Care Coordination to Increase Referrals to Smoking Cessation Telephone Counseling: A Demonstration Project

An intervention to increase tobacco treatment rates through care coordination for telephone counseling was effective in raising referral rates and in achieving excellent long-term abstinence.
Published Online: March 01, 2008
Scott E. Sherman, MD, MPH; Nancy Takahashi, MPH; Preety Kalra, MS; Elizabeth Gifford, PhD; John W. Finney, PhD; James Canfield, BS; John F. Kelly, PhD; George J. Joseph, MS; and Ware Kuschner, MD

Objective: To test the effectiveness of a care coordination program for telephone counseling in raising referral and treatment rates for smoking cessation.

Study Design: A demonstration project implementing a smoking cessation care coordination program offering telephone counseling and medication management to patients referred from primary care.

Methods: The study was performed at 18 Veterans Health Administration (VA) sites in California. Participants were VA patients receiving primary care. We randomly allocated 10 of 18 sites to receive the Telephone Care Coordination Program, which included simple 2-click referral, proactive care coordination, medication management, and 5 follow-up telephone calls. Each patient received a 30- to 45-minute counseling session from the California Smokers’ Helpline. Patients at control sites received usual care.

Results: During 10 months, we received 2965 referrals. We were unable to reach 1156 patients (39%), despite at least 3 attempts. We excluded 73 patients (3%), and 391 patients (13%) were not interested. We connected the remaining 1345 patients (45%) to the Helpline. At 6-month followup, 335 patients (11% of all referrals and 25% of participating patients) were abstinent. Providers at intervention sites reported referring many more patients to telephone counseling than providers at control sites (15.6 vs 0.7 in the prior month).

Conclusions: The program generated a large number of referrals; almost half of the patients referred were connected with the Helpline. Long-term abstinence was excellent. These results suggest that managed care organizations may be able to improve tobacco control by implementing a similar system of care coordination.

(Am J Manag Care. 2008;14(3):141-148)

This demonstration project tested the effectiveness of a telephone care coordination program for smoking cessation. The structure of the program is summarized below.

The program generated a large number of referrals; almost half of the patients referred were connected with the California Smokers’ Helpline. Long-term abstinence was excellent.

The Veterans Health Administration care coordinator attempted to contact each referral by telephone up to 3 times. If the patient agreed, the coordinator then connected the patient with the Helpline on a 3-way telephone call.

Once connected to the Helpline, patients were scheduled to receive a single 30- to 45-minute counseling session, generally within 7 days.

Smoking is the leading preventable cause of death in the United States and is a particular problem within the Veterans Health Administration (VA).1,2 The VA has done an excellent job of identifying smokers and advising them to quit, with rates for asking and advising exceeding 90% nationwide for the last several years.3 Unfortunately, although patients are interested in quitting, the prevalence of smoking has remained high, in part because treatment rates have remained low.4 In a 1999 survey of VA patients, 60% had tried to quit in the prior year, but only 20% reported receiving the services they needed to help them quit.2 In a recent survey of VA patients, Sherman et al5 found that, while 45% of smokers tried to quit in the prior year, only 28% reported being referred to a smoking cessation program, and only 9% actually attended the program. Increasing the rates of smoking cessation treatment is a challenge facing the VA and other healthcare systems. Primary care–based treatment is effective and would have broad reach, but the many competing demands on providers limit the time available for smoking cessation counseling.6,7 Interdisciplinary in-person smoking cessation programs have the highest success rate, but most smokers cannot or will not attend them.6,8 Telephone counseling for smoking cessation is another effective approach, merging the broad reach of primary care with the higher effectiveness of in-person smoking cessation programs.6,9

Although telephone counseling is effective, healthcare systems seldom use it. Among the reasons healthcare systems fail to use telephone counseling, the most important seems to be that telephone counseling requires significant changes to the usual system of care. For telephone counseling to be a viable option for increasing rates of smoking cessation treatment, there needs to be a way to systematically increase referrals. In this article, we describe the results of an evaluation of a system implemented at multiple VA sites to increase referrals to telephone counseling.


This demonstration project took place at 2 VA healthcare systems in California. We randomly assigned 10 of 18 sites within these 2 systems to receive the Telephone Care Coordination Program (TCCP). The remaining 8 sites served as usual-care control sites (usual care comprised direct treatment by a primary care provider, referral to a VA smoking clinic, or informal referral to an outside resource such as a quitline). Our goal was to increase referrals to telephone counseling for smoking cessation. The project was approved by the institutional review boards at both healthcare systems and was exempted from informed consent requirements (because patients received routine clinical care and because research staff received aggregated data only). The intervention period was 10 months (mid May 2003 to mid March 2004).

Setting and Subjects
In southern California, the VA Greater Los Angeles Healthcare System provides care to approximately 79,000 patients across 5 ambulatory care centers and 5 communitybased outpatient clinics. In northern California, the VA Palo Alto Healthcare System serves approximately 53,000 patients at 3 ambulatory care centers and 5 community-based outpatient clinics.

We do not have exact information on the characteristics of the providers in this study because our survey included only 4 questions on reported practice patterns. However, these sites were part of a larger VA study previously reported by Meredith et al,10 and the characteristics of that study are reasonably similar to those of the present sample. Meredith et al found that 80% of the providers were at an academic setting, with 78% in an urban area; 87% were at a medical center, with the remainder at an ambulatory care center. Providers reported being in practice for a mean of 15 years since training, and 78% were women. Of the respondents, 67% were physicians, 26% were nurse practitioners, and 7% were physician assistants. Inferring patient characteristics from the same larger study, smokers were on average 57 years old, 93% were male, 41% were married, and 64% were of white race/ethnicity. Most smokers (55%) had at least some college education, and 66% reported an annual income of less than $20,000.5 The best estimate for smoking prevalence at these sites comes from the VA’s External Peer Review Program, which performs structured explicit review on a large sample of medical records at every VA medical center, ambulatory care center, and community-based outpatient clinic. The prevalence of smoking among primary care patients at the VA Greater Los Angeles Healthcare System is about 27% (range across the individual sites, 17%-35%), while that at the VA Palo Alto Healthcare System is about 21% (range across individual sites, 7%-26%).

All sites use a fully electronic medical record system that includes progress notes, laboratory results, medications, and consults.11 It also includes locally designed computerized clinical reminders on a wide range of diseases and problems. Reminders are a means to increase adherence to VA nationally mandated practice guidelines. The level of guideline adherence is measured at all sites by an external peer review organization, and the results form part of the performance assessment for each facility’s director.12,13 In particular, smoking cessation is a mandated guideline and performance measure, and all sites use computer reminders to prompt providers to ask about smoking and to advise smokers to quit.

Our previous attempts to increase referrals to telephone counseling have had little or no success, and we hypothesized the following 3 main barriers: (1) there is a lack of knowledge about available telephone counseling resources, (2) referral to an outside resource generally takes more time than referral internally, and (3) difficulties inherent in prescribing, monitoring, and refilling medications are apparent when someone else is providing the counseling. We believed that the lack of knowledge could be easily addressed. However, the barriers about time and prescribing were not as easily solved, so we designed our demonstration project to address them.

To make providers aware of the new program, e-mail announcements were sent to all facility providers. The announcements described the program and the method to refer patients. In addition, a study physician (SES or WK) and a study coordinator (NT or PK) visited each clinic at the beginning of the intervention period to promote the program to clinic managers and to key providers.

The TCCP comprised the following 4 components:
Simple Computerized Referral. When completing computerized clinical reminders for tobacco use, a VA provider could easily refer a patient by 2 additional mouse clicks. The process of referring a patient to the TCCP was fully integrated into VistA, the VA’s electronic health record, as part of routine clinical practice. A button was added to the existing clinical reminder treatment options to “refer to telephone counseling”; clicking the button led to a popup referral window. The provider answered 2 brief questions (identifying contraindications to nicotine patches or to bupropion hydrochloride) and submitted the referral. Before the intervention, referring a patient to a smoking clinic involved completing a multiquestion consult referral requiring a minute or longer to complete. We shortened the computerized referral to telephone counseling or to a smoking clinic to 2 brief questions requiring only a few seconds of provider time. Because of the way the VA’s electronic health record is structured, we were unable to limit access to the new TCCP referral option to intervention sites only. We compensated by listing the clinics for which the program was available on the referral screen (eg, “This option is only available at…”). Clinicians at control sites could still refer patients directly to the quitline or choose to treat the patient directly with usual care.

Proactive Recruitment Into Telephone Counseling. The TCCP staff initially included only 1 full-time care coordinator for each facility, but 2 more full-time coordinators were added at each facility as the rate of referrals increased. Once the consult was received, the VA care coordinator proactively attempted to contact the patient by telephone up to 3 times. If the patient agreed, the coordinator then connected the patient with the California Smokers’ Helpline on a 3-way telephone call. We used the 3-way telephone call because in a prior study14 more than half of the patients intending to call the Helpline did not follow through, despite multiple reminders.

Once connected to the California Smokers’ Helpline, patients were scheduled to receive a single 30- to 45-minute counseling session, generally within 7 days. The Helpline used a structured counseling protocol that has previously been shown to be efficacious and effective.15,16 The content of the counseling addressed behavioral and cognitive issues that the individual smoker faced in his or her quit attempt.17 Some of the topics addressed include motivation, self-efficacy, difficult situations, coping strategies, medication use, and relapse prevention.

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