mayo clinic nicotine dependence center: a working model in a medical center attud inaugural meeting...
TRANSCRIPT
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Mayo Clinic Nicotine Dependence Center:
A Working Model in a Medical Center
ATTUD Inaugural MeetingDecember 13, 2003
Lowell C. Dale MD
Nicotine Dependence Center Education Program Director
Kay M. Eberman MS
Nicotine Dependence Center Education Program Coordinator
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Mayo Clinic practice sites
Scottsdale, Arizona
Rochester, Minnesota
Jacksonville, Florida
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Mayo Program:Background
• Smoke free facilities 1987
• “Smoking Cessation Center” 1988
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Mayo Clinic Nicotine Dependence Center
Vision and Mission
• Vision statement: “The best is where we begin”
• Mission: “To promote tobacco-free living through an integrated program of intervention services, education, and research”
• Full concept of the treatment program. • Providing choices of treatment to meet
different levels of addiction and individual needs.
• Providing program branches for practice, research, education
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System Changes
• Smoke free buildings and campus
• Department of Medicine support
• Human Resources Policy: compliance a condition of employment
• Employee Benefit Package: Full Coverage of all of our services and medications
• Easy referral: ordered like any other test
• “Open Access”: The “teachable moment”
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System Changes
• Counselors go to the patient• Outpatient area of referring physician• Hospital bedside
• Educational Efforts• Resident education (8 hours)• Medical student curriculum• Grand rounds, committee meetings, etc• Nursing in-services
• Research• Study recruitment• Press releases
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Basic service design: Partnership
PATIENT
PHYSICIANCOUNSELOR
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Mayo NDC Current Profile: Branches of Service
• Research Program: • Areas of investigation include treatment methods,
adolescents, family and support persons, medications• Separate staff and funding
• Education Program (Training Health Care Providers) • NIH Grant funding for 2001 - 2006. • Internal Mayo education: medical residents and fellows,
nurses, respiratory therapy students, medical students• External education: medical systems, conferences
• Community Outreach: Mayo Outreach to Students & Teachers
• Treatment Program
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Target Population
• Mayo patients who are using/ have used tobacco• Outpatients• Hospitalized patients
• Self-referred for treatment of tobacco use
• Local patients: majority within 50 miles
• Average age: 50 years
• <10% Mayo employees/dependents
• <1% teens
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The Referral Base
• Mayo medical community (80%)
• Self referral (15%)
• Other (5%)•Regional Practices•NDC Research Program•Other medical groups and hospitals•Community: public health, dental offices,
health clubs•Internet, media
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Role of Medical Staff
• Leadership, vision
• Medical management of the center
• Medical back up for patients as needed (review medical conditions, medication advice, write prescriptions)
• Research: Primary Investigators
• Education: NDC staff, other professionals
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NDC Staffing
• Counselor responsibilities• Provide patient care
• Maintain records, paper and computerized
• Provide lectures for patients
• Provide information for MDs, other medical staff
• Train new staff
• Take part in NDC education program
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Components of Care
• Individualized
• Alliance with patient: a helping relationship
• Counseling rather than teaching
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Foundation for Treatment Model • Chemical Dependence Concepts
• Behavioral Change Techniques
• Pharmacologic Therapy
• Relapse Prevention
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Ending Tobacco Use: Process of Change
• Ending tobacco use may take years
• Relapse is common
• Health care provider facilitates the process of positive change
• Understanding the process of behavior change helps tailor initial intervention
• Forming a motivational partnership enhances the possibility of positive change
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Consultation/Assessment
• Basic service
• Counselor meets with patient
• 45 - 60 minutes
• Majority of patients seen face to face one time only
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Tools for the Consultation/Assessment Session• Assessment forms
• Treatment interview
• Carbon monoxide measurement
• Treatment planning
• Medication planning
• Self help materials
• Relapse prevention system
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ServicesOptions for service: • outpatient consultation • hospital consultation• on going counseling • intensive individual program • group program• residential treatment • telephone counseling (Quitline) • support group • Nicotine Anonymous
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Outcome Evaluation
• Stop rates measured at 6 months
• Telephone interviews
• “Intent-to-Treat” Analysis
• 7 day point prevalence tobacco use status
• 22% - 45% stop rate
• Rate is higher with more intensive treatment
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Financial
• Outpatient services are billed to insurance and/or the patient
• Hospital services are not billed directly, but can be considered in room rate adjustments
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Insurance Coverage• Medicaid/Medical Assistance
• Coverage varies from state to state• May cover face to face counseling,
medications
• Private insurance
• Varied between and within companies• Call the 800# for information
• Telephone Quitlines
• Many states and third party payers offer a tobacco quitline at no charge
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Billing Codes
• CPT Codes with a possible fit for outpatient services:• Preventive Medicine codes: 99401 -
99412• Health and Behavior assessment
codes: 96150-96155• Psychiatric dx codes: 90805 - 90809
• ICD-9 diagnostic code: Tobacco use disorder 305.1
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Determining Coding
• Health and Behavior Assessment codes for tobacco dependence tx are recognized by Medicare
• However, Medicare carriers will determine whether or not to cover the cost
• Best method of determining the codes to use: work with revenue recognition expert or medicare expert
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Summary of Clinical Service
• Individualized counseling service provided within medical setting: the teachable moment
• Timely - same day service or within 24 - 48 hours of medical visit
• Brief focused counseling service, long follow up
• Choices of services following first visit
• Addiction basis for treatment approaches
• Use motivational and models for change
• Use tools of behavior change, medications, and relapse prevention
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Summary• Mayo program: integrated into medical setting,
uses partnership, trained counselors, service options, faced many challenges
• Basic components of treatment: chemical dependence/chronic disease, behavior change, pharmacotherapy, relapse prevention
• Counseling strategies for intensive interventions include models for behavior change and motivational interviewing
• This type of service can be used in other settings
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Opportunities for Growth
• JCAHO
• Enhanced Relapse Prevention
•Work-site Programs
• Educational Efforts• Internally• State• National