Maine Case Study
Comprehensive Treatment of Tobacco Dependence in Maine
What were the important elements to the intervention's success?
An important factor was the development of CTI's programs within MaineHealth, a large, integrated health system that has proven experience in supporting programs that aim to improve the health of populations.
With the state's Tobacco Treatment Initiative requiring a comprehensive approach, a wide variety of expertise and staff were brought together to implement the programs. While challenging to do this simultaneously, it also created significant inherent coordination of program elements. For example, there is a large degree of content overlap in training telephonic specialists for HelpLine counseling and training tobacco specialists statewide. There are many examples of overlap and coordination with this model.
Additional factors that generated success was the strong collaboration between CTI and partners, including Intellicare, CHP, and Goold Health Systems.
It was very helpful that all programs were packaged together in one Request-for-Proposal so that staging could occur—first the Quit Line HealthLine was implemented followed by the training program and then the medication voucher program.
Describe the policy and/or program interventions applicability/replicability to other sites, and include recommendations for other sites.
It is feasible to replicate this comprehensive program, or specific components only. Each program element has specific functions and deliverables.
The primary recommendation for other sites, if a comprehensive approach is desired, each component should be tackled carefully. It is preferable to implement each component in succession, or delay overall program implementation than to implement multiple components simultaneously and poorly.
Describe the challenges faced, and below each challenge, describe any solutions used to correct or reduce the problem.
Challenge: For a number of reasons, a significant challenge has been the effective integration of this program into the existing health care system throughout the state.
- First, because of the many demands placed upon providers, it is essential to demonstrate credibility and to show the program's value within a limited amount of time. Finding appropriate vehicles to educate providers outside of a classroom setting in a way that captures their attention is one component of this challenge.
- Second, many providers may not immediately recognize the value of a state-funded program because they believe that the marketing/public relations efforts intended to increase program awareness are sufficient.
- Third, our efforts to integrate the program into health care systems are more difficult because we are competing with Quality Improvement (QI) initiatives in chronic disease that have begun to capture providers' attention. These QI efforts are beginning to take hold in treating conditions such as diabetes, cardiovascular disease, and asthma. Smoking cessation efforts should be integral to these QI initiatives but, thus far, have been perceived along parallel tracks.
- Lastly, many in the health professional community don't feel sufficiently empowered to assist patients to quit smoking. Rather than focusing on smoking as a chronic condition for which the providers assistance is indicated, the habit is viewed as behavior over which the patient has complete control or, conversely, that the provider cannot be effective other than telling them to stop.
Solution(s): There are both short-term and longer-term (or big picture) solutions to this multifaceted challenge. In the short-term, an important component of the Maine program is placement of clinical outreach staff throughout the state. The objectives of these mid-level practitioners, who work on a part-time basis, is to visit providers and educate them to recognize tobacco as a chronic condition and to teach them how to focus on the process of quitting rather than solely on the desired outcome of smoking cessation. In the longer-term, the program is striving to become more integrated into the current wave of chronic disease QI efforts so that these initiatives are not viewed separately. Additionally, tobacco intervention should be viewed as a model for behavior change initiatives required in many other areas. For example, QI protocol may exist to assist asthma sufferers to change their behavior in proper use of medications. Techniques that have been established by tobacco professionals are just as effective and applicable to a broad range of required behavior change as they are to smoking cessation.
Challenge: The success of state-funded tobacco cessation programs is creating disincentives for private-sector purchasers to improve and initiate covering of tobacco cessation treatments. For those private payers who currently cover these services, it is a challenge to maintain or enhance coverage given a state-funded alternative. For those not currently covering cessation services, the state programs provide a disincentive to their consideration of adding coverage to their benefit plans. This disincentive exists even if the state-funded services are less comprehensive than those currently provided or under consideration by private payers. As a result, a danger exists that if the state discontinues funding in the face of budget shortfalls, more people will be without access to cessation programs than was the case before the inception of the state's program.
Solution(s): The model for state-funded programs should be modified to ensure that states are the primary payers for the uninsured or those enrolled in publicly funded health care plans (e.g., Medicaid, Medicare, etc.). Private employers and other third-party payers should remain the primary sponsors for enrollees covered by their private health care benefit plans.
What would you have done differently?
Lessons Learned Notes
In smaller states such as Maine, a small number of people in very influential positions can more successfully effect change. These are individuals that work within state government, lead voluntary state organizations, and are Coalition members and outspoken public health advocates. For example, the American Lung Association director in Maine is a highly influential citizen who was instrumental in program implementation.
When implementing a program of this breadth and magnitude, it's essential to have specific defined goals and strategies, clearly defined roles and responsibilities, partners with relevant expertise, and strong clinical expertise. It is more difficult to integrate programs such as this into a variety of health care settings and systems where programs may already exist. There is a general lack of knowledge around tobacco treatment—even among health care professionals.
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