Building Effective Tobacco Treatment Services for Pregnant and Parenting Women. The House Calls Smoking Cessation Progra

State: MI Type: Model Practice Year: 2011

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House Calls provides home-based smoking cessation education and support to pregnant and parenting women who smoke. Services are delivered in a relationship-based model of care. The practice addresses the important public health issue of reducing tobacco use. The target population for the practice is low-income pregnant and parenting women who smoke and receive services at Ingham County Health Department (ICHD). Eighty-six percent of the 813 women receiving prenatal care at ICHD’s Women’s Health Services in 2006 were covered by Medicaid. Research has shown that persons on Medicaid smoke at higher rates than the general population.

House Calls began in November 2008 with the goal of developing comprehensive, sustainable, and accountable smoking cessation services for pregnant and low-income women.<p>Initial program objectives included developing a multi-component home-based cessation intervention, training staff, and implementing an incentive system for participants. All objectives were selected based on a literature review indicating that they were efficacious for the target population.

The practice was strategically integrated into existing home-visiting services to assure its sustainability. Project objectives were attained, and the intervention was delivered to twice as many women (107) than had been projected in the first year (50).

Over 200 women have now been served, and enrollment in House Calls continues. The specific factors leading to the success of the practice included:

• The practice is specifically designed to address barriers identified by the target population.

• The practice is integrated into existing home-visiting services predicated on a relationship-based model of care.

• Vigorous outreach is used to engage community partners in making referrals.

• Staff receive training to increase their knowledge about tobacco cessation support and to facilitate their confidence in delivering the intervention.

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Ingham County Health Department
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Building Effective Tobacco Treatment Services for Pregnant and Parenting Women. The House Calls Smoking Cessation Progra
House Calls provides home-based smoking cessation education and support to pregnant and parenting women who smoke. Services are delivered in a relationship-based model of care. The practice addresses the important public health issue of reducing tobacco use. The target population for the practice is low-income pregnant and parenting women who smoke and receive services at Ingham County Health Department (ICHD). Eighty-six percent of the 813 women receiving prenatal care at ICHD’s Women’s Health Services in 2006 were covered by Medicaid. Research has shown that persons on Medicaid smoke at higher rates than the general population. House Calls began in November 2008 with the goal of developing comprehensive, sustainable, and accountable smoking cessation services for pregnant and low-income women.<p>Initial program objectives included developing a multi-component home-based cessation intervention, training staff, and implementing an incentive system for participants. All objectives were selected based on a literature review indicating that they were efficacious for the target population. The practice was strategically integrated into existing home-visiting services to assure its sustainability. Project objectives were attained, and the intervention was delivered to twice as many women (107) than had been projected in the first year (50). Over 200 women have now been served, and enrollment in House Calls continues. The specific factors leading to the success of the practice included: • The practice is specifically designed to address barriers identified by the target population. • The practice is integrated into existing home-visiting services predicated on a relationship-based model of care. • Vigorous outreach is used to engage community partners in making referrals. • Staff receive training to increase their knowledge about tobacco cessation support and to facilitate their confidence in delivering the intervention.
The public health issue this practice addresses is tobacco use among low-income pregnant and parenting women. Over the past 40 years, smoking has increasingly and disproportionately become a habit of low income, less educated, and disenfranchised individuals. These individuals suffer a disproportionate burden of tobacco-related disease. In 2006, ICHD served 20,659 patients, over 14,000 of them women and 81.6% of them living below the poverty level. In the United States, smoking prevalence is higher among women living below the poverty level. Additional empirical work reports smoking prevalence as high as 44% among young women who earn a high school equivalency degree (GED) compared to 12% among female college graduates. This population also comprises the “most exploited victims of predatory marketing practices that capitalize on their lack of education and other vulnerabilities.” As a consequence, social justice and health inequity issues are inherent considerations in the use of tobacco among this population. Cessation support, including individual counseling appointments and tobacco education was offered regularly at ICHD’s prenatal clinic, but women were not taking advantage of the services.
Agency Community RolesICHD developed this practice and was responsible for implementing it, adapting it as staff learned from working with clients, and sustaining it. A resident in ICHD’s Women’s Health Services health center developed and implemented the survey which identified barriers facing the women we serve. Staff completed a literature review and worked closely with a national tobacco expert to involve home-visiting staff in development of the practice. ICHD engaged in vigorous outreach in the community to raise awareness about House Calls. Costs and ExpendituresHouse Calls provides home-based smoking cessation education and support to pregnant and parenting women who smoke. Services are delivered in a relationship-based model of care. The practice addresses the important public health issue of reducing tobacco use. The target population for the practice is low-income pregnant and parenting women who smoke and receive services at Ingham County Health Department (ICHD). Eighty-six percent of the 813 women receiving prenatal care at ICHD’s Women’s Health Services in 2006 were covered by Medicaid. Research has shown that persons on Medicaid smoke at higher rates than the general population. House Calls began in November 2008 with the goal of developing comprehensive, sustainable, and accountable smoking cessation services for pregnant and low-income women. Initial program objectives included developing a multi-component home-based cessation intervention, training staff, and implementing an incentive system for participants. All objectives were selected based on a literature review indicating that they were efficacious for the target population. The practice was strategically integrated into existing home-visiting services to assure its sustainability. Project objectives were attained, and the intervention was delivered to twice as many women (107) than had been projected in the first year (50). Over 200 women have now been served, and enrollment in House Calls continues. The specific factors leading to the success of the practice included: • The practice is specifically designed to address barriers identified by the target population. • The practice is integrated into existing home-visiting services predicated on a relationship-based model of care. • Vigorous outreach is used to engage community partners in making referrals. • Staff receive training to increase their knowledge about tobacco cessation support and to facilitate their confidence in delivering the intervention. ImplementationThe House Calls Smoking Cessation Program had three primary goals: 1) Develop comprehensive, sustainable, and accountable smoking cessation services for pregnant and parenting low-income women; 2) Increase the number of smoking pregnant and parenting women who engage in cessation support and successful stop smoking; and 3) Increase the number of women who maintain abstinence from tobacco in the postpartum period. The tasks and activities to reach those goals are described below. Staff training was an integral component of the success of the House Calls project. Dr. Scott Thomas, a national tobacco expert worked on the project and provided training to home visitors. Training content included the 5A/5R smoking cessation intervention as recommended by the US Public Health Service, and Motivational Interviewing techniques, which provide collaborative strategies to support clients seeking to stop smoking. Documentation was an iterative process that evolved as forms were modified through staff feedback. Demographic and evaluation information was collected by staff, and compiled by a researcher evaluating the project, along with ICHD’s epidemiologist. At the beginning of the House Calls Project, staff used cotinine testing to evaluate each woman’s smoking behavior. Ultimately, staff instead used a CO monitor to assess smoking rates. Participants breathed into the monitor, which displayed a numerical value of the parts per million of Carbon monoxide. Families enrolled in House Calls were able to actively track their progress through their quit journey using the visual of immediate numeric feedback. The two year grant included an incentive protocol. During the first grant year, women received an enrollment kit and a $20 gift card to an area store. Pregnant participants received the gift card monthly throughout her pregnancy and for 12 weeks postpartum. Women who had already delivered were limited to 12 weeks of incentives. During the second year of House Calls, enrollment kits were down-sized and the incentives were reduced to $10 per month, in response to budgetary reductions. Participants expressed the greater appreciation for access to CO monitor results than for the incentives. The House Calls smoking cessation project began in May 2008, as a one year grant funded initiative by the Legacy Foundation. Following the success of the first year, ICHD was chosen from a selective pool, to receive second year of funding. Grant funds concluded in June 2010. Following receipt of funding, staff constructed the initiative over a six month period. The first referrals were accepted within one month. The project utilized an iterative and on-going feedback process, with changes continually applied as needed. Staff who were providing home-based cessation services provided critical guidance to administrators, who actively engaged as part of the implementation team. The home visitation team, comprised of Public Health Nurses (PHN) and Public Health Advocates (PHA), collaborated to determine trainings needs, to determine needed form modifications, and to develop and adjust the incentive protocol as needed.
• Increase the number of smoking pregnant and parenting women engaging in tobacco cessation support. The measure used for the primary objective was a program output measure: the number of clients served. Forms were developed to collect programmatic information such as basic demographics, medical history, and smoking history. Carbon monoxide monitors were used to measure exhaled carbon monoxide levels. Home visiting staff collected the information, including exhaled carbon monoxide levels, on program forms and input the data into a database specially created for the project. • House Calls clients, regardless of which grant period they enrolled in, reported an average age of tobacco use initiation of approximately 13 years. By an average age of 15, tobacco use was a habit. Women in the program reported smoking an average of 10 cigarettes (half a pack) daily. Daily consumption among Year 2 participants ranged from 2 cigarettes per day to 30 cigarettes per day. Nearly all clients reported smoking cigarettes (100% in Year 1 and 93.9% in Year 2), but a small minority in both grant years also reported using cigars, cigarillos, pipes, and smokeless tobacco products. At each home visit the amount of carbon monoxide (CO) exhaled by the client was measured using a PICO Smokelyzer®. A CO measurement greater than 6 parts per million (ppm) was an indication of smoking. At intake the average exhaled CO level for Year 1 participants was 9.5ppm (standard deviation (sd): 9.9). For Year 2 participants the average exhaled CO at intake was 10.3 ppm (sd: 8.2). Exhaled CO for Year 2 participants at their intake visit ranged from 1.0 ppm to 41.0 ppm. Because quitting tobacco use is a process, we were particularly interested in reduction in CO levels, both at the individual level as well as for the group. The opportunity clients have to receive feedback at each visit using the PICO Smokelyzer® enabled them to experience ‘small’ successes and maintain their motivation to quit. At the group-level mean exhaled CO was used to measure program progress. Year 1 participants experienced an average CO decline from 9.5 ppm to 5.4 ppm over the course of five sessions. The Year 2 cohort experienced a decline from 10.3 ppm to 6.6 pmm over the course of five sessions. Non-smoking is defined as having an exhaled CO measurement of 6 ppm or less using the PICO Smokelyzer®. The Year 2 cohort experienced a modest increase in the number of non-smoking women. Over five sessions, the prevalence of non-smoking increased from 60.7% to 65.0%. As their self-efficacy increases and their small successes compound, it is expected that participants will be able to transition into becoming permanent non-smokers. ICHD successfully implemented activities which supported the objectives of House Calls. By November 2008 a multi-component home-based smoking cessation intervention for pregnant and parenting women was developed as well as a monetary incentive system. Staff was trained in the 5A/5R smoking cessation intervention recommended by the U. S. Public Health Service and motivational interviewing techniques; the home-based smoking cessation intervention (including incentives and documentation) at each home visit with pregnant and parenting women who smoked was implemented. • The objectives of House Calls were attained. We proposed serving 50 participants in Year One and actually served 107. By the end of the grant period 210 women had participated in the House Calls program. As of November, 2010, 237 pregnant and parenting women have participated in the program. • Reduce the average exhaled carbon monoxide level of women in the program. The measure used for the secondary objective was clients’ exhaled carbon monoxide levels. Evaluation results were sent to the funder (American Legacy Foundation) and to the Deputy Health Officer in charge of the Public Health Services division of ICHD.
Vigorous outreach was essential in establishing new relationships and helping create strong allies for House Calls. At the initiation of the project in 2008, the Medical Residents in training at ICHD were generally opposed to providing pregnant women nicotine replacement therapies (NRTs). One of the lead nurses in the project engaged in ongoing dialogue and educational discussions to increase the knowledge and awareness of the residents. Ultimately the efforts of project staff resulted in a significant shift in the medical ideology of residents as well as providers in our community. House Calls staff can now call an ICHD provider and promptly receive a faxed prescription for NRTs to assist the client in her quit attempt. Partnerships across various units within ICHD were also strengthened as a result of House Calls. In addition to stronger, more collaborative working relationships between the nurses and advocates delivering the intervention, a number of other internal collaboration were established and strengthened. WIC and Women’s Health Services were critical expansion sites for the projects, and their providers now regularly refer women to House Calls. Additional community alliances were forged with a number of diverse partners, including: • Shared Pregnancy Services • Ingham County Infant Mortality Coalition • Smoke Free Michigan • Early On (for families of children with developmental delays) • Great Start Collaborative (for families with young children) • Ingham Substance Abuse Prevention Coalition • Area OB/GYN providers Program staff presented at numerous state and national meetings, including an April 2010 presentation at the Health Education Council's national meeting focused on Achieving Health and Social Equity in Tobacco Control. Through these presentation opportunities, staff have built the reputation of this program, garnered greater visibility and positioned the department for future funding in this area. We developed the House Calls proposal with sustainability in mind and deliberately began to integrate the cessation intervention into the ongoing work of home visiting staff. Staff now consider cessation support an integral part of the services provided to the clients we serve. Staff have continued to receive various training on cessation support, as a result, staff are now more comfortable and skilled in delivering this intervention. Grant funds ended in 2010, but staff continue to provide cessation services to the women that we serve. The Carbon monoxide monitors purchased with grant funds remain an invaluable tool when used with families in their homes and at other community events. Other financial sources, including donations from area groups and businesses, have been identified to purchase participants incentives. The ICHD Health Officer is strongly committed to tobacco control and prevention, which are department priorities. House Calls has expanded the capacity of ICHD to respond to smoking cessation needs and has strengthened the overall culture of client service and collegial partnerships within the department. Staff now engage in deeper, richer conversations with clients to effectively include them in identifying and developing cessation strategies.
 
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