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Open Access Highly Accessed Research article

Implementing a fax referral program for quitline smoking cessation services in urban health centers: a qualitative study

Jennifer Cantrell12* and Donna Shelley3

Author affiliations

1 Department of Cariology and Comprehensive Care, School of Medicine and Dentistry, New York University, New York, NY, USA

2 Mailman School of Public Health, Columbia University, New York, NY, USA and Public Health Solutions, National Development Research Institutes, Inc., Behavior Science Training Program

3 Department of Cariology and Comprehensive Care and Department of General Internal Medicine, School of Medicine and Dentistry, New York University, New York, NY USA

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Citation and License

BMC Family Practice 2009, 10:81  doi:10.1186/1471-2296-10-81

Published: 17 December 2009

Abstract

Background

Fax referral services that connect smokers to state quitlines have been implemented in 49 U.S. states and territories and promoted as a simple solution to improving smoker assistance in medical practice. This study is an in-depth examination of the systems-level changes needed to implement and sustain a fax referral program in primary care.

Methods

The study involved implementation of a fax referral system paired with a chart stamp prompting providers to identify smoking patients, provide advice to quit and refer interested smokers to a state-based fax quitline. Three focus groups (n = 26) and eight key informant interviews were conducted with staff and physicians at two clinics after the intervention. We used the Chronic Care Model as a framework to analyze the data, examining how well the systems changes were implemented and the impact of these changes on care processes, and to develop recommendations for improvement.

Results

Physicians and staff described numerous benefits of the fax referral program for providers and patients but pointed out significant barriers to full implementation, including the time-consuming process of referring patients to the Quitline, substantial patient resistance, and limitations in information and care delivery systems for referring and tracking smokers. Respondents identified several strategies for improving integration, including simplification of the referral form, enhanced teamwork, formal assignment of responsibility for referrals, ongoing staff training and patient education. Improvements in Quitline feedback were needed to compensate for clinics' limited internal information systems for tracking smokers.

Conclusions

Establishing sustainable linkages to quitline services in clinical sites requires knowledge of existing patterns of care and tailored organizational changes to ensure new systems are prioritized, easily integrated into current office routines, formally assigned to specific staff members, and supported by internal systems that ensure adequate tracking and follow up of smokers. Ongoing staff training and patient self-management techniques are also needed to ease the introduction of new programs and increase their acceptability to smokers.