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Clinical
Policies and Procedures: The TRAC System
Overview of TRAC
Tobacco Reduction, Assessment, and Care (TRAC) is
an office-based systems approach designed to overcome many barriers to delivering
effective tobacco interventions in a busy managed care setting (Hollis,
et al., 1993; Hollis, et al., 2000; Lichtenstein, et
al., 1996).
- The TRAC System implements a team approach for
the delivery of the Five A's.
- TRAC distributes time-intensive tasks to those
employees who have more time or job flexibility.
Case study:
Kaiser Permanente Northwest, a 430,000-member group-model
HMO, implemented the TRAC team approach for delivering the "5
A's" throughout its primary care facilities.
- The long-term quit rate nearly doubled with the use of the nurse assisted component compared to 30 seconds of physician counseling alone.
(American Association of Health Plans, 2001)
- Post-visit
surveys of 20,372 randomly selected patients in five TRAC and five non-TRAC
facilities showed that implementation increased assessment (60% vs.
54% of all patients) and clinician advice (72% vs. 59% of smokers) at
the visit.
- Post-visit
stage-of-change assessment
also improved significantly in TRAC facilities. Virtually all tobacco users
(96%) reported that staff "should encourage smoking patients to
quit and offer assistance to those who want to quit," and visit
satisfaction was higher for those who reported clinician advice than
for those who did not (4.2 vs. 3.9 on a 5-point
scale).
- Intervention efforts, and especially documentation
practices, decreased over time. A later chart review showed that 85%
of patients had been assessed at some point, and 28% of smokers with
visits in a six-month
period had documentation of advice.
Conclusions:
Though implementation was successful initially,
maintaining the program required additional system-level supports. Additional Kaiser facilities have implemented TRAC, and tobacco control is
a high-priority clinical quality target. Prompting and documentation
have been integrated into the electronic medical record, monitoring and
monthly feedback continue, and compensation is tied to performance
throughout the organization (Hollis
& Bills, 1999; Kaiser Permanente, 2003).
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