Oregon Case Study
Comprehensive Treatment of Tobacco Dependence in Oregon
Local: Business/Organizational Policy
Other: Clinical policy within all components of Oregon health care system
What is the policy and/or program intervention designed to do?
The intervention is designed to reduce morbidity and mortality associated with tobacco use by facilitating access to cessation services and promoting the motivation to use them.
Explain the implementation of the policy and/or program intervention.
To initiate Oregon's Statewide Tobacco Cessation project, the TOFCO Health Systems Task Force provided the theoretical framework, cessation expertise and planning and coordination functions for all participating health plans, especially for the large commercial plans.
The first step in implementation was to develop the Oregon-based guidelines for tobacco cessation in health care systems that were adapted from the AHCPR Smoking Cessation Clinical Practice Guidelines. The adaptation process fostered understanding and ownership of the content. The guidelines were developed by TOFCO's Health Systems Task Force with input from a panel of reviewers from many of the health care systems throughout the state, and with substantial staffing from the state's tobacco program. Please note that AHRQ (formerly known as AHCPR) updated their Clinical Practice guidelines and were issued through the Public Health Service. The Task Force on Community Preventive Services guidelines were also used. These updates have been incorporated into Oregon's protocols.
Because of their capabilities and requirements, the Oregon Health Plan (OHP), the state's Medicaid program, provided the hands-on input that was essential for widespread implementation of the program. Enlisting the support of the Medicaid agency was easy because of its entire orientation to prevention. Oregon uses a prioritized list of services, based on effectiveness, and treatment of tobacco addiction rates fairly high on the list. At the time the program was initiated, the reimbursement rates for providers were adequate and managed care was achieving significant savings through care management. Thus, obtaining support from the contracting health plans was fairly easy. The challenge, however, of aligning all of the complicated Medicaid bureaucratic processes to assure easy access to treatment was formidable. The state tobacco funding of a position within the Medicaid agency to address contracting, reimbursement, data collection, evaluation, quality improvement, communication and coordination was essential to success.
Specifically, OHP, through their "Project Prevention" program and their contractor requirements, was able to gather participant plans' commitment to the program. Because of OHP's strong links to virtually all of Oregon's health care providers, they were able to serve as the catalyst for the implementation of statewide training programs and other program requirements. With guidance from the state tobacco program and TOFCO OHP determined evaluation measures and the data collection and reporting requirements for monitoring the cessation efforts. Measures were selected that have been tested nationally and agreed upon by participating health care plans. A reporting plan was developed to measure the success of cessation efforts and for making recommendations for further activities including progress reports from each participating health plan.
The next major implementation activity was to develop a plan for communicating with health care providers that included the cessation guidelines, a letter of program endorsement from health care and state leaders and a schedule for periodic updates and reminders.
Two types of training were developed to support health systems' and plans' efforts to implement the cessation guidelines. The first training targeted health plan and provider group representatives responsible for implementing or contracting for comprehensive cessation programs in their respective organizations. The second program was established to develop clinic capacity for the delivery of cessation services to individual patients, including forming the referral linkage to the comprehensive programs. Essentially, the health care providers became the front-line implementers of the health plan's or provider group's comprehensive program.
To address the proportion of smokers who need more intensive services to stop smoking, an analysis was conducted to assess the costs and benefits of consolidating individual health plan resources to provide a single, comprehensive Quitline for OHP participants and, for those private health plans that chose to, for commercially insured individuals.
Lastly, the Tobacco Prevention & Education program (TPEP) within the Oregon Health Division took the lead in issuing a request-for-proposal from qualified agencies to offer a single, state-wide, no-charge telephone-based resource to provide screening, counseling, support materials and referral for tobacco cessation assistance. The Quitline provides a single call intervention using evidenced-based counseling based on readiness to change, motivational interviewing and cognitive skill building. The Quitline was intended to provide comprehensive pro-active follow-up counseling support and NRT ONLY for uninsured Oregonians. For insured individuals, the Quitline is responsible for coordinating with Oregon's health care delivery system to link the quitter with the appropriate resource for comprehensive follow-up services.
A major requirement of the RFP was that the vendor could sell its services to the private sector, including the offering of volume discounts and seamless enrollment. TPEP emphatically did not provide comprehensive counseling to individuals who were insured, but whose insurance did not cover tobacco treatment. The principle that scarce state funds were used to leverage rather than replace the private sector's responsibilities was fundamental. Tobacco users enrolled in Medicaid or in about half of the remaining commercial programs had access to full support through the referral and/or shared purchasing mechanism. The implementation activities associated with the Quitline are ongoing, including marketing, program promotion, and outreach to providers and users. These activities are tailored to specific audiences.
While tobacco prevention had been identified as a significant issue for many years by many of the stakeholders, a primary motivating force behind this collaboration and implementation of the Quitline was the imposition of a cigarette excise tax with proceeds designated to support prevention efforts. At that time, intervention efforts were highly variable.
With the availability of funding, the various entities determined that their effectiveness could be enhanced by establishing a public/private partnership that would achieve economies of scale and consistency in terms of the dissemination of information throughout the state's health care delivery systems. The limited funding available through the excise tax would go further by sharing the cost of the various activities among both public and private funding sources. Lastly, because Oregon is primarily a rural state, the various entities determined that a telephone-based intervention such as a Quitline, in conjunction with the other supporting activities, would be the most cost-effective way to provide access for all Oregonians.
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