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Rural Health Information Hub

Systems Change Interventions to Support Clinicians

Rural communities are conducting systems change interventions to support tobacco cessation. Systems changes in a hospital, clinic, or healthcare practice refer to the organization's goals, administrative processes, workflow, technology, staff development, and training. Systems change interventions can support clinicians in screening patients about tobacco use and providing options for evidence-based treatments.

This model may involve implementing tobacco use screening, promoting the capacity of clinicians to treat tobacco dependence, and designating staff in hospitals or clinics to coordinate and assess the delivery of tobacco dependence treatment. Systems interventions to support clinicians are recommended by the Public Health Service in the Clinical Practice Guidelines for Treating Tobacco Use and Dependence.

The Centers for Disease Control and Prevention (CDC) Best Practices for Comprehensive Tobacco Control Programs recommends that states implement health systems changes to reduce tobacco use. The guidelines describe major components that health systems may choose to address:

  • Delivery System Design. Health systems can change the healthcare delivery system to ensure that care is structured in a way that integrates tobacco use screening and cessation treatment. This can involve identifying members of the care team who will conduct screening and counseling, redesigning and implementing a clinical workflow that supports tobacco interventions, and providing feedback to clinicians about their performance and other metrics associated with tobacco screening and cessation. The SAMHSA-HRSA Center for Integrated Health Solutions offers resources for better integration of behavioral health services within a primary care provider setting.
  • Clinical Information Systems and Electronic Health Records. Health systems can develop functionalities in their clinical information systems and electronic health records (EHR) that facilitate tobacco screening and cessation interventions. This can involve adding a reminder to the EHR that prompts the provider to screen for tobacco at each visit. Health systems may also choose to use EHRs to compile data and track metrics associated with tobacco use among their patients. There are several measures related to tobacco that have been endorsed by the National Quality Forum (NQF), the organization that advises the government and other payers on measures that should be used in payment and accountability programs. NQF-endorsed measures include adult current smoking prevalence; children who are exposed to secondhand smoke inside the home; and medical assistance with smoking and tobacco use cessation, among others.
  • Decision Support Systems. These systems are designed to increase the use of evidence-based guidelines. Implementing decision support systems may involve training staff on evidence-based tobacco screening and treatment guidelines and tailoring EHR systems to facilitate the delivery of evidence-based interventions.

Examples of Systems Change Interventions to Support Clinicians

  • The Upper Peninsula Health Care Network (UPHCN) is providing quality improvement activities for primary care provider offices and rural health clinics through the Lean for Clinical Redesign Clinical Process Initiative. This involves working with office staff to help map their workflows and incorporate tobacco cessation metrics into their EHR. Through increased screening of tobacco use for improved follow-up of quit attempts, UPHCN is aiming to increase access to tobacco cessation counseling and reduce tobacco use among patients.
  • Altura Centers for Health implemented a quality improvement intervention to better identify tobacco users and promote cessation attempts. Altura providers are prompted to ask each patient about tobacco use by the EHR and linked electronic disease registry system. Providers then direct tobacco users to cessation services, such as the California Smoker's Helpline (1-800-No-Butts) and clinic-provided counseling services and health education.

Considerations for Implementation

Widespread systems change is a challenging endeavor. It require significant investments of funding, effort, and time. In particular, rural communities may need to secure additional resources to implement or adapt EHR systems. The Rural Health Information Hub's Telehealth and Health Information Technology in Rural Healthcare topic guide provides additional information about funding opportunities for rural providers. Additionally, Rural Health Information Technology Workforce Curriculum Resources are available on RHIhub's website.

Systems changes are often instituted and supported at the health-system level. Rural clinics and providers will need to coordinate with health system leadership on systems change initiatives. Additionally, gaining the support and buy-in of clinic leadership and staff is critical to successfully implementing systems changes. Clinics implementing systems change will likely need to identify a lead or champion. This can be especially difficult in rural clinics with limited resources, or in clinics where providers practice intermittently. Clinic managers may need to redesign workflow to ensure that key members can lead tobacco screening and treatment activities.

Program Clearinghouse Examples

Resources to Learn More

Chapter 6: Department Of Veterans Affairs Tobacco-Control Activities
This extensive report discusses changes the Veterans Affairs health system has implemented to attempt to reduce tobacco use among veterans.
Organization(s): Institute of Medicine (US) Committee on Smoking Cessation in Military and Veteran Populations, Department Of Veterans Affairs Tobacco-Control Activities
Date: 2009

Facilitators of Health Systems Change for Tobacco Dependence Treatment: A Qualitative Study of Stakeholders' Perceptions
This research article describes interviews with representatives of health systems, funders, and technical assistance providers that discuss facilitators to success for tobacco dependence programs.
Author(s): Jansen, A., Capesius, T., Lachter, R., Greenseid, L., & Keller, P.
Journal: BMC Health Services Research
Date: 11/2014

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment
This guide describes ways in which healthcare facilities have successfully implemented tobacco control programs, and gives examples of ways in which business owners, public health agencies, and healthcare facilities have collaborated to initiate programs.
Organization(s): Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health
Date: 2006

Treating Tobacco Use and Dependence: 2008 Update
This report is an update to the 2000 Clinical Practice Guideline was published that describes new and effective clinical treatments for tobacco.
Organization(s): Tobacco Use and Dependence Guideline Panel, U.S. Department of Health and Human Services
Date: 5/2008