# Use of organizational change strategies and personalized agency feedback improves addressing tobacco in behavioral health outpatient treatment settings

## TL;DR

A new model for organizational change improves tobacco treatment in mental health clinics by boosting staff skills and patient referrals.

## Contribution

The study shows that organizational change strategies and personalized feedback significantly improve tobacco disorder treatment in behavioral health settings.

## Key findings

- The ATTOC model significantly improved clinic preparedness and implementation of tobacco use disorder interventions.
- Composite preparedness and activities were strongly associated with increased patient referrals to evidence-based tobacco interventions.
- Significant improvements were observed in staff training, tobacco discussions, and documentation over a 9-month period.

## Abstract

Implementing evidence-based interventions for tobacco use disorder (TUD) in community mental health agencies is critical, given the low adoption rates of these interventions and the high rates of TUD among patients, contributing to the high morbidity and shortened lifespan of this population. Implementation efforts require enhancing organizational preparedness to integrate these evidence-based interventions.

When the Addressing Tobacco Through Organizational Change (ATTOC) model was evaluated in a cluster-randomized trial (with 13 clinics, 610 clients, and 222 staff) and compared with an education-only intervention, ATTOC proved to be better at having more TUD treatment, policies, and staff skills. This paper presents a secondary analysis focusing only on the ATTOC sites, examining whether clinic-level preparedness is associated with increased implementation activities and estimating the combined direct and indirect impact on patient referrals to evidence-based TUD interventions.

Seven sites applied the ATTOC model over 9 months, with the ATTOC Environmental Scan (ES) conducted at baseline and 3, 6, and 9 months to assess the following: (1) the environment inside and outside the building, (2) staff training and personal tobacco use, (3) clinical TUD services and documentation, and (4) tobacco policies. Summary statistics are provided, and generalized linear mixed model analyses for repeated measures were used to assess time trends and relationships among composite preparedness, activities, and number of referrals.

Over the 9-month period, significant improvements were observed in ES composite preparedness (p < 0.001) and individual ES areas (p < 0.001 for each). Eight out of 11 ATTOC Dashboard items showed significant changes, including increased number of patients treated (p = 0.002); tobacco discussions (p = 0.022); provision of educational brochures (p = 0.034); referrals to a Nicotine Anonymous group (p < 0.001), an in-house wellness or tobacco group (p < 0.001), and state quitline (p = 0.012); and documentation in treatment plans (p = 0.008). Both composite preparedness (p = 0.006) and composite activities (p < 0.001) were significantly associated with the number of composite referrals.

Significant TUD intervention uptake was found over time through the ATTOC model organizational change intervention and tracking tools.