Chronic Care Model Tested to Treat Tobacco Use and Dependence
During 2001 and 2002, project staff at Brandeis University, Waltham, Mass., developed a system for treating tobacco use and dependence as a chronic disease, along with a planning guide for its implementation in a clinical setting.
The system of care incorporates current tobacco intervention practice guidelines into a chronic care model designed to improve the treatment of a range of chronic illnesses.
- Project staff published Treating Tobacco Use and Dependence as a Chronic Disease: A Planning Guide for Practice Sites in Developing an Office-Based System of Care. The planning guide includes:
- A tool for clinical practice sites to assess their current system of care.
- Suggestions for organizing both internal and external care systems to sustain continuing treatment of tobacco use and dependence.
- Implementation of the planning guide at the Urban Medical Group, a five-physician practice, in Boston, revealed that the chronic care model works well with tobacco use treatment.
The Robert Wood Johnson Foundation (RWJF) provided $140,061 for the project between January 2001 and December 2002.
According to the Centers for Disease Control and Prevention (CDC), tobacco use is the leading preventable cause of death and disease in America. However, although 70 percent of smokers see their physicians each year, only 50 to 60 percent of them report that their physicians have ever advised them to quit. A 1999 study by Jack Hollis in 1999 showed that simply raising the percentage of physicians who counsel patients to quit from 60 to 90 percent would stimulate 756,000 physician-generated quitters.
In June 2000, the U.S. Public Health Service released A Clinical Practice Guideline for Treating Tobacco Use and Dependence, which outlines a five-step intervention that can be readily incorporated into every day physician practice:
- Ask all patients about tobacco.
- Advise all tobacco users to quit.
- Assess quitting readiness.
- Assist using proven methods.
- Arrange follow-up support.
In order to fully implement the Guideline, however, clinical practices must make a series of changes to their systems in order to integrate evidence-based cessation treatments into routine care.
Through its national program, Improving Chronic Illness Care, RWJF has funded the MacColl Institute for Healthcare Innovation to develop a chronic care treatment model and test it in a variety of health care settings. The model identifies four dimensions of care that encourage effective chronic disease management:
- Self-management support.
- Delivery system redesign.
- Guideline-based decision support.
- The use of clinical information systems to identify and track chronic conditions.
It also addresses key organizational variables and incentives within the larger health care system and the importance of linkage to community resources.
Focusing on these components should foster productive interactions between patients who take an active part in their care and providers backed up by resources and expertise. (See Overview of the Chronic Care Model.) This project sought to determine if the Chronic Care Model could be configured and applied to the treatment of nicotine-addiction.
RWJF also has funded dissemination of the Clinical Practice Guideline for Treating Tobacco Use and Dependence (see Grant Results on  ID#s 029389, 030329, 030520, 030375, 030254 and 030525,  ID# 034068, and  ID#s 043405 and 045383), and through its national program Addressing Tobacco in Managed Care it is promoting adoption of innovative approaches for helping Americans enrolled in managed care organizations to quit using tobacco.
Project staff at Brandeis University developed a system for treating tobacco use and dependence as a chronic disease, along with a planning guide for its implementation in a clinical setting. The system of care incorporates current tobacco intervention practice guidelines into the Chronic Care Model, which is designed to improve the treatment of a range of chronic illnesses. From June through November 2002, a clinical practice in Boston field-tested the planning guide.
The project accomplished the following:
- Project staff published Treating Tobacco Use and Dependence as a Chronic Disease: A Planning Guide for Practice Sites in Developing an Office-Based System of Care (see the Bibliography for publication details; also available online). The planning guide includes (1) a tool for clinical practice sites to assess their current system of care; and (2) suggestions for organizing both internal and external care systems to sustain continuing treatment of tobacco use and dependence. Suggestions include:
- Flagging tobacco use in medical records.
- Using the 5As practice guideline (Ask all patients about tobacco; Advise all tobacco users to quit; Assess quitting readiness; Assist using proven methods; Arrange follow-up support).
- Providing patient support materials about quitting tobacco use at the clinical practice site.
- Providing information for self-help, such as quit smoking groups, hotlines, Web sites and other community programs.
- Implementation of the planning guide at the Urban Medical Group, a five-physician practice, in Boston, revealed that the chronic care model works well with tobacco use treatment. The Medical Group:
- Added smoking status to patient records.
- Established a census of patients who smoke.
- Identified community resources for smoking cessation counseling.
- Reviewed clinical guidelines for tobacco treatment in staff meetings.
Through the project, the Medical Group discovered that 20 percent of its 5,000 patients currently smoke. Project Director Krevor reported: "Instead of thinking of the interventions as a private event where a doctor talks with one patient, they began to take a disease management approach, which would include periodic outreach to that group of patients. This was quite a change seeing those 1,000 patients as a population with the same condition." The Medical Group also found that the Chronic Care Model's team approach delegating responsibilities to non-physicians helps overcome barriers to treating tobacco use.
The project offers the following lessons for the field:
- Reductions in state spending on tobacco-related projects may hamper the implementation of innovative treatment models. In the absence of state-supported programs, integration of tobacco treatment into primary care practice becomes particularly important. (Project Director)
- Without outreach to practice sites and promulgation of the Chronic Care Model along with ongoing technical support self-generated practice site changes are unlikely. Accordingly, potential sponsorship of the model by health systems and dissemination strategies to promote its adoption for tobacco use became important concerns of this project. (Project Director)
AFTER THE GRANT
Brandeis University received a $50,000 mini-grant through RWJF's national program, Smoke-Free Families: Innovations to Stop Smoking During and Beyond Pregnancy, to adapt the Planning Guide for use with two obstetrics and gynecology practices in Vermont (see Grant Results). The clinical sites are using the self-assessment tool to help design clinical systems for identifying tobacco use and dependence among their pregnant patients.
GRANT DETAILS & CONTACT INFORMATION
Developing System Strategies For Tobacco Use Treatment
Brandeis University (Waltham, MA)
Dates: January 2001 to December 2002
Brad Krevor, Ph.D.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Treating Tobacco Use and Dependence as a Chronic Disease: A Planning Guide for Practice Sites in Developing an Office-Based System of Care. Waltham, Mass.: Brandeis University, 2002. Available online.
Report prepared by: Kelsey Menehan
Reviewed by: Robert Crum
Reviewed by: Molly McKaughan
Program Officer: C. Tracy Orleans