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Tobacco Treatment Specialists Across Healthcare: Spotlight on Outpatient Care

This occasional series highlights some of the practice areas where tobacco treatment specialists (TTS) work. In this post, we share tips on how to build a successful outpatient smoking cessation program.

Smoking cessation in outpatient settings takes on a variety of forms, from short conversations during a primary care office visit to more in-depth treatment from a dedicated smoking cessation program. No matter the setting, there are a few common keys to success.

Jillian Dirkes, MSW, LCSW

I sat down with Jillian Dirkes, MSW, LCSW, Program Manager for the Duke Smoking Cessation Program (DSCP) and co-founder of the Duke-UNC Tobacco Treatment Specialist Training Program, to get her insight on building a successful outpatient smoking cessation practice. The DSCP sees more than 1,750 unique patients yearly in its outpatient program, using a hybrid format of telehealth and in-person clinic visits. To put this number in perspective, when the program started in 2016, it had 143 unique patients in the first 12 months.

Jillian credits the program’s success to three key elements: recruitment, a focus on providing effective treatment, and financial sustainability. “When we were starting out, we asked ourselves, ‘How do we get intensive treatment to patients, and how do we make this program sustainable?'”

TIP 1: How to find people to show up to your outpatient tobacco program

An area where outpatient programs can often struggle is getting patients, she explains. “You build a beautiful program, and then no one shows up.” It is very typical in tobacco use treatment to have high no-show rates. One way to overcome this is to focus on increasing the number of people being referred to your program.

“Think about a funnel,” Jillian says. “You want a whole bunch of people coming into the top of the funnel. You want to recruit the biggest number of people possible, knowing that people are going to drop off for reasons outside your control. So your focus should be on increasing the top of the funnel.”

The DSCP, which is housed within the Duke Cancer Institute, has done this in several ways. First, by reaching out to primary care providers and making it really easy for them to put in a referral. “Don’t make them answer questions. It’s a barrier for providers to complete a referral,” she says.

The program also uses Best Practice Advisory (BPA) alerts within the electronic health record that pop up for active tobacco users suggesting that the provider place a referral to the smoking cessation program. “These don’t work great,” Jillian says. “Providers have alert fatigue.”

In fact, a recent study Jillian was involved with found that BPAs generate a service utilization rate of only 0.6%, compared to a traditional provider referral at 3.8%. This study also found that direct population outreach—contacting patients directly to offer services—led to a 6.3% service utilization rate.

“We really pivoted toward patient-facing outreach, reaching out to patients regularly and asking if they are ready to quit,” Jillian says. This is done largely through automated systems with messages sent to patients through the patient EHR portal and automatic telephone calls. If a patient says yes, a team member reaches out. Patients are also given a way to opt out of calls. These calls and messages are timed before an upcoming appointment with their oncology provider.

“When we started reaching out to patients directly, we doubled our program referrals.” --Jillian Dirkes, Duke Smoking Cessation Program Manager on using patient-facing outreach for program recruitment

Another game-changing move that increased patient volume for the DSCP was the addition of telehealth visits. In response to the COVID-19 pandemic in March 2020, the program transited from 100% in-person visits to 100% telehealth visits.

“Our patient visits more than doubled,” Jillian recalls. “We saw 190 visits in Feb 2020, transitioned to telehealth in March 2020, and by June 2020 we saw 409 visits. We’ve since moved to a hybrid model of telehealth and in-person visits, which even better meets the needs of our patients.”

Telehealth has allowed the program to expand its reach to patients living in other parts of the state and has improved no-show rates by decreasing the impact of scheduling conflicts and transportation issues experienced by patients.

TIP 2: Don’t trade effectiveness for reach

Another issue Jillian sees often is that outpatient programs will rely heavily on apps, handouts, videos, and self-help websites as a means of treatment to improve reach to more patients. These services are better than nothing and a good adjunct to treatment, but they shouldn’t be a replacement for evidence-based care.

“We know what works—smoking cessation medications plus behavioral counseling,” says Jillian. “Really standing in clinical expertise and using what works will keep your program efficacy high.” Thinking of these other resources as part of a menu of services is a better approach, since not every patient is the same. “Our outreach specialists know how to connect people to apps and other services if needed.”

High quality smoking cessation treatment requires an individualized approach based on the best evidence-based treatments. “There is no one-size fits all plan,” Jillian says.

TIP 3: Making your program financially solvent

“With smoking cessation you can at least keep the lights on if you are billing,” says Jillian, who explains that in the beginning they experienced a lot of trial and error in setting up this model.

Leadership with the DSCP sat down with Duke’s compliance team and told them what they wanted to do. They then went back and forth for several months, bringing their expertise and educating billers and compliance team members. “You have to advocate for tobacco use as a chronic medical problem. I will talk about it like hypertension and diabetes. You aren’t going to fix this issue with 10 minutes of counseling," says Jillian.

They drafted sample notes for tobacco treatment based on notes used for hypertension and diabetes management. “Seeing that there weren’t any differences helped make the case that tobacco use is a chronic relapsing disorder and not just a habit.”

Using this strategy, DSCP medical providers are able to bill visits for tobacco treatment like any other outpatient visit for chronic disease management, while mental health providers bill using psychotherapy codes.

For more tips on building a successful outpatient tobacco cessation program, check out our upcoming Duke-UNC virtual Comprehensive Tobacco Treatment Specialist Training!

About The Author

Rachael Joyner is a family nurse practitioner with the Duke Smoking Cessation Program. She holds a National Certificate in Tobacco Treatment Practice and received her Doctorate in Nursing Practice from the University of Florida. She loves working collaboratively with patients to help them become tobacco free.


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