 following medical conditions – congested heart failure,; myocardial infarctions; community inquired pneumonia; and/or pregnancy
  • Refer to CPG page 167 There is a diagnosis code for Tobacco Dependence If you check this the insurer will know there is a need to counsel
  • Refer to CPG page 167 There is a diagnosis code for Tobacco Dependence If you check this the insurer will know there is a need to counsel
  • These are just the suggested coding disorders affiliated with Smoking Cessation Intervention Need to check off that you did something

Transcript

  • 1. Clean Air for Healthy Children and Families Health Care Professional Training in Smoking Cessation Counseling Techniques Edward G. Rendell, Governor Calvin B. Johnson, M.D., M.P.H., Secretary of Health Pennsylvania Chapter American Academy of Pediatrics In partnership with Pennsylvania Area Health Education Center (AHEC)
  • 2. Program Development PA DOH Funding to Fox Chase 1989-1994 PA DOH Funding to PA AAP 1996-Present Clean Air Program Adopted 1996 AAP Policy 2001 Primary Contractors 2002 Curriculum Revised & Updated 2004, 2006 PA DOH Funding to AHEC to PA AAP 2005-Present ACS 1997 CPG, ACOG 2000
  • 3. Program Goal Every clinician, who interacts with pregnant women, mothers, caregivers of young children, teens and others, will deliver effective smoking cessation advice and counseling.
  • 4. CAFHCF Program Objectives
    • Ensure that smokers are fully informed of the health risks
    • associated with smoking and secondhand smoke
    • Motivate smokers to quit
    • Increase cessation attempts by delivering the 5 A’s/2 A’s and R
    • brief smoking cessation counseling intervention
    • Increase successful cessation by providing effective
    • counseling, pharmacotherapy, self-help materials, and referrals
    • Reduce the number of children and individuals who are
    • exposed to secondhand smoke at home
  • 5. Today’s Learning Objectives
    • At the end of this training you should:
    • Understand the 5 A’s/2 A’s and R brief smoking cessation
    • counseling intervention
    • Feel more confident in your ability to provide brief
    • smoking cessation counseling
    • Be motivated to discuss smoking cessation with your patients
    • and smoke-free environment with your patients
    • Develop a plan to implement the 5 A’s/2 A’s and R brief
    • smoking cessation counseling intervention
  • 6. What Is Your Office Doing Now?
    • In what ways do you feel your office is effective or ineffective?
    • What works well?
    • What do you feel your patients need?
    • What skills do you feel you are lacking to counsel patients?
    • What do you hope to gain from the training today?
  • 7. Program Components
    • Identify smokers and recent quitters
    • Counsel (5 A’s/2 A’s and R)
    • Patient education materials: self-help magazines, optional
    • materials, etc.
    • Practice tools: documentation
    • forms, stickers, etc.
  • 8. Integrating an evidence-based Intervention into practice
    • Practical Counseling
      • Problem solving
      • Skills training
      • Relapse prevention
      • Stress management
    • Support by Providers
    • Social Support
    • Pharmacotherapy
      • Nicotine replacement
      • Bupropion
      • Varenicline
    USPHS Guideline
  • 9. Brief counseling is effective
  • 10. Counseling Intervention sk about tobacco use dvise to quit ssess willingness ssist in quit attempt rrange for follow-up sk dvise efer 5 A’s (3-5 min.)* 2 A’s / R (1-3 min.)
    • Community Resources
    • 1-800-QuitNOW
    • Rx Pharmacotherapy
    *Can extend to 10-15 min. for all patients *Smoke Free Families recommends 10-15 min. for pregnant women A A A A A A A R
  • 11. Efficacy of Various Levels of Contact Fiore et al., (2000) Smoke Free Families recommends 5-15 minutes counseling in pregnancy
  • 12. Totals for cessation flow sheets through 12/31/97-06/01/06 Patient Outcomes Smoking status self-reported by patients n= 9,882 20% 23% 41% 3% 12%
  • 13. Recommendations of Center for Disease Control
    • Increase utilization of the 5 A’s
    • Every visit, every time
    • Reminder systems
    • Clinician education
    • Promote system change
  • 14. The scope of the problem
  • 15. Comparative Causes of Annual Deaths in the U.S. USDHHS, CDC (TIPS): Comparative Causes of Annual Deaths in the United States
  • 16. Smoking Prevalence Men Women Pregnant Women 2004 National Health Interview Survey {(MMWR 2005(54)44} 2005 PA Behavioral Risk Factor Surveillance System PA DOH Vital Statistics Resident Live Births 2004 Table B-25 National Vital Statistics Reports: Births: Final Data for 2003 (Martin, J. A. et al.)
  • 17. Smoking During Pregnancy USDHHS, Smoking During Pregnancy-United States, 1990-2000. MMWR, 2004;53(39):911-915
  • 18. Smoking During Pregnancy High School > High School < High School National Vital Statistics Reports: Births: Final Data for 2003 (Martin, J. A. et al.), Table 31
  • 19. Smoking Quit Rates During Pregnancy
    • Approximately 30% of quitters relapse during their pregnancy
    • Many women who quit smoking during pregnancy plan to smoke
    • again once the baby is born
    • 70% of remaining quitters relapse within 12 months of delivery
    PA Department of Health, 2004 Vital Statistics Resident Live Births by Age (Table B-19A) and Race (Table B-19B) 22.7 23.7 28.2 37.3 20-24 21.2 22.7 28.0 35.4 15-19 8.9 9.2 11.4 16.3 Hispanic 13.8 14.1 16.6 20.9 Black 15.1 15.7 18.5 25.5 White 3 rd Trimester 2 nd Trimester 1 st Trimester 3 Mos. Prior PA Birth Certificate Data: % Pregnancy Smoking Status
  • 20. “ We’ve known for decades that smoking is bad for your health...the toxins from cigarette smoke go everywhere the blood flows. There is no safe cigarette...the only way to avoid the health hazards of smoking is to quit completely or to never start smoking.” U.S. Surgeon General Richard H. Carmona News Release, 2004, SGR, The Health Consequences of Smoking News Release 06/27/06, SGR, The Health Consequences of Involuntary Exposure to Tobacco Smoke “ The scientific evidence is now indisputable: secondhand smoke is not a mere annoyance. It is a serious health hazard that can lead to disease and premature death in children and nonsmoking adults.” The Debate is Over
  • 21. The Life Cycle of the Effects of Smoking on Health SIDs Bronchiolitis Meningitis Infancy Low Birth Weight Stillbirth Neurologic Problems In utero Asthma Otitis Media Fire-related Injuries Influences to Start Smoking Nicotine Addiction Cancer Cardiovascular Disease COPD Adulthood Adolescence Childhood Aligne CA, Stodal JJ. Tobacco and children: An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997;151:652
  • 22. Prenatal/Neonatal Outcomes
    • 20-30% low birth weight infants
    • Fetal growth retardation
    • Spontaneous abortion
    • Fetal death
    • Pre-term deliveries
    • Ectopic pregnancies
    • Placenta previa and placental
    • abruption
    • Lower APGAR
  • 23. SHS and Children: Short Term Health Effects
    • Respiratory tract infections such as pneumonia & bronchitis
    • Decreased pulmonary function
    • Triggers asthma attacks
    • Ear Infection (Otitis Media)
    • Tooth decay
    • House fires
  • 24. SHS and Children: Long Term Health Effects
    • Sudden Infant Death Syndrome (SIDS)
    • Asthma
      • SHS accounts for 8-13% of asthma cases in children <15 years
      • SHS exposure increases frequency of episodes and severity of
      • symptoms
      • 200,000-1 million asthmatic children are affected by SHS
    • Possible problems with cognitive functioning and behavioral development
    • More likely to become smokers
  • 25. Risks for Women Who Smoke
    • Reproductive health problems
      • Infertility
      • Conception delay
      • Pregnancy complications
      • Menstrual irregularity
      • Earlier menopause
    • Compromised immune system
    • Respond differently to nicotine
    • Cancer
    • Less likely to breast feed
    • Osteoporosis
    • Thrombosis with use of
    • oral contraceptives
  • 26. Adult Health Risks Associated With Tobacco Use
    • Cancer
      • Major cause of: lung, oral and nasal cavity, laryngeal, esophageal,
      • bladder and cervical
      • Increased risk for: pancreas, uterine, penile, kidney, liver, anal and
      • stomach
    • Lung changes, COPD, Asthma
    • Cardiovascular & heart disease
    • Male & female reproductive problems
    • Digestive disorders
    • Rheumatoid arthritis
    • Impaired healing
    • Visual difficulties
    • Decline in hearing
    • Facial wrinkles
    • Tooth loss, plaque & staining
    • Dementia & Alzheimer’s
    • House fires
  • 27. SHS and Adult Health Risks
    • Nonsmokers who are exposed to secondhand smoke at home or at the workplace are at an increased risk of developing;
    • Lung cancer 20-30%
    • Coronary heart disease (25-30%)
    • Acute respiratory problems
    • Other significant health risks as per the SGR:
    • http://www.surgeongeneral.gov/library/secondhandsmoke
    “ There is no risk-free level of exposure to SHS. Breathing even a little SHS can be harmful to your health. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate SHS smoke exposure that controls the health risks.” USDHHS, The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the SGR (2006).
  • 28. What can be done?
  • 29. Smokers Want to Quit
    • 70% report wanting to quit
    • 3 out of 4 smokers want to quit
    • Most have made at least one quit attempt
    • Smokers cite physician/clinician advice as
    • important
  • 30. Nicotine Addiction
  • 31. Addiction The repeated, habitual use of a substance that affects a person’s mood and the course is chronic, progressive, and ultimately fatal.
  • 32. Nicotine Addiction
    • Characterized by:
    • Use stimulates the production of dopamine which changes brain
    • chemistry and is associated with feelings of reward and pleasure
    • Need to use the substance to feel normal
    • The inability to control use resulting tolerance
    • Continued use regardless of the negative consequences
    • Being the most addictive drug
    • Impacting all areas of a person’s life – biopsychosocial effects
  • 33. Addiction
    • Physical – A physical craving for tobacco and withdrawal symptoms may be present in the absence of the drug
    • Habit – The use is ritualistic and done without thought
    • Psychological – The belief that the user cannot function without the habit
    3 Components Recovery is possible when all 3 components are treated
  • 34. The Process of Behavior Change Preparation Contemplator Relapse Action Maintenance Ex-Smoker Pre-Contemplator Prochaska and DiClemente, 1983
  • 35. Relapse or Slip?
    • Reframe the experience as a partial success versus a total failure
    • Learn from the experience and understand what happened
    • Develop optimism about continuing cessation or trying again
    • An instance or several instances of smoking
    • Avoid negative emotional reaction
    • leading back to baseline level of
    • smoking (one cigarette does not
    • mean they are a smoker again)
    • A return to baseline level of smoking
    • Can occur at any stage, returning to Pre-
    • Contemplation, Contemplation,
    • Preparation or Action stages
    • May recycle through the stage of change
    • several times (6-8) before the change
    • becomes truly established
    Relapse Slip
  • 36. The Process of Behavior Change and Pregnancy
    • Pregnant women often are more open to change and can
    • move through the stages of change differently than when
    • they are not pregnant (The fetus can be a wonderful
    • motivator)
    • May have more support to quit while pregnant
    • May not be socially acceptable to smoke in public if
    • pregnant
  • 37. Requirements for Change X = BASIC Motivation (Should I?) Self-Confidence (Can I?) Commitment (Will I?)
  • 38. Motivational Interviewing/ Consulting A patient-centered counseling style for obtaining behavior change by helping patients explore and resolve ambivalence
  • 39. Motivational Interviewing/ Consulting
    • Principles
    • Express empathy to show you understand the person’s point of
    • view
    • Develop discrepancy between smoking and future goals
    • Avoid arguing and confrontation be collaborative and friendly
    • Roll with the resistance and avoid argument
    • Support patient’s self-efficacy and belief in the possibility of
    • making a change
  • 40. Counseling Intervention sk about tobacco use dvise to quit ssess willingness ssist in quit attempt rrange for follow-up sk dvise efer 5 A’s (3-5 min.)* 2 A’s / R (1-3 min.)
    • Community Resources
    • 1-800-QuitNOW
    • Rx Pharmacotherapy
    *Can extend to 10-15 min. for all patients *Smoke Free Families recommends 10-15 min. for pregnant women A A A A A A A R
  • 41. sk: About Tobacco Use
    • Ask or verify responses in a non-judgmental way:
    • Identify smoking status
      • Counsel all smokers and recent quitters
    • Household environment
      • Determine possible barriers to quitting
      • Possible affects of SHS
    • If they smoke assess
      • Nicotine dependence
      • Patterns of use
      • Past quit attempts
    A
  • 42. Health Surveys
  • 43. Chart Stickers
  • 44. dvise: to Quit
    • Advice to quit should be clear, strong and personalized while
    • using a non-judgmental manner
    • Discuss the effects of smoking on the patient, fetus and
    • children
    • Discuss the health benefits
    • of quitting
    • Acknowledge the difficulty
    • in quitting
    A
  • 45. ssess: Willingness to Make a Quit Attempt
    • Assess patient’s level of interest in quitting and intention
    • to take action to quit
    • Ask key questions
    A
  • 46. Assess: Key Questions
  • 47. ssist: in Quit Attempt
    • Pre-Contemplation and Contemplation Stages
    • (Unwilling to make a quit attempt)
    • The 5 R’s:
    • Relevance to patient’s individual situation
    • Risks of smoking
    • Rewards of quitting smoking
    • Roadblocks or barriers to quitting
    • Repeat intervention at every visit
    • In successful interventions clinicians should be empathetic, promote patient choices, avoid arguments, listen, reflect and instill self-confidence
    A
  • 48. ssist: in Quit Attempt
    • Preparation Stage
    • (Willing to quit)
    • Help the patient with a quit plan
    • Provide practical counseling
    • Provide social support
      • Social support with treatment (Intra-treatment)
      • Social support outside treatment (Extra-treatment)
    • Recommend pharmacotherapy
    • Provide supplemental materials (Quitline, groups)
    A
  • 49. A combination of pharmacotherapy and intervention doubles a patient’s chance of successfully quitting smoking
  • 50. Pharmacotherapy* for Cessation
    • Nicotine gum
    • Nicotine patch
    • Nicotine nasal spray
    • Nicotine inhaler
    • Bupropion SR (Zyban)
    • Lozenge
    • Varenicline (Chantix)
    *Unless contraindicated
  • 51. Pharmacotherapy and Pregnancy “ If the increased likelihood of smoking cessation, with its potential benefits, outweighs the unknown risk of nicotine replacement and potential concomitant smoking, nicotine replacement products or other pharmaceuticals may be considered.” ACOG. (2005). Committee Opinion: Smoking Cessation During Pregnancy , Number 316. Concomitant = accompanying
  • 52. Handouts for Patients Note: Most materials available in Spanish
  • 53. Personalized Plan for Patients Note: Most materials available in Spanish
  • 54. PA DOH Free Quitline 1-800-QUIT-NOW
    • In partnership with the American Cancer Society
    • Intake 24 hours a day/7 days a week
    • Proactive referral (Fast Fax) versus
    • Reactive referral (patient calls)
    • Develop a personalized plan for quitting
  • 55. PA DOH Free Quitline 1-800-QUIT-NOW
    • Up to 5 follow-up scheduled counseling sessions (8 if
    • pregnant)
    • Special counseling for pregnant smokers & available for teens
    • Offered printed materials, referrals, information on medications
    • (NRTs)
    • English and Spanish; other languages as necessary
    • Confidential & HIPPA compliant
  • 56. PA DOH Free Quitline transitioning from 1-877-724 -1090 to 1-800-QUIT-NOW 1-800-784-8669
  • 57. Community Resources
    • Pre-Approved Tobacco Cessation Registry: Pennsylvania
    • Department of Health http://www.dsf.health.state.pa.us (click
    • on tobacco or Quit NOW (1-800-Quit-NOW) and follow
    • prompts
    • Local tobacco coalitions, county websites, and county
    • organizations or groups committed to smoking cessation
    • Quitline also refers to community resources
  • 58. Optional Materials See Appendix B of the Clean Air program manual for additional patient handouts and practice tools Clean Air Website: www.cleanairforhealthychildren.org
  • 59. rrange: for Follow-Up
    • Pre-Contemplation or Contemplation stage requires
    • continual support and encouragement
    • Preparation stage:
      • Follow-up within 1 week of Quit Date
      • Ask at next visit about progress
    • Action or Maintenance stage:
      • Praise success at quitting
      • Problem solve challenges to maintaining abstinence
    A
  • 60. Documentation Forms
  • 61. Case Study #1 Sylvia
    • 19-year old
    • Smokes 16 cigarettes a day for past
    • 3 years
    • Fights frequently with husband
    • Pregnant with first baby
    • One prior quit attempt for a few days
    • Interested in effects on baby &
    • children
    *Remember to discuss pharmacotherapy if appropriate **Refer to the Quitline (1-800-QUITNOW) and/or community resources 1. Ask about smoking status using a health history or survey. 2. How will you Advise with a clear, strong, personalized message to quit smoking? 3. Assess the patient’s stage of readiness to quit. 4. To Assist * her in making a quit plan what might you include? 5. What barriers or concerns about quitting would you address and would you do this? 6. Arrange for follow-up via appointment, telephone, or referral.** 7. Document the intervention in the patient chart.
  • 62. Case Study #2 Linda
    • 27-year old
    • Lives with her boyfriend who smokes
    • Smokes a pack a day for past 13 years
    • Has little interest in quitting
    • 3 Children; 6, 4, and 2
    • Several prior quit attempts; one in
    • last pregnancy for 1 month
    • Reluctant to set a quit date
    *Remember to discuss pharmacotherapy if appropriate **Refer to the Quitline (1-800-QUITNOW) and/or community resources 1. Ask about smoking status using a health history or survey. 2. How will you Advise with a clear, strong, personalized message to quit smoking? 3. Assess the patient’s stage of readiness to quit. 4. To Assist * her in making a quit plan what might you include? 5. What barriers or concerns about quitting would you address and would you do this? 6. Arrange for follow-up via appointment, telephone, or referral.** 7. Document the intervention in the patient chart.
  • 63. Case Study #6 Lisa
    • 17-year old
    • 6 months pregnant, admitted to hospital
    • for pre-term labor
    • Smokes a pack & a half a day and has
    • smoked for 6 years
    • Boyfriend smokes
    • Hospitalized 4 days & medicated to
    • stop contractions
    • Contraction free & being discharged
    • Enjoys smoking & has no interest
    • in quitting
    *Remember to discuss pharmacotherapy if appropriate **Refer to the Quitline (1-800-QUITNOW) and/or community resources 1. Ask about smoking status using a health history or survey. 2. How will you Advise with a clear, strong, personalized message to quit smoking? 3. Assess the patient’s stage of readiness to quit. 4. To Assist * her in making a quit plan what might you include? 5. What barriers or concerns about quitting would you address and would you do this? 6. Arrange for follow-up via appointment, telephone, or referral.** 7. Document the intervention in the patient chart.
  • 64. Case Study #8 John
    • 32-year old father
    • Smokes a pack a day for past 14 years
    • John is sick with bronchitis
    • Has a son who has asthma
    • Concerned about stress with work & home
    • life and avoiding weight gain
    • Had several prior quit attempts
    • Occasionally uses smokeless
    • tobacco instead of cigarettes
    • Wife encourages him to quit
    • Not sure about trying again
    *Remember to discuss pharmacotherapy if appropriate **Refer to the Quitline (1-800-QUITNOW) and/or community resources 1. Ask about smoking status using a health history or survey. 2. How will you Advise with a clear, strong, personalized message to quit smoking? 3. Assess the patient’s stage of readiness to quit. 4. To Assist * him in making a quit plan what might you include? 5. What barriers or concerns about quitting would you address and would you do this? 6. Arrange for follow-up via appointment, telephone, or referral.** 7. Document the intervention in the patient chart.
  • 65. Case Study #8 Grace
    • 55-year old women
    • Has emphysema
    • Smokes a pack a day for the past 30 years
    • Has tried to quit several times in the past
    • Daughter and grandson lives with her
    *Remember to discuss pharmacotherapy if appropriate **Refer to the Quitline (1-800-QUITNOW) and/or community resources 1. Ask about smoking status using a health history or survey. 2. How will you Advise with a clear, strong, personalized message to quit smoking? 3. Assess the patient’s stage of readiness to quit. 4. To Assist * him in making a quit plan what might you include? 5. What barriers or concerns about quitting would you address and would you do this? 6. Arrange for follow-up via appointment, telephone, or referral.** 7. Document the intervention in the patient chart.
  • 66. Implementing into a Healthcare Setting Create A Quit Smoking Team Step 1. Develop administrative commitment Step 2. Involve staff early Step 3. Assign one coordinator Step 4. Provide training Step 5. Adapt procedures to your setting Step 6. Monitor and provide feedback What will it take to implement this intervention into your office?
  • 67. Implementation and Follow-Up Forms
  • 68. HEDIS
    • Health Employer Data Information Set
    • Survey of randomly sampled patients who were seen in the past year.
    • Used as a qualitative measure of practices to determine the level of care consistently
    • given to patients.
    • Survey Questions
    • Have you smoked at least 100 cigarettes in your lifetime?
    • Do you now smoke cigarettes every day, some days or not at all?
    • How long has it been since you quit smoking?
    • In the past 12 months, on how many visits were you advised to quit smoking?
    • On how many visits was medication recommended or discussed?
    • On how many visits did your doctor or healthcare provider recommend or discuss
    • methods or strategies to assist you with quitting?
  • 69. JCAHO - Joint Commission of Accreditation of Hospitals
    • Diagnoses that are mandated to receive tobacco education counseling:
    • At least 2 of 3 measures - congested heart failure; myocardial
    • infarctions; community acquired pneumonia
    • Patients that have quit tobacco use one year prior to their
    • admission
    • Interventions - advice to quit, assistance to quit, brochures,
    • video, referral or tobacco cessation aids
    • Must be documented
  • 70. Billing for Smoking Cessation Counseling
    • Always have your billing person/department check with health plan benefits contact person to see what is covered and what codes they recognize
    • Also ask what page in billing manual you can find this information
    • Even if not reimbursed it is important to code to promote future coverage
  • 71. ICD-9 Diagnostic Codes: Smoking Related
    • COPD
    • 491.2
    • Emphysema
    • 492.8
    • Asthma
    • 493.00
    • Diabetes
    • 250
    • Chest Pain
    • 786.50
    • Carcinoma: in situ/broncus, lung
    • 231.2
    • Bronchitis
    • 490
    • Cough
    • 786.2
    • Toxic Effect/Tobacco
    • 989.84
    • Tobacco Dependence/Disorder
    • 305.1
    Also can use ICD-9 Codes for medical procedures related to smoking co-morbidity.
  • 72. ICD-9 Diagnosis Codes for Counseling Parents on Harms of SHS
    • Sample codes for the child’s diagnosis
    • Routine infant/child health
    • check
    • V20.2
    • Acute bronchiolitis due to
    • respiratory synctial virus
    • 466.11
    • Extrinsic asthma, with acute
    • exacerbation
    • 493.02
    • Sample codes associated with the parent’s smoking:
    • Other specified personal
    • history presenting hazards to
    • health (exposure to tobacco
    • smoke as a potential risk)
    • V15.89
    • Toxic effects of tobacco
    • 989.84
  • 73. CPT Billing Codes
    • Preventive Medicine Examination
      • New Patients: 99383-99387
      • Established Patients: 99393-99397
      • Pediatric under 1 year: 99381
      • Pediatric age 5-11: 99393
      • Higher level 99213 only if face to face counseling >50% of visit time
    • Tobacco Dependence Treatment
      • Individual Counseling: 99401-99404
      • Group Counseling: 99411-99412
    • Psychiatric Therapeutic Procedures
      • Outpatient: 90804-90809
      • Inpatient: 90816-90822
    • CPT code 99211: if nurse counsels and not physician
  • 74. Medical Assistance
    • PA DOH pre-approved list
    • Bulletins #99-02-02, 99-04-11, and clarification #02-06
    • www.dpw.state.pa.us/omap
    • Billing Code #S9075
    • Promise billing system if available
    • If Health Choices provider discuss carve out in contract?
    • Medications are covered if patient has prescription coverage but each plan may have “rules”
    Become a Pre-Approved Tobacco Cessation Provider by applying at PA Department of Health Website: http:// www.dsf.health.state.pa.us/health/cwp/view.asp?A =174&Q=236582
  • 75. Clean Air Program Evaluation (optional)
    • Pre & Post Training Evaluation Forms
    • Implementation Plan (initial practice assessment)
    • 2, 6 & 12 Month Follow-Up of practice
    • Smoking Cessation Counseling Documentation Form
    • System change
  • 76. Clean Air Website
    • Please visit us at our Website:
    • www.cleanairforhealthychildren.org
    • Request a training
    • Order and download materials
    • Participate and view teleconferences
    • Access resources and other links
    • Contact us
  • 77. Good Luck! Please feel free to contact: Dottie Schell (484)446-3002 or (800)375-5217 (PA only) [email_address]
  • 78. Clean Air for Healthy Children Program PA Chapter of the American Academy of Pediatrics Rose Tree Corporate Center II 1400 N. Providence Road, Suite 3007 Media, PA 19063-2043 www.paaap.org
  • 79. The Real Reason Dinosaurs Became Extinct!
  • 80. Adult Risks Associated With Tobacco Use
    • Lung Changes
    • Lung cancer
    • Chronic cough, mucus, shortness of breath, wheezing
    • Cold & lung infections
    • Flu & pneumonia
    • Chronic Obstructive Pulmonary Disease (COPD) - chronic
    • bronchitis and emphysema
    • Asthma
  • 81. Adult Risks Associated With Tobacco Use
    • Cardiovascular & Heart Disease
    • Increases blood pressure & heart rate
    • Reduces blood & oxygen supply to body tissue
    • Blood clot formation
    • Damages blood vessels
    • Leads to stroke
    • Women using oral contraceptives have an increased risk for
    • thrombosis
  • 82. Adult Risks Associated With Tobacco Use
    • Cancer
    • Major cause of: lung, oral cavity, laryngeal, esophageal,
    • bladder and cervical
    • Increased risk for: pancreas, uterine, penile, kidney, anal
    • and stomach
    • Digestive Disorders
    • Rheumatoid Arthritis
  • 83. Adult Risks Associated With Tobacco Use
    • Reproductive Health Problems
    • Male impotence
    • Cervical and penile cancer
    • Impaired Healing
    • Following surgery or disease
    • Broken bones (twice as likely)
  • 84. Adult Risks Associated With Tobacco Use
    • Visual Difficulties
    • Cataracts (twice as likely)
    • Macular Degeneration
    • Poorer night and peripheral vision
  • 85. Adult Risks Associated With Tobacco Use
    • Other Risks
    • Decline in hearing
    • Facial wrinkles
    • Tooth loss, plaque, staining and gingivitis
    • Dementia & Alzheimer’s (twice as likely)
    • House Fires
  • 86. Step 1: Develop Administrative Commitment Restricted by the allocation of limited resources such as staff time Strengthened by mandates of institutional governing boards or accrediting agencies Effective problem solving for implementation of smoking cessation program Consider requirements of funding agencies or availability of reimbursement for smoking cessation services Administrators and supervisors who are committed to providing smoking cessation services to their patients
  • 87. Step 2: Involve Staff Early
    • Staff meeting:
      • Invite participation by all staff responsible for patient
      • care at any level
      • First with key staff members then with all front line
      • staff
    • Meeting agenda to gain staff support:
      • Overview of the 5 A’s smoking cessation counseling
      • intervention
      • Questions and answers
      • Identify barriers to implementation at each step
      • Develop Implementation Plan
  • 88. Step 3: Assign One Coordinator
    • One person should oversee implementation to ensure that
    • tasks are not overlooked
    • The coordinator can:
      • Answer questions
      • Troubleshoot problems
      • Arrange for training
      • Monitor implementation
  • 89. Step 4: Provide Training
    • 5 A’s Smoking Cessation Counseling Intervention
    • Regional - 3 hours
    • Practice-Based – 1- 1.5 hours
    • Modules
  • 90. Step 5: Adapt Procedures to Your Setting
    • Determine how the following will occur:
    • Obtaining the smoking status of every patient/parent
    • Timing and delivery of the 5 A’s
    • Documenting the intervention in patient records
    • Follow-up with each patient and the PA AAP
  • 91. Step 6: Monitor and Provide Feed Back
    • A Periodic Review of the Program
      • Observe whether procedures are working as intended
      • Determine if staff is completing assigned tasks
      • Assess if documentation is complete and accurate
      • Evaluate use of patient materials for distribution and inventory
    • Revise Program Procedures
      • Anticipate revisions to original plan
    • Give Feedback to Staff and Administrators
      • Maintain staff enthusiasm
      • Assure continued success
  • 92.