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RRP 11-019 – HSR&D Study

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RRP 11-019
The Patient Centered Medical Home and Integrated Tobacco Cessation care
Steven S. Fu MD MSCE
Minneapolis VA Health Care System, Minneapolis, MN
Minneapolis, MN
Funding Period: October 2011 - September 2012

BACKGROUND/RATIONALE:
Tobacco use is the leading preventable cause of morbidity and mortality in the United States and disproportionately affects Veterans. Tobacco cessation counseling from a clinician nearly doubles a patient's odds of quitting. Motivational interviewing (MI) is an effective communication technique in tobacco cessation counseling, but strategies to train providers on MI are needed. Key barriers to doing so are lack of expertise, training, and time.

OBJECTIVE(S):
We developed the VA Motivational Interviewing Smoking Treatment Enhancement Program (MI-STEP), a motivational interviewing and tobacco cessation counseling training program for healthcare providers in the Patient Aligned Care Teams (PACT). The objectives were as follows: 1) Assess the feasibility of implementing a high-intensity versus a moderate-intensity motivational interviewing and tobacco cessation counseling training program at two separate VA Medical Centers during implementation of PACT/Patient Centered Medical Home; and 2) Evaluate the performance of the high intensity versus moderate intensity VA MI-STEP trained PACT members in delivering motivational interviewing and tobacco cessation counseling.

METHODS:
This project evaluated the feasibility and performance of two models for the VA MI-STEP intervention: high intensity versus moderate intensity. PACT members at each of two facilities were randomized to moderate- or high-intensity MI training. Guided by the Simpson Technology Transfer Framework and Roger's Diffusion of Innovations Theory, both training models included the following components: 1) three site-based MI clinical champions who received 2 days of intensive training in MI and tobacco cessation counseling, 2) one site-based MI expert consultant (the facility Health Behavior Coordinator), 3) Half day on-site training workshop for PACT members, and 4) materials for self-study. We varied the intensity of the coaching booster sessions for PACT team members (half were randomly selected to participate in booster sessions and half did not participate in booster sessions). The high-intensity model included six booster sessions coached by the MI champions. Three booster sessions used telephone interactions with simulated patients (patient actors) and occurred at four, eight, and 12 weeks after the initial training. Three additional booster sessions (at two, six, and 10 weeks) used small group coaching facilitated by the site-based MI champions. Each booster was one hour in duration and focused on role-playing and specific MI skills.

To evaluate the two training strategies, a structured clinical evaluation (OSCE) was conducted with providers in each group before and 12 weeks after the onsite training. The OSCEs assessed provider competence and acquisition of MI and tobacco cessation skills through interaction with a simulated patient. A trained rater, who was blinded to the groups, assessed the provision of MI skills by listening to the audio-recorded OSCEs. The primary outcome was the rater's scores on the Motivational Interviewing Treatment Integrity (MITI) scales, which is a validated assessment of MI skills. Hierarchical models compared the average changes in MITI scale scores from the pre-training OSCE to the 12-week post-training OSCE assessment for the moderate intensity and the high intensity group. The models incorporated random effects for study site and participant and fixed effects for standardized patient and pre-training OSCE MITI scores.

FINDINGS/RESULTS:
A) Thirty-five PACT members were enrolled in the study and eighteen members were randomly assigned to the high intensity group and received the booster training sessions.

B) Compared to the moderate intensity group, the high intensity group scored significantly higher for three of five MITI competency scales; Global Spirit, Percent Open-Ended Questions, and Percent MI Adherence. Specifically, the high intensity group had a 0.31 increase in the Global Spirit scale compared to a 0.26 decrease for moderate intensity group. The model estimated difference was 0.57 (se 0.20, p = 0.009). The high intensity group had a 17% increase in Percent Open-Ended Questions scale compared to a 3% increase for the moderate intensity group, or a 14% difference (se 6%, p = 0.034) between the two groups. For the changes in the Percent MI adherence scale, the high intensity group had a 31% increase compared to a 0% increase for the moderate intensity group. The model estimated difference was 32% and statistically significant (se = 0.10, p = 0.005). The scores for the other two MITI scales (Percent Complex Reflections and Question to Reflection Ratio) were higher for the high intensity group compared to the moderate intensity group but not statistically significant.

C) In addition, the high intensity group performed significantly better compared to the moderate intensity group on two of five global assessment scales: Collaboration (difference in change scores .81 (se .28), p = .0081) and Evocation (difference .87 (se .35), p = .021). Non-significant improvement was seen in the other three scales; Autonomy/Support, Direction and Empathy.

IMPACT:
The project findings are highly relevant for VA medical centers, managers, providers, VA PACT leadership and for our project partners at NCP and VHA Office of Public Health. This project provides valuable information regarding successful implementation strategies that emphasize the adoption of motivational interviewing and evidence based tobacco cessation practices in the patient centered medical home. These findings indicate that a training strategy using several booster sessions, in addition to MI champions, expert on-site consultant, on-site day training and self-help study materials, was effective for sustaining and enhancing providers' MI skills in the delivery of tobacco cessation counseling. The study complements and supports the VHA NCP Prevention Initiative because our results demonstrates a model for training strategies that emphasize the adoption of MI and evidence-based tobacco cessation practices in the primary care setting.


PUBLICATIONS:

Journal Articles

  1. Haverhals LM, Sayre G, Helfrich CD, Battaglia C, Aron D, Stevenson LD, Kirsh S, Ho M, Lowery J. E-consult implementation: lessons learned using consolidated framework for implementation research. The American journal of managed care. 2015 Dec 1; 21(12):e640-7.
  2. Berlin NL, Cutter C, Battaglia C. Will preoperative smoking cessation programs generate long-term cessation? A systematic review and meta-analysis. The American journal of managed care. 2015 Nov 1; 21(11):e623-31.
  3. Fu SS, Roth C, Battaglia CT, Nelson DB, Farmer MM, Do T, Goldstein MG, Widome R, Hagedorn H, Zillich AJ. Training primary care clinicians in motivational interviewing: a comparison of two models. Patient education and counseling. 2015 Jan 1; 98(1):61-8.
Conference Presentations

  1. Battaglia C, Lambert-Kerzner AC, Aron D, Sayre G, Ho M, Haverhals LM, Stevenson L, Kirsh S, Helfrich CD, Au D. Evaluation of Electronic Consultations in the VHA: The Providers' Perspectives. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
  2. Battaglia C, Lambert-Kerzner AC, Ho M, Haverhals LM, Helfrich CD, Au DH. Integrated Telehealth Care Management and Smoking Cessation for Veterans with Post Traumatic Stress Disorder (PTSD). Paper presented at: Society for Research on Nicotine and Tobacco Annual Conference; 2015 Feb 26; Philadelphia, PA.
  3. Fu SS, Roth CS, Battaglia C, Nelson D, Farmer MM, Do T, Goldstein MG, Kavathekar R, Widome R, Hagedorn H, Zillich AJ. A Randomized Trial of Two Approaches to Training Veterans Affairs (VA) Medical Home Healthcare Providers on Motivational Interviewing for Tobacco Cessation. Presented at: International Conference on Communication in Healthcare; 2013 Sep 29; Montreal, Canada.
  4. Farmer Coste MM, Roth C, Fu SS, Battaglia C, Nelson D, Do T, Goldstein MG, Kavathekar R, Widome R, Hagedorn H, Zillich AJ. Training Members of Veterans Affairs Medical Home Healthcare Teams to Use Motivational Interviewing for Tobacco Cessation. Paper presented at: American Academy on Communication in Healthcare International Conference on Communication in Healthcare; 2013 Sep 1; Montreal, Quebec.
  5. Fu SS, Roth C, Battaglia C, Nelson D, Farmer MM, Do T, Goldstein MG, Kavathekar R, Widome R, Hagedorn HJ, Zillich AJ. A Randomized Trial of Two Approaches to Training Veterans Affairs (VA) Medical Home Healthcare Providers on Motivational Interviewing for Tobacco Cessation. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2013 Apr 24; Denver, CO.


DRA: Mental, Cognitive and Behavioral Disorders, Substance Abuse and Addiction
DRE: none
Keywords: none
MeSH Terms: none

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