Health systems change for tobacco dependence screening and treatment: Measuring progress at the state level

Promoting health systems change is a key tobacco cessation strategy. Healthcare systems relevant for tobacco-related interventions include written policies and standards of care, health record systems, referral processes, and audit procedures. Challenges associated with implementing and evaluating health systems change interventions include clearly defining “systems” and prioritizing target organizations. For example, mental health treatment facilities are less likely to use written policies than hospitals, but their patients/clients are more likely to be tobacco users. Moreover, assessing systems change at the state level requires a systematic approach, distinct from the qualitative approach feasible within a single organization. We will discuss how we translated the evidence base into a conceptual model that articulates the systems change intervention’s theory of change. Using our conceptual model facilitated our evaluation planning by outlining intervention components and short-term and intermediate outcomes. We will discuss the health systems change initiative in New York (NY), now in its tenth year. One of our studies found that 90.3% of NY community health centers (CHCs) use written clinical policies or procedures, but only 51.6% of CHCs have written clinical policies or procedures related to tobacco. We will highlight recommendations to respond to challenges encountered in health systems change intervention and evaluation, including the importance of prioritizing targets to optimize reach to the target population and maximize program efficiency. For example, our evaluation determined that NY’s intensive evidence-based intervention was reaching a low proportion of practices in the state; shifting the target increased the likelihood of significantly changing cessation outcomes.