The implementation of ask-advise-connect in a federally qualified health center: a mixed methods evaluation using the re-aim framework

Abstract

Ask-Advise-Connect (AAC) efficiently links smokers in healthcare settings with evidence-based Quitline-delivered tobacco treatment through training clinic staff to systematically ask patients about smoking status, advise smokers to quit, and connect patients with state Quitlines using the electronic health record. This study utilized a mixed-methods approach, guided by the RE-AIM framework, to evaluate the implementation of AAC in a Federally Qualified Health Center (FQHC). AAC was implemented for 18 months at a FQHC serving primarily low-socioeconomic status (SES) Latinos and Latinas. Results are presented within the RE-AIM conceptual framework which includes dimensions of reach, effectiveness, adoption, implementation, and maintenance. Quantitative patient-level outcomes of reach, effectiveness, and Impact were calculated. Post-implementation, in-depth interviews were conducted with clinic leadership and staff (N = 9) to gather perceptions and inform future implementation efforts. During the implementation period, 12.0% of GNHC patients who reported current smoking both agreed to have their information sent to the Quitline and were successfully contacted by the Quitline (Reach), 94.8% of patients who spoke with the Quitline enrolled in treatment (Effectiveness), and 11.4% of all identified smokers enrolled in Quitline treatment (Impact). In post-implementation interviews assessing RE-AIM dimensions, clinic staff and leadership identified facilitators and advantages of AAC and reported that AAC was easy to learn and implement, streamlined existing procedures, and had a positive impact on patients. Staff and leadership reported enthusiasm about AAC implementation and believed AAC fit well in the clinic. Staff were interested in AAC becoming the standard of care and made suggestions for future implementation. Clinic staff at a FQHC serving primarily low-SES Latinos and Latinas viewed the ACC implementation process positively. Findings have implications for streamlining clinical smoking cessation procedures and the potential to reduce tobacco-related disparities.

Lay Summary

Ask-Advise-Connect (AAC) simplifies and streamlines the process of asking patients about their smoking status, advising smokers to quit, and connecting patients through the electronic health record with free, evidence-based tobacco cessation treatment offered by state Quitlines. This study is the first to evaluate perceptions of AAC among clinic leadership and staff. After an 18-month implementation of AAC at a clinic serving mostly low-income Latinos and Latinas, clinic staff (e.g., medical assistants) and leaders were interviewed. Respondents reported that AAC streamlined their efforts to get patients to quit smoking, was easy to carry out, and fit well into the clinic flow. Staff wanted to keep AAC as the standard of care and made suggestions to improve how AAC works. They reported positive feedback from patients. In addition, a similar proportion of smokers enrolled in Quitline treatment as in other AAC trials. Thus, AAC worked well for patients and clinic staff. Having AAC in other clinics could improve enrollment in evidence-based smoking cessation treatment, facilitate successful smoking cessation among low-income primary care patients, and reduce burden on healthcare providers.

Implications

Practice: Ask-Advise-Connect is effective at connecting smokers to Quitline treatment and is acceptable to clinic staff, reducing barriers for both parties compared to other in-clinic smoking cessation approaches.

Policy: In-clinic smoking cessation interventions should minimize staff burden and maximize effectiveness for patients.

Research: Future research should evaluate staff adherence to Ask-Advise-Connect, particularly in the context of different types of electronic health record systems.

INTRODUCTION

Cigarette smoking is the leading preventable cause of illness and death among U.S. adults [1]. While smoking prevalence has declined in the general population (12.5%), members of underserved populations (i.e., low-socioeconomic status [SES], 25.2%) continue to smoke at high rates and suffer disproportionately from the health consequences of smoking [2–4]. Nearly half of smokers report making a quit attempt each year [1]; yet, only about 7% of these attempts are successful [5]. This may in part be attributable to underutilization of evidence-based smoking treatments [6]. Notably, low-SES and racial/ethnic minority smokers have limited access to cessation resources and are less likely to successfully quit [4, 7–9]. Efforts are needed to provide underserved smokers with evidence-based treatment to reduce the incidence of preventable illness and eliminate health disparities.

Smoking cessation treatment delivered via Quitlines has demonstrated effectiveness equivalent to that of in-person treatment, even in diverse and underserved populations [6, 10–14]. Quitline-delivered treatment is free, available in all USA states, and is acceptable to diverse populations [15]. Furthermore, Quitline-delivered treatment eliminates many barriers associated with face-to-face treatment, such as lack of transportation and/or childcare [16, 17]. However, Quitlines only reach 1–2% of smokers annually [6, 18], and rates are even lower among special populations, such as Latinos and Latinas [19, 20].

Given that approximately 80% of U.S. smokers see a primary care physician each year [21], national initiatives have been developed to enhance the delivery of tobacco cessation treatment in medical settings. These include the 5 A’s (i.e., Ask, Advise, Assess, Assist, Arrange) and AAR (i.e., Ask-Advise-Refer) in which healthcare professionals offer information on how smokers may contact the Quitline on their own to enroll in tobacco treatment. Notably, these initiatives have not been well-integrated into healthcare settings [6, 22–27]. Efforts are needed to develop partnerships with healthcare systems to ensure that smokers are provided with evidence-based treatment [6], as even modest increases in reach would impact smoking cessation rates at the population level [28].

J.I. Vidrine and colleagues developed Ask-Advise-Connect (AAC) to address clinic- and patient-level barriers to treatment enrollment by linking smokers in healthcare settings with Quitline-delivered tobacco treatment via the clinic electronic health record (EHR) [16]. Results from two large group randomized trials revealed that AAC (vs. AAR) was associated with a 13–30 fold increase in Quitline-delivered tobacco treatment enrollment [24, 25]. Although these increases in treatment enrollment are encouraging, there is substantial room for improvement. Factors that influence enrollment in tobacco cessation treatment are multifaceted. Prior research has largely focused on psychological factors such as motivation to quit [29] and readiness to change [30], while environmental factors, such as provider-level and clinic-level factors have less often been examined [31–33]. Although AAC has demonstrated effectiveness for increasing Quitline treatment enrollment rates and facilitating smoking cessation [24, 25], research is needed to evaluate clinic-and provider-level factors influencing the implementation process.

RE-AIM [28] provides a framework for systematically evaluating the dissemination and implementation of health interventions [34]. Dimensions include: (i) reach (the proportion of the target population who receives a particular intervention); (ii) effectiveness (the positive and negative outcomes of an intervention); (iii) adoption (facilitators and barriers to initiating an intervention); (iv) implementation (the extent to which the intervention is delivered as intended); and (v) maintenance (the extent to which the intervention is maintained over time or becomes part of routine practice) [34]. Utilizing a multicomponent framework offers a more complete evaluation of real-world applications of health interventions than a single focus on intervention effectiveness. RE-AIM allows for insights into the perspectives of organizations and staff who are primarily responsible for intervention adoption and use. It has been used to evaluate organizational implementations of smoking cessation interventions [35, 36] and is suitable for evaluations using mixed methodology [34, 35].

This manuscript describes the implementation of AAC within a community health and dental clinic serving primarily low-SES Latino and Latina patients designated as a Federally Qualified Health Center (FQHC). Following the implementation of AAC, in-depth interviews informed by the RE-AIM framework were conducted with clinic staff and leadership to evaluate AAC and to determine ways to improve future implementation efforts. Consistent with our previous AAC studies [24, 25] the RE-AIM framework also guided the quantitative investigation of intervention reach, effectiveness, and impact for clinic patients [37]. Therefore, we present two sets of outcomes: (i) patient-level outcomes from an AAC implementation, (ii) and perceptions of clinic staff and leadership following the AAC implementation. Few prior interventions implemented in similar settings have evaluated both patient behavioral outcomes and the degree to which systems-level interventions were adopted and accepted by organizations [38]. The objective of the current investigation is to describe both (i) patient-level outcomes of reach, effectiveness, and impact and (ii) healthcare provider perceptions of the implementation of AAC in a FQHC.

METHODS

Study design

The current study is a mixed-methods design of an AAC implementation in which we report quantitative patient-level outcomes and qualitative provider-level outcomes. AAC was implemented at the Good Neighbor Healthcare Center (GNHC), a FQHC in Houston, Texas, for 18 months (March 2012–August 2013). Prior to the implementation of AAC, a system was in place to assess patients’ smoking status during clinic visits and fax referrals to the Texas Quitline. Fax referrals are processed by the Quitline in the same way as EHR referrals; thus, at GNHC AAC was designed to improve the ease and immediacy of the referral system. Following the implementation period, in-depth interviews (N = 9) were conducted with GNHC clinic staff and leadership to evaluate the program and inform future implementation efforts.

GNHC was approved as a FQHC by the U.S. Department of Health and Human Services in September 2005 [39] and provides residents of the greater Houston area with access to low-cost, quality healthcare regardless of individuals’ ability to pay. GNHC offers primary care, obstetric and gynecological care, and dentistry. GNHC served approximately 9,300 unique patients a year, of which 98% reported an income at or below 200% of the federal poverty level, 74% were uninsured, and 93% were members of racial/ethnic minority groups. Seventy-two percent were Latino/a, and 51% reported using a primary language other than English.

Ethics approval

A waiver of written informed consent and authorization was obtained from the Univeristy of Texas, MD Anderson Cancer Center Institutional Review Board (IRB) for patient-level data collected from GNHC and the Quitline. Patients were given an information sheet that included study details during the clinic visit. When patients who reported current smoking agreed to have their contact information sent to the Quitline, this provision of verbal informed consent was documented in the EHR. Ethics approval for the qualitative interviews was obtained from the MD Anderson IRB and the Texas Department of State Health Services. Clinic staff who participated gave informed consent prior to beginning the interviews.

AAC implementation procedures

Clinic staff attended an initial 30-min training session held during an all-staff meeting at the GNHC prior to the implementation of AAC where they learned how to: (i) assess and document all patients’ smoking status in the EHR during the vital signs assessment at every visit; (ii) provide smokers with brief advice to quit; and (iii) offer to immediately connect interested smokers with the Quitline. In addition, 30-min quarterly booster training sessions were held throughout the implementation period to ensure that staff were implementing AAC as designed. Booster sessions were also used to answer questions, and to ensure that new staff members were appropriately trained in the implementation of AAC. Staff were given laminated cards listing the AAC steps, which could be affixed to their identification badges. Clinic staff connected smokers to the Quitline by clicking an automated link in the EHR that sent patients’ contact information (i.e., name, phone number) directly to the research team who, in turn, sent this information to the Quitline within 24 hr. The Quitline was funded by the State of Texas, operated by Optum, and staffed by trained counselors who were available 24 hr a day, 7 days a week, and most holidays. Quitline counselors attempted to contact patients within 48 hr of receiving their contact information and made up to five attempts over the course of 2 weeks to reach each patient before coding them as unreachable. Patients received the standard counseling protocol offered by the Quitline, which included up to five proactive telephone counseling calls designed to provide practical support to plan for successful cessation and long-term abstinence (e.g., develop problem-solving and coping skills, secure social support). The initial call helped patients identify a quit date and follow-up calls occurred a day or two after the quit date, one week post quit date, and at subsequent 2- to 3-week intervals. Patients were able to call an 800 number as needed for support between counseling calls. Counseling was consistent with the Treating Tobacco Use and Dependence Clinical Practice Guideline [12] and delivered in English, Spanish, and at least 15 other languages through a third party. A 2-week supply of no-cost nicotine replacement therapy (NRT) was offered when available (i.e., to those residing in Tobacco Coalition Counties and when adequate funding was available) and was mailed to those accepting the NRT offer. Treatment enrollment data and acceptance of NRT were tracked by the Quitline and securely sent to the research team weekly. Data were stored in a secure Microsoft Access database.

Quantitative data collection

Patients

Participants were all patients ≥18 years of age who presented for care at the GNHC during the 18-month implementation period. Patients were not incentivized to participate.

Patient-level outcome measures

The RE-AIM framework [28] was used to evaluate the reach, effectiveness, and impact of AAC. Reach was defined as the number of smokers identified in clinic who talked with the Quitline divided by the total number of identified smokers. Effectiveness was the number of smokers who enrolled in Quitline treatment divided by the number of smokers who talked with the Quitline. Impact was the product of Reach and Effectiveness (i.e., the number of smokers who enrolled in Quitline treatment/ the total number of identified smokers). Throughout the implementation period, GNHC provided study staff with (i) the total number of smoking assessments performed, (ii) the proportion of patients who reported current smoking, and (iii) the proportion of smokers who agreed to have their contact information sent to the Quitline during the study period. The Quitline provided the proportion of smokers who agreed to be connected that (i) talked with someone from the Quitline, and (ii) enrolled in Quitline treatment.

Data analysis

Proportions for Reach, Effectiveness, and Impact were calculated.

Qualitative interviews

GNHC staff participants

One year following the implementation of AAC, key informants from GNHC clinic staff and leadership were invited to participate in individual in-depth interviews. Interviews were conducted from June to October 2013 with seven clinic staff (i.e., medical assistants [MAs], dental assistants [DAs]) and two members of the senior leadership team, the Chief Dental Officer and the Chief Executive Officer. All key informants were women. The majority were Latina, with Non-Latina White and Black women also represented.

Procedures

DSH conducted the in-depth interviews using a semi-structured guide (see Table 1) [40]. Questions were developed to assess dimensions of the RE-AIM framework. All interviews were conducted in person and in English at GNHC. A research coordinator was present to take notes and audio-record the interviews. Prior to the start of the interviews, study procedures were described, and participants provided written informed consent. Interviews lasted between 20 and 40 min. Participants were provided with refreshments and compensated for their time with a small gift (i.e., lunch bag, water bottle). Following each interview, DSH and the research coordinator met to debrief, review notes to ensure fidelity to the protocol, and determine whether saturation of key research topics had been reached. Saturation occurs when no new information is obtained and the data obtained from participants begins to be repetitive [41]. Theoretical memos were kept during data collection and analysis [42, 43].

Table 1

RE-AIM Dimensions, GNHC Interview Questions, and Key Findings

Dimension	Questions	Key findings
Reach	**	Staff perceived that AAC improved the number of patients who connected with tobacco treatment vs. the prior fax referral system
Effectiveness	What were some of the advantages of AAC? What were some of the disadvantages of AAC? What impact do you think that AAC has on patients at GNHC?	Staff felt more confident that the referrals were reaching the Quitline and that the Quitline was calling patients Staff mentioned that treatment reduced barriers for patients. Patients did not have to remember to call, arrange for transportation or childcare, and treatment was free Staff mentioned that treatment facilitated quitting for patients (e.g., access to free NRT)
Adoption	What were your initial impressions of AAC? How did AAC fit with the way things are done here at GNHC?	Staff perceived that the whole clinic, including leadership, was enthusiastic about AAC prior to implementation AAC was easy to learn and carry out which facilitated adoption AAC fit into the clinic’s existing mission to offer tobacco treatment and helped demonstrate meaningful use criteria
Implementation	What were some of the things that made AAC easy to implement at GNHC? What were some of the things that made AAC difficult to implement at GNHC?	Staff felt that training was sufficient and AAC was easy to implement Staff were hopeful about AAC prior to implementation and felt that it met or exceeded expectations Most staff reported no or minimal barriers to AAC implementation. The dental clinic had to switch between the clinic-wide EHR and a dental-specific EHR to note smoking status Staff noted that seeing patients respond to treatment after AAC implementation was motivating and that patient feedback was motivating
Maizntenance	What are your current impressions of AAC? What would you think about AAC becoming the new standard of care of GNHC? What recommendations do you have for improving the implementation of AAC?	There was strong interest in AAC becoming the standard of care Participants made minor recommendations for AAC going forward, including: • The option to offer treatment to family members of patients • A drop down box in the EHR to note smoking treatment status • An option to add alternative phone numbers • Following up with patients about AAC

^**Although in-depth interview participants spontaneously mentioned themes related to Reach, no planned questions for the semi-structured interview tapped the Reach dimension.

Data analysis

Audio recordings of the interviews were transcribed verbatim by a professional outside vendor. DSH checked the transcripts for accuracy and managed and coded them using QSR International’s NVivo 10 qualitative analysis program. A qualitative descriptive approach was followed [44]. Qualitative description is based on principles of naturalistic inquiry, and provides rich descriptive content from participants’ perspectives [45]. Coding and analyses used inductive and deductive approaches [46, 47]. An initial set of codes mapping onto the RE-AIM framework came from the interview topics and other codes emerged from the data. The objective of coding was to capture as many concepts as possible and to examine relationships and patterns of the concepts within and across transcripts to identify conceptual linkages or themes. Two coders independently coded each transcript and met to discuss findings, resolve inconsistencies, and refine the coding system, when warranted. Coding inconsistencies were resolved to consensus through discussion.

RESULTS

Implementation of AAC—quantitative patient-level outcomes

During the 18-month implementation period, 14,888 smoking status assessments were conducted, and patients reported current smoking in 1,591 of these assessments (10.7%).

Reach

Patients who reported smoking were given brief advice to quit and offered connection with the Quitline; 49.2% of these (783/1,591) agreed to have their information sent to the Quitline and 12.0% (191/1,591) were successfully contacted by the Quitline. Thus, the reach of AAC was 12.0%.

Effectiveness

Of the 191 smokers who talked with the Quitline, 181 enrolled in treatment, resulting in a 94.8% effectiveness rate.

Impact

The impact (12.0% [reach] × 94.8% [effectiveness]) was 11.4%. In other words, 11.4% of all identified smokers seen at the GNHC during the AAC implementation period enrolled in treatment with the Quitline (181/1,591).

Qualitative interviews

Thematic results that emerged from key-informant interviews (N = 9) are presented as they relate to each RE-AIM dimension.

Reach

Research staff monitored patient Quitline enrollment and provided feedback. Research staff provided GNHC leadership and staff with regular updates about how many patients were offered treatment and connected with the Quitline. Clinic staff acknowledged the usefulness of such monitoring and feedback. One stated, “[They] gave us the numbers, and we were like, ‘Wow.’ We didn’t know it was so many patients that received the information and are doing the information. So the staff is pretty happy about it.” (Medical Assistant, Interview 3). Another staff member said, “It’s been really positive. A lot of our numbers have increased. So a lot of our patients have been able to connect with y’all a lot better.” (Medical Assistant, Interview 1).

Effectiveness

Smokers were effectively connected with the Quitline. Clinic staff noted that, prior to the implementation of AAC, they were often unsure if the fax referrals ever reached the Quitline or if smokers were successfully contacted and enrolled in treatment. Following the implementation of AAC, clinic staff reported greater confidence in their ability to connect smokers with treatment. One staff member stated,

We’re able to do it through our EMR, so it is just a click here, click there, and it just goes smoothly. We don’t have to fax. We don’t have to get a confirmation… We do our end, and y’all [research staff] do your end, and y’all connect with the patient. It’s fabulous. (Medical Assistant, Interview 1).

Another said, “Everybody was excited about the program, because you didn’t have to get the paper and go to the fax and fax it. Then you worry, ‘Did it go through? Did they get the fax?’” (Title, Interview 3). Clinic staff also reported that AAC took the pressure off of the smokers. For example, one staff member said, “Well, I thought it was better because the patient didn’t have to do anything. They [the Quitline] would call the patient, and the patient would get the help if they would want it.” (Medical ­Assistant, ­Interview.

AAC had a positive impact on patients. Clinic staff reported receiving positive feedback about AAC from patients. One staff member described the impact of AAC on a patient, “This program really helped him. It gave him a lot of information and he decided it was the best way to quit smoking would be with this program. And to this day, he stopped smoking.” (Medical Assistant, Interview 3). Another said,

All these patients come, and I ask them, “How is the program going, helping you out?” And… they’re happy about it, that they have stopped smoking, and they said it really helped them out in their life and it changed their life.” (Dental Assistant, Interview 5).

Treatment was free and addressed common barriers associated with smoking cessation treatment. Clinic staff noted that another advantage was the fact that Quitline-delivered treatment was free. One identified “the ability to get them [smokers] the help for free” as a major benefit and went on to say, “That’s a good thing for most of our patients since we’re low income.” (Medical Assistant, Interview 2). A member of the leadership echoed this by saying,

We deal with the underserved communities, so a lot of times, patients may have a desire to do things as far as quitting, but then the finances involved with that have been an issue, so we’ve eliminated, with this program, some of the barriers to that, so they don’t have to worry about paying for it. (Senior Leadership, Interview 6).

Furthermore, AAC addressed other barriers to treatment (e.g., lack of transportation or childcare) that racial/ethnic minorities and those with low-SES often face. For example, one staff member stated:

We tell them that they don’t have to drive anywhere, it’s free, they’re going to call you and offer you a patch or gum. And they deliver it to their home… And they feel like, “Okay, they’re going to help me out. I want in too.” (Medical Assistant, Interview 4).

Adoption

Staff and leadership were enthusiastic about AAC prior to its implementation. Prior to the implementation of AAC, clinic staff were hopeful about its potential to improve how the clinic handled smokers by seamlessly connecting them with evidence-based treatment. One staff member stated, “I thought it was great. We did have a lot of smokers and we want to help them out. I thought it was a good idea.” (Medical Assistant, Interview 5). Staff also indicated that the clinic leadership was very supportive of AAC. For example, one staff member said, “It [was] also helpful to have your leadership remind you that this was a study we were partaking in…” (Medical Assistant, Interview 1).

The ease of AAC procedures made adoption more successful. When asked about advantages of AAC, clinic staff said that it took little time to connect smokers with the Quitline compared to previous procedures (e.g., fax referrals) and that it was easy to follow the procedures. For example, a member of the leadership said,

…if something comes in that’s new—that’s problematic—we hear lots of complaints. I never heard any complaints about Ask Advise Connect, so it must have been easy to do. It made it easier for their jobs. I didn’t hear anything, so it must have been good! (Senior Leadership, Interview 8).

Staff expressed similar sentiments. One said, “It’s pretty fast, and it’s good for the patients. And we ask if they would like to participate and say they’ll contact you. That’s all that we do.” (Medical Assistant, Interview 4).

AAC served the dual purpose of helping smokers get evidence-based treatment and demonstrating meaningful use criteria. At the time of AAC’s implementation, health care facilities were required to demonstrate the meaningful use of certified EHRs in order to qualify for an incentive payment from the Centers for Medicare and Medicaid Services (CMS). Leadership reported that AAC helped GNHC meet meaningful use criteria. One member of the leadership team said, “Plus it was a new outcome measure that we had to do for [CMS] so it was perfect timing.” (Senior Leadership, Interview 8). A staff member similarly stated, “It fit in perfectly, because… it’s part of meaningful use.” (Clinic Staff, Interview 9).

Implementation

In-person trainings and laminated cards sufficiently described implementation procedures. Staff said that the provision of in-person trainings and laminated “cheat sheets” listing the AAC steps supported the implementation of AAC. One staff member stated, “The training was very simple and very easy and it was step-by-step and it wasn’t confusing... You could just give us the piece of paper—we can follow [the instructions].” (Medical Assistant, Interview 1). A member of the leadership said,

The training was beneficial… I think the little card that we got—that you can put with your ID tag and whatever was helpful, because in addition to sitting in the class and getting information, you can also have a tool outside of the training to use. (Senior Leadership, Interview 6).

AAC implementation streamlined the existing standard of care. Clinic staff said that a key facilitator of AAC was that it did not require a complete change in practice; rather, it helped simplify and extend existing procedures. One staff member stated, “It [the standard of care] pretty much didn’t change because we were already doing it [assessing smoking status] in the system. I guess the only difference was that [smokers were] actually being connected.” (Medical Assistant, Interview 2).

Others agreed, citing that connecting smokers with the Quitline via the EHR was faster and easier than faxing referrals. One staff member stated, “It probably took not even a minute to ask these questions, which is way better than the way we were doing it.” (Medical Assistant, Interview 3).

There were minimal barriers to implementing AAC. When clinic staff were asked to identify factors that impeded or slowed down the implementation of AAC, they mostly reported that there were “no barriers”. However, clinic staff and leadership noted minor procedural issues, including that it took some time to add the new questions into the EHR and to get the clinic staff up to speed on the procedural changes. Leadership noted,

Well, of course you’re adding something else for the staff to do, so I think it took a little adjustment. Once they got used to what’s to be done, how it is done, and just remembering to do it, I don’t think it was a problem. (Senior Leadership, Interview 6).

One staff member described difficulty with switching between systems to enter information:

The eClinical Works part [the clinic-wide system used to implement AAC] we only use with the front desk. So we wouldn’t really use it in the back office as far as like with patients. The Dentrix is what we would use as far as patient information and noting that the patient is a smoker. So it was just a push of reminding ourselves that we needed to open up eClinical Works also to be able to put in the data. (Dental Assistant, Interview 7).

There were minimal disadvantages of the AAC implementation. When clinic staff were asked about disadvantages of AAC they were, for the most part, unable to think of any. Several noted that patients were occasionally annoyed that their smoking status was assessed at every clinic visit, particularly if they were smokers uninterested in quitting; however, they did not view this as a disadvantage. One staff member said:

It does get frustrating for the patient, but… I do let them know, “This is for your health. You are in a healthcare facility. We want the best for you so this is why we’re asking. We’re not bothering you. We’re not hassling you. If you’re not ready to quit, you’re not ready to quit. If you are, these are the things that we can do to help you.” (Medical Assistant, Interview 1).

Leadership also recalled patients expressing annoyance with questions being asked at each visit,

We have had patients who may express that. “Well, you already asked that.” We just encourage that—every opportunity, it may change. I think that has been something. It’s just the repetitiveness—the patients may get a little bit frustrated about that at times. (Senior Leadership, Interview 6).

Staff and leadership continued to be enthusiastic about AAC following its implementation. Clinic staff reported continued enthusiasm due to seeing AAC have a direct positive impact on patients. For example, one said, “I’m really at the same level of excitement—seeing it in place and how patients are responding to it.” (Senior Leadership, Interview 6). Another staff member said:

I’m happy about it. All these patients come, and I ask them, “How is the program going, helping you out?” And then they’re happy about it, that they have stopped smoking, and they said it really helped them out in their life and it changed their life… (Dental Assistant, Interview 5).

Furthermore, leadership indicated that they had received positive feedback from patients who had benefited from treatment, “We have a lot of patients who come back and talk about, ‘Well, I stopped smoking,’ or when we inquire, ‘Did you get connected?’ they will say, ‘Yes, they sent me this.’ So we’ve just had a lot of positive feedback.” (Senior Leadership, Interview 6).

Maintenance

AAC was a good fit at GNHC throughout the 18-month implementation period. When asked to comment on the fit of AAC at GNHC, respondents reported that it was a good fit within the clinic and in the EHR, as it helped ensure that smoking was assessed regularly and that Quitline treatment was offered when appropriate. For example, one member of the leadership stated, “It fit in with our goal—of smoking cessation as well as the clinic’s overall goal of helping people stop smoking... I was really excited about it.” (Senior Leadership, Interview 8).

Strong interest in AAC becoming the standard of care at GNHC. Participants unanimously expressed interest in the permanent implementation of AAC at GNHC. For example, one participant stated, “I would love for it to be here at Good Neighbor all the time. It really helped us out a lot.” (Medical Assistant, Interview 5). Leadership echoed this by saying,

…especially if the data shows that it [AAC] does lead to quitting smoking, because I think the fewer smokers we have in our adult population, the fewer that we’ll have in the younger population coming up. And we do see a lot of parents as part of our population—our client population. (Senior Leadership, Interview 8).

Minor suggestions to improve the implementation of AAC. When asked what should be changed to enhance the future implementation of AAC, for the most part, participants said that no changes were needed. One participant stated, “No it’s just easy. Keep it easy.” (Medical Assistant, Interview 1). Another said, “I mean the way it’s working now, it’s working perfectly fine. So I wouldn’t change anything about it.” (Medical Assistant, Interview 2). Some participants made minor recommendations, including: (i) the option to offer treatment to patients’ family members and other non-patients; (ii) a drop-down box in the EHR to specify smoking treatment status; (iii) a field in the EHR where alternate phone numbers could be added; and (iv) following up with patients about their experiences with AAC.

DISCUSSION

This mixed-methods study, guided by the RE-AIM framework [28], evaluated the 18-month implementation of AAC in a FQHC serving predominantly low-SES Latino and Latina patients. During the implementation phase, 11.4% of all identified smokers enrolled in treatment with the Quitline. Results are consistent with prior research demonstrating that connecting smokers with the Quitline via AAC results in relatively high levels of treatment enrollment [24, 25].

This study also elucidated clinic staff and leadership perceptions of the implementation of AAC. Staff and leadership expressed that AAC fit into GNHC’s existing standard of care and streamlined clinic goals to increase smoking cessation among patients. Further, they identified numerous advantages and facilitators of AAC. Importantly, clinic staff and leadership felt that because AAC seamlessly fit into clinic flow and improved upon the prior fax-referral system of connecting patients to the Quitline, it was easy to maintain throughout the implementation period, and had positive outcomes for GNHC staff and patients. They, therefore, expressed interest in AAC becoming the standard of care in the clinic.

Clinic leadership and staff highlighted four primary advantages of AAC. First, AAC procedures were quick and easy for clinic staff to follow. Clinic staff found training procedures and badge reminder cards effective at conveying and reinforcing AAC procedures. After minimal initial adjustment, AAC was easily integrated into clinical care and less burdensome than prior procedures. Second, based on feedback from research staff and patients, clinic staff reported feeling confident that patients were actually being connected with the Quitline, which eliminated uncertainty associated with fax referrals (i.e., questioning whether the fax went through). These results are encouraging as adequate training, low clinic burden, positive experiences helping patients quit, and provider confidence are all associated with greater likelihood that providers will offer tobacco cessation support [31, 48]. Third, treatment was free and addressed barriers often associated with participating in smoking cessation treatment (e.g., lack of transportation, lack of childcare, appropriate language) [49–51]. Finally, AAC served the dual purpose of giving smokers access to evidence-based treatment and demonstrating the clinic’s meaningful use of EHR technology to improve patient care, which ultimately helped the clinic meet requirements for continued federal funding [52].

It was somewhat surprising that clinic staff and leadership identified minimal to no disadvantages of AAC. Some provided minor suggestions to enhance future AAC implementations (e.g., including a field for alternate phone numbers and following up with smokers after connecting them with treatment). These recommendations would likely expand the reach of AAC and enhance treatment enrollment rates. For example, future implementations could benefit from follow-up via text messaging or email, which might further encourage treatment enrollment [53, 54].

Strengths

The current investigation has several strengths. First, we used a mixed-methods approach to investigate an extended AAC implementation (18 months) in a high-volume FQHC clinic. Thus, we were able to assess all RE-AIM dimensions, including long-term maintenance, of AAC as an integrated part of standard practice [34]. Further, we assessed perspectives of key informants from all levels of the organization. Staff and leadership alike were enthusiastic about AAC before, during, and after the implementation period, which is an important component of successful intervention adoption [55]. Smokers rate healthcare professionals as highly legitimate sources of information regarding cessation, yet providers often feel overburdened by delivering tobacco treatment [48]. For example, due to time constraints and efficacy ­concerns, providers often do not perform the final crucial steps of the 5 A’s—Assist and Arrange [31]. AAR, which removes these steps for providers, is not very effective at connecting smokers to treatment [24, 25]. Our study demonstrates that AAC may marry the ease of AAR with the connection to treatment recommended in 5 A’s, simultaneously benefiting providers and patients. Thus, AAC has potential to greatly impact smoking cessation for primary care patients.

Limitations and future directions

This study also has several limitations:

• 1) Data were collected from a FQHC serving primarily low-SES Latinos and Latinas (72%) in Texas, which may affect the generalizability of results. During the implementation period, 10.7% of assessments indicated current smoking which is consistent with the smoking prevalence among Latinos and Latinas in the US, but lower than the general prevalence of smoking nationally (12.5%) and among other underrepresented groups of smokers, such as those who are Black/African American (14.4%) [2]. Additionally, EHR systems vary widely; the “connect” portion of ACC may be less streamlined in different EHR systems [54].

• 2) We did not collect data on smoking cessation outcomes and, thus, the quantitative results of this investigation largely reflect how well the staff at GNHC implemented AAC and the efficacy of Quitline counselors at encouraging treatment enrollment. However, our other large scale AAC implementation study found that diverse, low-income patients linked with Quitline-delivered treatment via AAC had smoking abstinence rates comparable to those of individuals who called Quitlines on their own [56].

• 3) Although the impact of AAC observed in our study (i.e., 11.4%) was comparable that observed in other AAC studies, reach (i.e., 12.0%) was lower and the effectiveness (i.e., 94.8%) was higher than observed in our previous AAC studies [24, 56]. The relatively low percentage of smokers who were successfully contacted by the Quitline in the current study (reach) may be partially attributable to the fact that GNHC had an established Quitline fax referral program in place prior to the implementation of AAC. Thus, it may be that patients were sensitized to offers of treatment enrollment and thus may have only accepted calls from the Quitline when receptive to enrolling in treatment. This potential explanation also aligns well with the exceptionally high effectiveness rate observed in the current study (i.e., ~95% of patients who talked with the Quitline enrolled in treatment).

• 4) Because a goal of AAC is to minimize burden to clinic staff and disruption to clinical encounters, we did not assess smokers’ sociodemographic or smoking-related characteristics (e.g., nicotine dependence, motivation) which limits our ability to understand other factors associated with smoking cessation in this trial.

• 5) In the current implementation of AAC, research staff were responsible for sending referrals from the clinic EHR to the Quitline. That is, there was not a direct connection from the clinic to the Quitline. However, a subsequent implementation of AAC that did directly send patients’ contact information to the Quitline reported a similar impact rates [56].

• 6) Although staff indicated good adherence to the AAC protocol and reported that clinic leadership frequently checked in on implementation, adherence to AAC was not formally monitored in our study. Future studies should carefully assess fidelity to AAC procedures.

CONCLUSIONS

AAC was successfully implemented in a FQHC serving primarily low-SES Latino and Latina smokers. Consistent with prior AAC trials, connecting smokers with the Quitline via AAC resulted in relatively high levels of treatment enrollment [24, 56]. Interviews assessing RE-AIM dimensions indicated that, clinic staff and leadership believed that AAC streamlined clinic procedures and helped clinic staff offer patients smoking cessation treatment options immediately after providing brief advice to quit. Many staff members reported positive feedback from patients who benefited from Quitline-delivered treatment and there was strong interest in AAC being permanently adopted at GNHC. Thus, findings support that AAC is feasible, acceptable to busy providers, and effective in connecting patients with Quitline treatment. This is critical for low-SES and minority populations, who experience profound tobacco-related disparities and are less likely to receive high quality smoking cessation treatment that minimizes barriers to access.

Acknowledgements

The authors would like to acknowledge Judith Vazquez and Elizabeth Caballero, who assisted with project management and data collection. We are also appreciative of the staff at Good Neighbor Healthcare Center and Alere Wellbeing, and the study participants whose efforts made this research possible.

Funding

This research is supported by a grant from: the Cancer Prevention and Research Institute of Texas [PP110171; PI: JIV]; the Oklahoma Tobacco Settlement Endowment Trust [092-016-0002; PI: JIV]; the National Cancer Institute to the University of Texas MD Anderson Cancer Center as a Cancer Center Support Grant [P30CA016672; PI: Pisters]; the National Cancer Institute to the Stephenson Cancer Center as a Cancer Center Support Grant [P30CA225520; PI: Mannel]; the National Cancer Institute to Moffitt Cancer Center as a Cancer Center Support Grant [P30CA076292; PI: Cleveland]; the National Institute on Drug Abuse [K23 DA040933; PI: DSH]; and the National Center for Complementary and Integrative Health [K23AT008442; PI: CAS]; and the National Institutes of Health Training Grant in Behavioral Oncology [T32CA090314-18, PIs: Brandon, Vadaparampil; trainees: BSF, CCD]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance with Ethical Standards

Conflicts of Interest: The authors declare that they have no conflicts of interest.

Author Contributions: J.I.V. is the senior author and was the PI on a grant from the Cancer Prevention and Research Institute of Texas (PP110171) that supported this research. She was responsible for the study’s conceptualization and design, data collection, designing the analytic plan, interpreting the data, and editing the manuscript. B.S.F. drafted and revised the manuscript and assisted with qualitative data interpretation. C.C.D. analyzed and interpreted the qualitative data and was involved in drafting and revising the manuscript. D.S.H. was involved in study conceptualization and design, data collection, analysis, interpretation, and in drafting and revising the manuscript. C.A.S. was involved in analyzing and interpreting the qualitative data and drafting and revising the manuscript. N.N. assisted with data management, analysis, and interpretation. B.P. and D.J.V. reviewed and edited the manuscript. L.H.M. and D.W.W. assisted with study conceptualization and design and reviewed and edited the manuscript. N.N., D.S.H., and J.I.V. had full access to all of the data and take responsibility for the integrity of the data and the accuracy of the data analysis.

Human Rights: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent: A waiver of written informed consent and authorization was obtained from the M.D. Anderson IRB for in-clinic data collection. Informed consent was obtained from all key-informant interview participants.

Welfare of Animals: This article does not contain any studies with animals performed by any of the authors.

Transparency Statements: This study was not formally registered. The analysis plan was not formally pre-registered. De-identified data from this study are not available in a public archive. De-identified data from this study will be made available (as allowable according to institutional IRB standards) by emailing the corresponding author. Analytic code used to conduct the analyses presented in this study are not available in a public archive. They may be available by emailing the corresponding author. Some of the materials used to conduct the study are available by request to the corresponding author.