Tim McAfee, Larr


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  • Thank you to GHC for letting me tell story - Both a parent and a child Consumer-governed, nonprofit mixed-model health care system - Historical core is an integrated system – staff-model HMO 9,600 staff members - 522,000 enrollees Multiple facilities Provides a range of health plan options to individuals, employers of all sizes, and government purchasers Historical emphasis on prevention, chronic care model, population perspective, primary care
  • in quality, IS, prevention, health promotion, marketing, communications, medicine, nursing, pharmacy, clinic & hospital administration etc
  • Quasi-experimental design employers agreed to different benefits 4 benefit structures examined: behavioral coverage 100%, drug 50% behavioral coverage 50%, drug 100% behavioral coverage 100%, drug 100% behavioral coverage 50%, drug 50% Robert Wood Johnson/Group Health Foundation funded Highest participation in full-coverage group (10% vs 2-5%) Removing co-payments for behavioral program increased use No significant difference in 6-mo quit rates “ The results of our study provide compelling evidence to support provision of full coverage for smoking-cessation programs” (2.8% quit with full, 0.7% with reduced) NEngJMed 9/3/98 339:673-679 Curry et al
  • Automated tracking data not available to clinicians at time of visit Not a registry - no over-time data, no panel-specific review capacity no centralized follow-up Now integrated into Electronic Health Record
  • Free & Clear: spun off by GHC because: dissemination work was national in scope required ongoing capitalization & expert business attention required an institutional platform that demanded and incented national growth, innovation, and attention to service efficiency and quality, product development, marketing, sales, client relations, and research “ to beat the tobacco companies, and collegially compete with the pharmaceutical companies, behavioral therapy needs companies using the same set of business tools they both bring to bear with such skill – sales, marketing, distribution networks, and capitalizing product development Next year will likely pass the one million mark for smokers receiving services Seeing new interest and success in employers – both large & medium-sized Continue to collaborate with Group Health as its phone tobacco service provider, research partner on first varenicline post-market randomized trial, and on community initiative such as I-901
  • Tim McAfee, Larr

    1. 1. KICKS BUTT! Tim McAfee, MD, MPH [email_address] Clinical & Behavioral Sciences Free & Clear 206-876-2551
    3. 3. 1991 report: Decreasing Tobacco Use at Group Health During the 1990s <ul><li>Goal: “Decrease the prevalence of tobacco use at Group Health by 50% from 1985 level of 25% to 12.5% by the year 2000” </li></ul><ul><li>Authors: </li></ul><ul><ul><ul><li>Sue Curry </li></ul></ul></ul><ul><ul><ul><li>Sallie Dacey </li></ul></ul></ul><ul><ul><ul><li>Doug Louie </li></ul></ul></ul><ul><ul><ul><li>Tim McAfee </li></ul></ul></ul><ul><ul><ul><li>Neal Sofian </li></ul></ul></ul><ul><ul><ul><li>Larry Ziedman </li></ul></ul></ul>
    4. 4. 1991 report: Decreasing Tobacco Use at Group Health During the 1990s <ul><li>Objective: “A comprehensive coordinated set of interventions will be available at Group Health covering all the stages of tobacco use” </li></ul><ul><ul><li>Key Partners: </li></ul></ul><ul><li>Tracy Orleans </li></ul><ul><li>NCI & CDC OSH </li></ul><ul><li>Michael Fiore/USPHS GL group/ATMC </li></ul><ul><li>Ed Wagner & Sue Curry (CHS) </li></ul><ul><li>Robert S. Thompson (DPC) </li></ul><ul><li>Bill Beery & Anne Smith (CHP) </li></ul><ul><li>Key Partners </li></ul><ul><li>Phil Nudelman/Cheryl Scott /Scott Armstrong (CEOs) </li></ul><ul><li>Al Truscott/Louise Liang/ Hugh Straley (Med. Directors) </li></ul><ul><li>Jim Truess (CFO) </li></ul><ul><li>Hundreds of VPs, managers and directors </li></ul><ul><li>Thousands of physicians, nurses, MAs, pharmacists, etc </li></ul><ul><li>Tens of thousands of patients </li></ul>
    5. 5. Adult Smoking Prevalence:
    6. 6. 1991 - COP report: 7 Strategies <ul><li>1)”Identify, track and treat tobacco use with the same vigor as other diseases with significant morbidity and mortality” </li></ul><ul><li>2)“Advocate for coverage of tobacco services where clinical effectiveness has been convincingly established” </li></ul><ul><li>3) “Encourage adolescents to never become tobacco users, both during clinic contacts and through school and community outreach” </li></ul><ul><li>4)”Encourage and support population-based projects to decrease tobacco use” </li></ul><ul><li>5)”Make tobacco a top lobbying priority of the GHC legislative affairs office” </li></ul><ul><li>6) “Develop educational programs about tobacco use and services for staff at all levels, including nursing, physician, clerical, medical assistant and pharmacy. Encourage and support on-going programs to decrease the prevalence of tobacco use among employees” </li></ul><ul><li>7)”Treat coverage for smokers in the same manner we treat coverage for other individuals with significant chronic diseases” </li></ul>
    7. 7. Elements of comprehensive approach <ul><ul><li>Reliance upon evidence </li></ul></ul><ul><ul><li>Identifying tobacco users in primary care </li></ul></ul><ul><ul><li>Training practice teams in brief advice </li></ul></ul><ul><ul><li>Referral to phone and group programs </li></ul></ul><ul><ul><li>Coverage for counseling & medications </li></ul></ul><ul><ul><li>Integration with Prevention, Quality & Chronic Care initiatives </li></ul></ul><ul><ul><li>Support for community policy change </li></ul></ul>
    8. 8. Health system opportunity:
    9. 9. SMOKE-FREE FITS GHC MISSION Fits GHC’s preventive care and health promotion mission Supported by marketing and communications Issue of quarterly member magazine
    10. 10. Top take-home lessons <ul><li>Science is a good starting place </li></ul><ul><li>It’s a product, marketing and sales challenge! </li></ul><ul><li>Hold on to the tiger’s tail </li></ul><ul><li>People, systems, and measurement make a difference </li></ul><ul><li>Design for end-users </li></ul>Advise Ask Refer
    11. 11. Research Collaborations <ul><ul><li>NEngJMed 9/3/98 339:673-679 Curry et al </li></ul></ul>
    12. 12. Primary care: tobacco status identification on all charts * > 85% in all 29 primary care clinics
    13. 13. Provider advice to smokers *p<0.05 for both ** Top10% of HEDIS
    14. 14. Documentation of Patient Tobacco Status using the TRF: TOBACCO USE STATUS (circle one) Non-Tobacco user 4 Current Tobacco User 1 Recent Quitter <1 year 2 PROVIDER INTERVENTION Tobacco Use Disorder 305.1 /Intervention
    15. 15. TRF Tobacco status identification:
    16. 17. Cessation Program Quality Improvement Why: Excellent program, but little impact due to low reach (in 1992 only 180 participants/year) Difficult to sustain clinic-based assistance/follow-up
    17. 18. Free & Clear improvements <ul><li>Removal of financial barriers </li></ul><ul><li>Integrated pharmacotherapy: </li></ul><ul><ul><li>program assesses, generates Rx </li></ul></ul><ul><ul><li>individualized </li></ul></ul><ul><ul><li>ensures follow-up received </li></ul></ul><ul><li>Strong quality controls/reporting </li></ul><ul><li>Promotional support </li></ul>
    18. 19. Free & Clear Participation Group Health Enrollees One-year quit rate: 25-30% (30-day abstinence ~ Intent-to-Treat)
    19. 20. Policy/population tobacco efforts <ul><li>NW Health articles </li></ul><ul><li>Smoke-free campuses </li></ul><ul><li>Master Settlement Agreement </li></ul><ul><li>Seattle Times ad ban </li></ul><ul><li>Labor and Industry worksite ban </li></ul><ul><li>Access/merchant fee bill </li></ul><ul><li>Defeating “Smokers Rights” bill </li></ul><ul><li>Testimony/op-ed pieces </li></ul><ul><li>Passage of two state initiatives </li></ul><ul><li>Free & Clear external & state quit lines </li></ul>
    20. 21. I – 773 and I-901 <ul><li>I-773 2001 WA state initiative </li></ul><ul><li>Raised tax on pack of cigarettes 60 cents  </li></ul><ul><li>“Guarantees” 26 million to Tobacco Control </li></ul><ul><li>I-901 2005 Clean Indoor Air </li></ul><ul><li>100% ban </li></ul><ul><li>GHC Board endorsed, contributed $$, & lobbyist/staff time for both </li></ul>
    21. 22. “ To serve the greatest number…”
    22. 24. Free & Clear Participation Rates per 1000 (Note: 2004 rates annualized based on first 2 quarters)
    23. 25. Smoking Prevalence 2003 by GHC Delivery System (Data Source: CAHPS Adult Survey 2002-2004) Commercially Insured Adults aged 18-65 years
    24. 26. Chronic Care Model <ul><li>Organization of care </li></ul><ul><li>Clinical information systems </li></ul><ul><li>Delivery system design </li></ul><ul><li>Decision support </li></ul><ul><li>Self-management support </li></ul><ul><li>Community resources </li></ul><ul><li>Glasgow RE, Orleans CT, Wagner EH. Does the Chronic Care Model serve also as a template for improving prevention? The Milbank Quarterly, Vol. 79, No. 4, 2001. </li></ul>