Living Well, Smoke Free - Tobacco management planning tool kit

Flinders ProgramTM

Living Well, Smoke Free A Chronic Condition Management Approach for Tobacco Interventions Tobacco Management Care Planning Tool Kit

Tobacco Management Care Planning Tool Kit Online ISBN: 978 1 920966 38 2 Copyright Statement © Flinders Human Behaviour and Health Research Unit, Flinders University 2013 This Toolkit is copyright. Apart from any use permitted under the Copyright Act 1968 (Cth), no part of this Manual may be reproduced, published, communicated to the public or adapted without the prior written authorisation of Flinders Human Behaviour and Health Research Unit.

This Toolkit was funded and developed by the Commonwealth Department of Health and Ageing through the ‘Helping Indigenous Australians Self-Manage their Chronic Disease’ initiative.

Requests and enquiries concerning authorised use of this Manual may be addressed to the Flinders Human Behaviour and Health Research Unit, Flinders University, GPO Box 2100, Adelaide SA 5001 or emailed to tmp@flinders.edu.au.

Acknowledgements In the development of this guide we have made use of external resources, in particular: • Flinders Closing the Gap Chronic Condition Management ProgramTM resources, including the NT Flinders/Menzies Self-Management resources • Intensive Clinical Tobacco Dependence Treatment resource. Authors: Renee Bittoun, Donna Harrison and Haniki Mohamed of the Smoking Cessation Unit Brain Mind Research Unit, University of Sydney • Department of Health and Ageing (DOHA) LifeScripts • Flinders Living Well™ Program.

©FHBHRU Flinders University 2013

FLINDERS Tobacco Management CARE PLANNING TOOL KIT The purpose of this resource is to provide health practitioners with the tools to explore the impact of tobacco smoking on clients, and promote positive changes around smoking. The resource has been specifically designed for Aboriginal and Torres Strait Islander people, living in urban, rural and remote areas.

The first-line tools are (for all smokers): a. The Tobacco Yarn. This tool consists of 5 brief questions used to establish the person’s readiness to make changes to their smoking. b. Weighing it Up. This is a decisional balance exercise used with clients who are unsure of whether they want to make changes. c. Assessment Tools. comprised of the Fagerstrom Test for Nicotine Dependence (FTND), Mood and Physical Symptoms Scale (MPSS), Hospital Anxiety and Depression Scale (HADS), Indigenous Risk Impact Screen (IRIS). d. Conversation about Tobacco. This 12-question tool can be used with people who express concerns about their smoking and are open to talking about the possibility of making changes. The question-and-answer approach is similar to that used within the Flinders Chronic Condition Management ProgramTM to talk about health problems, but has been made specific to tobacco.

The second-line tools (for those indicating they are ready to change): a. My Journey – Problem and Goal: Tobacco. This is very similar to the Problems and Goal tool used within the Flinders Chronic Condition Management ProgramTM but has been modified for smoking cessation. The tool is used to help the person describe their problem with smoking, the impact of the problem and how they feel about this. The person has the opportunity to identify change/s they would like to make and set timelines against this. b. Self-Management Care Plan: Tobacco. This summarises the client’s plan to address smoking, identifying high risk situations, coping strategies and avenues of support.

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The third-line tools (for those actively working on their smoking) a. Tobacco Follow Up. This tool consist of brief questions to help explore the client’s progress. b. Withdrawal Monitoring Diary. This keeps a record of the main withdrawal symptoms the person is experiencing when they quit or cut back. It is important to discuss these with clients as symptoms, such as cravings, are often linked with relapse. This provides an opportunity for the health practitioner to assist the person with finding better ways of coping. c. Reviewing My Progress. This provides a guide to measuring progress at each client visit. This is relevant for people trying to quit and those who are reducing. Once the care plan has been developed and baseline measures have been completed, the practitioner should schedule further sessions with the client, particularly during the first weeks of quitting or reducing smoking. d. My Long-Term Progress. This maintains a record of progress over the longer term.

It is expected that the client will be followed up 3, 6 and 12 months following initial intervention, as part of normal relapse prevention practice.

Guide to using this resource It is assumed that demographic information of the client is already available to the service.

A brief medical review has been included but people with extensive medical history would require assessment beyond the scope of this guide.

Starting point: Health service identifies that client is currently smoking.

THE TOBACCO YARN Conduct conversation around tobacco smoking using open-ended questions.

1. What worries do you have about your smoking?

2. How many cigarettes would you have on a typical day?

3. What would you like to change about your smoking and why?

4. Is there anything that makes it hard for you to stop or cut down?

5. Have you tried to quit or cut down before?

Reflect and summarise.

Explore readiness to change.

Q: Do you think you might make changes to your smoking?

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Person wants to make changes to smoking

Very resistant

Not sure

A. Very resistant Offer a pamphlet on quitting smoking. Consider providing assistance for a health condition and/or other risk factor.

B. Not sure Complete worksheet Weighing it Up. If person is still unsure give them time to think it over and arrange a time to follow-up. Offer pamphlet on quitting smoking and provide assistance for a health condition and/or risk factor.

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More Ready

C. More ready 1. Complete Assessment for Dependence Tools (FTND and MPSS).

2. Optional - HAD and/or IRIS tools if there are mental health/alcohol & substance use concerns.

3. Complete Conversation about Tobacco.

4. Complete My Tobacco Journey and Tobacco Self-Management Care Plan. Arrange a time to follow up.

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DECISIONAL BALANCE

• _______________________________

• _______________________________

• _______________________________

• _______________________________

• _______________________________

• _______________________________

• _______________________________

• _______________________________

• _______________________________

• _______________________________

• _______________________________

• _______________________________

• _______________________________

WEIGHING IT UP

• _______________________________

• _______________________________

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On weighing things up, do you think you might make changes to your smoking?

• _______________________________

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ASSESSMENT FOR DEPENDENCE

OTHER ASSESSMENT TOOLS

Fagerström test for nicotine dependence (ftnd): short form

Hospital Anxiety and Depression (HAD) Scale This is a validated measure of anxiety and depression. Complete first at baseline and then at review appointments. Reducing smoking can initially heighten anxiety or depressive symptoms, usually on a temporary basis.

1. How soon after you wake up do you smoke your first cigarette?

• Within 5 minutes

(3)

• 6-30 minutes

(2)

• 31-60 minutes

(1)

• After 60 minutes.

(0)

The client fills in the first page and then the health practitioner uses the second page to score. The person has a score for anxiety (HAD-A) and another for depression (HAD-D).

The scoring sheet shows which questions relate to each. Scores of 8 – 10 suggest closer monitoring of the person’s mental wellbeing; scores of 11 and over warrant further psychiatric assessment or referral.

2. How many cigarettes per day do you smoke?

• 0-10 or less

(0)

• 11-20

(1)

• 21-30

(2)

• 31 or more.

(3)

Indigenous Risk Impact Screen (IRIS) This measure has been validated for use in Indigenous communities. It helps identify a number of risk factors at the time of screening which may impact on a person’s ability to successfully quit or reduce their smoking.

Total Score

Mood and Physical Symptoms (MPSS) Scale (Used at assessment and as a progress measure) How much of the time have you felt the urge to smoke today?

0 Not at all

1 A little

2 Sometimes

3 A lot

4 Nearly all the time

5 All the time

How strong have the urges been today?

0 No urges

1 Slight

2 Moderate

3 Strong

4 Very strong

5 Extremely strong

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Total Score

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CONVERSATION ABOUT TOBACCO Partners in Health: Tobacco 1 I know about smoking and how it affects my health and well-being

Cue and Response

Notes

KNOWLEDGE

.........................................................................................

• How do you think smoking is affecting your health?

.........................................................................................

• What other parts of your life are affected? For example, your family, money, limits where you can go and what you can do

......................................................................................... ......................................................................................... ......................................................................................... ......................................................................................... .........................................................................................

My score

2

I have reasons for changing my smoking

My health worker score

......................................................................................... agreed score

IMPACT

.........................................................................................

• What are your main reasons for wanting to make changes to your smoking?

.........................................................................................

• How important are these to you?

.........................................................................................

......................................................................................... ......................................................................................... ......................................................................................... .........................................................................................

My score ©FHBHRU Flinders University 2013

My health worker score

......................................................................................... agreed score

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CONVERSATION ABOUT TOBACCO Partners in Health: Tobacco 3 I know about how my health can recover if I stop smoking

Cue and Response

Notes

IMPACT

.........................................................................................

• How could your health get better if you stop or cut back smoking?

.........................................................................................

• Why might some people think it is too late to quit?

......................................................................................... ......................................................................................... ......................................................................................... ......................................................................................... .........................................................................................

My score

4

I know about ways to quit or cut back on smoking

My health worker score

......................................................................................... agreed score

INVOLVEMENT

.........................................................................................

• What things can help you when you are trying to stop smoking?

.........................................................................................

• What do you think would work best for you?

.........................................................................................

......................................................................................... ......................................................................................... ......................................................................................... .........................................................................................

My score ©FHBHRU Flinders University 2013

My health worker score

......................................................................................... agreed score

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CONVERSATION ABOUT TOBACCO Partners in Health: Tobacco 5 I am able to change things in my life to help me deal with my smoking problem

Cue and Response

Notes

MONITOR AND RESPOND

.........................................................................................

• What things might make it hard for you if you wanted to stop smoking

.........................................................................................

• What could you change to make it easier for you?

......................................................................................... ......................................................................................... ......................................................................................... ......................................................................................... .........................................................................................

My score

6

My health practitioner/s listen and can help me make changes to my smoking

My health worker score

......................................................................................... agreed score

SUPPORT

.........................................................................................

• Can you talk to your health practitioner/s about your smoking?

.........................................................................................

• Would they give you more support if you needed it?

.........................................................................................

......................................................................................... ......................................................................................... ......................................................................................... .........................................................................................

My score ©FHBHRU Flinders University 2013

My health worker score

......................................................................................... agreed score

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CONVERSATION ABOUT TOBACCO Partners in Health: Tobacco 7 I know ways to deal with cravings when I stop or cut back smoking

Cue and Response

Notes

MONITOR AND RESPOND

.........................................................................................

• What cravings have you had when you’ve tried to stop or cut back before?

.........................................................................................

• What are some of the ways you could deal with cravings?

......................................................................................... ......................................................................................... ......................................................................................... ......................................................................................... .........................................................................................

My score

8

I am able to get support from family and friends to cut down or stop smoking

My health worker score

......................................................................................... agreed score

SUPPORT

.........................................................................................

• What do your family and friends think about your smoking?

.........................................................................................

• Would they be supportive of you making changes?

.........................................................................................

• Is there anyone who might make it hard for you?

......................................................................................... ......................................................................................... ......................................................................................... .........................................................................................

My score ©FHBHRU Flinders University 2013

My health worker score

......................................................................................... agreed score

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CONVERSATION ABOUT TOBACCO Partners in Health: Tobacco 9 I am able to deal with the emotions which come from quitting or cutting down.

Cue and Response MONITOR AND RESPOND

.........................................................................................

• When you’ve tried to quit or cut down before, did you find yourself becoming (… angry, upset, stressed, bored, anxious, depressed, lonely)?

.........................................................................................

• Do you have any ideas how you might deal with difficult emotions when you are quitting?

My score

10

I can find other things to do instead of smoking

Notes

My health worker score

......................................................................................... ......................................................................................... ......................................................................................... ......................................................................................... ......................................................................................... ......................................................................................... agreed score

LIFESTYLE

.........................................................................................

• What else could you do instead of smoking?

.........................................................................................

• How could you reward yourself for not smoking or cutting down?

......................................................................................... ......................................................................................... ......................................................................................... ......................................................................................... .........................................................................................

My score ©FHBHRU Flinders University 2013

My health worker score

......................................................................................... agreed score

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CONVERSATION ABOUT TOBACCO Partners in Health: Tobacco 11 I am able to avoid people and places that remind me of smoking

Cue and Response

Notes

INVOLVEMENT

.........................................................................................

• Do you have favourite places to smoke?

.........................................................................................

• How do you feel about smoking inside your home or your car?

• Are you around other people smoking at work or other places you go?

......................................................................................... ......................................................................................... ......................................................................................... ......................................................................................... .........................................................................................

My score

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I know about other things that can make it hard to change smoking

My score ©FHBHRU Flinders University 2013

My health worker score

......................................................................................... agreed score

KNOWLEDGE

.........................................................................................

• Are there things you do, such as drinking, using drugs or gambling that might make it harder for you? How could you work around this?

.........................................................................................

• How much tea, coffee or other caffeine drinks would you have in a day? How might this change if you cut back smoking?

.........................................................................................

My health worker score

......................................................................................... ......................................................................................... ......................................................................................... ......................................................................................... ......................................................................................... agreed score

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MY TOBACCO JOURNEY – PROBLEM AND GOALS Open-ended Questions

Notes

What do you see as your main worry?

What happens because of this worry?

How does this worry change the way you live? Are there things you do more or less of? (eat, exercise, go out, sit) Are there things you don’t do at all?

How does your worry make you feel? (angry, flat, weak)

My Main Worry

(should include Problem, Impact, Feeling)

My worry

Specific actions: What would you like to change/achieve: Timelines:

How long and how often: Conditions:

My Life Goal1

(visit my country, attend community group, walk, return to work)

My progress

My Goal around Tobacco

(stop smoking, cut down, not smoke in the house/car/at work)

My progress

Goal statements should be SMART – Smart, Measurable, Action-based, Realistic, Timely

1

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MY TOBACCO SELF-MANAGEMENT CARE PLAN Identified issues from Cue and Response

What do I want to achieve?

Pharmacological intervention/s

Sign off – Patient/Client

Signature ………………………………................... ©FHBHRU Flinders University 2013

Steps to get there

Who will do it?

Who can help?

Plan to use NRT pp

Product: ………………………………………….

Plan to use Medication pp

Product: …………………………………………

Sample Initials

Date

Date reviewed

Progress

Sign off – Practitioner

NB. Patches are subsidised under PBS. Smoking cessation medications require a script from a Medical Officer.

Sample Initials

Date

Signature ………………………………...................

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MY TOBACCO SELF-MANAGEMENT CARE PLAN Identified issues from Cue and Response

©FHBHRU Flinders University 2013

What do I want to achieve?

Steps to get there

Who will do it?

Who can help?

Progress

Date reviewed

Client’s initials

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HAD SCALE

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HAD SCALE

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TOBACCO FOLLOW UP At each visit progress against the client’s care plan should be reviewed. This form provides a specific focus on the client’s progress against their goal with tobacco. Plans for dealing with high risk situations may be added to their care plan.

REVIEW CARE PLAN

1. How are you going with making changes to your smoking?

2. What changes have you made?

................................................................................................................................... ...................................................................................................................................

................................................................................................................................... ...................................................................................................................................

3. Is there anything making it hard for you?

(common ones are being with people smoking, needing to relax, having nothing to do, when drinking …)

4. Have you noticed any benefits?

(financial, health, comments from others?)

................................................................................................................................... ...................................................................................................................................

................................................................................................................................... ...................................................................................................................................

Plan for dealing with high risk situations: ............................................................................................................................................................................................................................................................................... ...............................................................................................................................................................................................................................................................................

©FHBHRU Flinders University 2013

UPDATE CARE PLAN

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PARTNERS IN HEALTH TOBACCO REVIEW TOOL 1. I know about smoking and how it affects my health and well-being

My Progress

2. I have reasons for changing my smoking My Progress

3. I know about how my health can recover if I stop smoking My Progress

4. I know about ways to quit or cut back on smoking

7. I know ways to deal with cravings when I stop or cut back smoking 8. I am able to get support from family and friends to cut down or stop smoking 9. I am able to deal with the emotions which come from quitting or cutting down.

6. My health practitioner/s listen and can help me make changes to my smoking ŠFHBHRU Flinders University 2013

My Progress

My Progress

10. I can find other things to do instead of smoking My Progress

5. I am able to change things in my life to help me deal with my smoking problem

My Progress

My Progress

My Progress

My Progress

11. I am able to deal with the emotions which come from quitting or cutting down 12. I know about other things that can make it hard to change smoking

My Progress

My Progress

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TOBACCO FOLLOW UP

DATE

SYMPTOMS (Refer to list)

WITHDRAWAL MONITORING DIARY OVERALL SEVERITY 0 1 2 3 4 Low

High 0 1 2 3 4

Low

High 0 1 2 3 4

Low

High 0 1 2 3 4

Low

POSSIBLE WITHDRAWAL SYMPTOMS Cravings

Constipation/diarrhoea

Nervous, restless

Weight gain/increased appetite

Tense, angry

Lightheaded, spacy

Sadness, depression

Dreaming about smoking

Poor concentration

Missing the handling of the cigarette

Unable to sleep

Thinking about cigarettes a lot

Sleeping too much Headaches

High 0 1 2 3 4

Low

High 0 1 2 3 4

Low

High 0 1 2 3 4

Low ŠFHBHRU Flinders University 2013

High

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REVIEWING MY PROGRESS DATE

TTFC

CIGS/DAY

Expired CO (ppm)

TTFC refers to Time To First Cigarette after waking MPSS refers to score from Mood and Physical Symptoms Scale HAD A and B refers to the anxiety and depression scores on the HAD scale respectively. ŠFHBHRU Flinders University 2013

Problem

Goals (1 and 2)

MPSS

SYMPTOM SEVERITY

HAD A

HAD D

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MY LONG-TERM PROGRESS 3 MONTH EVALUATION DATE

TTFC

CIGS/DAY

Expired CO (ppm)

Problem

Goals (1 and 2)

MPSS

SYMPTOM SEVERITY

HAD A

HAD D

Clinical Notes ......................................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................................................................

6 MONTH EVALUATION DATE

TTFC

CIGS/DAY

Expired CO (ppm)

Problem

Goals (1 and 2)

MPSS

SYMPTOM SEVERITY

HAD A

HAD D

Clinical Notes ......................................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................................................................

12 MONTH EVALUATION DATE

TTFC

CIGS/DAY

Expired CO (ppm)

Problem

Goals (1 and 2)

MPSS

SYMPTOM SEVERITY

HAD A

HAD D

Clinical Notes ......................................................................................................................................................................................................................................................... .................................................................................................................................................................................................................................................................................. ©FHBHRU Flinders University 2013

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IRIS - Indigenous Risk Impact Screen QUESTION 1. In the last 6 months have you needed to drink more to get the affects you want?

RESPONSES

6. What time of day do you usually start drinking or using drugs?

1 = At night 2 = In the afternoon 3 = Sometime in the morning 4 = As soon as I wake up

7. How often do you find that your whole day has involved drinking or using drugs?

1 = Never/hardly ever 2 = Sometimes 3 = Often 4 = Most days/every day

8. How often do you feel down in the dumps, sad or slack?

1 = Never/hardly ever 2 = Sometimes 3 = Most days/every day

9. How often have you felt that life is hopeless?

1 = Never/hardly ever 2 = Sometimes 3 = Most days/every day

10. How often do you feel nervous or scared?

1 = Never/hardly ever 2 = Sometimes 3 = Most days/every day

11. Do you worry much?

1 = Never/hardly ever 2 = Sometimes 3 = Often 4 = Most days/every day

1 = Never/hardly ever 2 = Sometimes 3 = Most days/every day

12. How often do you feel restless and that you can’t sit still?

1 = Not difficult at all 2 = Fairly easy 3 = Difficult 4 = I couldn’t stop or cut down

1 = Never/hardly ever 2 = Sometimes 3 = Most days/every day

13. Do past events in your family, still affect your wellbeing today (such as being taken away from your family?)

1 = Never/hardly ever 2 = Sometimes 3 = Most days/every day

1 = No 2 = Yes, a bit more 3 = Yes, a lot more

2. When you have cut down or stopped drinking or using drugs in the past, have you experienced any symptoms, such as sweating, shaking, feeling sick in the tummy/vomiting, diarrhoea, feeling really down or worried, problems sleeping, aches and pains?

1 = Never 2 = Sometimes when I stop 3 = Yes, every time

3. How often do you feel that you end up drinking or using drugs much more than you expected?

1 = Never/hardly ever 2 = Once a month 3 = Once a fortnight 4 = Once a week 5 = More than once a week 6 = Most days/every day

4. Do you ever feel out of control with your drinking or drug use?

5. How difficult would it be to stop or cut down on your drinking or drug use?

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ACTIVITY LOG When you’re trying to make changes to your smoking it may be a good idea to plan your week with things to do to keep your mind off the smokes. It can also be useful to find places where you can’t smoke or limit the time you spend with other smokers. Physical activity can also help you cope with withdrawal symptoms.

MON

TUES

WED

THURS

FRI

SAT

SUN

Morning

Afternoon

Evening

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STRUCTURED PROBLEM SOLVING Coping with changes to your smoking can sometimes feel overwhelming.

Structured problem solving is a skill that can assist you to step back and see your problem clearer and solve it step by step. It helps you be aware of the support you have, your personal strengths and how you have coped with similar situations in the past.

My problem is

Possible solutions

Advantages

Disadvantages

Six steps you can use: 1. Name the problem 2. List all possible solutions (there are no right or wrong answers, write all ideas down, ask other people if needed) 3. List the advantage and disadvantage of each solution 4. Choose the best option you want to use to deal with the problem (leave the list as you may want to try another option next time) 5. Write the steps you need to do for this option

Best option for me Steps I need to take

6. Review how it went.

Review How did I go? What didn’t go so well? Do I need to add some steps? Do I want to try another option?

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For further information please contact: Sue bertossa sue.bertossa@flinders.edu.au Curriculum Coordinator

Peter Harvey peter.harvey@flinders.edu.au Project Manager