Bright Spot: Clinical Integration of Fax Referrals to Quitlines
Photo by Mathew MacQuarrie on Unsplash
This bright spot was originally published in the 100 Million Healthier Lives Change Library and is brought to you through partnership with 100 Million Healthier Lives and the Institute for Healthcare Improvement.
Tobacco use Quitlines offer free, evidence-based individualized counseling to tobacco users ready to make a quit attempt within 30 days. Quitlines are available in all states, and many states also provide quit medication including over-the-counter nicotine replacement therapy in the form of patches, gum, or lozenges. Quitlines also serve as a resource for the busy healthcare provider who asks patients about their tobacco use status and then links those that are ready to quit to Quitline cessation services. Fax Referral to Quitlines is a program that facilitates this linkage between the clinic and Quitline. With this intervention, tobacco users are not expected to make that first step and call the quitline. Instead, the quit coach from the quitline will proactively contact the tobacco user to provide services once the quitline receives the faxed referral.
As of May 2014, there is no cost for using the intervention materials. Staff training can be done during "lunch-and-learns," staff meetings, or via webinar. Patient materials can be downloaded or copied from state or local health departments. Fax forms can be downloaded and printed with clinic information or recreated to send as secured email.
Key Steps for Implementation
- Identify a Physician or Clinician Champion within a clinic. This person will provide a critical role in overall leadership for tobacco treatment efforts. The Clinician Champion will be charged with providing recommendations and/or overseeing implementation of system changes to integrate tobacco cessation treatment into the practice.
- Identify an Office Champion. The Office Champion will assist in the coordination of the change efforts, keep supplies such as Fax Forms and patient education materials readily available for the office and help place visual cues such as posters and brochures in the office.
- Examine current system of identifying tobacco users and providing tobacco use treatment. Look at the practice environment and current system.
- Examine how patients flow through your office and identify any barriers and successes in integrating tobacco use treatment in your office. Ask every patient at every clinic visit their tobacco use status and document. Many health care settings consider tobacco use status as a vital sign to be documented like weight or blood pressure. After initial identification of the patient as a tobacco user, Electronic Health Records (EHR) or paper charts should then be programmed or flagged to remind the clinician to ask about tobacco use at subsequent visits.
- Advise every tobacco user in a clear, strong and personalized manner to quit. Tie tobacco use to current symptoms and health concerns or the impact of smoking have on the children and others in the household.
- Assess whether the patient is willing to make a quit attempt in the next 30 days AND is ready to accept a call from the Quitline. If the patient makes excuses or do not have regular access to a phone, faxing a referral to the Quitline may not be appropriate at this time.
- Provide patient with a Quitline brochure or a card with the Quitline number. Fax referring patients who are not ready to quit will only provide frustration to the patient, the quit coach and will generate unnecessary costs to the Quitline funder.
- Assist the tobacco user ready to quit in the next 30 days or have quit within the past six months by providing a prescription to medications if appropriate and a fax referral to the Quitline. If the patient is a good candidate for a fax referral, the clinician or healthcare staff explains the Quitline program and asks the patient to complete the consent form. By signing the consent form, patients give the Quitline permission to call them. The forms are then faxed by the clinic to the Quitline. After the Quitline receives the form and enters it into the queue, the Quitline will make five attempts over 3-5 days to reach the tobacco user during the times specified on the form.
- Arrange for follow up with the patient. The Quitline will fax a report back to the clinic site on whether the patient accepted services from the Quitline, the patient's quit date, type of coaching intervention and dosage and type of medication sent if applicable. This can be used to start a discussion about tobacco use at the next visit.
- Create a team approach to provide the Five A's (Ask, Advise, Assess, Assist, and Arrange) mentioned in steps 4 to 8. Decide who will be involved and the roles taken. When and who will provide information about the Quitline and who will fax the referral? Who will obtain the faxed patient outcome report and document it in the chart? Who will collect the referral reports from the state office that manage the Quitline and provide feedback to the clinicians? Break down in small steps and test the ease and flow of integration in your setting.
- Provide training on the integration of tobacco treatment in your clinic and ask for technical assistance when necessary.
Partnership with the Quitline Administrator in the state.
Required Staffing (FTEs)
Small portion of key staff time
State-based Quitline funding but no special local funding required
- Fax machine Fax forms - paper or electronic
- Quitline educational materials - brochure, card, or flyer and posters
Training on brief interventions for tobacco use and dependence and incorporating the quitline fax referral program.
Types of Staff
Need someone to prescribe medication if appropriate and needed.
Return on Investment Details
ROI would vary according to the number of patients seen with tobacco use dependence; the size of the organization; reimbursement rates for treating tobacco use; and the use or development of an EHR system to document tobacco use and refer to state quitlines with a feedback loop. However, patients quitting tobacco use will be less likely to receive acute respiratory care and less likely to be admitted for hospital care.
- Six-month quit rates for Quitline participants
- Participant satisfaction with quitline services
- Number of referrals to the quitline
- Number of referrals accepting services from the quitline
- Number of clinicians within health system consistently referring tobacco users who want to quit to the quitline