Stimulus Funding Conference Call



Stimulus Funding for U.S. Quitlines

Summary of Conference Call

September 2, 2009

Welcome and Call Logistics

Linda Bailey, President and CEO of NAQC welcomed participants to the call and noted that follow up questions related to this topic can be emailed to naqc@.

The call included three presentations:

• Stimulus Funding for Quitlines: How Likely Is it and What Will It Look Like? – Linda Bailey, President and CEO of NAQC

• Planning and Preparations: Quitline Manager/Tobacco Control Program Perspective – Judy Martin, Tobacco Control Program Manager for Nebraska and a member of NAQC’s Advisory Council

• Planning and Preparations: Quitline Service Provider Perspective – Mary Kate Salley, Vice President of Business Development, Free & Clear and a member of NAQC’s Advisory Council

Stimulus Funding for Quitlines: How Likely Is it and What Will It Look Like?

Introduction

The American Recovery and Reinvestment Act of 2009 (ARRA), otherwise known as the stimulus package, set aside $650 million in funding for a Health and Wellness Fund. Over the past ten months, NAQC and other national organizations have been talking with colleagues at CDC and HHS about the funding. Although there are many priorities for this funding, we have been advocating that some of this funding should be earmarked for quitlines.

There is no guarantee, but the likelihood of stimulus funding for quitlines looks positive. Information shared during this call is intended to help quitlines begin planning for possible funding, using it to achieve the greatest possible impact on cessation and demonstrating progress through reach, quit rates and job creation.

Summary of Current Information

The U.S. Department of Heath and Human Services (HHS) is considering a stimulus package for state quitlines that MAY include the following:

• Up to $45-50 million to be divided between all state and territorial quitlines

• Funding through CDC in a new cooperative agreement

• Distribution formula similar to other CDC formulas. It is likely there will be a core amount for each state and then a distribution based on size of population and prevalence of tobacco use

• Match requirements that would discourage states from replacing current quitline funding with the stimulus funding

• Quarterly reporting requirements that may include some MDS data and information on job creation

• Likely to include performance goals related to reach and quit rates

• Funding as early as November 2009 and expenditures allowed over two years

Process

• Information about the use of the funding has NOT been forthcoming, but NAQC has recommended that state quitlines should be able to use the funding for a wide range of quitline activities including counseling, medications, media and infrastructure expansion

• Although CDC/OSH is participating in decisions on the stimulus funding, final decisions will be made by HHS and likely reviewed by OMB/White House

• CDC will provide details on the contracting mechanism once they have HHS approval. They will convene conference calls with the states and will give all states time to submit their proposals. CDC wants to minimize the burden on states. CDC has emphasized the importance of demonstrating an impact from this funding.

• OSH is committed to the best funding description possible and ensuring the mechanisms are supportive of quitline growth.

• NAQC and its partners are doing all we can to make sure that the stimulus funding will be allocated to quitlines, but there is no guarantee that this will happen.

QUESTIONS/COMMENTS

Questions and concerns to share with CDC:

• Reporting requirements should not create more of a burden on callers during the intake process.

• Will these monies be able to override state restrictions on promotions?

• Careful planning will be important to avoid disruptions when funding stops. Response: To address this, the consensus seems to be that spending should be distributed over two years.

• Demonstrating job creation benefits could be challenging for individual states. Response: Recommended discussing with service providers and reviewing the NAQC Issue Paper: Tobacco Cessation Quitlines – A Good Investment to Save Lives, Decrease Direct Medical Costs and Increase Productivity at .

• States would need time to demonstrate that prevalence rates have decreased. Response/Clarification: It looks like prevalence will be part of the funding formula but not required for reporting. Shorter term measures (i.e. reach and quit rates) are more likely to be required for reporting.

• When will the guidance be released? Timing is a great concern. Response: We are hoping for release before November with proposals due before the end of the year.

Participants wanted to know if the funding could be used for the following:

• Face-to-face counseling

• Quitline promotions

• Infrastructure upgrades (operating systems)

• Pharmacotherapy

• Evaluation

What is the proposed time frame for quit rates?

Response: We are asking CDC to be consistent with current practice and are encouraging use of NAQC’s annual survey data, MDS questions and quit rate and reach standards.

Resources available at :

• NAQC Issue Paper: Measuring Reach of Quitline Programs

• NAQC Issue Paper: Measuring Quit Rates

How will quitlines differentiate tobacco users reached as a result of stimulus funds versus those reached through normal operating funds? Will separate reporting be required?

Response: NAQC has shared this concern with CDC.

Has NAQC made recommendations regarding types of promotions or focus on priority populations?

Response: Most of our efforts to date have been related to securing funding. We are just now talking with CDC about the components of the package and have advocated for promotions money. We have heard that there may be some measures related to priority populations.

Planning and Preparations: Quitline Manager/Tobacco Control Program Perspective

Introduction

An investment of $45-50 million over the next two years will significantly increase the budgets of many quitlines. This level of funding can greatly increase quitline reach and service levels. Based on current information that the funding is likely to be distributed in Nov/Dec, require quarterly reports and be linked to accomplishing increased reach, below are some of the issues and key questions to consider:

Alerting Agency Management

• Who needs to be informed of the pending stimulus funding – your supervisor? Chief medical officer? Governor’s office?

Writing a Proposal to CDC

• This is a new funding stream, so proposals are likely to be required.

• Demonstrating impact will be important.

• Prepare information on current quitline status including successes and our challenges. Pull from recent CDC grant application.

• Consider what CDC is likely to want. Does Best Practices give us a likely idea? Increase reach to 8% and provide counseling and medications (2 weeks to all callers and 4 weeks for uninsured/Medicaid).

• Integration is important. Is CDC likely to want to see ways in which the quitline is being integrated into other partnership efforts throughout the health department (chronic, diabetes, maternal child health, etc), with healthcare partners (health plans, insurers, hospitals) and with community partners (other cessation groups at local level, priority pop groups, etc)

• * Action: work with tobacco control staff to identify how to spend the funding, what it will cost, the likely impact and how to monitor spending, quitline services and outcomes and new job creation.

• After internal discussions, discuss potential plans with service provider to assure proposed changes/expansion can be accommodated.

Receipt of Funding from CDC

• Other ARRA funding has been provided through new contract mechanisms. This means the funding is NOT likely to be added to existing coop agreements.

• Are there things I can do at the health department to prepare the contracting officers?

• Will this require a new bid process or will the state allow for an amendment to existing quitline vendor contract?

• How long will it take to complete the contract or contract amendment?

• What will be the start date for new activities?

• Do we want to spend state funding at higher levels once the CDC announcement is made and then rely more heavily on ARRA funding when available?

• *Action: need to work with tobacco control staff, contract officer and service provider to determine at what point we change our services.

Contracting for Quitline Services and Reporting

Need to coordinate with our service provider to discuss:

• Is it possible to increase capacity? If so, how long will it take to recruit, hire and train new staff?

• If not, will we need to contract with a back-up vendor and for how long?

• If we are not providing medications, what will it take to build that capacity and how will we plan to distribute meds (voucher, mail, other?) Will my service provider do this work or do I need to contract with another firm?

• What additional reporting will the service provider need to provide? Can they do it?

• How will we and the service provider, if appropriate, track job creation?

• How long will it take to modify our contract?

• When can new services begin?

Contracting for Other Cessation Services

• Do I need to add other services such as Internet, medications, face-to-face counseling, language services?

Promotion

• How will we make sure that the increased capacity gets used? Do we want to promote the quitline via TV ads, radio or other effective means (e.g., free medications, partnerships with health care, community groups, etc)?

• What is our current reach and what will it take to get 6-8% reach? Where can we get help on these issues?

Coordination with Partners

• Need to coordinate with existing partners and think about new partnerships (consistent with OSH’s integration focus).

• Partnerships can help increase reach.

Complying with Reporting and Other Requirements of the CDC

• It is likely that we will have to provide new quarterly reports on services delivered and outcomes.

• Can my service provider do that?

• What resources do I need to make sure the quality of reporting is good?

QUESTIONS AND COMMENTS

Do others have issues regarding competitive contracting/bidding?

If an amendment to existing contract is not possible, states may have to go out to bid extending implementation timelines. Perhaps sole source contracts might be one way to get around the competitive bidding requirement.

Research: Consider developing and implementing health care services collaborative research projects using this funding to continue to advance and improve telephonic interventions. [Note: it is unlikely that funding can be used for research.]

Priority populations: This may be a great opportunity to focus on priority populations.

Response: We have conveyed priority population needs to CDC. We are still lacking data (prevalence, reach and quit rates) in this area as a quitline community. There may be an opportunity for research or evaluation projects.

Delegate authority to service provider: Would it be possible to delegate authority so funds go directly to service providers rather than to the state?

Response: Will follow up with CDC.

Adding NRT/medications: Consider risks of creating obligations using temporary funds. Is it sustainable to provide medications?

When primary funder is NOT a state health department: Will funding be disbursed to the primary funders of quitlines regardless of whether the funders are state health departments? Response: We are waiting for a response from CDC on that issue.

Re-granting money: Will states be allowed to re-grant money to businesses and insurers to contract for quitline services? Response: Have not heard anything about re-granting. New York has had some re-granting success giving start up money to health plans to get key stakeholders engaged. These plans are now providing quitline services to members leaving public funds for the uninsured.

Fax referral training (promotion of the quitline): Will money be allotted for training? Response: There is a good evidence base for referral efforts and NAQC is pushing for full use of the funding.

Planning and Preparations: Quitline Service Provider Perspective

Introduction

This information was prepared to assist service providers of all sizes and funders. We have a huge opportunity to demonstrate effectiveness by creating jobs and helping people quit which ultimately drives down medical costs. We can demonstrate cost effective health care delivery. All we do is measurable. Our quit rates can demonstrate fairly quick return on investment.

Preparations

Initial preparations can include:

• Building network capacity

• Upgrading software and licenses

• Determining how to spread out use of current state funds to prevent ramping up systems or employees and then having to scale back later.

Translating budgets (services and promotions) into services

• Assess when calls will come in monthly and the staffing levels needed to address these calls

• Use telephony equipment and software to help project staffing needs or map out day-to-day flow and use safety nets such as web enroll options, voice mail or overflow staff

• Review promotions plans and consider:

– individual states

– bordering states

– national promotions

– earned media

• Set clear expectations with funders and participants

Staffing – Timeline

Think about reverse timelines, titrating between state and stimulus funding and what staffing will be needed to handle the first wave of callers. Other considerations:

• Allow for recruiting, hiring and training

• Plan for continuation of services while recruiting

• Cross-train staff to take registration calls

• Hire part-timers who can flex up to full time

• Schedule split shifts

• Prepare for training needs

• Add trainers and/or supervisors

• Consider overflow support

Hiring Process

• Estimated number of staff needed to meet service levels

• Approval process for hiring

• Short term strategies versus longer-term planning

• Hiring process and budgets. Will call volumes be sustained to justify staffing up?

Contracting

• Consider all parties involved (CDC, funder, service provider)

• Process includes timing and turn around for amendments with service providers

• Provide legal support if possible and necessary

• Track process to get the contract through the organization

Infrastructure and Technology

When planning for increased calls, the following issues need to be considered:

• Office space and furniture for staff

• Adequate equipment, phone lines and voice mail capacity

• Training space

• Software, licenses

• Set up web registration or voice mail if they do not already exist

• Assess where calls terminate at quitline service provider to prevent blockage

• Adjust caller expectations

Reporting and Evaluation

• Include funding for evaluation in budgets

• Definitions and consistency in reporting will contribute to aggregate, national calculations

Telephone:

• How many calls?

• How many calls were answered?

• Service Levels

• Any phone blockage?

Number of hits to 1-800-QUIT-NOW is not a measure of reach. Rather, need:

• Number who registered

• Number who received coaching

• Number who received medication (if offered)

• Overall profile of who is calling (are we reaching our priority groups?)

• How callers learned about the quitline

This information should be shared with funding partners to inform promotions plans (paid or earned media) and determine if reaching priority groups.

Outcomes:

• Who is the quitline reaching?

• Satisfaction with services

• Quit rates – NAQC Defined

• Impact on life years saved, productivity and reduction in health care costs (use existing formulas)

• Reach – NAQC Defined

Demonstrating number of employees added. Considerations include:

• Adding 90-95% variable staff (i.e. those providing services, registration, supervisors and trainers)

• Fulfillment staff

• Medication provided through pharmacy benefit managers

• Reporting and data support staff (analysts)

• Free & Clear estimated 20 jobs per $1 million

We need:

• Heads up regarding reporting requirements and need consistent definitions for effective nationwide reporting

• Best practices for using earned media approaches and how to talk about the impact of the quitline, call volumes, who’s getting services and why it’s important to quit

• Educating employers and others who can cover services and provide support for quitlines

Communication between service providers and funders

• Always let each other know what you are doing with as much advanced notice as possible to protect service levels

• Coordinate around bordering states

• Involve each other in decisions

• Promotions levels needed (more or less needed to generate calls)

• Target populations reached (who is calling and do adjustments need to be made)

• Bring in those working on other chronic conditions

• Communicate contingency plans (when kick in, what changes look like, increases or decreases in promotions)

QUESTIONS/COMMENTS

How can we use stimulus money to get more involved in the systems approach? (i.e. bringing in non-traditional players such as health systems and corporate entities) Response: If CDC guidance includes enough leeway, can create a linkage between stimulus money and systems change. Quitlines could back into systems change through fax referral or fully electronic referral programs. Work with health care systems around their systems changes. Embed fax referral program into their systems but frame the changes to make sure you can show impact. Systems change is also a way to address disparities, especially through community-based health centers.

GENERAL QUESTIONS

Will any money be spent on modifications to the portal? NCI should work to address callers using cell phones from other states to direct people to their state of residence.

Response: We anticipate that CDC and NCI will have funds for administrative activities such as this.

Can linkages between community health centers and quitlines (partnerships) be counted towards the number of people hired and job creation? Consider utilization of promotoras and health care workers and the potential impact on chronic disease management.

RESOURCE LINKS

From NAQC

• Measuring Reach and Increasing Reach of Quitlines

– NAQC Issue Paper: Measuring Reach of Quitline Programs at .

The following resources can be found on NAQC’s Event Calendar at :

– Call Summary from NAQC Seminar Series: Innovative Approaches and Proven Strategies for Increasing Reach

– PowerPoint Presentation: Ohio’s Fax Referral Initiatives

– PowerPoint Presentation: Innovative Promotion for British Columbia’s QuitNow Services

– PowerPoint Presentation: Purchasing Tobacco Users’ Email as a Strategy to Increase Reach (Free & Clear)

– PowerPoint Presentation: Increasing Reach of Tobacco Cessation Quitlines: A Review of the Literature

The following resources can be found on NAQC’s 2009 Annual Conference page at :

– NAQC Annual Conference PowerPoint Presentation: Taking Fax Referral Programs to New Frontiers: 3rd Generation Innovation and Quality Standards in the e-World (Massachusetts)

– NAQC Annual Conference PowerPoint Presentation: Driven to the Quitline: Mobilizing Partners (Canadian Cancer Society)

– NAQC Annual Conference PowerPoint Presentation: QuitNow & WIN: Zero to 60 in 50 Days

– NAQC Annual Conference PowerPoint Presentation: Improving Reach: Making the Most of Limited Funds (Alabama)

– Forthcoming NAQC resources on increasing reach (literature review, member examples, Implementation Guide, Summary of Critical Recommendations and worksheet)

• Measuring Quit rates and Increasing quit rates

– NAQC Issue Paper: Measuring Quit Rates at .

The following resources can be found on NAQC’s Event Calendar at :

– Call Summary from NAQC Seminar Series: Maintaining Quality Across Quitlines in North America at

– PowerPoint Presentation: Maintaining Quality Across Quitlines in North America

– Forthcoming NAQC resources on increasing reach (Implementation Guide, Summary of Critical Recommendations and worksheet)

• Cessation Medications and Quitlines

The following resources can be found on NAQC’s Event Calendar at :

– Call Summary from NAQC Seminar Series: Cessation Medications and Quitlines: Current Practice and the Evidence Base

– PowerPoint Presentation: South Dakota’s Provision of Medications

– PowerPoint Presentation: NRT and NRT+Pilot Preliminary Results (Arizona)

– PowerPoint Presentation: NYS’ Smokers’ Quitline – Screening and Distribution of NRT Through an Online Process

– NAQC Annual Conference PowerPoint Presentation: Evaluation of Quitline NRT Distribution (Public Health Management Corporation)

– Draft NAQC Issue Paper: Standard Practices and Measurement of Medications Delivered by Quitlines

• Quitline Sustainability (includes an estimate on job creation)

– NAQC Issue Paper: Tobacco Cessation Quitlines – A Good Investment to Save Lives, Decrease Direct Medical Costs and Increase Productivity at .

• The following NAQC Minimal Data Set (MDS) technical resource materials are available at :

– NAQC Report: Realizing Opportunities Implementation Assessment of the Minimal Data Set in North America

• NAQC Strategic Goals at

.

OTHER RESOURCES

• Best Practices for Comprehensive Tobacco Control Programs – 2007

at .

Follow up questions and suggestions can be sent to naqc@. Thank you for your participation.

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