North Carolina’s First Tobacco-Free Healthcare System- Paving the Road

1. North Carolina’s First Tobacco-Free Healthcare System- Paving the Road

2. Sallie Beth Johnson, MPH, CHES sbjohnson@firsthealth.org Cindy Laton, BS claton@firsthealth.org FirstHealth of the Carolinas Community Health Services Pinehurst, North Carolina 1-877-342-2255 Presenters

3. Learning objective Methods for tobacco-free initiative Results of policy change Discussion of challenges and impact Q&A (questions and answers) Presentation Outline

4. At the end of this presentation, participants will be able to: Identify ways to engage a tobacco growing community during the adoption, implementation and enforcement of a tobacco-free policy Learning Objective

5. FirstHealth of the Carolinas • A private, non-governmental, not-for-profit health care system serving 15 counties in the rural tobacco growing region of the mid-Carolinas

6. FirstHealth of the Carolinas • Three hospitals (Moore Regional, Richmond Memorial and Montgomery Memorial) • Primary care clinics, health and fitness centers, home and hospice care, EMS and health plan • Core Purpose: “to care for people”

7. On July 4, 2004, FHC declared “Freedom From Tobacco” Adopting a comprehensive tobacco-free policy that prohibits staff, patients and visitors from using tobacco products anywhere on campus FirstHealth of the Carolinas(FHC)

8. Policy affects 4,000 employees, 300 providers and 800 volunteers that work at one of the 30 system sites Over 300,000 patients that receive care and the family members and friends who visit Estimated that 15-18% of FHC staff use tobacco (600-800 individuals) IMPACT- Look at the Numbers

9. How Did the Initiative Get Started? • Tobacco control programs funded through the American Legacy Foundation & NC Health & Wellness Commission • Working with local schools and youth-oriented businesses on advancing tobacco-free policies (A CHALLENGE!) • Presented work to FH Community Health Board and they recommended action, FHC Board approved

10. Timeline of Events • Board recommended policy change in May 2003 • Staff consulted on timeline & number of tobacco users, June – August 2003 • Task force created in Oct. 2003 • Communications initiated in Jan. 2004 • Staff input on support requested in Feb. 2004 • Staff training on policy, May – July 2004 • Policy approved in June 2003 • Tobacco-free on Independence Day, July 4, 2004

11. Task Force and Plan • Identified VP of Medical Affairs as lead • Created a task force of non-smokers and smokers • Developed a plan that addressed: • Communications • Physician leadership • Support • Compliance (enforcement) • Added topical questions to employee satisfaction survey • Identified local champions

12. Task Force Membership Members enlisted: • VP, Medical Affairs • VP, Communications • VP, Human Resources • Board member • Physician • Director, Community Health • Director, Graphic Design • RN, Cardiac Cath Ad Hoc Members: • Director, Corp Education • Director, Security • Acct Mgr, Communications Should have included: • Site-based Managers • Director, Public Relations • Pharmacist • Additional providers

13. Physician Leadership • Invited physicians to be part of the task force • Held discussion of the policy elements at medical executive committees & service line meetings • “Houston, we have a problem!” Solutions…. • Exceptions for psychiatric patients • Pre-printed orders for NRT for in-patients • CME offered on medication assistance • Simplified referral form for cessation program

14. Communications • Researched other tobacco-free organizations • Developed a timeline for audience-specific strategies • Created a plan for signage • Shared premise paper with board & administration • Gained additional staff input • Presented at medical staff, leadership & service line meetings • Developed and approved policy

15. Initial Communications

16. “Provide monthly communications and increase that as the July 4th date gets closer.” “The surgeon general’s warning on cigarettes should be posted as one of the reasons.” “Find cheaper alternatives for the gum, patch, support drugs. Our insurance does not cover these items and they can be expensive.” Employee Responses “Create a buddy system or support system of fellow quitters.”

17. “I think it is a violation of each person’s rights as an individual. Rumor has it that patients’ families may smoke so you won’t lose business?” “Discrimination will occur if psych and detox patients are allowed to smoke and not the rest of the population.” “What about all the overweight people? Why do they have a doughnut cart at the cafeteria?” Additional Responses

18. FirstQuit- Cessation Program…… • Customized quit plan • 1:1 sessions • Coping strategies • Support groups, workshops, resources • Medications Results……. • Covering all expenses of program • 32% quit rate at 6 months • 90%+ using medication • Combination of oral medications & NRT

19. FirstQuit Components • Trained personnel • RNs and health educators (1.8 FTEs); accessible at each hospital campus; 1 FTE per 400 patients • Training • Freedom from Smoking, QuitSmart, Mayo Clinic • Medication assistance • Offered at no charge (purchased at cost) • Utilized physician recommendations

20. FirstQuit Components • Annual expense • $105,000 for salaries/benefits • $135,000 for medications/supplies/ mailings • $80,000 for FH employees & family -- $320/participant

21. FirstQuit Components

22. In FY04, 248 of the new 754 FirstQuit clients (33%) were FirstHealth staff January 1, 2004 July 4, 2004

23. Compliance (originally known as Enforcement) • HR participation & leadership • E-learning module for scripting • Security staff role-playing Ten months into the process…… • Labor law communications, “bus stop” smoking • Manager focus groups • Inpatient assistance • Physician orders allowing patients to smoke (5 times) • NRT requests (370 patients, $15,000)

24. Ensuring Compliance ….

25. …..or the Aftermath

26. Key Components of a Successful Implementation • Create a comprehensive task force membership • Need staff support for task force • Seek continual input from staff & smokers • Expect resistance, but they are not the majority • Assess financial implications • Mainstream the policy & enforcement in the organizational culture

27. Key Components Continued • Communicate & engage frequently off-campus sites • Take initiative to engage staff who use tobacco • Create the perception of “no barriers” for support • Educators are not the enforcers • Expect increased demands and anxiety the week before the policy change • Most people follow the rules

28. Elements of a Good Policy • Address purpose and who it affects • Identify geographic areas covered • Note nursing, physician, employee, patient and security staff responsibilities • Identify communications with visitors Policy should fit organizational culture

29. Tobacco-free advocacy youth groups 100% tobacco-free schools Smoke-free dining campaign Tobacco-free parks and recreation Health department and local health coalitions supporting resolutions for increasing cigarette product pricing Media coverage, letters to the editor and news stories devoted to tobacco use Community Impact- Paving the Road

30. Youth Empowerment • Over 220 youth trained to serve as tobacco-free policy advocates

31. New Signs in “Tobacco Country”

32. FirstHealth’s “Freedom from Tobacco” is paving the road and changing the social norms in a tobacco-growing community. Where it is said “100% tobacco-free will never happen here”, changes are occurring. Changing Social Norms

33. ? ? ? Questions