In Wisconsin's Fax to Quit program, trained health care providers at more than 500 participating clinic sites who identify a tobacco user during a routine health care visit educate the patient on the availability of the Wisconsin Tobacco Quit Line, a phone-based tobacco cessation counseling service. If the patient expresses an interest in quitting, the provider completes a form with patient contact information and faxes it to the quitline. A quitline coach calls the patient within 3 days to initiate counseling. To optimize participation in Fax to Quit and to ensure that appropriate patients are linked to the service, state-based outreach workers train providers in the fax referral service during visits to practices to explain tobacco cessation guidelines and services. Key elements of the program include the following:

• Using outreach workers to recruit providers: University of Wisconsin Center for Tobacco Research and Intervention (hereafter referred to as “the Center”) outreach workers describe the Fax to Quit program when visiting local health systems, hospitals, and clinics as part of their efforts to promote use of Treating Tobacco Use and Dependence clinical practice guidelines from the U.S. Public Health Service. Outreach workers explain how the program can be integrated into the “5 A's” (Ask, Advise, Assess, Assist, Arrange) of tobacco cessation. Because Fax to Quit has now achieved nearly full saturation among medical providers across the state, program developers are reaching out to new provider groups, such as dentists and mental health/substance use practitioners.
• Training providers on the program and appropriate referrals: Outreach staff work with each provider site on an individual basis to help the site systematically integrate Fax to Quit into tobacco treatment. Outreach staff provide 10 to 15 minutes of training to providers, with a focus on available quitline services, the ability of Fax to Quit to serve as a treatment extender, and how to use the fax referral form. Critical to the success of the program, the training emphasizes which types of patients are most likely to benefit from quitline services and therefore should be targeted for recruitment. This education maximizes the chances that appropriate patients are referred to the quitline and increases the chances that a referral will lead to participation in quitline services. Outreach workers also distribute a provider manual to support implementation. Clinics that hear about the Fax to Quit program from colleagues may request an outreach visit or contact the Center for brief phone-based training in order to participate in the program.
• Informing and educating appropriate patients about quitline: Following the “5 A's,” participating providers ask patients about their tobacco use, advise tobacco users to quit, and assess their willingness to quit within the next 30 days. For those indicating a desire to do so, the provider assists by prescribing medication if appropriate and describing the state's tobacco cessation quitline. The provider also gives interested patients a quitline brochure, business card, and bookmark. The brochure describes quitline service options, which include one-on-one telephone-based counseling with a coach, a Web-based counseling program with a discussion forum (called WebCoach ^TM ), a free 2-week starter kit of over-the-counter nicotine replacement therapy, printed self-help materials, and referrals to local tobacco cessation resources. Users may participate in any number and combination of quitline services.
• Faxing referral form for patients interested in proactive quitline contact: The provider asks the patient if he/she would like to receive a call from a quitline coach. If so, the provider arranges the call by completing and faxing a referral form to quitline staff, who then enter the information into an electronic system. As of July 2011, more than 500 participating provider sites have referred over 21,000 patients in this manner. The form includes the following:
  • Provider information: The form is preprinted with the provider's identification and contact information.
  • Patient information and consent: The patient fills in his/her name, contact information, language preference, type of tobacco used, preferred time for contact, and specific issues the provider or patient would like the quitline coach to cover (such as asthma or pregnancy). The patient's signature on the bottom of the form confirms that he/she consents to be proactively contacted by a quitline coach.
  • Reminders: The form includes a reminder that the patient is being referred because he/she expressed readiness to quit within 30 days, as well as a notation of the caller identification that will appear on the patient's telephone when the quitline coach calls.
• Contacting patient: A quitline coach attempts to initiate contact with the patient within 3 days, and makes up to four subsequent attempts if the first attempt fails. Overall, approximately 65 percent of quitline referrals result in contact with the patient. Once the coach reaches the patient, he/she describes available services and enrolls the patient in them as appropriate.
• Following up with provider: The quitline coach faxes an update to the provider, indicating whether he/she reached the patient and, if so, what services the patient requested. The provider can include this information in the medical record and discuss it with the patient during the next office visit. Each month, the program sends a report to each participating provider site with statistics on number of patients contacted, services requested, and other utilization indicators. Outreach staff use the monthly fax referral report to identify provider sites with low referral and/or enrollment rates and then offer additional technical assistance and support to get them back on track.