Nancy La Pelle, Ph.D. University of Massachusetts Medical School February 2007

1. Sustainability of Public Health Programs: The Example of Tobacco Treatment in Massachusetts CommunityHealth Settings Nancy La Pelle, Ph.D. University of Massachusetts Medical School February 2007 Grant # RO1 CA86282 funded by National Cancer Institute State and Community Tobacco Control Interventions Research Initiative

2. Principal Investigator: Judith K. Ockene, PhD UMMS Co-Principal Investigators: Lori Pbert, PhD UMMS Donna Warner, MBA, CAC MDPH Co-Investigators: Nancy La Pelle, PhD UMMS Jane Zapka, ScD UMMS Sarah Reiff-Hekking, PhD UMMS Harriet Robbins, MEd MDPH Project Directors: Denise Jolicoeur, MPH, CHES UMMS Mary Jo White, MS, MPH UMMS

3. Sustainability • “Sustainability” contrasts with the notion of “institutionalization” which implies that a service is continued within the original organizational structure and that it is unchanged • Sustainability includes adaptations to scope of services offered, organizational context, and supporting resources

4. Massachusetts Tobacco Treatment Policy Study (MASSTTPS) Sustainability Substudy • Qualitative comparative case study • Sample • Massachusetts Tobacco Control Program (MTCP) statewide Smokers’ Helpline funded by MDPH • 77 of 86 defunded community-based tobacco treatment programs • 21 hospitals; 27 community health centers; 9 substance abuse treatment centers; 6 mental health agencies; 14 “other” agencies

5. Data Collection and Analysis • Telephone-based key informant interviews with community agency staff (77) • In-person interviews with DPH/MTCP staff regarding Smokers’ Helpline (5) • Tape-recorded and transcribed • Thematic and relational analysis conducted to idenify strategies used to sustain services

6. Results: Essential Strategies for Sustainability When Defunded • Redefine Scope of Services: • Align services with organizational goals • Select acceptable and affordable services Sustainable Services • Creative Resourcing: • Find funding sources for services offered • Adjust staffing pattern • Assign resources to create demand for services

7. Align Services with Organizational Goals • Meet needs of high smoking prevalence populations served • Meet needs to provide tobacco treatment to patients with co-morbid conditions • Support staff needs to quit at smoke-free sites • Dovetail with cessation-related research at the site

8. Select Acceptable and Affordable Services • Target specific at-risk subpopulations • Offer selected services only • Reduce availability: hours and sites when/where services are offered

9. Find Funding for ServicesOffered • Charge fees • Use grant-writing expertise to find other funding • Get other entities (departments, collaborators, etc.) to fund, share costs, or provide space • Bill as encounter that has insurance coverage

10. Adjust Staffing Pattern • Reduce tobacco treatment specialist (TTS) staff • Find other roles TTS staff can play part-time in other departments • Outsource TTS staff • Find non-TTS staff resources to provide services

11. Assign Resources to Create Demand for Services • Create referral system from providers and other departments • Educate healthcare providers about services • Program staff networks with other community organizations to generate referrals • Enlist marketing resources to advertise services

12. Sustainability Results After9 Months

13. Level 1: 33% Non-Sustaining (Minimal Scope; No Resources) Redefining Scope: • Drop tobacco treatment - low priority • Refer to other agencies for treatment Creative Resourcing: • No funding; Fees not acceptable to clients; No grant-writing resources • No staff to deliver services • No staff to create demand

14. Level 2: 34% Low Sustaining(Restricted Scope; Minimal Resources) Redefining Scope: • Serve high prevalence smokers where possible • Limited services for specific populations; No nicotine replacement therapy (NRT) unless covered by insurance; Integrate with other treatment services Creative Resourcing: • Limited grant-writing resources • TTS staff provide fewer sessions at fewer sites; Services provided by interns, volunteers, non-specialists • No outreach since not staffed for full service; Internal referral systems not optimized

15. Level 3: 27% Mid-Sustaining(Expanding Scope; Expanding Resources) Redefining Scope: • Gradually restore services available to all • Provide only group services; Provide all previous services except NRT; Provide only phone- or web-based services Creative Resourcing: • Seek alternate funding sources/charge fees; Seek collaborators with funding; Seek grants to serve specific ethnic groups; Seek NRT funding source • Use contract staff or share staff with other departments; Transfer program to related groups with more resources • Emphasize use of internal referral system

16. Level 4: High Sustaining(Similar Scope; Similar Resources) Redefining Scope: • Continue services to all smokers • Continue to offer same level of services as when funded Creative Resourcing: • Seek alternate funding sources/charge fees • Maintain staff required • Provide marketing and outreach support; Encourage internal referrals agency-wide

17. Sustainability Results After9 Months * The percentage is of the agency type total

18. Key Strategies at Defunding Redefine Scope of Services: Align services with organizational goals Select acceptable and affordable services Creative Resourcing: Find funding sources for services offered Adjust staffing pattern Assign resources to create demand for services Additional Key Strategies at Planning Program design Standard operating routines Capacity building Community board involvement Local institutional support Administrative system support Evaluation Sustainability Strategies

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