Regional Training 3 Hours 09 13

Health Care Professional Training

in Smoking Cessation Counseling Techniques

Clean Air for Healthy

Children and Families

Edward G. Rendell, Governor

Calvin B. Johnson, M.D., M.P.H., Secretary of Health

Pennsylvania Chapter

American Academy of Pediatrics

In partnership with Pennsylvania Area Health Education Center (AHEC)

PA DOH Funding to Fox Chase

1989-1994

PA DOH Funding to PA AAP 1996-Present

Clean Air

Program

Adopted

1996

AAP Policy2001

Primary Contractors

2002

ACS1997

CPG, ACOG2000

Curriculum

Revised & Updated

2004, 2006

PA DOH Funding to AHEC to PA AAP 2005-Present

Program Development

Every clinician, who interacts with pregnant women, mothers, caregivers of young children, teens and others, will deliver effective smoking cessation advice and counseling.

Program Goal

Ensure that smokers are fully informed of the health risks associated with smoking and secondhand smoke

Motivate smokers to quit

Increase cessation attempts by delivering the 5 A’s/2 A’s and R brief smoking cessation counseling intervention

Increase successful cessation by providing effective counseling, pharmacotherapy, self-help materials, and referrals

Reduce the number of children and individuals who are exposed to secondhand smoke at home

CAFHCF Program Objectives

Today’s Learning Objectives

At the end of this training you should:

Understand the 5 A’s/2 A’s and R brief smoking cessation counseling intervention

Feel more confident in your ability to provide brief smoking cessation counseling

Be motivated to discuss smoking cessation with your patients and smoke-free environment with your patients

Develop a plan to implement the 5 A’s/2 A’s and R brief smoking cessation counseling intervention

What Is Your Office Doing Now?

In what ways do you feel your office is effective or ineffective?

What works well?

What do you feel your patients need?

What skills do you feel you are lacking to counsel patients?

What do you hope to gain from the training today?

Identify smokers and recent quitters

Counsel (5 A’s/2 A’s and R)

Patient education materials: self-help magazines, optional materials, etc.

Practice tools: documentation forms, stickers, etc.

Program Components

Integrating an evidence-based Intervention into practice

Practical Counseling

Problem solving Skills training Relapse prevention Stress management

Support by Providers Social Support Pharmacotherapy

Nicotine replacement Bupropion Varenicline

USPHSGuideline

Brief counseling is effective

sk about tobacco use

dvise to quit

ssess willingness

ssist in quit attempt

rrange for follow-up

CounselingIntervention

AA

AA

AA

AA

AA

AA

AA

RR

sk

dvise

efer

5 A’s (3-5 min.)* 2 A’s / R (1-3 min.)

Community Resources 1-800-QuitNOW Rx Pharmacotherapy

*Can extend to 10-15 min. for all patients*Smoke Free Families recommends 10-15 min. for pregnant women

Fiore et al., (2000)Smoke Free Families recommends 5-15 minutes counseling in pregnancy

Efficacy of Various Levelsof Contact

10.9

13.4

16

22

0

5

10

15

20

25

Perc

enta

ge No Contact

Minimal Contact < 3 min.

Brief Counseling 3-5 min.

Counseling > 10 min.

Patient OutcomesTotals for cessation flow sheets through

12/31/97-06/01/06

QuitReductionRecent QuitterNo ChangeRelapse

20%

23%41%

3%

12%Smoking status self-reported by

patients

n= 9,882

Increase utilization of the 5 A’s

Every visit, every time

Reminder systems

Clinician education

Promote system change

Recommendations of Center for Disease Control

The scope of the problem

Comparative Causes of Annual Deaths in the U.S.

14

17

19

30

41

81

430

0 200 400 600

Drug Induced

Aids

Homicide

Suicide

Motor Vehicle

Alcohol

Smoking Related

# of Deaths(thousands)

USDHHS, CDC (TIPS): Comparative Causes of Annual Deaths in the United States

SmokingPrevalence

23

19

11

25

22

18

12 12

0

0

5

10

15

20

25

% Cur

rent

Smok

ers

US PA Healthy People2010 Goal

Men

WomenPregnant Women

2004 National Health Interview Survey {(MMWR 2005(54)44}2005 PA Behavioral Risk Factor Surveillance System PA DOH Vital Statistics Resident Live Births 2004 Table B-25National Vital Statistics Reports: Births: Final Data for 2003 (Martin, J. A. et al.)

Smoking DuringPregnancy

35

25

15

108 7

0

5

10

15

20

25

30

35

% C

urre

nt S

mok

ers

LowIncome

HighIncome

Employment GradeUSDHHS, Smoking During Pregnancy-United States, 1990-2000. MMWR, 2004;53(39):911-915

Smoking During Pregnancy

High School> High School

< High School

National Vital Statistics Reports: Births: Final Data for 2003 (Martin, J. A. et al.), Table 31

Smoking Quit Rates DuringPregnancy

Approximately 30% of quitters relapse during their pregnancy

Many women who quit smoking during pregnancy plan to smoke again once the baby is born

70% of remaining quitters relapse within 12 months of delivery

PA Birth Certificate Data: % Pregnancy Smoking Status3 Mos. Prior 1st Trimester 2nd Trimester 3rd Trimester

White 25.5 18.5 15.7 15.1

Black 20.9 16.6 14.1 13.8

Hispanic 16.3 11.4 9.2 8.9

15-19 35.4 28.0 22.7 21.2

20-24 37.3 28.2 23.7 22.7

PA Department of Health, 2004 Vital Statistics Resident Live Births by Age (Table B-19A) and Race (Table B-19B)

“We’ve known for decades that smoking is bad for your health...the toxins from cigarette

smoke go everywhere the blood flows. There is no safe cigarette...the only way to avoid the

health hazards of smoking is to quit completely or to never start smoking.”

U.S. Surgeon General Richard H. CarmonaNews Release, 2004, SGR, The Health Consequences of Smoking

News Release 06/27/06, SGR, The Health Consequences of Involuntary Exposure to Tobacco Smoke

“The scientific evidence is now indisputable: secondhand smoke is not a mere annoyance. It

is a serious health hazard that can lead to disease and premature death in children and

nonsmoking adults.”

The Debateis Over

The Life Cycle of the Effects of Smoking on HealthThe Life Cycle of the Effects of Smoking on Health

SIDsSIDsBronchiolitisBronchiolitisMeningitisMeningitis

InfancyInfancy

Low Birth WeightLow Birth WeightStillbirthStillbirthNeurologic ProblemsNeurologic Problems

In uteroIn utero

AsthmaAsthmaOtitis MediaOtitis MediaFire-related InjuriesFire-related Injuries

InfluencesInfluencesto Startto StartSmokingSmoking

Nicotine AddictionNicotine Addiction

CancerCancerCardiovascular DiseaseCardiovascular DiseaseCOPDCOPD

AdulthoodAdulthood

AdolescenceAdolescence

ChildhoodChildhood

Aligne CA, Stodal JJ. Tobacco and children: An economic evaluation of the medical effects ofAligne CA, Stodal JJ. Tobacco and children: An economic evaluation of the medical effects ofparental smoking. Arch Pediatr Adolesc Med. 1997;151:652parental smoking. Arch Pediatr Adolesc Med. 1997;151:652

Prenatal/Neonatal Outcomes 20-30% low birth weight infants

Fetal growth retardation

Spontaneous abortion

Fetal death

Pre-term deliveries

Ectopic pregnancies

Placenta previa and placental abruption

Lower APGAR

SHS and Children: Short TermHealth Effects Respiratory tract infections such as pneumonia & bronchitis

Decreased pulmonary function

Triggers asthma attacks

Ear Infection (Otitis Media)

Tooth decay

House fires

SHS and Children: Long TermHealth Effects Sudden Infant Death Syndrome (SIDS)

Asthma SHS accounts for 8-13% of asthma cases in children <15 years SHS exposure increases frequency of episodes and severity of symptoms 200,000-1 million asthmatic children are affected by SHS

Possible problems with cognitive functioning and behavioral development

More likely to become smokers

Risks for Women Who Smoke Reproductive health problems

Infertility Conception delay Pregnancy complications Menstrual irregularity Earlier menopause

Compromised immune system

Respond differently to nicotine

Cancer

Less likely to breast feed

Osteoporosis

Thrombosis with use of oral contraceptives

Adult Health Risks AssociatedWith Tobacco Use Cancer

Major cause of: lung, oral and nasal cavity, laryngeal, esophageal, bladder and cervical Increased risk for: pancreas, uterine, penile, kidney, liver, anal and stomach

Lung changes, COPD, Asthma

Cardiovascular & heart disease

Male & female reproductive problems

Digestive disorders

Rheumatoid arthritis

Impaired healing

Visual difficulties

Decline in hearing

Facial wrinkles

Tooth loss, plaque & staining

Dementia & Alzheimer’s

House fires

SHS and AdultHealth RisksNonsmokers who are exposed to secondhand smoke at home or at the workplace are at an increased risk of developing;

Lung cancer 20-30%

Coronary heart disease (25-30%)

Acute respiratory problems

Other significant health risks as per the SGR: http://www.surgeongeneral.gov/library/secondhandsmoke

“There is no risk-free level of exposure to SHS. Breathing even a little SHS can be harmful to your health. Separating smokers from

nonsmokers, cleaning the air, and ventilating buildings cannot eliminate SHS smoke exposure that controls the health risks.”USDHHS, The Health Consequences of Involuntary Exposure to Tobacco Smoke: A

Report of the SGR (2006).

What can be done?

SmokersWant to Quit

70% report wanting to quit

3 out of 4 smokers want to quit

Most have made at least one quit attempt

Smokers cite physician/clinician advice as important

Nicotine Addiction

Addiction

The repeated, habitual use of a substance that affects a person’s mood and the course is chronic, progressive, and ultimately fatal.

NicotineAddiction

Characterized by: Use stimulates the production of dopamine which changes brain chemistry and is associated with feelings of reward and pleasure

Need to use the substance to feel normal

The inability to control use resulting tolerance

Continued use regardless of the negative consequences

Being the most addictive drug

Impacting all areas of a person’s life – biopsychosocial effects

Addiction

1) Physical – A physical craving for tobacco and withdrawal symptoms may be present in the absence of the drug

2) Habit – The use is ritualistic and done without thought

3) Psychological – The belief that the user cannot function without the habit

3 Components3 Components

Recovery is possible when all 3 components are treated

The Process of BehaviorChange

Preparation

Preparation

Contemplator

Contemplator

RelapseRelapse

ActionAction

Maintenance

Maintenance

Ex-Smoker

Ex-Smoker

Pre-Contemplat

or

Pre-Contemplat

or

Prochaska and DiClemente, 1983

Relapse or Slip?

Relapse Slip

A return to baseline level of smoking Can occur at any stage, returning to Pre- Contemplation, Contemplation, Preparation or Action stages May recycle through the stage of change several times (6-8) before the change becomes truly established

An instance or several instances of smoking Avoid negative emotional reaction leading back to baseline level of smoking (one cigarette does not mean they are a smoker again)

Reframe the experience as a partial success versus a total failure

Learn from the experience and understand what happened

Develop optimism about continuing cessation or trying again

The Process of Behavior Changeand Pregnancy Pregnant women often are more open to change and can move through the stages of change differently than when they are not pregnant (The fetus can be a wonderful motivator)

May have more support to quit while pregnant

May not be socially acceptable to smoke in public if pregnant

Requirementsfor Change

X =

Motivation

(Should I?)

Self-Confide

nce(Can I?)

Commitment

(Will I?)

Motivational Interviewing/Consulting

A patient-centered counseling style for obtaining behavior change by helping patients explore and resolve

ambivalence

Motivational Interviewing/Consulting

Principles Express empathy to show you understand the person’s point of view

Develop discrepancy between smoking and future goals

Avoid arguing and confrontation be collaborative and friendly

Roll with the resistance and avoid argument

Support patient’s self-efficacy and belief in the possibility of making a change

sk about tobacco use

dvise to quit

ssess willingness

ssist in quit attempt

rrange for follow-up

CounselingIntervention

AA

AA

AA

AA

AA

AA

AA

RR

sk

dvise

efer

5 A’s (3-5 min.)* 2 A’s / R (1-3 min.)

Community Resources 1-800-QuitNOW Rx Pharmacotherapy

*Can extend to 10-15 min. for all patients*Smoke Free Families recommends 10-15 min. for pregnant women

sk: About Tobacco Use Ask or verify responses in a non-judgmental way: Identify smoking status

Counsel all smokers and recent quitters

Household environment Determine possible barriers to quitting Possible affects of SHS

If they smoke assess Nicotine dependence Patterns of use Past quit attempts

AA

Health Surveys

Chart Stickers

dvise: to Quit Advice to quit should be clear, strong and personalized while using a non-judgmental manner

Discuss the effects of smoking on the patient, fetus and children

Discuss the health benefits of quitting

Acknowledge the difficulty in quitting

AA

ssess: Willingness to Make a Quit Attempt Assess patient’s level of interest in quitting and intention to take action to quit

Ask key questions

AA

Assess: KeyQuestions

ssist: in Quit Attempt

Pre-Contemplation and Contemplation Stages(Unwilling to make a quit attempt)

The 5 R’s: Relevance to patient’s individual situation

Risks of smoking

Rewards of quitting smoking

Roadblocks or barriers to quitting

Repeat intervention at every visitIn successful interventions clinicians should be empathetic, promote patient choices, avoid arguments, listen, reflect and instill self-confidence

AA

Preparation Stage(Willing to quit)

Help the patient with a quit plan

Provide practical counseling

Provide social support Social support with treatment (Intra-treatment) Social support outside treatment (Extra-treatment)

Recommend pharmacotherapy

Provide supplemental materials (Quitline, groups)

ssist: in Quit AttemptAA

A combination of pharmacotherapy and intervention

a patient’s chance of successfully quitting smoking

Nicotine gum

Nicotine patch

Nicotine nasal spray

Nicotine inhaler

Bupropion SR (Zyban)

Lozenge

Varenicline (Chantix)

*Unless contraindicated

Pharmacotherapy* for Cessation

“If the increased likelihood of smoking cessation, with its potential benefits,

outweighs the unknown risk of nicotine replacement and potential

concomitant smoking, nicotine replacement products or other

pharmaceuticals may be considered.”

ACOG. (2005). Committee Opinion: Smoking Cessation During Pregnancy, Number 316.Concomitant = accompanying

Pharmacotherapy and Pregnancy

Handouts forPatients

Note: Most materials available in Spanish

Personalized Plan forPatients

Note: Most materials available in Spanish

PA DOH Free Quitline1-800-QUIT-NOW In partnership with the American Cancer Society

Intake 24 hours a day/7 days a week

Proactive referral (Fast Fax) versus Reactive referral (patient calls)

Develop a personalized plan for quitting

PA DOH Free Quitline1-800-QUIT-NOW Up to 5 follow-up scheduled counseling sessions (8 if pregnant)

Special counseling for pregnant smokers & available for teens

Offered printed materials, referrals, information on medications (NRTs)

English and Spanish; other languages as necessary

Confidential & HIPPA compliant

PA DOH Free Quitline

transitioning from1-877-724 -1090

to 1-800-QUIT-NOW 1-800-784-8669

Pre-Approved Tobacco Cessation Registry: Pennsylvania Department of Health http://www.dsf.health.state.pa.us (click on tobacco or Quit NOW (1-800-Quit-NOW) and follow prompts

Local tobacco coalitions, county websites, and county organizations or groups committed to smoking cessation

Quitline also refers to community resources

CommunityResources

See Appendix B of the Clean Air program manual for additional patient handouts and practice tools

OptionalMaterials

Clean Air Website: www.cleanairforhealthychildren.org

rrange: forFollow-Up Pre-Contemplation or Contemplation stage requires continual support and encouragement

Preparation stage: Follow-up within 1 week of Quit Date Ask at next visit about progress

Action or Maintenance stage: Praise success at quitting Problem solve challenges to maintaining abstinence

AA

Documentation Forms

19-year old

Smokes 16 cigarettes a day for past 3 years

Fights frequently with husband

Case Study #1 Sylvia

Pregnant with first baby

One prior quit attempt for a few days

Interested in effects on baby & children

*Remember to discuss pharmacotherapy if appropriate**Refer to the Quitline (1-800-QUITNOW) and/or community resources

1. Ask about smoking status using a health history or survey.2. How will you Advise with a clear, strong, personalized message to quit smoking?3. Assess the patient’s stage of readiness to quit.4. To Assist* her in making a quit plan what might you include?5. What barriers or concerns about quitting would you address and would you do this?6. Arrange for follow-up via appointment, telephone, or referral.**7. Document the intervention in the patient chart.

Case Study#2 Linda

27-year old

Lives with her boyfriend who smokes

Smokes a pack a day for past 13 years

Has little interest in quitting

3 Children; 6, 4, and 2

Several prior quit attempts; one in last pregnancy for 1 month

Reluctant to set a quit date



Case Study#6 Lisa

17-year old

6 months pregnant, admitted to hospital for pre-term labor

Smokes a pack & a half a day and has smoked for 6 years

Boyfriend smokes

Hospitalized 4 days & medicated to stop contractions

Contraction free & being discharged

Enjoys smoking & has no interest in quitting



Case Study#8 John

32-year old father

Smokes a pack a day for past 14 years

John is sick with bronchitis

Has a son who has asthma

Concerned about stress with work & home life and avoiding weight gain

Had several prior quit attempts

Occasionally uses smokeless tobacco instead of cigarettes

Wife encourages him to quit

Not sure about trying again


1. Ask about smoking status using a health history or survey.2. How will you Advise with a clear, strong, personalized message to quit smoking?3. Assess the patient’s stage of readiness to quit.4. To Assist* him in making a quit plan what might you include?5. What barriers or concerns about quitting would you address and would you do this?6. Arrange for follow-up via appointment, telephone, or referral.**7. Document the intervention in the patient chart.

Case Study#8 Grace

55-year old women

Has emphysema

Smokes a pack a day for the past 30 years

Has tried to quit several times in the past

Daughter and grandson lives with her


1. Ask about smoking status using a health history or survey.2. How will you Advise with a clear, strong, personalized message to quit smoking?3. Assess the patient’s stage of readiness to quit.4. To Assist* him in making a quit plan what might you include?5. What barriers or concerns about quitting would you address and would you do this?6. Arrange for follow-up via appointment, telephone, or referral.**7. Document the intervention in the patient chart.

Create A Quit Smoking Team Step 1. Develop administrative commitment

Step 2. Involve staff early

Step 3. Assign one coordinator

Step 4. Provide training

Step 5. Adapt procedures to your setting

Step 6. Monitor and provide feedback

Implementing into a Healthcare Setting

Implementation and Follow-Up Forms

HEDIS Health Employer Data Information Set

Survey of randomly sampled patients who were seen in the past year.

Used as a qualitative measure of practices to determine the level of care consistently given to patients.

Survey Questions

Have you smoked at least 100 cigarettes in your lifetime?

Do you now smoke cigarettes every day, some days or not at all?

How long has it been since you quit smoking?

In the past 12 months, on how many visits were you advised to quit smoking?

On how many visits was medication recommended or discussed?

On how many visits did your doctor or healthcare provider recommend or discuss methods or strategies to assist you with quitting?

JCAHO - Joint Commission of Accreditation of Hospitals

Diagnoses that are mandated to receive tobacco education counseling: At least 2 of 3 measures - congested heart failure; myocardial infarctions; community acquired pneumonia

Patients that have quit tobacco use one year prior to their admission

Interventions - advice to quit, assistance to quit, brochures, video, referral or tobacco cessation aids

Must be documented

Billing for Smoking CessationCounseling Always have your billing person/department

check with health plan benefits contact person to see what is covered and what codes they recognize

Also ask what page in billing manual you can find this information

Even if not reimbursed it is important to code to promote future coverage

ICD-9 Diagnostic Codes: Smoking Related COPD 491.2 Emphysema

492.8

Asthma 493.00

Diabetes 250

Chest Pain 786.50

Carcinoma: in situ/broncus, lung 231.2

Bronchitis 490

Cough 786.2 Toxic Effect/Tobacco 989.84

Tobacco Dependence/Disorder 305.1

Also can use ICD-9 Codes for medical procedures related to smoking co-morbidity.

Also can use ICD-9 Codes for medical procedures related to smoking co-morbidity.

ICD-9 Diagnosis Codes for Counseling Parents on Harms of SHS Sample codes for the child’s diagnosis Routine infant/child health check V20.2 Acute bronchiolitis due to respiratory synctial virus 466.11

Extrinsic asthma, with acute exacerbation 493.02

Sample codes associated with the parent’s smoking: Other specified personal history presenting hazards to health (exposure to tobacco smoke as a potential risk) V15.89 Toxic effects of tobacco 989.84

CPT Billing Codes Preventive Medicine Examination

New Patients: 99383-99387 Established Patients: 99393-99397 Pediatric under 1 year: 99381 Pediatric age 5-11: 99393 Higher level 99213 only if face to face counseling >50% of visit time

Tobacco Dependence Treatment Individual Counseling: 99401-99404 Group Counseling: 99411-99412

Psychiatric Therapeutic Procedures Outpatient: 90804-90809 Inpatient: 90816-90822

CPT code 99211: if nurse counsels and not physician

MedicalAssistance PA DOH pre-approved list Bulletins #99-02-02, 99-04-11, and

clarification #02-06 www.dpw.state.pa.us/omap Billing Code #S9075 Promise billing system if available If Health Choices provider discuss carve out in

contract? Medications are covered if patient has

prescription coverage but each plan may have “rules”Become a Pre-Approved Tobacco Cessation Provider by applying at PA Department of

Health Website:http://www.dsf.health.state.pa.us/health/cwp/view.asp?A=174&Q=236582

Clean Air Program Evaluation (optional) Pre & Post Training Evaluation Forms

Implementation Plan (initial practice assessment)

2, 6 & 12 Month Follow-Up of practice

Smoking Cessation Counseling Documentation Form

System change

Clean AirWebsite

Please visit us at our Website:www.cleanairforhealthychildren.org Request a training

Order and download materials

Participate and view teleconferences

Access resources and other links

Contact us

GoodLuck! Please feel free to contact:

Dottie Schell(484)446-3002

or (800)375-5217 (PA only)

[email protected]

Clean Air for Healthy Children Program

PA Chapter of the American Academy of Pediatrics

Rose Tree Corporate Center II

1400 N. Providence Road, Suite 3007

Media, PA 19063-2043www.paaap.org

The Real Reason Dinosaurs Became Extinct!

Adult Risks Associated WithTobacco Use

Lung Changes Lung cancer

Chronic cough, mucus, shortness of breath, wheezing

Cold & lung infections

Flu & pneumonia

Chronic Obstructive Pulmonary Disease (COPD) - chronic bronchitis and emphysema

Asthma


Cardiovascular & Heart Disease

Increases blood pressure & heart rate

Reduces blood & oxygen supply to body tissue

Blood clot formation

Damages blood vessels

Leads to stroke

Women using oral contraceptives have an increased risk for thrombosis


Cancer Major cause of: lung, oral cavity, laryngeal, esophageal, bladder and cervical

Increased risk for: pancreas, uterine, penile, kidney, anal and stomach

Digestive Disorders

Rheumatoid Arthritis


Reproductive Health Problems

Male impotence

Cervical and penile cancer

Impaired Healing Following surgery or disease

Broken bones (twice as likely)


Visual Difficulties Cataracts (twice as likely)

Macular Degeneration

Poorer night and peripheral vision


Other Risks Decline in hearing

Facial wrinkles

Tooth loss, plaque, staining and gingivitis

Dementia & Alzheimer’s (twice as likely)

House Fires

Step 1: Develop Administrative Commitment

Administrators and supervisors who are committed to providing smoking cessation

services to their patients

Consider requirements of

funding agencies or availability of

reimbursement for smoking cessation

services

Strengthened by mandates of institutional

governing boards or accrediting

agencies

Restricted by the allocation of limited resources such as

staff time

Effective problem solving for implementation of smoking cessation program

Step 2: Involve Staff Early Staff meeting:

Invite participation by all staff responsible for patient care at any level First with key staff members then with all front line staff

Meeting agenda to gain staff support: Overview of the 5 A’s smoking cessation counseling intervention Questions and answers Identify barriers to implementation at each step Develop Implementation Plan

Step 3: Assign One Coordinator One person should oversee implementation to ensure that tasks are not overlooked

The coordinator can: Answer questions Troubleshoot problems Arrange for training Monitor implementation

Step 4: Provide Training

5 A’s Smoking Cessation Counseling Intervention

Regional - 3 hours

Practice-Based – 1- 1.5 hours

Modules

Step 5: Adapt Procedures to Your Setting

Determine how the following will occur: Obtaining the smoking status of every patient/parent

Timing and delivery of the 5 A’s

Documenting the intervention in patient records

Follow-up with each patient and the PA AAP

Step 6: Monitor and Provide Feed Back A Periodic Review of the Program

Observe whether procedures are working as intended Determine if staff is completing assigned tasks Assess if documentation is complete and accurate Evaluate use of patient materials for distribution and inventory

Revise Program Procedures Anticipate revisions to original plan

Give Feedback to Staff and Administrators

Maintain staff enthusiasm Assure continued success

Regional Training 3 Hours 09 13

Health & Medicine

Transcript of Regional Training 3 Hours 09 13