Maine Case Study
Comprehensive Treatment of Tobacco Dependence in Maine
What is the policy and/or program intervention designed to do?
As requested in an RFP released by the Maine Bureau of Health, the program intended delivery of a statewide tobacco dependence treatment program with the following components:
- Maine Tobacco HelpLine—a telephone-based tobacco counseling service for state residents
- Voucher program for access to tobacco treatment medications
- Training of health professionals in tobacco treatment
- Training and credentialing of Tobacco Cessation Specialists
- Statewide coordination of tobacco treatment program elements
Focusing specifically on the statewide Toll-Free Telephone Counseling Program, this intervention was designed to offer to Maine residents a state-of-the-art tobacco quit line service providing telephone-based, time-limited tobacco treatment interventions. In addition to counseling smokers seeking assistance to quit, the HelpLine is also coordinated with a voucher program that provides nicotine replacement therapy (NRT) to eligible callers.
Explain the implementation of the policy and/or program intervention.
The Maine program is somewhat unique in that a single contractor was sought to simultaneously implement multiple elements of a comprehensive tobacco dependence treatment initiative. Implementation components corresponded to the five goals listed above. The Bureau of Health selected the Center for Tobacco Independence (CTI), a new entity that brought together leading individuals across the state in a collaborative, coordinated structure. CTI grew as a program of MaineHealth, the state's largest nonprofit health care delivery system. Other CTI collaborators include the American Lung Association of Maine, the Center for Outcomes Research and Evaluation at Maine Medical Center (CORE) and Intellicare, Gould Health Systems and the Center for Health Promotion. Further discussion of the program intervention will focus specifically on the HelpLine component of overall program activities.
CTI examined evidence-based models for quit lines, including the Center for Health Promotion's (CHP) Free & Clear program and the California Smokers' Helpline. Since CTI's aim was to create a Maine-based service, they specifically partnered with CHP because of their willingness to license their software and intellectual property. CTI brought together the call center technology, counseling protocols, database and experience in counselor training to build the HelpLine locally in Maine. The HelpLine is a multi-user database modeled after the CHP Free & Clear program. The core counseling system is linked to Intellicare's call center system. HelpLine Specialists provide stage-appropriate interventions, with scripting support from a fully computerized system. The HelpLine creates call records, caller queues and callback schedules, and manages tailored mailings and Quit Kit fulfillment activities.
Specific implementation action plans included the following:
- Lease facility space to house HelpLine operations.
- Develop and implement an equipment/technology plan, including installation of work stations, toll-free service line and recorded messaging system.
- Establish hours of operation. The Maine HelpLine operates 51 hours/week, 52 weeks/yr. Staff is available from 10am to 8pm Monday–Thursday; 10am to 5pm Friday; 10am to 2pm Saturday.
- Establish mechanism to monitor caller demand and plan to adjust staffing structure and hours of operation to effectively provide service to calls.
- Coordinate staffing requirements with the media contractor prior to media campaigns. Develop staffing plan.
- Develop information system—The CTI system uses sophisticated software that tracks calls and maintains consistency, report creation and data confidentiality. The tracking and documentation capability includes digital recording and time stamps for every call, call center agent, and work station location. For each participant, a series of call records are created. The call record consists of demographic information, tobacco history, intention to quit, past quit attempts and other relevant information. The Tobacco Specialist records the disposition of each call, including referral information and call summaries in a comment section.
- Develop reports for Partnership for Tobacco-Free Maine on a prescheduled, agreed upon basis. Reports include information on amount and types of services utilized by callers, and call patterns by time of day, day of week and month.
- Develop information privacy plan to ensure patient privacy, individual health data security, state/federal privacy regulations and applicable property rights of CTI collaborators.
Time-Limited Counseling and Follow-up
- Initial Screening—All callers are assessed by a trained Telephone Screener using "readiness to quit" criteria. Data are collected regarding type of caller, demographics and place of residence. Screeners determine disposition to the call and specialist triage, mailed material, or referral to other staff.
- Initial Intervention—All callers interested in quitting in the next 30 days are encouraged to talk to a specialist. Specialists conduct a comprehensive assessment including dependence level and quit history, identify smoking triggers and barriers to quitting, and provide an overview of the counseling program available to them.
- A quit plan is then customized for each caller and a Quit Kit is mailed. All callers are mailed Quit Kits that are appropriate to their intention to quit. If a caller is not ready to quit within 30 days, appropriate materials are mailed and the individual is encouraged to call back in the future.
- Callers interested in quitting or using medications to quit are assessed for Medication Voucher eligibility and contraindications to cessation medications.
- Follow-Up Calls—Three follow-up calls are scheduled to support the client's efforts to quit. The timing of calls is arranged around the quit date using a relapse-related protocol. The counseling protocol is modeled after the CHP Free and Clear program.
- Conduct periodic review of counseling protocols to ensure they remain state-of-art.
- Examine processes to implement Quality Assurance and monitor Specialist performance. Schedule weekly meetings with HelpLine manager to review calls.
- Establish protocols for dealing with difficult cases, including establishing incident reports, etc.
- Measure counselor productivity.
- Establish outcome measures.
- Mentoring of Helpline staff to maintain knowledge and skills for continuous improvement.
Services for Callers Other Than Tobacco Users The HelpLine serves as the major entry point for any Maine resident to find information and resources on tobacco-related issues. Information is provided on the health impact of tobacco use and environmental tobacco smoke and how family members can encourage and support the quitting process. General materials on tobacco use and dependence are disseminated on request to any HelpLine caller.
Medication Voucher Program (Voucher)
An important component of the overall treatment program is the Medication Voucher Program. Access to nicotine replacement therapy is through the Tobacco HelpLine. Tobacco users who speak with a HelpLine specialist and meet the eligibility criteria are offered a Medication voucher. Individuals are eligible if they have no health insurance or no pharmacy benefit for nicotine replacement therapy, are not pregnant, are aged 18 or older, are planning to quit within the next 30 days, and schedule follow-up counseling sessions with the HelpLine Specialist. The CTI Medical Director provides clinical supervision of the Medication Voucher program.
Eligible clients can obtain up to 8 weeks of NRT at any Maine pharmacy, authorized for 4 weeks per Voucher. Once a Voucher is approved, the HelpLine faxes information to Gould Health Systems (a pharmacy benefit management program), who then contacts the pharmacy with specific dosing information. To obtain a second voucher, the client must speak to a HelpLine Specialist and discuss their progress with quitting tobacco use.
The primary implementation steps are:
- Establish eligibility criteria that includes insurance determination, readiness to quit and willingness to receive follow-up calls.
- Establish the HelpLine as the initial primary entry point for medication vouchers. Integrate Voucher protocols into HelpLine database.
- Voucher information sent directly to pharmacies through a pharmacy benefit manager. An eight-week supply of NRT is available; 4 weeks/voucher, twice per year.
- Assure appropriate data collection to monitor and evaluate Voucher use.
Promotion and Outreach
CTI works with the PTM and its media contractor to design marketing strategies to promote the statewide HelpLine in the most cost-effective way, including the use of population–specific, targeted recruitment methods to reach high risk, highly motivated and disparate population groups. Specific activities include the following:Collaboration with PTM and the Media contractor to coordinate the timing of promotion efforts. Collaboration with PTM and other Bureau of Health programs to promote the services offered by the HelpLine, including counseling, medication therapy, information and technical assistance. Work closely with the media contractor to devise appropriate strategies for targeting populations with disparities. Evaluations of the HelpLine use patterns and medication services are to be used to tailor marketing strategies accordingly.
Services for Healthcare, Human Service Providers and Tobacco Treatment Specialists
CTI and HelpLine staff provides several levels of technical assistance to health professionals. HelpLine staff is trained to answer a range of questions about the programs and provide information describing services and benefits. CTI staff provides more in-depth training of health professionals about tobacco dependence and treatment, as part of the Tobacco Treatment Training component of the PTM Treatment Initiative. CTI provides the following:
- Information and training to clinicians and other professionals on tobacco intervention, pharmacotherapy, behavioral treatments and PTM services.
- Office-based clinical outreach at physician and dental offices and other clinic-based sites.
- A statewide inventory about community tobacco treatment services are collected and updated as needed.
- Development and implementation of a Tobacco Treatment Specialist training program. In collaboration with the American Lung Association of Maine, a Specialist certification program.
The Partnership for a Tobacco-Free Maine (PTM) was "born" in 1997 with the implementation of a $.25 tobacco tax designated for program activities. The program was initiated and housed under the State Bureau of Health within the Department of Health Services. In 1999, PTM funding came from the Tobacco Settlement in lieu of tobacco tax revenue. A significant portion of Settlement funds was designated for the "Funds for Healthy Maine." In 2000, the Bureau of Health issued a Request-for-Proposal to select a contractor for implementing of a statewide, comprehensive tobacco dependence treatment program. The program's intent was to supplement rather than replace programs offered by Aetna, CIGNA, etc. Coverage for NRT by third-party payers was found to be moderate and coverage for counseling services was severely restricted.
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