Tobacco dependence is a leading cause of morbidity and mortality among veterans and accounts for substantial health care expenditures. VA Community Based Outpatient Clinics (CBOC) were established to offer veterans easily accessible community-based health care, including treatment for nicotine dependence. There are currently over 700 CBOC's in the nation providing primary care and mental health treatment services to veterans. CBOC providers follow the VA/DOD nicotine guidelines, and the CBOC treatment setting presents an opportunity to develop comprehensive, and inform future, nicotine treatment services. Therefore, this study intended to pilot test and modify the Addressing Tobacco Through Organizational Change (ATTOC) intervention for CBOC's within the VA system. The ATTOC model includes a manual-guided approach developed by Dr. Douglas Ziedonis (Chair, Department of Psychiatry, University of Massachusetts Medical School), a recognized expert in tobacco dependence treatment and implementation of organizational change interventions. The ATTOC model consists of staff training for both evidence-based practices and organizational change strategies and has demonstrated to be effective in non-VA treatment settings. The staff training component of ATTOC includes a focus on brief intervention approaches including Brief Motivational Enhancement Therapy (MET) with personalized feedback including use of a CO monitor and selected exercises from the Learning about Healthy Living manual. These brief interventions are designed specifically to increase motivation among lower motivated smokers to actively participate in treatments (medications / quitline / quitters group) for nicotine dependence. The ATTOC organizational change intervention is well developed and includes a model for adapting for use in outpatient settings - including the identification of project leaders (champions / leadership team); an environmental scan; an agency readiness assessment; change plan, patient flow review, patient education review, staff recovery assessment, and sample policy strategies.
1.To conduct a formative and summative evaluation of the implementation of the ATTOC intervention in two CBOCs with the goal of adapting the existing ATTOC implementation process and materials to the VA CBOC setting.
2.A secondary objective was to collect both quantitative and qualitative data from CBOC clinicians regarding their attitudes about addressing tobacco use, their practices addressing tobacco use, and their knowledge of tobacco and tobacco cessation strategies.
This proposal involved a pilot implementation project of our Addressing Tobacco Through Organizational Change (ATTOC) intervention in two CBOCs in VISN 1 (Lynn and Gloucester) with one control site (Fitchburg CBOC) and specifically targeted a diverse group of general and specialty providers as an initial step to develop uniformity of care. The CBOCs participated in a 4-month intervention that provided staff training and ongoing technical assistance to help develop patient, staff, and environmental strategies designed to improve access to and demand for tobacco dependence treatment and ultimately improve treatment outcomes via use of the ATTOC model. The assessment included evaluating staff-level changes in nicotine knowledge, attitudes, and practices (including pre/post changes on the nicotine performance measures); environmental / program level practices; and as a result, client-level changes in exposure to and utilization of nicotine dependence treatment.
Primary outcomes of this study include: (1) primary care CBOC staff recognized the importance of addressing tobacco dependence, but felt more pressure to address other presenting medical problems; (2) primary care staff had little confidence that their efforts to address tobacco use would influence patient behavior or decision making; (3) adaptations to the manualized ATTOC organizational change model have been made to accommodate the many competing demands of the busy CBOC primary care staff; (4) despite lack of time, CBOC clinicians expressed an interest in further training to enhance their ability to address tobacco with their patients and we have identified the need to create brief, teachable moments within the CBOC treatment setting; (5) CBOC clinicians also reported that the initial training they received as part of this project was helpful; (6) CBOC-based behavioral health specialists greatly strengthen the ability of CBOC staff to address tobacco use in patients, both in the direct service they provide to veterans and in indirect ways (e.g., providing a brief consultation) in which they can serve as a resource to other CBOC primary care staff; and (7) ongoing relationships with hospital-based smoking cessation providers are crucial to the sustainability of an organizational change intervention such as ATTOC.
To our knowledge, these findings are the first contribution to a knowledge base about the barriers and facilitators to implementing an organizational change intervention in VA CBOCs. This project is also the first to report on the results of a preliminary investigation to evaluate the impact of the intervention on knowledge, attitudes and practices of CBOC clinical staff and has offered insights in modification of the ATTOC approach for the VA. Our group has submitted a VA Merit as a follow up to this study and used the knowledge gained in this work to modify the intervention and inform the proposed design.
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