Practice administrator Glenn Jennings, M.B.A., lost both his parents to smoking-related illnesses and his father-in-law to lung cancer, so he and his wife, family physician Carrie Burns, M.D., already were advocates of not smoking well before their Baytown, Texas, practice participated in the AAFP's Office Champions Tobacco Cessation Pilot Project.
Sergio Gomez, M.D., of Pomona, Calif., served as the office champion when his practice participated in the AAFP's smoking cessation pilot project. He is shown here with staff members, from left, Silvia Rosales, Yolanda Jiron, Bentura Varela and Cynthia Del Mora.
"What the project did was raise our level of awareness in our office, give us some tools and make us do some thinking about how we could be more effective," said Jennings, who served as the practice's office champion. "We became more effective as an office in identifying people who needed to quit smoking and adding new procedures."
Jennings' experience with the pilot is far from unique. Forty-nine participating practices were asked to review patient charts before and after the 13-month pilot, which was based largely on the AAFP's evidence-based Ask and Act program. The percentage of patient charts with documentation of tobacco use status increased from 82.1 percent to 90.2 percent during that period, while the percentage of charts with documentation that patients were offered cessation assistance increased from 47.8 percent to 72.1 percent.
Each practice was required to name an office champion to lead the project and a physician champion to ensure that the office champion had the support of staff. The office champions were required to complete a training program, identify and implement system changes to better integrate tobacco cessation activities into daily office routines, and create a culture that encourages cessation.
- The AAFP's Office Champions pilot project helped practices increase the percentage of patient charts that included documentation of tobacco use status and the percentage of charts that included documentation that patients were offered cessation assistance.
- The project, which was based largely on the AAFP's evidence-based Ask and Act program, also helped physicians by delegating some of the responsibility for smoking cessation efforts to office staff members.
According to the pilot's final report, practices successfully implemented 85 percent of the changes identified in their implementation plans, and 98 percent of practices expressed confidence that the changes they did make could be sustained.
Many of the changes were based on a practice toolkit provided by the AAFP that includes the following resources:
- quit-smoking posters;
- a smoking cessation group visits guide;
- billing and coding information for smoking cessation-related services;
- patient education materials;
- lapel pins; and
- "prescription pads" that list helpful information for patients before, during and after they quit smoking.
Jennings said Burns' office had patient education materials and quitline cards in the waiting room and every exam room. In addition, medical assistants reviewed a stop-smoking booklet with patients and gave copies to patients who indicated they were ready to quit. The medical assistants followed up with those patients a week after their appointments to check their progress.
Ten family physicians spent Sept. 23-24 learning how to improve smoking cessation efforts in their practices and reduce tobacco use in their communities by influencing public policy.
Overall, more than 50 physicians selected from the memberships of the AAFP, the AMA, the American Academy of Pediatrics, the American College of Physicians, and the American College of Obstetricians and Gynecologists attended the Protecting Children and Families from Tobacco: Leadership Advocacy Training program in Chicago.
"We all have the same goals," FP Sarah Mullins, M.D., of Wilmington, Del., said of physicians represented at the event. "We need to collaborate to be effective. It was inspiring to be in a room with people seeking the same goal."
In addition to improving tobacco cessation efforts, physicians were instructed in media training; working with state and local health organizations; and advocating tobacco control policies, such as limiting secondhand smoke exposure in public places.
Tom Houston, M.D., of Dublin, Ohio, chairman of the AAFP Tobacco Cessation Advisory Committee and newly named chair of the Academy's Commission on Health of the Public and Science, was one of the event's speakers. In addition to Mullins, the following family physicians participated in the program:
- Melody Counts, M.D., of Meadows of Dan, Va.;
- Abigail Halperin, M.D., M.P.H., of Seattle;
- David Head, M.D., of Nome, Alaska;
- Jocelyn Hines, M.D., of Baltimore;
- Robert Monteleone, M.D., of Kennett Square, Pa.;
- Paul Neumann, M.D., of Stayton, Ore.;
- Allen Nord, M.D., of Rapid City, S.D.;
- Clare Reinhardt, M.D., of Pinehurst, N.C.; and
- Bernard Richard, M.D., of Greenfield, Ind.
"It let them know we really are interested in helping," Jennings said. "That's something we had never thought of before we got into the project. It was a permanent change in our system, and it was very little extra work. We just needed to think about it."
Jennings said the pilot didn't change what Burns does to help patients quit smoking, but now she has more support from her staff.
"She always advocates that everyone stop smoking," Jennings said, "but now there's more she can do. She can say to the medical assistant, 'Go give your talk with the booklet to this lady, and put her in the system for a follow-up call.'"
Jennings was one of nine practice administrators who served as office champions during the pilot. Office champions also included physicians, nurses, medical assistants, residents and other staff members.
Sarah Mullins, M.D., served as the office champion in her Wilmington, Del., practice, which has five other physicians and three nurse practitioners. Mullins, who co-authored a practice manual created specifically for the pilot project, said she took on the office champion role because she was so familiar with the material.
However, she told AAFP News Now, "I think in the big picture it's best to have an office champion who is a nonphysician because it's a role that can be easily delegated, and then you have more buy-in from the entire practice. The physicians already are tuned into working with patients to stop smoking, but the front desk and nurses may not be.
"Docs are always giving orders to staff members, so I think having an office manager or a very motivated nurse coordinating the staff gives a more holistic view and motivation for working with patients."
Mullins, who is a member of the AAFP's Tobacco Cessation Advisory Committee, said her office used posters to notify patients that the practice was interested in helping people quit smoking. The practice also used quitline cards, stop-smoking prescriptions and the stop-smoking guides.
The practice's medical assistants also treated smoking as a vital sign, asking patients about their tobacco use status and documenting it in their electronic health records, or EHRs.
"It's a parameter for 'meaningful use,'" Mullins said referring to CMS' EHR incentive programs. "As a Medicare-supported goal, we need to do this anyway. We're nearly 100 percent with reporting of smoking as a vital sign."
Mullins said having staff talk to patients takes some of the load off physicians.
"A lot of the burden for the measurements that are done in primary care lies on the physician, so anything that can help delegate responsibility for something the physician is held accountable for is helpful," she said. "You can't remember to do everything in every visit. If you have some help, you'll have better outcomes."
The project was supported by Pfizer Inc. Pamela Rodriguez, the AAFP's tobacco control manager, said the Academy now plans to submit a grant proposal that would allow the Office Champions project to be disseminated nationally.