Referral Methods
- Direct patient outreach, e.g., via mail, EHR portal, appointment reminders (automated phone or text messages), or automated interactive voice response call system (see Taylor et al., 2020, Fig. 1)
- Automated referrals based on tobacco use status as recorded in the EHR or tumor registry (in patient-facing surveys, automated interactive voice response calls to patients, or screening conducted by clinic teams (see Case Studies)
- Referrals ordered by clinic team members/clinicians (see Case Studies)
- Tumor board meetings regarding patients currently using tobacco that trigger Tobacco Treatment Specialist outreach to patients (see sample Tumor Board workflow).
These methods can be modified so that referral to treatment occurs by default unless a patient opts out. See Ohde et al., 2021 for rationale and Jose et al. 2020 for an example of opt-out referral to specialty tobacco treatment.
Outreach and Engagement Methods
- At outpatient intake (e.g., a nurse navigator may conduct intakes and deliver tobacco treatment)
- At the bedside during hospital admissions
- At infusion centers during cancer treatment
- At radiation appointments
- Via warm handoff at other outpatient encounters
- Via telephone (automated or live calls)
- By scheduling or inviting patients to stand-alone video, phone, or in-person appointments for tobacco treatment or for low-dose lung cancer screening eligibility assessments
- By sending patients treatment starter kits and education materials via mail and/or electronic means.
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Cerner Users
For Cerner users, consult the Cerner-specific guide for EHR referral tools.
Intervention Prompts
- Epic reporting workbench reports show Tobacco Treatment Specialists which patients are due for outpatient outreach or tobacco treatment. Patients may be due for outreach because they are on a tobacco use registry or because they have been referred (actively or by default) to Tobacco Treatment Specialists. See the Epic-specific build guide (p. 57) for detailed instructions on building such reports.
- Epic inpatient lists can serve the same function if tobacco use status and tobacco intervention status are added as columns to the patient list. See the Hospitals Helping Patients Quit and Tobacco Treatment Best Practices Electronic Records Support guide (p. 4) and Trapskin et al., 2022 for sample patient lists.
- Incoming referrals in the Epic inbasket may serve as another prompt to deliver tobacco treatment.
Clinical Decision Support & Orders
- An Epic order set for Tobacco Treatment Specialists who provide counseling, refer to a state tobacco quitline and/or to SmokefreeTXT, and refer back to themselves to queue up follow-up contacts is available. This order set also diagnoses tobacco dependence, documents counseling delivery, and generates patient instructions by default. An order set to pend medication orders for prescriber approval is also available.
- An Epic flowsheet that Tobacco Treatment Specialists use to offer treatment and document patient preferences is shown here. This is often supplemented by encounter notes using a note template that prompts documentation of relevant tobacco history, motivation, triggers, and quit plans.
- Some health systems adopt a delegation protocol to expand the workforce that can independently order nicotine medication without cosigners for each order. See a sample delegation protocol that enables pharmacists to order NRT.
Advice from a C3I Grantee
No-show rates at appointments for tobacco treatment can be high. Piggybacking tobacco treatment appointments to other cancer clinic visits may improve attendance.