Pre-Implementation Module – Case Studies

Context: Matrix cancer center affiliated with an academic medical center that treats >20,000 oncology patients per year, roughly 6% of whom report current tobacco use. 

Tobacco Treatment Program target population: Outpatients, started with radiation patients and expanded to other oncology patients. Patients’ family members who smoked were referred to the state tobacco quitline.

Intervention: A message-based referral system in Cerner allows care teams to refer patients to a Tobacco Treatment Specialist (TTS). This system implemented a tobacco dependence treatment program that provided pharmacotherapy, and external referrals to the state tobacco quitline and text/mobile-based programs.

Opt-in workflow: Every patient identified by nursing staff as smoking in the past 30 days who is referred by oncology care teams to tobacco treatment gets a live call from a Tobacco Treatment Specialist (TTS) for assessment, including for pharmacotherapy contraindications. The TTS places a tobacco quitline referral to connect patients with remote cessation counseling, and uses an order set to coordinate pharmacotherapy prescribing with oncologists (or a designated alternative prescriber if oncologists are not comfortable managing tobacco treatment). Patient education materials (including testimonial videos), written at the 3rd-4th-grade reading level are used to promote uptake of referrals.

Challenges and solutions: Some patients reported that coming to the center for in-person assessment and treatment was difficult, and traffic in the area was heavy. One solution to this barrier was offering telehealth appointments. The program is also working to expand to additional sites, and to integrate tobacco treatment referrals into lung cancer screenings. 

Context: Cancer center affiliated with an academic medical center that treats >30,000 oncology patients per year, roughly 10% of whom report current tobacco use. 

Tobacco Treatment Program target population: All medical oncology outpatients in the cancer center, and in more than 700 affiliated clinic sites (including rural areas).

Intervention: Point-of care brief counseling and pharmacotherapy education and prescribing, supplemented by telehealth counseling from tobacco treatment specialists and external referrals to the state tobacco quitline, SmokefreeTXT, and web resources.

Opt-in workflow: Medical assistants and nurses screen for tobacco use frequently (not just at intake), advise quitting, add tobacco use disorder to the problem list, and see an EHR alert prompting tobacco treatment offers that link to quitline and Smokefree.gov (text or App) eReferral orders. Then, oncology clinicians see an EHR alert that prompts medication orders for cessation or reduction of tobacco use. The state quitline and Smokefree external referral programs return eReferral results to the EHR. Patients receive hard-copy education materials about tobacco treatments at the point of care. Medical assistants and nurses follow-up with patients.

Challenges and solutions: The program was designed to address key barriers to tobacco treatment implementation. To address lack of clinician time, the program team worked with clinician champions to design an EHR module that would be efficient and acceptable to clinicians.  To address clinician and program leader lack of knowledge about how implementation is going, oncology teams were provided initial training and ongoing feedback regarding implementation and effectiveness via a sustainable learning health system approach. To address barriers to an in-house referral model (i.e., few referrals, low referral yield, unsustainable billing for tobacco treatment specialist services), the program adopted a model in which tobacco counseling and pharmacotherapy can occur at the point of care (supplemented by external referrals to public resources).

Context: Comprehensive Cancer Center and academic medical center affiliated with a network of cancer centers that sees >30,000 patients per year, approximately 5% of whom report current tobacco use. Endorses tobacco control as a fourth pillar of cancer care throughout the network.

Tobacco Treatment Program target population: Eligible populations included inpatients, outpatients, family members, staff, and community members at multiple locations.

Intervention: Individual, group, and point of care counseling, both in-person and via telehealth, provided by a nurse practitioner. Pharmacotherapy was provided, and billed to insurance, along with counseling. This system also offered referrals to state tobacco quitlines and SmokefreeTXT, web resources, and educational videos. Community outreach efforts were part of the program, along with targeted outreach based on geospatial data analyses to enhance health equity.

Opt-out workflow. The program moved from an opt-in program to an opt-out program facilitated by an EHR prompt for clinicians at the point of care. Counseling by a tobacco treatment specialist is offered via telehealth to enhance its reach. Cessation support groups are offered.

Challenges and solutions: Clinicians are trained to address the BPA, and clinician and nurse champions are identified and trained at each site and each clinic to enhance initially low rates of adoption and implementation of the program. Center directors offer “shout-outs” to programs to reinforce their engagement. Tobacco treatment specialists are allocated to areas with high tobacco prevalence. Acceptance of referrals was low initially, so treatment outreach efforts then focused on key “teachable moments” (e.g., at screening, diagnostic, or new treatment planning visits). Patient choices regarding treatment components and modalities were diversified to increase patient interest in treatment. Cessation support groups were added to address psychosocial stressors, in response to patient interest. Funding challenges have been met in part by helping patients utilize HMO-provided tobacco treatment resources already available to them, and through state and county grants. Charitable funding is used to provide pharmacotherapy at no cost to patients who could not otherwise afford it. Maintaining leadership focus and support is aided by ongoing communication regarding value and equity.

Context: Academic medical center serving >10,000 oncology patients per year, roughly 7% of whom report current tobacco use. 

Tobacco Treatment Program target population: Oncology outpatients and patients’ family members in the flagship center and affiliated sites.

Intervention: The program provides individual in-person and telehealth counseling to offer patients flexibility. This system also offers pharmacotherapy, SmokefreeTXT, and web resources. Roughly a third of patients are referred to psychosocial oncology services. 

Opt-in workflow: Medical assistants screen for tobacco use at every clinic visit and all those who report current smoking receive an outreach letter describing tobacco treatment resources, including the state tobacco quitline and SmokefreeTXT. In addition, patients who smoke receive a tobacco treatment outreach call. All patients have access to in-person or phone counseling from tobacco treatment specialists. In-person counseling is delivered by a nurse practitioner who can also provide free NRT (provided at no cost to patients by a corporate donor).

Challenges and solutions: Sustaining funding was a challenge, and this was successfully navigated by keeping senior leaders engaged in program planning and providing updates regarding the reach and impact of the program, and by securing NRT donations to reduce barriers to NRT access for patients after grant funding ended. Inviting an expert (Graham Warren, MD) to give a Grand Rounds presentation on the clinical importance of addressing tobacco in cancer care helped engage interested parties and enhance buy-in. Holding monthly meetings with IT staff helped to address challenges as did sustaining efforts to educate clinicians about the importance of addressing tobacco use with all new patients. Offering the option to complete counseling by phone helped address access challenges (distance, parking problems) for in-person care.

Context: University-affiliated cancer center  treating >100,000 patients per year, with roughly 5% reporting current tobacco use.

Tobacco Treatment Program target population: Inpatients, outpatients, and family members who currently use tobacco or recently quit were eligible for tobacco treatment services. 

Intervention: Comprehensive and long-standing tobacco treatment program that offers in-person behavioral counseling, video visits for counseling, pharmacotherapy, walk-in services, self- or clinician-referral, and proactive outreach to all patients whose EHR captures current tobacco use, and those who recently quit using tobacco. 

Opt-out workflows: Tobacco screening occurs via the patient EHR portal prior to visits, or in a tablet in the waiting room, and is reviewed by medical assistants during vital sign assessment. Patients can initiate treatment many ways, and will receive proactive outreach. Medical assistants and clinicians advise quitting tobacco, and clinicians provide counseling and order pharmacotherapy at the point of care, and alert patients they are being referred to a tobacco treatment specialist who sends a text message to the patient before calling to offer motivational interviewing and schedule a tobacco treatment intake. The tobacco treatment specialist offers in-depth counseling and then loops in a prescriber who can evaluate and prescribe pharmacotherapy. The tobacco treatment specialist sends printed tobacco control materials (to both patients who engaged in services and those who decline or are not reached). Treatment specialists offer 6-8 additional counseling sessions via telehealth. Prescribers and clinicians do a medication check three weeks after prescription, and treatment specialists follow-up with patients 6, 9, 12, and 15 months after entering treatment.

Challenges and solutions: The program is internally funded. An effort to bill for services was accompanied by a decline in engagement, so the program stopped billing for services.

Context: Matrix comprehensive cancer center affiliated with an academic medical center that treats >30,000 oncology patients per year, roughly 10% of whom report current tobacco use. Initiated the program in radiation oncology before expanding center-wide.

Tobacco Treatment Program target population: Inpatients, outpatients, and family members who currently use tobacco are eligible for tobacco treatment services. 

Intervention: The program offers individual in-person and telehealth counseling and referrals to the state Quitline, using an automated EHR clinical decision support (CDS) and eReferral system. A reimbursement model for counseling services helps fund the program.

Opt-out workflow: A CDS embedded within the EHR supports standardized, mandatory assessment of smoking status for all oncology patients and automated electronic referral to a certified tobacco treatment specialist. Rooming staff screen for tobacco use at all new patient visits, and use the CDS tool to place an unsigned referral-to-treatment order in the patient’s encounter record. This pended order prompts oncologists to review and sign the order, if appropriate for the patient.

Challenges and solutions: High rates of clinician order cancellation in the automated referral process were identified as a significant barrier to patient treatment engagement. Qualitative interviews with clinicians and patients identified specific biases that supported the cancellation rates and undermined the reach of the program. The program team developed and tested behavioral economics-informed implementation strategies, nudges in the automated EHR referral system, to combat these biases; they found that the clinician nudges reduced order cancellations and increased patient engagement.

Context: Matrix comprehensive cancer center affiliated with an academic medical center that treats >90,000 oncology patients per year, roughly 9% of whom report current tobacco use. 

Tobacco Treatment Program target population: Outpatients who currently use tobacco are eligible for tobacco treatment services. 

Intervention: The program offers individual in-person and telehealth counseling, pharmacotherapy, and referrals to SmokefreeTXT, and to relevant smoking cessation and harm reduction studies that are recruiting. A fee-for-service model for counseling services helps fund the program. Patients with no or limited insurance coverage are referred to free services, such as the state Quitline.

Opt-in workflow: Rooming staff screen for tobacco use at all new patient visits. If a patient reports current tobacco use, an EHR alert prompts oncologists and nurse practitioners to assess suitability for tobacco use treatment before selecting pharmacotherapy (if appropriate) and signing a pre-populated pharmacotherapy and referral order. Patients who smoke are added to a tobacco use registry in the EHR that program staff use to guide proactive outreach to patients. A reporting mechanism identifies which patients view outreach messages and engage in treatment.

Challenges and solutions: As the program expanded across multiple care centers in the network, there was heterogeneity in local support for implementation. The program lead, tobacco treatment specialist, clinical champion, and IT staff member attended monthly care network meetings, dedicated time to understanding the workflows and clinical cultures of each center, and solicited clinician feedback to tailor EHR tools for improved integration and adoption across the network.

Champions: This center had a key administrative champion directing

the care network and a key physician champion who served as a 

representative at the care centers to influence adoption of the workflow.

Context: Matrix comprehensive cancer center affiliated with an academic medical center that treats > 6,000 oncology patients per year, roughly 19% of whom report current tobacco use. Initiated the program in the cancer center and expanded to two sites in a rural cancer care network.

Tobacco Treatment Program target population: Inpatients and outpatients who currently use tobacco are eligible for tobacco treatment services. 

Intervention: The program offers point-of-care brief counseling and pharmacotherapy education and prescribing, supplemented by individual and group telehealth counseling and referrals to the state Quitline, SmokefreeTXT, and web resources.

Opt-in workflow: Navigators screen for tobacco use in health records prior to visits, and rooming staff assess tobacco use. If a patient reports tobacco use, their smoking status is highlighted with vital signs in the EHR. Oncologists and nurse practitioners can prescribe brief counseling and pharmacotherapy; import documentation templates into their notes to document and bill for these tobacco treatment services at the point of care; and refer patients to additional telehealth counseling delivered by a certified tobacco treatment specialist, the state Quitline, or SmokefreeTXT. 

Challenges and solutions: To implement a point-of-care model, the program team adopted a systems change approach to integrate tobacco treatment services in existing clinical workflows through staff training and EHR modification. The team utilized rapid-cycle quality improvement to test and optimize incremental workflow changes and increase tobacco screening and treatment reach. The EHR was modified to incorporate smoking status as a highly visible vital sign, templates were disseminated to facilitate tobacco treatment documentation and billing, and medication lists were streamlined in the EHR templates to better support the workflow. The Director of Nursing was engaged as a key stakeholder to provide one-day training to all advanced practice providers to support point-of-care treatment. The program added a tobacco registry in the EHR to improve prospective treatment tracking and incorporated counseling and medication measures in their cancer registry to enable retrospective tracking.

Context: Matrix comprehensive cancer center affiliated with an academic medical center that treats >60,000 oncology patients per year, roughly 8% of whom report current tobacco use. 

Tobacco Treatment Program target population: Inpatients and outpatients who currently use tobacco are eligible for tobacco treatment services. 

Intervention: The program offers brief counseling and pharmacotherapy education and prescribing at the point-of-care , supplemented by individual telehealth counseling and referrals to the state Quitline, SmokefreeTXT, and web resources, with interactive voice response (IVR) follow up.  A reimbursement model for counseling services helps fund the program.

Opt-in workflow: The program utilizes two workflows: a high-volume, low-touch population approach, and a low-volume, high-touch individual approach. Navigators screen for tobacco use prior to visits and rooming staff assess tobacco use. Providers use a clinical decision support EHR set to efficiently provide and document brief point-of-care counseling, order pharmacotherapy, place a closed-loop eReferral to the state tobacco quitline, and/or set up additional appointments with a tobacco treatment specialist (TTS). The patient EHR portal enables proactive outreach to patients who currently use tobacco and connects them to self-led educational resources or TTS-led treatment services. Patients who engage in individual counseling with a tobacco treatment specialist are offered nicotine metabolite ratio testing for precision medication prescribing and no-cost nicotine replacement therapy. Patient follow-up is conducted via automated IVR calls.

Challenges and solutions: The program experienced significant and repeated challenges related to staff turnover. To combat this, team roles and responsibilities were fluid, and staff were flexible in working across the inpatient and outpatient programs. In addition, the program’s use of automated IVR calls alleviated patient follow-up and tracking responsibilities for staff.

Context: Matrix comprehensive cancer center affiliated with an academic medical center that treats >20,000 oncology patients per year, roughly 6% of whom report current tobacco use. The program is part of their community outreach and engagement program.

Tobacco Treatment Program target population: Inpatients and outpatients who currently use tobacco are eligible for tobacco treatment services. 

Intervention: The program offers individual and group in-person and telehealth counseling, pharmacotherapy, and referrals to the state Quitline, texting programs, and web resources. 

Opt-in workflow: Rooming staff screen for tobacco use. If patients report current tobacco use, rooming staff or providers order referrals to counseling services and place an eReferral to the state quitline. Clinicians can prescribe pharmacotherapy. Utilizing a tobacco registry, a certified tobacco treatment specialist reaches out to patients who did not receive smoking treatment at their clinic encounter, and follows up with patients who were referred to treatment services.

Challenges and solutions: Referral orders to counseling services or the state quitline in the EHR originally required a physician signature, which created a bottleneck in the workflow. With support from the Chief Medical Information Officer, the program team worked with IT to get the signature requirement dropped so that all rooming staff can directly refer patients to treatment.

Context: Collaborative cancer research center affiliated with an academic medical center that treats >20,000 oncology patients per year, roughly 8% of whom report current tobacco use. Piloted in head-and-neck and lung cancer clinics before expanding to all clinics.

Tobacco Treatment Program target population: Outpatients who currently use tobacco are eligible for tobacco treatment services.

Intervention: The program offers individual telehealth counseling, and rolling group telehealth counseling, along with pharmacotherapy and referrals to the state Quitline, SmokefreeTXT, and web resources. The program also uses interactive voice response (IVR) calls for referrals and follow ups. A reimbursement model for counseling services helps fund the program.

Opt-out workflow: Medical assistants screen for tobacco use and offer verbal advice to quit and educational materials through EHR templates for patient information and instructions at every patient visit, at all cancer clinics. Data on tobacco use status in the EHR are used to identify patients who will receive five IVR calls and emails with customized messaging and motivational prompts promoting use of tobacco treatment on an opt-out basis. Follow-up contacts assess smoking and prompt additional treatment and re-enrollment. A certified tobacco treatment specialist (TTS) reaches out manually to patients who are unresponsive to six-month IVR follow up. 

Challenges and solutions: Initially the program experienced a low response rate to six-month IVR calls. To reach unresponsive patients, the program supplemented IVR calls with email communications and direct outreach from the TTS.

Champions: The program engaged the Chief Medical Information Officer and the Clinical Research Integration Specialist as key champions who secured IT department buy-in for EHR modifications by classifying the workflow as a “standard of care.” This enabled the program to bypass the IT queue as a priority project.

Context: Comprehensive cancer center affiliated with an academic medical center that treats >60,000 oncology patients per year, roughly 3% of whom report current tobacco use. 

Tobacco Treatment Program target population: Inpatients, outpatients, and community members who currently use tobacco are eligible for tobacco treatment services. 

Intervention: The program offers individual telehealth counseling and referrals to the state quitline and SmokefreeTXT with interactive voice response (IVR) facilitation of referrals and follow up.

Opt-in workflow: Rooming staff screen for tobacco use at every patient visit and order referrals to the IVR system in the EHR. Patients witha current tobacco use status data in the EHR receive up to five IVR calls offering customized messaging and motivational prompts for enrollment in telehealth counseling, quitline services, or SmokefreeTXT. The IVR system also automates follow-up calls and treatment offers.  

Challenges and solutions: The program experienced low rates of assessment and referral, as well as missing EHR data. The team conducted a mixed-method implementation study that used qualitative interviews with clinic staff, quantitative surveys, and EHR analysis to identify barriers to assessment and referral. Analyses also identified patient characteristics associated with missing data. The team then simplified the EHR tobacco use assessment form to a single question that expands to brief follow-up questions and an IVR referral order if a patient reports ever having used tobacco. This EHR modification improved assessment and referral rates

Context: Comprehensive cancer center affiliated with an academic medical center that treats >56,000 oncology patients per year, roughly 6% of whom report current tobacco use. Piloted in thoracic clinic before expanding center-wide.

Tobacco Treatment Program target population: Inpatients and outpatients who currently use tobacco are eligible for tobacco treatment services.  

Intervention: The program offers individual in-person and telehealth counseling, pharmacotherapy, and referral to SmokefreeTXT and web resources. Revenue from billing for services helps fund the program. 

Opt-out workflow: Rooming staff screen for tobacco use as a vital sign at all patient visits. If a patient reports current tobacco use, an EHR alert prompts providers to order a referral to the tobacco treatment program. A nurse practitioner who is a certified tobacco treatment specialist (TTS) then reaches out to schedule treatment with referred patients. When possible, same-day counseling is prioritized. The nurse practitioner TTS can prescribe pharmacotherapy for patients engaged in treatment. Program staff reach out six times in the first 12 weeks of a patient’s quit attempt and follow up at six months to see how patients are doing. Patients are also able to self-refer to the program online.

Challenges and solutions: To devise an EHR adaptation to fit heterogeneous clinical workflows, the program partnered with a sociotechnical development team to conduct workflow analysis and develop flowsheets for EHR modifications.

Champions: The program engaged three key champions at the leadership level: the CEO of the center who secured funding for the program and all pharmacotherapy; the Chief Medical Quality Officer who facilitated program integration with the clinical workflows; and the Chief Medical Information Officer who expedited EHR modifications.

Context: Comprehensive cancer center affiliated with an academic medical center that treats >50,000 oncology patients per year, roughly 300 of whom engaged in TTP services. 

Tobacco Treatment Program target population: Inpatients and outpatients who currently use tobacco are eligible for tobacco treatment services. 

Intervention: The program offers individual in-person counseling, pharmacotherapy, and referral to the state quitline, SmokefreeTXT, and a state-based text line. 

Opt-in workflow:  During rooming, clinic staff screen for and record tobacco and e-cigarette use as fifth vital sign in the EHR. Tobacco use or e-cigarette use documentation triggers a Clinical Decision Support tool, which prompts staff to discuss treatment options with patients, document readiness to quit, and order a referral to the tobacco treatment clinic or a closed-loop eReferral to the state quitline. Patients who smoke are added to a tobacco use registry in the EHR that program staff use to guide proactive outreach and follow-up to patients.

Challenges and solutions: The center serves a sizable percentage of Black/African American patients, as well as other historically underserved patient groups. Based on community member and patient focus group input, the center implemented strategies for targeted and culturally specific outreach and treatment for their patient population, including hiring staff from the communities served, pairing patients with navigators of the same race and/or language, designing patient education and communication media that represents patients and providers of different genders and skin tones, and training schedulers and providers on culturally concordant patient engagement and the socio-political context of tobacco use disparities experienced by the communities served. These targeted strategies based on community input improved patient acceptance, reach, engagement and cessation rates.

Context: Comprehensive cancer center affiliated with an academic medical center that treats >50,000 oncology patients per year, roughly 7% of whom report current tobacco use.

Tobacco Treatment Program target population: Outpatients and family members who currently use tobacco are eligible for tobacco treatment services. 

Intervention: The program offers individual in-person and telehealth counseling, pharmacotherapy, and a smartphone application program for real-time support. 

Opt-in workflow: Patients complete an intake survey screening for commercial tobacco (vs. traditional or ceremonial tobacco use) use prior to their first consult. Responses are recorded in the EHR as a vital sign. At every first clinic visit and every six months after establishing care, rooming staff screen for use of commercial tobacco update the EHR record. Patients with documented use of commercial tobacco in the EHR are automatically added to a tobacco registry. A certified tobacco treatment specialist (TTS) reaches out to patients on the tobacco registry within a week of their initial visit to offer counseling, no-cost pharmacotherapy, and access to a smartphone application offering real-time support. Treatment sessions are documented in the EHR. Automated follow-up communications follow at regular intervals determined by patient preference. Quarterly, six-month, and annual reports are generated in the EHR for quality improvement.

Challenges and solutions: To partner with local communities to better meet their needs, the center launched an Indigenous-specific health promotion program. The program utilizes culturally and linguistically appropriate strategies to provide outreach, patient navigation, and advocacy for Indigenous individuals and communities in cancer care and tobacco treatment. The program supports a dedicated Indigenous patient navigator; conducts focus groups with Indigenous community members to elucidate facilitators and barriers to non-ceremonial tobacco cessation; hosts in-person and virtual culturally tailored education events for local communities and tribes; and collaborates with local organizations to deliver tobacco treatment counseling and no-cost pharmacotherapy.

Context: Comprehensive cancer center affiliated with an academic medical center that treats 64,000 oncology patients per year, roughly 2-3% of whom report current tobacco use. Piloted in the head-and-neck clinic before expanding to more than 20 clinics across three sites.

Tobacco Treatment Program target population: Outpatients and family members who currently use tobacco are eligible for tobacco treatment services. 

Intervention: The program offers individual and group telehealth counseling, pharmacotherapy, and referrals to the state quitline and SmokefreeTXT. 

Opt-out workflow: Medical assistants screen for and record tobacco and e-cigarette use in the EHR at all patient visits. If a patient reports tobacco use, a certified tobacco treatment specialist (TTS) reaches out by phone up to three times to engage the patient in treatment. Tobacco use prevalence and engagement rate reports are generated monthly from the EHR. Patient follow-up is conducted 6 months and 24 months after treatment via email, EHR message, and phone to assess effectiveness and re-engage in treatment as needed. 

Challenges and solutions: To sustain a high-touch workflow and offer tobacco treatment to every patient, the center adopted a practicum student model, under which predoctoral clinical psychology students can provide telehealth counseling under supervision while earning their clinical hours. 

The center also formed an external partnership with a pharmacy, which delivers pharmacotherapy and offers a two-week free trial of nicotine replacement therapy (NRT) for patients.

Context: Comprehensive cancer center part of a multi-state network of oncology practices that treats >20,000 oncology patients per year, roughly 38% of whom report current tobacco use.

Tobacco Treatment Program target population: Inpatients and outpatients who currently use tobacco are eligible for tobacco treatment services. 

Intervention: The program offers point-of-care counseling, as well as individual and group in-person and telehealth counseling, pharmacotherapy, and a mobile health program. 

Opt-out workflow: An EHR alert prompts rooming staff to screen for tobacco use if they are new, have an incomplete tobacco history, or previously reported tobacco use. If a patient reports tobacco use, they are automatically referred to the tobacco treatment program and “nicotine dependence” is added to their visit diagnoses list in the EHR. A clinician co-sign is not required for referral. Clinicians can document additional conversations about tobacco use in the EHR using an optional charting shortcut. When referred patients “check out” of their visits, scheduling staff make an appointment for in-person or telehealth tobacco treatment, unless the patient declines.

Challenges and solutions: Based on qualitative interviews conducted during pre-implementation planning, the program found that clinics were not consistently screening for tobacco use and referring patients to treatment. Although clinicians supported routine patient referral to tobacco use treatment, they reported resistance to an increased burden of EHR interactions. Staff who conduct rooming activities expressed the greatest interest in helping patients address their tobacco use, even if staff responsibilities increased. In response to these findings, the program designed an EHR alert that would enable staff conducting rooming to directly refer patients to tobacco treatment without clinical provider intervention or co-signature. This reduced clinician burden and increased referrals.

Context: Comprehensive cancer center affiliated with an academic medical center that treats >20,000 oncology patients per year, roughly 10% of whom report current tobacco use. Piloted in the thoracic and lung clinic before expanding center-wide.

Tobacco Treatment Program target population: Outpatients and family members who currently use tobacco are eligible for tobacco treatment services. 

Intervention: The program offers individual in-person counseling, pharmacotherapy, and referrals to the state quitline and a texting program. 

Opt-out workflow: Nurse navigators meet with every new patient to establish a treatment plan, and they screen for tobacco use at these meetings. Patients who report tobacco use are automatically referred to tobacco treatment. Nurse navigators then reassess tobacco use during the delivery of a patient’s survivorship care plans at the end of their treatment. Rooming staff also assess tobacco use at every patient visit, and medical assistants, social workers, and providers can refer directly to the program. Referred patients are entered into a database, which a certified tobacco treatment specialist (TTS) uses to reach out and schedule treatment. Patient follow-up is conducted 6 months after treatment to assess effectiveness and re-engage in treatment as needed. 

Challenges and solutions: The center serves a significant population of Spanish-speaking patients, so the program prioritized hiring a bilingual certified tobacco treatment specialist (TTS) who offers counseling in both English and Spanish. 

With approval from their compliance director, the program established a contract with an external pharmaceutical company to ship nicotine replacement therapy (NRT) directly to patients.

In addition, the program piloted an adaptive automated SMS texting intervention to increase engagement and support abstinence. Tailored text messages are sent to patients in multiple series of four weeks until the patient enrolls in the program or for a maximum of twelve weeks. A similar tailored message series is sent to patients upon program completion to encourage abstinence and assess treatment effectiveness. The intervention resulted in increased patient satisfaction and decreased patient tobacco use.

Champions: Tobacco screening and treatment referrals were integrated with nurse navigation, as navigators meet with 100% of patients at the center at regular intervals. This allowed the program to expand center-wide quickly and significantly increase reach.