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Million Hearts in Municipalities: Tobacco Cessation in a Mental Health Clinic in Albany County, New York

State: NY Type: Promising Practice Year: 2019

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Albany County Department of Health
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Million Hearts in Municipalities: Tobacco Cessation in a Mental Health Clinic in Albany County, New York

Albany County is located in eastern New York State, 136 miles north of New York City. The total County population is 305,279, including 245,557 adults. The County population is predominantly white (78.2%), and the largest minority groups include Black or African American (12.8%), Hispanic/Latino (5.2%) and Asian (5.1%) persons. The percentage of minorities in Albany County is substantially below the estimated percentages for New York State; however, minority populations are concentrated primarily in the urban areas. While the City of Albany is home to approximately 32% of the County population, 77% of the African American population and more than 53% of the Hispanic population reside within the City of Albany.¹


Heart disease is the leading cause of death in Albany County, New York. Among adult residents, 30.8% have physician-diagnosed hypertension, which is higher than the comparable Upstate New York rate of 27.8%. Although the smoking rate of the general adult population in Albany County is 16.2%, evidence indicates that tobacco use for adult residents living with mental health challenges approximates 30.3%.² On average, mortality for Severely Mentally Impaired (SMI) is 28.5 years fewer than the general population.³ Unique challenges in the SMI population include pharmacological interaction between tobacco smoke and medications; social acceptability of tobacco use within mental health settings; inaccurate perception that tobacco use helps to alleviate anxiety, sadness, and agitation; and belief that quitting smoking among people with SMI is difficult to achieve.


With funding from the Centers for Disease Control and Prevention (CDC) and the National Association of County and City Health Officials (NACCHO), through the 2017-2018 Million Hearts® in Municipalities Project, Albany County Department of Mental Health identifies and refers SMI clients to tobacco cessation resources by recognizing opportunities for improving diagnosis and referral, creating a registry of eligible clients, and documenting client tobacco cessation progress. Furthermore, the department expanded tobacco cessation services by training six providers as Certified Tobacco Treatment Specialists and created a brochure of local cessation services. Current activities include conducting group and individual tobacco cessation sessions and using educational supplies (e.g. hazards of smoking display, tarred lung model, smokers' roulette game).  Using existing electronic health records, health systems changes (HSC) now identify qualifying clients, track individual progress, and provide impactful support to enrolled SMI clients at Albany County Department of Mental Health's primary clinic site.


Albany County Department of Mental Health has had an impact on 20% of those wishing assistance in their own cessation efforts through either harm reduction - using tobacco less now than before the intervention - or through total cessation efforts as a direct result of the program. To date, over 400 patients have been provided tobacco cessation interventions during clinical sessions that include treatment plan goals, peer group treatment, and medical interventions. Since May 2018, twenty six patients have ceased tobacco use, ten patients have completely quit using tobacco for 90 or more days, and an additional thirty seven patients have reduced tobacco use. 


Albany County Department of Health http://www.albanycounty.com/Government/Departments/DepartmentofHealth.aspx served as a resource for technical assistance in assessing and improving internal processes.


A commitment by the organization's leadership to innovate, maintain a discrete project focus, and execute sustainable interventions were key in implementing effective cessation services. With select customization, reducing tobacco use for people with mental illness can be easily replicated by other behavioral health providers.

Albany County is located in eastern New York State, 136 miles north of New York City. It covers a land area of 523.45 square miles, a water area of 9.76 square miles and includes the Helderberg and part of the Catskill Mountain ranges. The terrain of the county ranges from flat near the Hudson and Mohawk Rivers to high and hilly to the southwest, where the Catskills begin. Its urban center is the riverfront City of Albany surrounded by suburban municipalities extending to rural hill towns. Albany County is part of the Albany-Schenectady-Troy, New York Metropolitan Statistical Area. More than ten colleges and universities offer undergraduate, graduate, medical, legal and other professional programs. Four (4) hospitals, including a Department of Veterans Affairs Medical Center, provide services to residents of Albany County and the larger metropolitan region. As home of the state capital, much of Albany County's population is employed by government, law, health, finance, education, and business. Transportation infrastructure supports rail, roadway, water, and air travel. Albany County has a humid continental climate, with cold, snowy winters, and hot, wet summers. Snowfall is significant, with an average annual accumulation of 63 inches, but much less than the lake-effect areas to the north and west. The total County population is 305,279, including 245,557 adults. The County population is predominantly white (78.2%), and the largest minority groups include Black or African American (12.8%), Hispanic/Latino (5.2%) and Asian (5.1%) persons. The percentage of minorities in Albany County is substantially below the estimated percentages for New York State; however, minority populations are concentrated primarily in the urban areas. While the City of Albany is home to approximately 32% of the County population, 77% of the African American population and more than 53% of the Hispanic population reside within the City of Albany.¹ Heart disease is the leading cause of death in Albany County, New York. Among adult residents, 30.8% have physician-diagnosed hypertension, which is higher than the comparable Upstate New York rate of 27.8%. Although the smoking rate of the general adult population in Albany County is 16.2%, evidence indicates that tobacco use for adult residents living with mental health challenges approximates 30.3%.² On average, mortality for Severely Mentally Impaired (SMI) is 28.5 years fewer than the general population.³ Unique challenges in the SMI population include pharmacological interaction between tobacco smoke and medications; social acceptability of tobacco use within mental health settings; inaccurate perception that tobacco use helps to alleviate anxiety, sadness, and agitation; and belief that quitting smoking among people with SMI is difficult to achieve. Beginning in 2014, in recognition of these disparities, Albany County Department of Mental Health began making organizational changes to support tobacco-free living for people living with mental illness. These changes included surveying all existing patients and screening all new patients for tobacco use and desire to quit; modifying the electronic health record to allow for routine inclusion of tobacco-related information; including tobacco-related diagnoses and intervention strategies to the treatment plan; disseminating tobacco-related health information to patients; and, working with clinical staff to implement tobacco cessation interventions for those patients requesting assistance. Preliminary results were very successful and set the stage for the enhancements made possible by the Million Hearts® 2022 initiative. Albany County Department of Mental Health implemented evidence-based tobacco cessation services as part of its work in the Million Hearts® 2022 Initiative. Using the training of Certified Tobacco Treatment Specialists and processes identifying patients at risk for tobacco use, the Albany County Department of Mental Health is providing tobacco cessation services, identifying and publicizing community tobacco cessation resources, and implementing referral processes to reduce tobacco use among severally mentally ill persons. As a result, hundreds of persons with mental illness or substance use disorders have received the intervention, and some have ceased tobacco use.
With funding from the Centers for Disease Control and Prevention (CDC) and the National Association of County and City Health Officials (NACCHO), through the 2017-2018 Million Hearts® in Municipalities Project, Albany County Department of Mental Health identifies and refers SMI clients to tobacco cessation resources by recognizing opportunities for improving diagnosis and referral, creating a registry of eligible clients, and documenting client tobacco cessation progress. Furthermore, the department expanded tobacco cessation services by training six providers as Certified Tobacco Treatment Specialists and created a brochure of local cessation services. Current activities include conducting group and individual tobacco cessation sessions and using educational supplies (e.g. hazards of smoking display, tarred lung model, smokers' roulette game). Using existing electronic health records, health systems changes (HSC) now identify qualifying clients, track individual progress, and provide impactful support to enrolled SMI clients at Albany County Department of Mental Health's primary clinic site. Albany County Department of Health served as a resource for technical assistance in assessing and improving internal processes, and St. Peter's Health Partners provided coordination of the Certified Tobacco Treatment Specialist training. Start-up costs for the Million Hearts® in Municipalities: Tobacco Cessation in a Mental Health Clinic in Albany County, New York practice includes Certified Tobacco Treatment Specialist ($ 1,200 per person x 6 providers = $ 7,200); smoking cessation supplies, health education materials ($ 3,105); and in-kind personnel services (20 hours).
The initiative inspired the Albany County Department of Mental Health to immediately implement practice changes, including integrating tobacco use assessment into electronic health records of at-risk patients, streamlining referrals, and publishing a listing of local tobacco cessation resources. The education and certification of six tobacco cessation specialists builds sustainable local resource capacity to address the needs of SMI patients at risk for tobacco use. To date, over 400 patients have been provided tobacco cessation interventions during clinical sessions that include treatment plan goals, peer group treatment, and medical interventions. An unexpected benefit of the initiative has been an increased likelihood of prescribers to initiate nicotine replacement therapy for SMI patients. Albany County Department of Mental Health has had an impact on 20% of those wishing assistance in their own cessation efforts through either harm reduction - using tobacco less now than before the intervention - or through total cessation efforts as a direct result of the program. Since May 2018, twenty six patients have ceased tobacco use, ten patients have completely quit using tobacco for 90 or more days, and an additional thirty seven patients have reduced tobacco use. Footnotes [1] The New York State Expanded Behavioral Risk Factor Surveillance System 2013-2014 (2014 eBRFSS) was design to supplement the Center for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS), which is conducted annually in New York State. The purpose of the 2014 eBRFSS was to produce local information on key public health issues. Data for the project were collected from April 15, 2013 to May 10, 2014. The 2014 eBRFSS reached both households with landline telephones and households which only had cell phones. Like the annual BRFSS, New York State's 2014 eBRFSS was designed to be representative of the non-institutionalized adult household population, aged 18 years and older. http://www.hcdiny.org/content/sites/hcdi/ebfrss_chart_books/Albany.pdf ²Combating Early Death in People with Serious Mental Illness. National Institute of Mental Health (November 4, 2015). Science Update https://www.nimh.nih.gov/news/science-news/2015/combating-early-death-in-people-with-serious-mental-illness.shtml ³Radcliffe, S. Why Do People with Mental Health Illness Smoke So Much?” Healthlink (October 17, 2017) https://www.healthline.com/health-news/mental-health-illnesses-and-smoking-cigarettes#1
Select health systems changes ensure that the Million Hearts® in Municipalities: Tobacco Cessation in a Mental Health Clinic in Albany County, New York initiative can be sustained. Specifically, critical startup costs (i.e. Certified Tobacco Treatment Specialist training, supplies) have been incurred; health systems change(s) is a sustainable approach to establishing an ongoing registry of qualifying SMI persons to enroll in tobacco cessation classes. Accordingly, tobacco cessation services will soon be expanded to Albany County Department of Mental Health's correctional facility, Assertive Community Treatment Unit, and Health Home Care programs. The project's success of reducing tobacco use for people with mental illness is multifactorial. First, it was critical to leverage the legacy of collaboration between Albany County Department of Mental Health and Albany County Department of Health, including previous interest in addressing tobacco use among SMI persons. Second, the use of a process mapping technique provided insights into current steps of identifying and treating SMI clients at risk for tobacco use. Through this, we learned it is valuable to use discrete Plan-Do-Study-Act cycles to test process improvements. Lastly, a commitment by the organization's leadership to innovate, maintain a discrete project focus, and execute sustainable interventions were key in implementing effective cessation training. There are some challenges to public health agencies implementing tobacco cessation activities including the time necessary to execute local government contracts and comply with purchasing procedures. With select customization, reducing tobacco use for people with mental illness can be easily replicated by other behavioral health providers.
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