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Sustainability of Public Health Programs: The Example of Tobacco Treatment

in Massachusetts CommunityHealth Settings

Nancy La Pelle, Ph.D.University of Massachusetts Medical SchoolFebruary 2007

Grant # RO1 CA86282 funded by National Cancer InstituteState and Community Tobacco Control Interventions Research Initiative

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Principal Investigator: Judith K. Ockene, PhD UMMS

Co-Principal Investigators: Lori Pbert, PhD UMMS Donna Warner, MBA, CAC MDPH

Co-Investigators: Nancy La Pelle, PhD UMMS Jane Zapka, ScD UMMS Sarah Reiff-Hekking, PhD UMMS Harriet Robbins, MEd MDPH

Project Directors: Denise Jolicoeur, MPH, CHES UMMS Mary Jo White, MS, MPH UMMS

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Sustainability

“Sustainability” contrasts with the notion of “institutionalization” which implies that a service is continued within the original organizational structure and that it is unchanged

Sustainability includes adaptations to scope of services offered, organizational context, and supporting resources

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Massachusetts Tobacco Treatment Policy Study (MASSTTPS)

Sustainability Substudy Qualitative comparative case study Sample

Massachusetts Tobacco Control Program (MTCP) statewide Smokers’ Helpline funded by MDPH

77 of 86 defunded community-based tobacco treatment programs

- 21 hospitals; 27 community health centers; 9 substance abuse treatment centers; 6 mental health agencies; 14 “other” agencies

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Data Collection and Analysis

Telephone-based key informant interviews with community agency staff (77)

In-person interviews with DPH/MTCP staff regarding Smokers’ Helpline (5)

Tape-recorded and transcribed Thematic and relational analysis

conducted to idenify strategies used to sustain services

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Results: Essential Strategies for Sustainability When Defunded

Redefine Scope of Services:1. Align services with

organizational goals2. Select acceptable and

affordable services

Creative Resourcing:3. Find funding sources for services offered4. Adjust staffing pattern5. Assign resources to create demand for services

Sustainable Services

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Align Services with Organizational Goals

Meet needs of high smoking prevalence populations served

Meet needs to provide tobacco treatment to patients with co-morbid conditions

Support staff needs to quit at smoke-free sites

Dovetail with cessation-related research at the site

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Select Acceptable and Affordable Services

Target specific at-risk subpopulations

Offer selected services only

Reduce availability: hours and sites when/where services are offered

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Find Funding for ServicesOffered Charge fees Use grant-writing expertise to find

other funding Get other entities (departments,

collaborators, etc.) to fund, share costs, or provide space

Bill as encounter that has insurance coverage

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Adjust Staffing Pattern

Reduce tobacco treatment specialist (TTS) staff

Find other roles TTS staff can play part-time in other departments

Outsource TTS staff Find non-TTS staff resources to

provide services

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Assign Resources to Create Demand for Services

Create referral system from providers and other departments

Educate healthcare providers about services

Program staff networks with other community organizations to generate referrals

Enlist marketing resources to advertise services

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Sustainability Results After9 Months

Level 1: Non-Sust.

Level 2: Low-Sust.

Level 3: Mid-Sust.

Level 4 : High-Sust.

Totals

Volume of Prior Services Still Provided

0% 5-19% 20-49% 50-100%

Totals 25 26 21 5 77

% of Total # Agencies

33% 34% 27% 7%

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Level 1: 33% Non-Sustaining (Minimal Scope; No Resources)

Redefining Scope:1. Drop tobacco treatment - low priority2. Refer to other agencies for treatment

Creative Resourcing:3. No funding;

Fees not acceptable to clients; No grant-writing resources

4. No staff to deliver services5. No staff to create demand

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Level 2: 34% Low Sustaining (Restricted Scope; Minimal Resources)

Redefining Scope:1. Serve high prevalence smokers where possible2. Limited services for specific populations;

No nicotine replacement therapy (NRT) unless covered by insurance; Integrate with other treatment services

Creative Resourcing:3. Limited grant-writing resources4. TTS staff provide fewer sessions at fewer

sites; Services provided by interns, volunteers, non-specialists

5. No outreach since not staffed for full service; Internal referral systems not optimized

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Level 3: 27% Mid-Sustaining(Expanding Scope; Expanding Resources)

Redefining Scope:1. Gradually restore services available to all 2. Provide only group services;

Provide all previous services except NRT; Provide only phone- or web-based services

Creative Resourcing:3. Seek alternate funding sources/charge fees;

Seek collaborators with funding; Seek grants to serve specific ethnic groups; Seek NRT funding source

4. Use contract staff or share staff with other departments; Transfer program to related groups with more resources

5. Emphasize use of internal referral system

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Level 4: High Sustaining(Similar Scope; Similar Resources)

Redefining Scope:1. Continue services to all smokers2. Continue to offer same level of services

as when funded

Creative Resourcing:3. Seek alternate funding sources/charge

fees4. Maintain staff required 5. Provide marketing and outreach support;

Encourage internal referrals agency-wide

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Sustainability Results After9 Months

Level 1: Non-Sust.

Level 2: Low-Sust.

Level 3: Mid-Sust.

Level 4 : High-Sust.

Totals

Volume of Prior Services Still Provided

0% 5-19% 20-49% 50-100%

Hospitals 1 (5%)* 8 (38%)* 9 (43%)* 3 (14%)* 21

Community Health Centers

8 (30%)* 12 (44%)* 6 (22%)* 1 (4%)* 27

Substance Abuse Treatment Agencies

5 (56%)* 3 (33%)v 1 (11%)* 0 9

Mental Health Treatment Agencies

1 (17%)* 3 (50%)* 2 (33%)* 0 6

Other Agency Types 10 (71%)* 0 3 (21.5%)* 1 (7.5%)* 14

Totals 25 26 21 5 77

% of Total # Agencies 33% 34% 27% 7%

* The percentage is of the agency type total

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Sustainability Strategies

Key Strategies at DefundingRedefine Scope of Services: Align services with

organizational goals Select acceptable and

affordable servicesCreative Resourcing: Find funding sources for

services offered Adjust staffing pattern Assign resources to

create demand for services

Additional Key Strategies at Planning Program design Standard operating

routines Capacity building Community board

involvement Local institutional

support Administrative

system support Evaluation

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