AHECs Catalysts for Systems Change
National AHEC Organization
June 24, 2010
Asma Aftab, MD, MPH, Research Assistant Professor
University of Miami AHEC Program
Debbie Hawkins, MPA, Associate Director
University of Florida AHEC Program
Introductions . . .
Florida AHEC Network is
comprised of the AHEC
Programs of the University
of Florida, University of
Miami, University of South
Florida, Nova Southeastern
University, and Florida State
University, and their 10
affiliated regional Centers.
Session Learning Objectives
• Identify characteristics of policy and system change in
undergraduate medical education.
• Understand the importance of tobacco dependency treatment as a
designated mandatory curriculum component in undergraduate
medical education.
• Identify strategies for implementing sustainable systems change.
• Identify strategies for implementing evidenced-based tobacco
curriculum and assessment protocols in undergraduate medicine
education and in the community-based educational experience.
Importance of Systems Change
– Dominant framework through which local,
state, and national funders are approaching
their work
– Purpose is to achieve better outcomes and
improve the status quo
Defining Systems Change
• Systems change initiatives are rooted in the assumption that
significant improvements in the outcomes of a targeted population
will not occur unless the surrounding system adjusts to
accommodate the desired goals (Cohen & Lavach, 1995).
• Systems change is an intentional process designed to alter the
status quo by shifting and realigning the form and function of a
targeted system (Foster, 2007).
Defining System
“The System” is the set of actors, activities, and settings that are
directly or indirectly perceived to have influence in or be affected by
a given problem situation (Foster, 2007).
Systems change agents are individuals or groups that help or
encourage progress or change. Agents have the ability to influence,
cause or sponsor change.
Systems change endeavors seek to alter the policies, routines,
relationships, resources, power structures, and values (Foster,
2007).
Systems Change and AHECs
• Systems Change
– Addresses problems holistically and at
multiple levels and domains
– Engages stakeholders/leadership in the
design and implementation
– Promotes sustainable systems change
Traditional Roles of AHECs
• Form partnerships with
community and academic
groups
• Create opportunities for
networking and coalition
building
• Foster collaboration
among and within
communities
• Provide financial and
other support to
academic and community
partners
• Facilitate academic &
community-based
activities and initiatives
Florida AHEC Mission Statement
Creating community and academic partnerships benefiting
the health of the underserved.
• Contracts with
academic departments
for student training
activities
AHECS
Departments
• Identifies faculty with
interest in medically
underserved
communities in need of
expertise
• AHEC supported
faculty provide services
in conjunction with
student training and
educational activities
Faculty
Underserved
Communities
• Benefit from
medical/health services
resulting from student
training initiatives
• Most often, AHECs
identification and
linkage to the project is
lost.
What’s an
AHEC?
Transformative Nature of AHECs
AHECs . . .
Systems Change Agents . . .
•
•
•
•
• Focused
• Mission and purpose driven
• Visionary
Innovative
Leadership Capacity
Consensus Builder
Visionary
Making the Case for Systems Change
FLORIDA AHEC TOBACCO TRAINING
AND CESSATION INITIATIVE
AHEC Tobacco Initiative Background
In July 2007, Governor Charlie Crist signed into law a bill that
included an appropriation of 10 million dollars each year for two
years to the Florida Area Health Education Centers (AHEC)
Network.
The funding was allocated to provide tobacco cessation and
prevention training to current and future health professionals and to
expand tobacco cessation services to each county of the state.
This appropriation was part of a larger, constitutionally mandated
yearly appropriation to the Department of Health totaling
approximately $57 million per year for anti-tobacco activities.
Case Study: Physician Tobacco Education and Training Needs
Unfamiliar with
cessation
interventions
Root
Cause
Physicians
provide
limited
tobacco
cessation
counseling
Lack of skill in
behavior change
Shortage of
cessation tools
Patient not motivated to
quit
Patients have more
immediate problems to
address
Limited learning
opportunities
Limited experience intervening
with patients who smoke
Insufficient services,
resources and organizational
supports
Lack of effective
smoking cessation
interventions
Limited time to devote
to cessation
Problem
Statement:
Lack of patientcentered self-help
materials
Patients
fail to quit
tobacco
Low financial
reimbursement
Limited time with
patients
13
Systems Change
Primary Care
Settings
Community
Clinics and
Health Center,
Safety-Net
Preceptors/
physician offices
Hospitals and
Residency
Programs
Community
Hospitals
Ambulatory
Clinics
Academic Health
Science Centers
Academic
Medical/Health
Institutions
Tobacco
Research
Networks
&Communities
Faculty
Faculty/
Researchers
Health Profession
Students
Hospitals and Other Acute Care Setting
Clinical
Pathways
Cessation
Intervention
Cessation
Treatment
Identify and
document
patients’
tobacco use
status
Dedicated and
trained tobacco
specialist on
staff
Cessation
treatment for all
patients who
smoke
Audits 5a’s
implementation
performance
Inpatient tobacco
dependency
consultation for all
patients who use
tobacco
Pharmacy
formularies include
pharmacotherapies
Training
Ongoing tobacco
training for staff
and clinicians
Primary Care and Allied Healthcare Settings
Awareness
Clinical Systems
Cessation
Support
Tobacco Treatment
Guidelines
Dedicate resources
Make self-help
materials available
Adopt
Recommendations
Identify patients’
tobacco use status
Refer tobacco using
patients Florida’s Quitline
Document provider
interventions
Primary Care and Allied Healthcare Settings
Quality Improvement
Reimbursement
Train clinicians on
effective smoking
cessation
interventions
Codes for tobacco
cessation counseling on
encounter or billing forms
Monitor if providers
are asking patient’s
tobacco status
Submit insurance claims
that include charges for
tobacco cessation
counseling
Monitor if providers
arrange for follow-up
with patients who are
ready to quit
Systems Change: Medical Education
Institutional
Level
Tobacco core
competencies added to
curriculum
Faculty
Level
Public health approach to
tobacco education
Student
Level
Tobacco cessation
knowledge and
intervention skill level
Influence attitudes towards
tobacco use
Campus System Changes
Campus
Community
Student Wellness and
Tobacco Cessation
Advocacy and
Policy Change
Worksite
Employee Smoking
Cessation Programs
Cessation Services as
a Covered Benefit
Research: Networking with Networks
Training
Resource
Tobacco Cessation Curriculum
Research
Leadership
Transformative Systems Change
• System Norms
– Organizational culture
– Attitudes, beliefs and values
• System Resources
– Human resources
– Social resources i.e. networking/interactions
– Economic resources
• System Regulations
– Policies and procedures
• Systems Operations
– Power structures and decision-making
Case Study: Integrating Tobacco Curriculum at the University of Miami.
Problem Statement: 70 percent of all physicians indicated that they did not have the
skills to assist their patients who smoke with proven cessation methods. 1
Undergraduate Medicine: Tobacco Addiction and Treatment
Faculty
Community
Preceptor
Science-based to
Public Health Model
Assessment of
Students
Accountability
Practice Environment
Institutional
Student
Clinical Systems
Curriculum
Knowledge
Tobacco Clinical
Pathways
Smoke Free Health
Science Center
Attitude
Referrals to Tobacco
Cessation
Testing (OSCE) and
Evaluation
Beliefs
Source: Spangler JG, George G, Foley KL et al. Tobacco Intervention Training: Current Efforts and Gaps
in US Medical Schools. JAMA:2002;288:1102-1109
AHEC
Catalyst for System Change
University of Miami Case Study
Why Target Undergraduate Medicine?
• 70% of smokers would quit if advised by their physician
• Less than 50% of smokers report receiving smoking
cessation advice from their physician.
• Physicians cite time as a barrier for not intervening with
their patients who use tobacco. Yet, 16 studies have
found that a brief 2-3 minute consultation to quit tobacco
use leads to higher odds of patients quitting
• 79% physicians believe that their medical school
education did not prepare them to help smokers quit
Source: Spangler JG, George G, Foley KL et al. Tobacco Intervention Training: Current Efforts and
Gaps in US Medical Schools. JAMA:2002;288:1102-1109
Reasons for Incorporating Tobacco
Education in Medical Student Training
• As role models in not smoking, or quitting smoking.
• In counseling patients not to smoke.
• In providing smoking cessation treatment.
• In organizing and speaking out publicly and lobbying for
comprehensive public policies to control tobacco use.
Source: Spangler JG, George G, Foley KL et al. Tobacco Intervention Training: Current Efforts and Gaps in
US Medical Schools. JAMA:2002;288:1102-1109
Missed Opportunities in Medical Schools
122 Medical School were surveyed;
• Only 3 had a required course devoted to tobacco
treatment
• 31.4% Schools spent 3 or less hours teaching smoking
counseling
• Most medical schools (69.2%) did not require clinical
training in smoking intervention techniques
• No national curricular model guideline exist for schools
to determine the content of tobacco dependence,
instruction or implementation
American Medical Association:
“Tobacco dependence is a chronic illness, much
like diabetes or high blood pressure, and it
requires that doctors take the same long-term
treatment approach to help patients succeed”.
Chronic Care Model for Tobacco Dependence*
•
•
•
•
Systematically ask and document tobacco use
Strongly advise all smokers to quit at each encounter
Assess the motivation to quit
Assist smokers to build self-efficacy through counseling,
medication and social support
• Track all smokers
• Support policies such as smoke free environment and
tobacco user fee
*Treating Tobacco Use and Dependence:2008Update.Available at:http://www.ahrq.gov/path/tobacco.htm
Case Study: Integrating Tobacco Curriculum at the University of Miami.
Problem Statement: 70 percent of all physicians indicated that they did not have the
skills to assist their patients who smoke with proven cessation methods.
Undergraduate Medicine: Tobacco Addiction and Treatment
Faculty
Community
Preceptor
Science-based to
Public Health Model
Assessment of
Students
Accountability
Practice Environment
Institutional
Student
Clinical Systems
Curriculum
Knowledge
Tobacco Clinical
Pathways
Smoke Free Health
Science Center
Attitude
Referrals to Tobacco
Cessation
Testing (OSCE) and
Evaluation
Beliefs
Source: Spangler JG, George G, Foley KL et al. Tobacco Intervention Training: Current Efforts and Gaps
in US Medical Schools. JAMA:2002;288:1102-1109
Institutional System Change Curriculum
• Traditional Didactic approach;
– Lectures, assigned reading and online TobaccoCME
• Patient Centered Methods
– Students trained in behavior modification skills
through motivational interviewing
– Role plays where students act themselves as a
smoker and physicians with a given script to practice
counseling skills
Institutional System Change Curriculum
• Standardized Patient Instructors
– Acts as patients who smoke following a standardized
script and gives students objective feedback
• Evaluation
– Pre-Post Tests
– Objective Structured Clinical Examination (OSCE)
Institutional System Change Students
•
Medical students volunteer as smoke free campus
ambassadors as UM campus goes smoke-free
•
Take lead in organizing and running anti-tobacco events
like Great American Smoke Out
•
Department of Community Services (DOCs) have initiated a
new tobacco intervention station at all of their 8 health fairs
•
Preventive Medicine Club has included tobacco counseling
training as part of club’s activities for students
Tobacco Education Model for Health Professions Students
Miller’s Pyramid of Clinical
Learning
Does
Patient Care
Shows How
Labs/Simulation/Role Play
Knows How
Small Groups/Workshops
Seminars
Knows
Large Lecture
Evaluation
OSCE,
Clinical
Training,
Service
Learning
Applied Learning & Skills
Training
Performance of
Learned) Tobacco
Cessation
Interventions
(Skill )
Activities and demonstrations
designed to provide students with
hands-on learning experiences
Advanced Didactic
Training programs tailored to a specific health
profession or targeted to expand upon core
concepts covered in the initial training. These
trainings build upon knowledge gained and serve
as a booster to “AHEC Tobacco 101”.
Initial Training
General introduction to tobacco dependency and tobacco use
prevention training. Usually, the training is the student’s first
encounter with an AHEC-sponsored tobacco educational
program, “AHEC Tobacco 101.”
Components: Day of Learning and Day of Service
AHEC Tobacco Training
Self Efficacy of
Cessation Intervention
(Affective)
Knowledge of Tobacco
Addiction and
Treatment
(Cognitive)
Medical School Faculty
• Faculty embraces the public health model of addressing
agent, host, vector, and environment for tobacco reflects
a systems approach based on lessons from the
communicable disease community can be highly
effective.
• Faculty gets audited for a set tobacco curriculum
required by the school curriculum committee
• Clinical practices adds clinical systems for tobacco
referrals and as part of students practicing tobacco at
their sites
Community Preceptors
• Students practice tobacco skills as part of their clerkship
rotation in community clinics
• Preceptor practices tobacco assessment themselves as
well as assess their students skills
• Preceptors initiate a tobacco referral system in their
clinics
Clinical Systems Change
• Students and Residents teams incorporate tobacco
intervention as part of in patients admission intake
• Tobacco prompts added in the electronic medical
records system
• In patient tobacco referral system and Pharmacotherapy
Protocol established
Policy Change
• Smoke-Free Campus
– Integration of tobacco training and systems
– Stakeholders buy-in
– Students, Residents, Faculty, Researchers,
Leadership champions
Implications for the Future
• Future funding
– Acquisition of multi-year funding
• NIH, CDC, NCI
– Public health focus
• Health care reform
– Transition to new practice environment
• Systems-based programming
Conclusion
• In the ancient, revered Egyptian myth, the goddess Isis
breathed clean air into her late husband Osiris to restore
him to life.
•
AHECs strive to contemporize the myth by developing a
tobacco program within the context of system change to
help people breath cleaner air and be restored to a
smoke-free life