an affiliate of the University of Arizona Arizona Smokers’ Helpline Annual Report Fiscal Year 2017 Breathing Vitality into the Lives of Arizonans through Inquiry Innovation Inspiration Envisioning an Arizona where everyone achieves a healthy lifestyle. Arizona Smokers’ Helpline Annual Report: FY17 Table of Contents I. II. III. IV. V. VI. VII. VIII. IX. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Community Development . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Public-Private Partnerships (PPP) . . . . . . . . . . . . . . . . . . . . . . 3 IT/Communications & Client Support . . . . . . . . . . . . . . . . . . .4 Client Enrollment and Characteristics Call volume and Enrollment . . . . . . . . . . . . . . . . . . . . . . . . .5 Client Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Clinical Services Utilization of services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Overall Quit Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Research and Evaluation Initiatives . . . . . . . . . . . . . . . . . . . .9 Data Brief - ASHLine Client Demographic Trends: 2011-201510 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 List of Figures and Tables . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Arizona Smokers’ Helpline Annual Report: FY17 I. Executive Summary In FY 2017, expanded service provision, quality control, and advanced technology led our strategic initiatives. A significant effort went into the launch of our new webbased platform (ASHLine 2.0) that will allow for more tailored services and metric analysis over time. In addition, we addressed quality control efforts through robust training initiatives and service call recording with feedback analysis. To further expand reach and move toward sustainability, new PPP contracts were also formed and implemented. As we look forward and partner with statewide efforts to increase quit attempts, we plan to expand training across the state. The enhanced use of technology will allow us to do this, by supporting greater client engagement in services that support their tobacco behavior change efforts. Regards, Cynthia Thomson, PhD, RD Director, Arizona Smokers’ Helpline Figure 1. Program Highlights Total Calls 28,312 0.7% from FY2016 Total Referrals 10,817 4.6% from FY2016 7-Month Tobacco Quit Rate 38.5% 6.3% from FY2016 7-Month Nicotine (Tobacco + ENDS) Quit Rate 37.2% 2% from FY2016 1 / ASHLINE ANNUAL REPORT | FY2017 | Total Enrollments 11,187 2.0% from FY2016 Arizona Smokers’ Helpline Annual Report: FY17 II. Community Development The focus of ASHLine’s Community Development Team is to promote tobacco-related health systems change across Arizona. We accomplish this by building, maintaining, and expanding ASHLine’s provider referral program and providing technical assistance to healthcare providers and community organizations to support them in connecting their clients to the quitline. Our core community development effort includes providing tailored trainings on Ask, Advise, Refer (AAR) briefinterventions that are evidence-based strategies for promoting tobacco behavior change. During FY17, we completed 99 trainings to over 1,030 providers across 12 different types of partner organizations. The majority of trainings were focused within behavioral health and medical settings. We also expanded our referral network to include new partner organizations and added more than 200 new locations. In our expansion efforts, we emphasized collaborating with medical, behavioral, specialty care, and community service organizations. Our ongoing efforts in this area continue to drive provider referrals to the quitline. In FY17, ASHLine received 10,817 proactive referrals from over 1,200 different providers. Similar to last year, the top three referring sectors were acute care hospitals (39%), medical practices (16%), and behavioral health clinics (11%) (See Figure 2). Figure 2. Referrals by Location Type Long Term Care Facility 1 Corrections/Probation/Re-Entry 1 Multi-unit Housing 3 Department of Defense/Veteran’s Affairs 4 16 16 Other Specialist 26 Hospital-Rehabilitation/Specialty 32 Work-site 42 Pediatric/Adolescent/Family 45 OB/GYN/Woman's Health 49 IHS/Tribal 638/Native American/American Indian 50 Well-Woman Health Check (WWHP) 106 Cancer/Oncology 128 Community Service Provider/Non-Profit Organization 133 Dental/Oral Health Practice 144 2 / ASHLINE ANNUAL REPORT | FY2017 | Pharmacy HIV/AIDS Specialist 286 Country Health Department Woman,Infants, and Children (WIC) 333 School/University 334 903 Health Insurance Plan 1085 Federally Qualified Health Center (FQHC)/FQHC Look-Alike 1194 Behavioral Health 1679 Medical Practice 4207 Hospital-Acute Care 0 500 1000 1500 2000 2500 3000 3500 4000 4500 Arizona Smokers’ Helpline Annual Report: FY17 Table 1. Percent of Referrals Reached and Enrolled by Top Five Location Types Top Five Location Types Percent Reached Percent Enrolled Medical Practice 63% 69% 20% 32% Behavioral Health 62% 24% Federally Qualified Health Center (FQHC)/FQHC Look-Alike Health Insurance Plan 71% 71% 34% 29% Hospital, Acute Care The Community Development team has worked with the IT/Communications team to launch a new electronic referral system. To facilitate the system’s use, we developed an accompanying user guide and training materials to assist providers who prefer to refer electronically. During the final quarter of FY17, we began training and transitioning providers interested in using the e-referral system. To date, we have received consistently positive feedback from providers who report that the system is easy to use. Our next steps include marketing for greater use and testing for secure electronic feedback reporting for referrals. We anticipate this going live in the first quarter of FY18. III. Public-Private Partnerships (PPP) During the pilot, ASHLine offered a no cost, employer-based tobacco cessation program to a select group of employers for two years. After reconvening with these employers and determining value-added services, ASHLine transitioned three of these relationships into paid service contracts as of February 2017. In addition to ASHLine’s standard services, these contracts include monthly reporting, on-site engagement (i.e., lunch and learns), online program enrollment, and promotion of insurancecovered cessation medications. Currently contracted employers come from healthcare and IT industries. With leadership and support from ADHS, ASHLine has also initiated fee-for-service discussions with one of the largest private insurers in Arizona. 3 / ASHLINE ANNUAL REPORT | FY2017 | ASHLine’s Public-Private Partnerships (PPP) team made important headway during FY17. We remain focused on building strategic partnerships with organizations (e.g., employers, insurance companies, and insurance brokers) who are interested in providing tobacco cessation services and staying informed on Arizona-specific health issues and policies. Through our outreach, we have established partnerships with existing worksite wellness promotion programs, including Healthy Pima and the Healthy Arizona Worksites Program. In the first quarter of FY17, we completed the pilot phase of our employer program. Arizona Smokers’ Helpline Annual Report: FY17 IV. IT/Communications & Client Support In FY17, the IT/Communications & Client Support Team has focused primarily on developing, implementing, and improving ASHLine 2.0, ASHLine's software platform. Since launching in June 2016, we have implemented numerous additions and fixes to improve the system’s functionality and user experience. Using the system, we are also able to now automate encrypted and secure status reports to providers who submit referrals, exceeding HIPAA industry standard compliance. This reduces reliance on fax technology to send incoming and outgoing referral communications. As we incorporated telephone services with the web platform, we were able to add SMS and call recording features. This improved our service and quality improvement capabilities while reducing the overall cost for phone services moving forward. 4 / ASHLINE ANNUAL REPORT | FY2017 | Arizona Smokers’ Helpline Annual Report: FY17 V. Client Enrollment and Characteristics Call volume and Enrollment During FY17, ASHLine received 28,315 calls and enrolled 11,187 clients into our tobacco cessation services. Although the total number calls were slightly lower compared to the previous fiscal year, the overall number of enrolled clients increased, indicating that we were able to improve our efficiency in converting incoming calls and referrals to enrollments. Our promotional reach (the percentage of total calls to the number of adults who use tobacco in AZ) this fiscal year was 4%, a comparable rate to other state quitlines. Of the 28,315 total calls to ASHLine, 21,740 were made during regular business hours. From the callers who reached ASHLine directly, 7,668 individuals opted to enroll, a conversion rate of 35% (see Table 1). An additional 6,575 calls were made after-hours, on weekends, or during holidays when ASHLine was closed. These were answered by Contact One, a HIPAAcompliant, contracted phone service. Of those who called Contact One, around 11% became ASHLine clients. Twenty-six percent of healthcare and community partner referrals were reached and enrolled in services. It is common across quitline settings to see a lower conversion from provider referrals than incoming calls. Research suggest a few factors may contribute to the difference; in general, provider-referred clients have more chronic conditions, are more dependent on nicotine, and experience greater barriers to accessing cessation medications. It is important to note that the provider referral system is integral to increasing access to care among to high-risk individuals who smoke. The Community Development team continues to work with providers to improve this process and our ability to reach and serve these individuals. Table 2. Conversion of Calls and Referrals to Enrollment Calls to Contact One* Referrals to ASHLine Total Enrollments Percent enrolled 21,740 6,575 10,817 7,668 733 2,786 35.3% 11.1% 25.8% 11,187 *Contact One is a live-answer phone service that receives after-hours calls to ASHLine 5 / ASHLINE ANNUAL REPORT | FY2017 | Direct Calls to ASHLine Total Arizona Smokers’ Helpline Annual Report: FY17 The increase in enrollments from FY16 is a result of multiple efforts, including direct marketing efforts that encourage smokers to call the ASHLine as well as the “Text2Enroll” campaign, an initiative that directs clients to initiate program contact online. Figure 3. How Clients Report Hearing about ASHLine 10% Media 11% 41% 2% Healthcare Provider Community Organizations Former Client Family/Friends 34% Yavapai 3% Cococino 1% Navajo 1% Mojave 5% Apache 0% Gila 1% Client Characteristics The majority of ASHLine clients (72%) reside in Maricopa and Pima counties (see Figure 4). Since last fiscal year, client enrollment increased in Cochise, Pima, Pinal, and Santa Cruz counties. The largest increase was in Pima County, which rose from 16% to 20%. The distribution of clients in the remaining counties either stayed the same or decreased. La Paz 1% Greenlee 0% Graham 1% Yuma 1% Pima 20% Pinal 6% Santa Cruz 2% Cochise 3% Figure 4. Distribution of Clients by County 6 / ASHLINE ANNUAL REPORT | FY2017 | Maricopa 52% Arizona Smokers’ Helpline Annual Report: FY17 Consistent with previous years, the majority of ASHLine clients in FY17 were female (56%), NonHispanic (79%), and white (84.8%). Over half of ASHLine clients were uninsured or AHCCCS (Medicaid) beneficiaries, and 78.6% reported having either a chronic or a mental health condition, or both (see Table 3). Individuals who use quitline services are those who face increased risk for tobacco use. For example, the proportion of clients reporting at least one chronic health condition is up from 71% in FY16. Conversely, the number of e-cigarette using clients declined by almost 50% (9% compared to 4.6%), despite the provision of full services for e-cigarette users. Table 4. Percent Enrolled by AHCCCS Insurance Plans AHCCCS Insurance Plans Mercy Care Plan United Healthcare Community Plan Health Choice AZ University Family Care Care 1st Arizona CRS UnitedHealthcare Community Plan Don't Know Table 2. Client Demographics Gender Female Male 56% 44% Ethnicity Non-Hispanic Hispanic 79% 21% Race White Black or African American Asian Hawaiian American Indian Multiracial Other Race 84.8% 8.2% 0.7% 0.3% 2.4% 2.0% 1.6% Insurance AHCCCS Other Types Uninsured 40.1% 43.9% 15.9% Electronic Cigarette Use Tobacco user only Electronic Cigarette User Only Dual User 95.4% 0.8% 3.8% Age ≤ 24 25 - 44 45 - 64 ≥ 65 3.6% 27.3% 50.9% 18.2% Percent Enrolled 28% 15% 14% 8% 5% 4% 3% 2% 0% 0% 20% Comorbid Condition None Chronic Health Condition Only Chronic Health Condition Only Chronic and Mental Health Condition 21.4% 25.4% 17.9% 35.4% 7 / ASHLINE ANNUAL REPORT | FY2017 | Health Net of Arizona Maricopa Health Plan Phoenix Health Plan Bridgeway Health Solutions - LTC Table 3. Client Characteristics Arizona Smokers’ Helpline Annual Report: FY17 VI. Clinical Services Utilization of services Based in elements of cognitive behavior therapy and motivational interviewing, ASHLine uses a client-directed, collaborative approach to providing cessation treatment. As part of our services, we offer behavioral coaching support and free nicotine replacement therapy in the form of nicotine gum, patches, and lozenges to clients who are uninsured or have private insurance. ASHLine does not provide NRT to clients with Medicaid insurance. The state’s tobacco fund currently pays Arizona’s state Medicaid program to cover the cost of cessation medications. This allows the state to avoid duplicative spending. Instead, we navigate clients to their primary care physician for a prescription to obtain cessation medications through their health insurance plan. During FY17, 69.5% of eligible clients received some form of NRT through the ASHLine. Over 76% of all clients received at least one coaching call and 20% received five or more coaching calls. Overall Quit Rates Studies have consistently shown that the best way to quit tobacco is using a combination of NRT and behavioral coaching. The efficacy of using such a combination is evident in our quit rates as well. While our overall quit rate is 38.5%, over half the clients (53%) who use NRT and engage in at least five coaching sessions report being quit at follow-up (see figure 5). Figure 5. Quit rates by number of coaching sessions and cessation medication use Meds No Meds 52.8% 29.8% 37.1% 22.1% 1-2 Sessions 3-4 Sessions 5+ Sessions 8 / ASHLINE ANNUAL REPORT | FY2017 | 29.8% 27.4% Arizona Smokers’ Helpline Annual Report: FY17 VII. Research and Evaluation Initiatives To improve ASHLine, we regularly monitor ongoing services and conduct quality improvement projects. In the past year, we focused on evaluating three aspects of service delivery. First, in taking advantage of our platform’s new ability to record calls, we initiated a call monitoring process to improve data collection, quality control, and program delivery fidelity. We developed call monitoring checklists and reports to monitor outcomes and inform members of our clinical team. Second, we developed an evaluation framework that delineated key factors pertinent to ASHLine’s performance. To do this, we constructed an ASHLine Entity Relationship Diagram which was used to identify monitoring metrics and indicators of performance success. Going forward, this will be used as a map to track metrics for key aspects of service delivery. Finally, recognizing a lack of clarity around the use of electronic cigarettes as potential cessation aids, a workgroup was created consisting of members from the Evaluation, Community Development, and Clinical teams. The workgroup developed an organizational policy around electronic cigarettes. To ensure that our policies are in line with emerging scientific evidence, this taskforce is scheduled to meet twice a year to review the latest ENDS research and recommendations to update policies and fact sheets as needed. into the program. A complete list and copies of published data briefs can be found on the Arizona Department of Health Services’ Tobacco Free Arizona website. Our evaluation initiatives also involve exploring other programmatic aspects of ASHLine’s services. These efforts are published as monthly data briefs on the Arizona Department of Health Services (ADHS) website. Past year data brief topics include a range of topics, including our new Short Message Service (SMS) program, using post-card reminders to increase client engagement and retention, the use of smoking cessation medication among Medicaid beneficiaries, and predicting which clients re-enroll • http://azdhs.gov/prevention/tobacco-chronicdisease/tobacco-free-az/#reports In addition to writing data briefs, ASHLine has organized an interdisciplinary team of researchers that produces research to share with the scientific community at research conferences and through scientific manuscripts. This year, we made presentations at five professional conferences, including an oral session at the North American Quitline Consortium’s (NAQC) annual conference in March 2017 and poster sessions at the University of Arizona’s Cancer Center, the American Academy of Health Behaviors, the American Society for Preventive Medicine, and the Society of Behavioral Medicine. We have one research article currently in press for publication and several others that are in progress. Topics include: • • • 9 / ASHLINE ANNUAL REPORT | FY2017 | • Predictors of tobacco cessation for quitline clients implementing home smoking bans (in press) Quit rates and program utilization among healthcare provider referred clients Tobacco cessation among American Indian/ Alaskan Native populations Medicaid clients, medication use, and cessation outcomes Review of electronic cigarette policy statements Arizona Smokers’ Helpline Annual Report: FY17 VIII. Data Brief - ASHLine Client Demographic Trends: 2011-2015 Quitlines are well-established as an evidence-based standard of care for tobacco cessation. However, as the prevalence of smoking has declined over time, some evidence exists that the clientele for quitlines may have shifted demographically. Theories like the “hardening hypothesis” explain this shift in terms of differences among smoker subgroups’ ability to quit and likelihood to continue smoking, particularly among those who seek assistance from treatment services.1 For example, as awareness of the harm of tobacco use has increased, light tobacco users and others who find it easier to quit have done so. Thus, over time, those who continue to use tobacco might be expected to experience risk factors that make cessation difficult, such as low socio-economic status and other physical and mental health conditions. The purpose of this data brief is to investigate trends in ASHLine client demographics from calendar years 2011 through 2015. 10 / ASHLINE ANNUAL REPORT | FY2017 | We observed that age, gender, educational level, and racial/ethnic distributions remained stable over the time period, as did the enrollment of gender and sexual minorities. While most chronic conditions remained stable over the five-year period, the percentage of clients who reported being diagnosed with a mental health condition rose from 32% to 43% (a 30% increase), and the percentage of clients reporting high blood pressure (hypertension), increased from 29% to 33%, with the largest increases occurring between 2013 and 2015 (see Figure 7) . With regard to insurance coverage and poverty, the percentage of clients reporting household income below the Federal Poverty Level was highest in 2013, while the percentage of clients enrolled in AHCCCS was lowest in the same year. In contrast, 2014 saw the percentage of clients enrolled in AHCCCS increase from 15.4% to 25.3% (see Figure 8). The timing of the jump is consistent with the initiation of the enforcement mechanism of the Affordable Care Act’s individual insurance mandate on January 1, 2014. Some research has shown that though smoking prevalence has been declining steadily in the U.S. population as a whole, those who are covered by Medicaid have not experienced a decline at all. This distinction can be explained in part by high rates of mental illness, chronic disease, and fewer quit attempts for those who are have Medicaid insurance.2 Arizona Smokers’ Helpline Annual Report: FY17 Figure 6. ASHLine Client Chronic and Mental Health Conditions, 2011-2015 50.0% 45.0% Mental Health 40.0% 35.0% High Blood Pressure 30.0% 25.0% 20.0% Asthma COPD 15.0% Diabetes Heart Disease 10.0% Cancer 5.0% 0.0% 2 Discussion 4 5 Next steps are to identify changes across these characteristics at the state level and compare them with ASHLine trends. This will allow us to understand if ASHLine is proportionally reaching smoking groups and whether changes in the smoking population translate to changes in ASHLine enrollment. This work would allow us to determine whether future efforts are warranted to increase the program's reach and engage underserved populations. 11 / ASHLINE ANNUAL REPORT | FY2017 | It has long been known that certain groups smoke at higher rates, like individuals with low socioeconomic status and those with mental illness. These characteristics are associated with an increased likelihood of smoking and pose barriers to quitting. As the overall prevalence of smoking continues to decline in the US and in Arizona, it is important to understand whether these reductions are experienced proportionally or disproportionally across these at-risk groups. From 2011 to 2015, for example, smoking rates in Arizona fell from 19.3% to 14%. Thus, in this brief we explored whether the distribution of individuals who smoke and use ASHLine services has changed. Our analysis has shown that the majority of demographic characteristics of ASHLine clients remained stable for the five-year period. 3 Arizona Smokers’ Helpline Annual Report: FY17 Figure 7. ASHLine Client AHCCCS Coverage and Household Income, 2011-2015 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 1 2 3 Household Income below Federal Poverty Level 4 5 Medicaid Insured References 1. Hughes JR. The Hardening Hypothesis: Is the Ability to Quit Decreasing Due to Increasing Nicotine Dependence? A Review and Commentary. Drug Alcohol Depend. 2011;117(23):111-117. 12 / ASHLINE ANNUAL REPORT | FY2017 | 2. Zhu S-H, Anderson CM, Zhuang Y-L, Gamst AC, Kohatsu ND. Smoking prevalence in Medicaid has been declining at a negligible rate. PLoS ONE. 2017;12(5):e0178279. Arizona Smokers’ Helpline Annual Report: FY17 List of Figures and Tables Figure 1. Program Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Figure 2. Referrals by Location Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Table 1. Percent of Referrals Reached and Enrolled by Top Five Location Types . . . . . 3 Table 2. Conversion of Calls and Referrals to Enrollment . . . . . . . . . . . . . . . . . . . . . . . 5 Figure 3. How Clients Report Hearing about ASHLine . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Figure 4. Distribution of Clients by County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Table 3. Client Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Table 4. Percent Enrolled by AHCCCS Insurance Plans . . . . . . . . . . . . . . . . . . . . . . . . . 7 Figure 5. Quit rates by number of coaching sessions and cessation medication use . 8 Figure 6. ASHLine Client Chronic and Mental Health Conditions, 2011-2015 . . . . . . . 11 Figure 7. ASHLine Client AHCCCS Coverage and Household Income, 2011-2015. . . . . 12 13 / ASHLINE ANNUAL REPORT | FY2017 | Breathing Vitality into the Lives of Arizonans through Inquiry Innovation Inspiration Envisioning an Arizona where everyone achieves a healthy lifestyle. For more information about the Arizona Smokers’ Helpline: ASHLine University of Arizona Mel and Enid Zuckerman College of Public Health Arizona Smokers’ Helpline Abrams Public Health Center 3950 S. Country Club Road, Suite 300 Tucson, Arizona 85714 t. 800-55-66-222 f. 520-318-7222 w. ashline.org e. info@ashline.org For questions regarding our report, please contact Dr. Uma Nair at: umanair@email.arizona.edu © Contents Copyright 2017, University of Arizona. All rights reserved.