10/13/2016

1

Growing Your

Business with

Smoking Cessation

Services: Join the

Quit Club

Travis Wolff, PharmD

Ken Saunders, PharmD, TTS

Jamie Mask, PharmD

Shelley S. Hammond, MMC

Travis Wolff, PharmDMed-World Pharmacy, Sapulpa, Oklahoma

10/13/2016

2

Disclosure

Travis Wolff is receiving an honorarium for this program. The conflict of interest has been resolved by peer review of presentation content.

• Outline strategies to identify, attract and target patients for smoking cessation services.

• Discuss the role of a community pharmacist in helping patients set a quit date and stay on track.

• Describe structure and payment models for community pharmacy provided smoking cessation programs.

Learning Objectives

10/13/2016

3

The Duck

Walk• Fly• Swim

The Pharmacist

10/13/2016

4

Identify, Target, Attract Patients

Current Patients

AND

Future Patients

Current Patients

Bag stuffers & in-store signage Referrals

Staff Buy-In

10/13/2016

5

Current Patients

• Dispensing data• Nicotine replacement

• Buproprion or varenicline

• Breathing and airway medications

• Follow your nose

Future Patients

• Outside signage

• Doctors’ offices, health department

• Hospital discharge

• 70% of smokers want to quit

10/13/2016

6

Take ACTION Now!

• Write down one prescriber you plan to address this idea with at home

• Write down one place to advertise this outside the walls of your pharmacy

• How will you best gain your staff’s support?

Setting a Quit Date and Staying on Track

• New help line commercial

• Patients need to be ready

• Use the Seasons to help you

10/13/2016

7

“The 5 A’s”

1. Ask

2. Advise

3. Assess

4.Assist

5. Arrange

ACCP Updates in Therapeutics 2016: Ambulatory Care Course

1. Ask

• Consider it a vital sign

2. Advise

• Clear, strong, and personalized

3. Assess

• Addiction level

• Readiness or belief they can quit

ACCP Updates in Therapeutics 2016: Ambulatory Care Course

10/13/2016

8

4. Assist

• Combination of drugs and counseling is more effective than either drugs or counseling alone

5. Arrange a follow-up contact

• Can take five years to quit for good

• 65% of self-quitters relapse during the first week

• 40% relapse after one year

ACCP Updates in Therapeutics 2016: Ambulatory Care Course

Motivational Interviewing for Patients Unwilling to Quit

• Express Empathy

• Develop Discrepancy

• Roll with Resistance

• Support Self-Efficacy

U.S. Public Health Service. Treating Tobacco Use and Dependence

10/13/2016

9

Take ACTION Now!

• Write down one place in your normal work routine you plan to ask patients about their smoking status.

• What season do you think would work best to start your own program?

• How will you respond when resistance to quitting is encountered? (important!)

Describe Structure and Payment Models

Structure:

• 12 week program• 6 weeks class setting• 6 weeks one-on-one

• Meet once per week in person with calls in between

• Support group environment can be helpful

• Be prepared: Emotions can run high!

• Written statements provide visual reminder

10/13/2016

10

Payment

• Average margin on varenicline $23

• Cmpd Nicotine Suckers 60-80% margin

• Flu & Pneumonia Vaccination• 13 strain margin of $30-55 and up• Will need the 23 strain one year later

• Corticosteroid/LABA or tiotropium average margin $29-58

Biggest Reward of All

• The impact you can have on a patient’s life is the biggest reward of all.

• A NEW patient for life (huge profit)

• A friend for life

10/13/2016

11

Take ACTION Now!

• Write down if you think a one-on-one or a group class would be more practical to implement your practice.

• How often do you plan to structure your contact with patients?

• How will you identify additional prescription and immunization needs of program participants?

Tomorrow’s Pharmacist

Is

A Different Kind of Animal

10/13/2016

12

Bibliography

• Duck or Rabbit Illusion. Digital image. DMN3 blog. https://www.dmn3.com/dmn3-blog/you-need-a-quality-website-to-create-trust-in-visitors-minds. Web. 13 September 2016.

• Medication Therapy Management Visual Wheel. Digital image. Pharmacist APhA. http://www.pharmacist.com/mtm. Web. 13 September 2016.

• Uncle Sam I Want You. Digital image. Know your meme. http://knowyourmeme.com/memes/uncle-sam-s-i-want-you-poster. Web. 13 September 2016.

• Cute Pink Elephant. Digital Image. 123rf. http://www.123rf.com/photo_2479192_cute-pink-elephant-vector-illustration.html. Web. 13 September 2016.

• Cute Snake. Digital image. Clipart Panda. http://www.clipartpanda.com/categories/cute-snake-clipart-black-and-white. Web. 13 September 2016.

• Moon, Jean. Pulmonary Disorders. In: Bainbridge JL, Cardone K, Cross LB, et al. Update in Therapeutics: Ambulatory Care Pharmacy Preparatory Review and Recertification Course, 2016 ed. Lenexa, KS: American College of Clinical Pharmacy, 2016:1-774-1-784.

• U.S. Public Health Service. Treating Tobacco Use and Dependence. Clinical Practice Guideline. U.S. Department of Health and Human Services. 2008. Available at www.ncbi.nlm.nih.gov/books/NBK63952/. Accessed September 13, 2016.

• Cash Cow. Digital image. Jaskon Systems Blog. http://blog.jacksonsystems.com/meet-the-cash-cow. Web. 14 September 2016.

Ken Saunders, PharmD, TTS CHI Health Lakeside Hospital Pharmacy, Omaha, Nebraska

10/13/2016

13

Disclosure

Ken Saunders is receiving an honorarium for this program. The conflict of interest has been resolved by peer review of presentation content.

“Our greatest weakness lies in giving up. The most certain way to succeed is always to try just one more time.”

- Thomas A. Edison

10/13/2016

14

The Real Reason Dinosaurs are Extinct

• Tobacco use is a chronic disease

• 21% of American men and 19% of American women smoke

• Smoking-related diseases claim 480,000 American lives each year

• Smoking costs the United States approximately $97.2 billion each year in health care costs and lost productivity

• Smoking is directly responsible for 87% of lung cancer cases and causes most cases of emphysema and chronic bronchitis

The Problem

10/13/2016

15

• 22% of high school seniors smoke daily

• Male smokers incur $15,800 more lifetime medical expenses and 4 days lost from work per year

• Female smokers incur $17,500 more in lifetime medical expenses and 2 days lost from work per year

• Only 70% of family physicians currently ask their patients if they use tobacco

• Only 40% take further action.

• Return on Investment of a Tobacco Cessation program in place is $3250 / year / employee

The Problem

Provider

Friends

Internet

Family

TV, Radio

Faith Community

Community

Newspapers,Magazines

Co-workers

Role of the Health Care Team

MD assisted quit rates at one year are 10-30%

Multiple Influences on a Tobacco User

10/13/2016

16

0

5000

10000

15000

20000

25000

30000

1998-1999 1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 2004-2005 2005-2006

Pharmacy Medicine Dentistry Nursing Total

National Estimates:Number of Students Trained

Nu

mb

er

of

stu

de

nts

tra

ine

d

Academic year

“Not enough time”

“Minimal interventions

lasting less than 3 minutes

increase overall tobacco

abstinence rates.”

The PHS Guideline

(Strength of Evidence = A)

10/13/2016

17

“I can’t help patients stop.”

Guideline available at www.ahrq.gov

Effective interventions exist:

• Pharmacotherapy

• Brief counseling

• Intensive counseling

• System changes

• Tobacco dependence exhibits classic characteristics of drug dependence

• Nicotine:

• Nicotine is as addictive as heroin

• Causes physical dependence characterized by withdrawal symptoms upon cessation

• Smokers use tobacco to regulate their moods and emotions

Tobacco Use Results in a True Drug Dependence

10/13/2016

18

• Tobacco dependence requires ongoing rather than acute care

• Relapse is a component of the chronic nature of the nicotine dependence — not an indication of personal failure by the patient or the clinician

Tobacco Dependence is a Chronic Disease

• ASK about tobacco use.

• ADVISE to quit.

• ASSESS willingness to make a quit attempt.

• ASSIST in quit attempt.

• ARRANGE for follow-up.

The 5 A’s For Patients Willing To Quit

10/13/2016

19

• Ask every patient if he or she smokes

• Document as you would any other vital sign

• Flag files of smokers: • Status apparent at subsequent visits• Progress can be easily monitored

• Interactions exist between smoke/medicines

• Smoking is the leading preventable cause of death and disability in the world

• Tobacco use is either:• Causing the illness you are treating• Exacerbating symptoms• Impeding healing

Why Ask?

• I document using a progress note will help manage any QA reports with employers, medical directors, practice managers, third party payers

• Some sites may want to include vital signs, BMI, Blood pressure, pulse, while others may want to include a pain scale

• Progress notes are essential when services are reimbursed by a third-party payer. Audits do and will occur, especially with Medicare recipients

Documentation

10/13/2016

20

Drug Allergies _____________________________________

Diagnosis _________________________ Quit Line contacted Y N

Session 1 Date Time in Time out Total time Physician

________ _______ _________ __________ ______________

Medications started: _______________________

Notes:

Signed:_________________________________________ Date:___________________ Vitals _____________________

Diagnosis _________________________ Quit Line contacted Y N

Session 2 Date Time in Time out Total time Physician

________ _______ _________ __________ ______________

Medications started: _______________________

Notes:

Signed:_________________________________________ Date:___________________ Vitals _____________________

Diagnosis _________________________ Quit Line contacted Y N

Session 3 Date Time in Time out Total time Physician

________ _______ _________ __________ ________________

Medications started: _______________________

Notes:

Tobacco Treatment Counseling Documentation

• Even brief advice to quit results in greater quit rates

• Should be clear, strong, and personalized

Advise

“As your health care provider, I

must tell you that the most

important thing you can do to

improve your health is to stop

smoking.”

10/13/2016

21

• Are you willing to try to quit at this time? I can help you.

• Have you attempted to quit in the past?

• If so, how many times have you tried to quit?

• I have the training and tools that can help you quit.

• We can work together to accomplish this important goal.

Assess Willingness to Quit

• Help set a quit date

• Provide practical counseling (alcohol, illicit drugs, other smokers in home)

• Past quit experiences

• Anticipate challenges and barriers

• “Pharmacotherapy should be offered to all smokers trying to quit except where contraindicated”

Assist

Fiore 2000

10/13/2016

22

• Bring everything together

• Provide carbon monoxide testing to illustrate the need to quit

• Help patient with third-party payers if needed

• Lobby third party payers if needed

• Show outcomes data to prove need / benefit / ROI

Arrange

• Utilize other departments to assist

• Allow low-cost / no-cost follow up

• Be prepared for slips / relapse

• Arrange realistic therapy endpoints

• Follow up, Follow up, Follow up

• Any patient education encounter is a Medication Therapy Management opportunity

Arrange

10/13/2016

23

Refer patient to other programs:

• Telephone Quit Line: 1- 800 – QUIT - NOW

• Product cessation programs

• Local groups

• Hospital based interventions

• Web Site: www.quitnet.com

Other Tools

• Set up reimbursement depending upon course structure

• Patient pays cash

• Billing arrangements through employers

• Bill third party payers

• Medicaid

• with or without NRT’s or medications

• Medicare – with a collaborative physician agreement

• 2 cessation attempts per year including max 4 sessions, up to 8 sessions per 12 months

• Must wait 11 months from the 1st of the 8 sessions

• Some Medicare Part D plans support medication payment

• Questions call 1-800-633-4227 (1-800-MEDICARE)

Reimbursement

10/13/2016

24

• Become a part of your state’s Tobacco Free Program and website

• Set up reimbursement depending upon course structure

• Individual one-on-one counseling in a Clinic / Outpatient setting

• Group sessions – weekend or 4 week, 6 week, 8 week courses

• Market to local service groups – Kiwanis / Rotary / Veterans

• Market to local employers as part of a “Wellness Program” and Employee insurance premium decrease

• Market and contract with city, county, and state employees

• Perform CE programs for health care employees

Reimbursement Sources and Marketing Your Practice

• Patient preference

• Clinician familiarity with the medications

• Contraindications for selected patients

• Previous patient experiences with a specific agent (positive or negative)

• Patient characteristics (concern about weight gain, history of depression)

• Cost, Cost, Cost

• Remind patient that therapy is less expensive than tobacco

• Overcome patient reluctance to use medications

• Use medication assistance programs if needed

Factors to Consider When Choosing a Pharmacotherapy

10/13/2016

25

• Relevance: Tailor advice and discussion to each patient

• Risks: Outline risks of continued smoking

• Rewards: Outline the benefits of quitting

• Roadblocks: Identify barriers to quitting

• Repetition: Reinforce the motivational message at every visit

Treating Patients Not Ready to Make a Quit Attempt

Quitlines

1-800-QUIT-NOW

callers are routed to

a state-run quitline

or the National

Cancer Institute

quitline.

10/13/2016

26

• Every tobacco patient encounter is an opportunity for MTM

• Review medications along with NRT’s or other medications used to quit tobacco

• Report findings to physician

• Include therapy adjustment or change recommendations

• Monitor any inhaler use and reeducate proper administration

• Review and encourage cessation because of DM, COPD, HTN, anything

• Use carbon monoxide breathe analyzer to track success and compliance

• Approach anesthesiologists and surgeons on tobacco Cessation initiatives

Medication Therapy Management (MTM)

• Accept referrals for tobacco cessation and utilize MTM as a way to gain patient and physician trust and share provide outcomes data

• Add MTM to Tobacco Cessation contracts with groups and employers

• Consider MTM and a Medication Assistance Program (MAP) for the underinsured

• Report outcomes data for MTM and MAP programs to employers and prospective clients

• Since December 2007 through June 2016, my program has seen over 4100 patients and obtained over 4.85 million dollars worth of medications / cost savings due to MTM and MAP

• Emergency visits down by 70% for those that used ER as primary medication source

• Document, Document, Document

Medication Therapy Management

10/13/2016

27

• CDC

www.cdc.gov/tobacco

• ALA

www.lungusa.org

• ACS

www.cancer.org

• Mayo Clinic

www.mayoclinic.org

Training Information and Helpful Websites

• University of Massachusetts

http://www.umassmed.edu

• Rx for Change

http://rxforchange.ucsf.edu

• Tobacco Free Nebraska

http://dhhs.ne.gov/publichealth/Pages/tfn.aspx

Review of Tobacco Free Nebraska and Medicaid Reimbursement

for Tobacco Cessation Counseling with Medications

10/13/2016

28

10/13/2016

29

10/13/2016

30

10/13/2016

31

• Become a part of your state’s Tobacco Free Program and website

• Set up reimbursement depending upon course structure

• Individual one-on-one counseling in a Clinic / Outpatient setting

• Group sessions – weekend or 4 week, 6 week, 8 week courses

• Market to local service groups – Kiwanis / Rotary / Veterans

• Market to local employers as part of a “Wellness Program” and Employee insurance premium decrease

• Market and Contract with City, County, and State employees

• Perform CE programs for health care employees

Reimbursement Sources and Marketing Your Practice

10/13/2016

32

10/13/2016

33

There is Always the Exception

Jamie Mask, PharmD, Creative Pharmacist, Brandon, Mississippi

10/13/2016

34

Disclosure

Jamie Mask is receiving an honorarium for this program. The conflict of interest has been resolved by peer review of presentation content.

Shelley S. Hammond, MMCCenters for Disease Control and Prevention (CDC), Atlanta, Georgia

10/13/2016

35

Disclosure

Shelley Hammond declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.

Panel Discussion

10/13/2016

36