Sample Treatment Workflows

1. Screen for tobacco use and document in EHR.
2. Advise those currently using or recently quit about the importance of reducing or quitting tobacco use.
3. Deliver 1:1 tobacco cessation counseling and provide patient education materials (this can be automated via EHR visit summaries).
4. Place electronic referrals to quitline or SmokefreeTXT.
5. Pend orders using EHR order sets for oncologists to review and approve.
6. Follow up with the patient on usual schedule for new cancer patients.

1. Medical Assistants (MA) or Licensed Practical Nurses (LPNs) screen for tobacco use during social history and document in EHR.
2. The EHR alerts the oncologist that the patient is currently using tobacco.
3. Through the alert, the oncologist opens an order set to document diagnosis, place medication orders, document billable cessation counseling, and place referrals to external services like quitlines or SmokefreeTXT.
4. The oncologist uses a note template to expedite documentation.
5. Patient instructions populate the patient visit summary automatically.
6. External referral results are returned to the oncologist’s inbox and the EHR.

1. Tobacco history and current use are reviewed (as assessed by MAs/LPNs or nurses in prior visits).
2. Tobacco Treatment Specialists contact all patients who currently use tobacco to offer:
   • Counseling (remote 1:1 calls/video visits).
   • Electronic referrals (quitline, SmokefreeTXT).
   • Medication (coordinated with prescribers on team).
   • Family counseling.
   • Follow-up 1, 3, and 6 months later.

Example: medication reconciliation

1. Nurses screen for tobacco use in the past 30 days and document in EHR.
2. At initial medication reconciliation, clinical pharmacists offer brief advice to quit and order nicotine replacement therapy under a standing delegation order (without required co-signer) for cessation support or withdrawal symptom management during the stay.
3. At discharge medication reconciliation, clinical pharmacists order additional nicotine replacement therapy and place an electronic quitline referral; patient discharge instructions include automated information about tobacco treatment resources.

See Palmer et al., 2021 for a description of other program models for hospital settings.

(as described in Palmer et al., 2021)

1. Nurses screen for tobacco use in the past 30 days and document in EHR.
2. Patients who use tobacco are offered a visit from a Tobacco Treatment Specialist, and nurses send electronic referrals to the Tobacco Treatment Specialist.
3. Tobacco Treatment Specialists provide bedside cessation advice, in-person or remote counseling, and treatment planning.
4. Tobacco Treatment Specialists screen for eligibility for low-dose CT lung cancer screening.
5. Tobacco Treatment Specialists text residents and pharmacists to coordinate pharmacotherapy.
6. At discharge, pharmacotherapy, referrals (to quitline, text message program, or in-person group counseling), and automated patient education materials are provided.
7. Follow-up by automated interactive voice response (IVR) system, email, text, or Tobacco Treatment Specialist outreach after discharge (up to 2 years later).

1. Tobacco Treatment Specialists conduct proactive outreach to all active tobacco-using patients who are not already receiving tobacco treatment via:

• • Mailed outreach and education materials
  • EHR patient portal (if patient has activated their account)
  • Automated IVR system calls offering immediate connection (warm handoff) to Tobacco Treatment Specialists
  • Live calls to patients.

2. Tobacco Treatment Specialists offer:
   • Phone/video counseling before and after a target quit or reduction date
   • Electronic referrals to quitlines or SmokefreeTXT
   • Pharmacotherapy (via pended orders reviewed and approved by oncologists or primary care providers)
   • Follow-up 1 month later.
3. Tobacco Treatment Specialists follow up with patients who declined treatment but agreed to later phone contact (with a minimum interval of 30 days between outreach calls).

1. Medical Assistants (MA) or Licensed Practical Nurses (LPNs) screen for tobacco use during social history and document in the EHR.
2. An EHR alert prompts the MA or LPN to refer the patient to internal Tobacco Treatment Specialists or to external resources (quitline, SmokefreeTXT, or automated phone system) via electronic referral unless the patient declines referral.
3. The MA, LPN, or authorized provider approves the referral order and it is transmitted automatically to the tobacco treatment provider.
4. Patient information about the referral service automatically populates the patient visit summary.
5. The referral service reaches out to the patient to initiate treatment (via phone, text, or EHR portal).

1. Reports identify patients due for infusion or radiation on the tobacco use registry (or with indicators of current tobacco use in their records).
2. Tobacco Treatment Specialists approach patients at infusion or radiation appointments to offer:
   • Brief advice to patients who use tobacco (as identified at screening that occurs at every visit that feeds an EHR report of patients needing outreach on a given day)
   • Tobacco treatment counseling and medication support (in coordination with oncologists)
   • eHealth resources such as Smokefree.gov or SmokefreeTXT.

1. Patient is asked to report on recent tobacco use.
2. Those who report recent use are offered automated outreach (e.g., via interactive voice response systems).
3. Automated outreach includes offers of external referrals (e.g., quitline) with immediate connection (warm transfer).
4. Tobacco Treatment Specialists follow up with patients based on their responses to automated calls to provide counseling and pharmacotherapy.

1. Automated messages offer patients treatment options on a schedule (e.g., 3 days before or 3, 14, 60 and 180 days after encounters).
2. Warm transfer (i.e., immediate connection) is offered to:
   • SmokefreeTXT
   • State quitline
   • Tobacco Treatment Specialists at the cancer program.