CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0343
Integrating Tobacco Cessation Quitlines Into Health Care: Massachusetts, 2002–2011
Donna D. Warner, MBA, MA; Thomas G. Land, PhD; Anne Brown Rodgers; Lois Keithly, PhD
Suggested citation for this article: Warner DD, Land TG, Rodgers AB, Keithly L. Integrating Tobacco Cessation Quitlines Into Health Care: Massachusetts, 2002–2011. Prev Chronic Dis 2012;9:110343. DOI: http://dx.doi.org/10.5888/pcd9.110343.
An analysis of QuitWorks data showed 3 phases in referrals between April 2002 and March 2011: referrals increased from April 2002 through November 2005, plateaued during December 2005 through January 2009, then substantially increased during February 2009 through March 2011. Factors responsible include partnerships with stakeholders, periodic program promotions, hospital activities in response to Joint Commission tobacco use measures, service evolutions, provision of nicotine replacement therapy for referred patients, and electronic referral options. QuitWorks’ history demonstrates that tobacco cessation referral programs can be successfully sustained over time; reach substantial numbers of tobacco users, benefit providers and health care organizations; and contribute to sustainable systems-level changes in health care.
Quitline services are generally funded by state-level tobacco control programs or a mix of state, federal, and private partners. Typically, a quitline counselor will conduct a screening interview and offer 1 or more counseling sessions before, during, and after a quit attempt. Some quitlines also offer free nicotine patches or other medications, self-help materials, and access to Internet resources. Most quitlines conduct evaluation calls after 6 months to assess clients’ quit status (3).
In April 2002, the Massachusetts Tobacco Control Program (now called the Tobacco Cessation and Prevention Program), an initiative of the Massachusetts Department of Public Health (MDPH), launched QuitWorks, a tobacco cessation program through faxed referrals that links health care organizations, providers, and patients to the state’s quitline. The goal was to fill a gap for providers who lacked a consistent resource to which to refer patients who use tobacco. The MDPH and 8 commercial and Medicaid health plans forged a partnership to make QuitWorks universally available and free to any provider in the state and to all residents, regardless of insurance status.
Following Massachusetts’ lead, other states adopted the fax-referral option. By 2009, all 50 US states, the District of Columbia, Puerto Rico, Guam, and all 10 Canadian provinces reported offering these services, although the range of program practices varied widely across locations (State quitline programs, unpublished survey of state quitline referral practices, 2010).
The heart of the QuitWorks program is a simple Health Insurance Portability and Accountability Act–compliant enrollment form completed by the provider, the patient, or both. The patient signs the form and the provider sends it to the quitline by fax or other electronic means. By signing the form, the patient gives consent for the quitline to call and authorizes the quitline to send reports on the patient’s progress to the provider. All referring providers receive 2 reports on each patient referred — 1 within 5 weeks on quitline attempts to reach the patient and the services accepted, and a second 7 months later on the patient’s quit status.
Throughout its history, QuitWorks has primarily received referrals from 4 classes of facilities — hospitals (56.0%), outpatient clinics (14.0%), community health centers (10.1%), and provider practices (8.7%). The remaining 11.3% consists of providers with no organization or groups that do not easily fall into the categories above, such as nursing homes, public housing programs, visiting nurses, or other human service providers.
QuitWorks has steadily grown during its 10 years of operations. Following its launch, the 8 commercial and Medicaid health plan partners conducted a promotion effort in 2002 and 2003, including delivery of QuitWorks kits door-to-door to 4,800 providers. This effort resulted in a substantial increase in referrals. Referrals increased again in 2005 as a result of hospital activity to meet 2004 Joint Commission tobacco measures (4) and expanded promotions to hospitals and community health centers. By 2006, QuitWorks had developed on-site technical assistance and clinical training services needed to integrate QuitWorks into the clinical workflow, medical record systems, and performance reporting. Beginning in 2009, the availability of free starter kits of nicotine patches for QuitWorks patients statewide contributed substantially to a new spike in referrals, as did the implementation of a fully electronic health records system in Atrius Health, a major QuitWorks user. Periodic free e-mail, newsletter, and fax promotions, conducted each year by MDPH and health plan partners, also increased in 2009 and 2010.
QuitWorks now includes many features not available when it was launched in 2002, among them a website (www.quitworks.org), customized and flexible manual and electronic referral options, enrollment forms, and reports for participating organizations. The availability in 2011 of Centers for Medicare and Medicaid Services (CMS) incentives for meaningful use of health information technology (5-7) has accelerated the trend among providers to use QuitWorks electronic referral options. Privacy, consent, and security issues for all QuitWorks innovations have been addressed with the assistance of expert consultants and cleared by provider, health plan, public health, and legal departments.