Self-Assessment: Kansas Tobacco Guideline for Behavioral Health Care

This self-assessment is a companion to the Kansas Tobacco Guideline For Behavioral Health Care (“Tobacco Guideline” at https://kdads.ks.gov/provider-home/providers/behavioral-health-tobacco-initiatives/). The self-assessment identifies which Tobacco Guideline steps your program is, or is not, implementing at various levels of fidelity. Completing this assessment on an annual basis will help identify strengths and targets for quality improvement in your program as well as provide measures of progress over time.

Please complete the following 12 items, which correspond to the 12 items in the Tobacco Guideline. Please choose ONLY ONE response for each item.

For assistance completing this assessment or implementing the Tobacco Guideline, please contact: [email protected].

Promoting wellness by integrating evidence-based tobacco treatment into routine clinical practice

1. Our program has assessed tobacco use status among the following percentage of our current consumers/clients: (Choose ONE)





Please type your evidence here and/or upload supporting documentation below. If you are ONLY uploading a file(s), or if you have selected the '0" entry from the check boxes, please enter NA in the text box.
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2. Our program has provided individual counseling, group counseling, or other behavioral support for tobacco treatment among the following percentage of our current consumers/clients who use tobacco: (Choose ONE)





Please type your evidence here and/or upload supporting documentation below. If you are ONLY uploading a file(s), or if you have selected the '0" entry from the check boxes, please enter NA in the text box.
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3. Our program has facilitated access to tobacco treatment medication among the following percentage of our current consumers/clients who use tobacco: (Choose ONE)





Please type your evidence here and/or upload supporting documentation below. If you are ONLY uploading a file(s), or if you have selected the '0" entry from the check boxes, please enter NA in the text box.
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4. Our program has integrated goals for tobacco into the treatment plans of the following percentage of our current consumers/clients who use tobacco: (Choose ONE)





Please type your evidence here and/or upload supporting documentation below. If you are ONLY uploading a file(s), or if you have selected the '0" entry from the check boxes, please enter NA in the text box.
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5. Our program has integrated tobacco into broader wellness/recovery initiatives for consumers/clients: (Choose ONE)





Please type your evidence here and/or upload supporting documentation below. If you are ONLY uploading a file(s), or if you have selected the '0" entry from the check boxes, please enter NA in the text box.
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6. Our program makes efforts to evaluate and improve the quality and extent of tobacco treatment: (Choose ONE)





Please type your evidence here and/or upload supporting documentation below. If you are ONLY uploading a file(s), or if you have selected the '0" entry from the check boxes, please enter NA in the text box.
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Building staff capacity to provide care

7. What percentage of your current staff has received training specifically in how to treat tobacco dependence? (Choose ONE)





Please type your evidence here and/or upload supporting documentation below. If you are ONLY uploading a file(s), or if you have selected the '0" entry from the check boxes, please enter NA in the text box.
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8. Our program has billed for, or obtains other resources, to pay for tobacco treatment among the following percentage of our current consumers/clients who use tobacco: (Choose ONE)





Please type your evidence here and/or upload supporting documentation below. If you are ONLY uploading a file(s), or if you have selected the '0" entry from the check boxes, please enter NA in the text box.
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9. Current program staff who use tobacco have easy access to free/low cost tobacco cessation medications and behavioral support: (Choose ONE)





Please type your evidence here and/or upload supporting documentation below. If you are ONLY uploading a file(s), or if you have selected the '0" entry from the check boxes, please enter NA in the text box.
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10a. What best describes where client tobacco use is permitted at your facility? (Choose ONE)





Please type your evidence here and/or upload supporting documentation below. If you are ONLY uploading a file(s), or if you have selected the '0" entry from the check boxes, please enter NA in the text box.
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10b. What best describes where staff tobacco use is permitted at your facility? (Choose ONE)





Please type your evidence here and/or upload supporting documentation below. If you are ONLY uploading a file(s), or if you have selected the '0" entry from the check boxes, please enter NA in the text box.
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Engaging in tobacco/e-cigarette cessation and prevention efforts among youth

11. Our program provides and or supports tobacco and e-cigarette treatment to help youth/young adults quit while they’re still young: (Choose ONE)





Please type your evidence here and/or upload supporting documentation below. If you are ONLY uploading a file(s), or if you have selected the '0" entry from the check boxes, please enter NA in the text box.
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12. Our program conducts or supports youth tobacco/e-cigarette use prevention efforts: (Choose ONE)





Please type your evidence here and/or upload supporting documentation below. If you are ONLY uploading a file(s), or if you have selected the '0" entry from the check boxes, please enter NA in the text box.
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Scoring Instructions:

  • Add the numbers checked for all items:
    • Lowest score is zero (0)
    • Highest score is sixty-five (65)
  • A program that scores 0 has implemented no steps in the Kansas Tobacco Guideline
  • A program that scores 65 has implemented all steps of the Kansas Tobacco Guideline, to a high degree of quality and with nearly all of their clients
  • A program that has implemented some steps, but not others, will score somewhere in between 0-65
  • Your program may choose to strengthen implementation of some steps, and/or begin implementing other steps, to increase its score
Please add your total score and enter it here.

PLEASE PRINT A COPY OF YOUR RESULTS FOR YOUR FILES BEFORE SUBMITTING (CTRL + P).

If you "Submit" your assessment and are not redirected to a "Success" screen, you may have left required fields empty. Please scroll up and find entries highlighted in red, complete those, and re-submit.