Early Childhood Oral Health: Improving Collaborative Care ......Early Childhood Oral Health:...
Transcript of Early Childhood Oral Health: Improving Collaborative Care ......Early Childhood Oral Health:...
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Early Childhood Oral Health:Improving Collaborative Care in
Clinical Practice
Rocio Rocio QuiñonezQuiñonez, DMD, MS, MPHRocio Rocio QuiñonezQuiñonezQuiñonez, DMD, MS, MPH, DMD, MS, MPHUNC Schools of Dentistry and MedicineUNC Schools of Dentistry and Medicine
Vegas, 2017
Objectives
• Trends in early childhood oral health • Rationale and evidence of collaborative care in
early childhood• Opportunities to promote collaborative oral health
care in clinical practice
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Spring 2000
Pediatric Medical Guidelines
2003: American Academy of Pediatrics- Oral health screening in the first year of life.
If high-risk, referral to a dentist.
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2006
New York State Prenatal Oral Health
Guidelines
Caries Progression
Cavity-free smile
Cavities
White spots
Cavities with abscess
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How can we break the cycle of break the cycle of poor oral health?
Early Early interventions are interventions are key…
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Heckman Equation: Heckman Equation: Return to a Unit Dollar Invested
http://heckmanequation.org/content/resource/presenting-heckman-equation
Interprofessional and collaborative systems
approach to care
Institute of MedicineInstitute of Medicine-Institute of Medicine2011
A successful oral health care system:• Include collaborative and
multidisciplinary teams working across the health care system
Two principles to guide its deliberation:1. Oral health is an integral part of
overall health- essential to comprehensive care.
2. Oral health promotion and disease prevention are key
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2011
Changing landscape of Changing landscape of health care delivery
All preventive interventions graded A or B-Fully Covered $
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Primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary
tooth eruption (B).
NEW CPT CODE
99188
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Changing landscape
CARE COORDINATION
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Lessons from NC
• 47th in the number of all dentists• 45th in the number of pediatric dentists• 44th in dentists’ participation in Medicaid• 1st in percent growth in its Hispanic
population between 1990 and 2000• had a child born into poverty every 23 minutes
47th in the number of all dentists
1990’s47th in the number of all dentists
1990’s-47th in the number of all dentists47th in the number of all dentists47th in the number of all dentists
1990’s- NC ranked:
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0102030405060708090
100
< 1 yr 1-5 yrs 6-14 yrs 15-20 yrs
Dental Medical
Age
Perc
ent
Percentage of NC Medicaid Recipients Percentage of NC Medicaid Recipients Utilizing Medical and Dental Services Utilizing Medical and Dental Services
in 1998
1999Recommendation #18:
“… develop new service package and payment method to cover early caries screening, education and administration of fluoride varnish provided by physicians and physician extenders to children between the ages of 9 to 36 months.”
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Goals of Into the Mouths of Goals of Into the Mouths of Babes (IMB)
• Increase access to preventive dental services• Reduce the prevalence of ECC• Reduce the burden for treatment on dentists
CONTROVERSY!
Who’s practicing dentistry?
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October 2001
SO…HAS IT WORKED?
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Pediatric practice (N=157)
Family Physician practice (N=153)
Health Department (N=83)
NorthNorth CarolinaCarolina Adoption of OralNorthNorthHealth
CarolinaCarolina Adoption of OralAdoption of OralNorth CarolinaCarolinaHealthHealth Preventive
Adoption of OralAdoption of OralPreventivePreventive Care
Adoption of OralAdoption of OralCareCare Package
November 2005
• Raleigh• Asheville
• Wilmington
*
• Charlotte
* The Family Physician practice in Virginia provides care to NC Medicaid patients.
Annual number of visits with preventive oral health services in NC medical offices: 2000-2014
Source: NC DMA.
45-50% of well-child visits
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Physician Screening & Referral
• Identify disease presence or absence: 93% accuracy
Pierce et al. Pediatrics. 2002;109:E82-2.
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Effect of IMB on Dental CariesEffect of IMB on Dental Caries-Effect of IMB on Dental Caries-related Effect of IMB on Dental CariesTreatments per 1,000 Medicaid
Effect of IMB on Dental CariesTreatments per 1,000 MedicaidTreatments per 1,000 Medicaid-
Effect of IMB on Dental CariesEffect of IMB on Dental CariesEffect of IMB on Dental Caries related related related Effect of IMB on Dental CariesEffect of IMB on Dental CariesTreatments per 1,000 MedicaidTreatments per 1,000 Medicaid--enrolled ChildrenNumber of IMB Visits
Age in Monthsat IMB Visit
Change inCRTs (95% CI)
% Change
1234
>4
1212, 2412, 15, 1812, 18, 24, 3512, 15, 18, 24, 35
-7 (-85, 84)19 (-82, 124)49 (-88, 163)
-281 (-469, -58)-458 (-623, -204)
-0.3%0.7%2.9%
-10.9%-17.7%
Number of children with 0 IMB visits = 194,730.Number of children with 1 IMB visit = 55,561.Number of children with 2 IMB visits = 37,353.Number of children with 3 IMB visits = 21,353.Number of children with >4 IMB visits = 13,424.Number of children with 5 or 6 IMB visits = 4,327.Confidence intervals generated based on 200 bootstrap iterations.
Impact of IMB on Oral Health Status Impact of IMB on Oral Health Status Kindergarten Students, NC
Kranz AM, Preisser JS, Rozier RG. Effects of Physician-Based Preventive Oral Health Services on Dental Caries. Pediatrics 2015;136(1):107-14.
• 4+ medical visits was associated with better overall oral health than 0 visits.
• No significant reduction on amount of untreated caries.
N=29,173
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Successes and Opportunities• Into the Mouth of Babes has been very successful
• >1000 providers trained• Increased access by 30-fold• More than 140,000 visits per year• Reduction in caries-related treatment needs
But…
Quinonez RB, Kranz A, Lewis CW, Barone L, Boulter S, O’Connor KG, Keels MA. Oral health opinions and practices of pediatricians: Updated results from a national survey. Acad Pediatr. 2014;14(6):616-23.
CHALLENGESCHALLENGESREFERRING TO A REFERRING TO A
DENTAL HOME
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GD willingness to accept a pediatrician’s GD willingness to accept a pediatrician’s
referral of an 18 month old…
Low-risk: No caries
High-risk: WSL
High risk: Cavitation
Long M, Quinonez RB, Rozier RG, Kranz A, Lee JY. Barriers to Pediatrician’s Adherence to AAP Oral Health Referral Guidelines: NC General Dentists’ Opinions. Pediatr Dent. 2014:36.
NC General Dentists Acceptance of NC General Dentists Acceptance of Pediatrician Referrals (N=423)
0%
10%
20%
30%
40%
50%
60%
70%
80%
Low Risk & No caries High Risk & WSL High Risk & Cavitation
75%
35%44%
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COMFORT
•Train future dental workforce•Improve access to care
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www.babyoralhealthprogram.org
2013
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Tablet Friendly
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bOHPReport Card
Clinical Exam
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bOHP business card
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Promoting Promoting bOHP
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• Lunch and Learn/Staff Meeting
Training Videos (2)“Provider Training” Role Play
“Caregiver Interview”
Talking points“Resources”
Review website
www.prenataloralhealth.org
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www.prenataloralhealth.org
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www.prenataloralhealth.org
Prenatal Oral Health
Infant Oral Health
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Prenatal Messages
Oral and Systemic Health
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3 min videos for moms
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Initiatives in North Carolina
2000 -Into the Mouths of Babes
2006 - 09Carolina Dental Home
2009 -PORRT Initiative
2010 -Connectingthe Docs
2009 -ZOE
•Educate teachers in oral health and communication
•Link families with providers
•Evaluate how it works
1Business Assessment &
Enhancement Plan 2Practice/FinancialEfficiency
&Clinic Flow 3Baby and Prenatal
Oral Health
Phase 1
1 2 3Implement Changes Using Quality Improvement
Phase 2
Pilot: Federally Qualified Community Health Centers
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Coordinated Coordinated Care
How Can We Work Hand in Hand?
New CDT 2017 codes
• Consultation with medical professional
• Dental Case Management- Care coordination- Addressing appointment compliance barrier- Motivational interviewing- Patient education to improve oral health literacy
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Dental VisitN=141 (35.6%)
ReferredN=396 (32.9%)
No Dental VisitN=255 (64.4%)
Dental VisitN=97 (12.0%)
Not referredN=808 (67.1%)
No Dental VisitN=711 (88.0%)
ECCECCN=1,204 (4.9%)
(Total N = 24,403)
Effectiveness of Physicians’ Effectiveness of Physicians’
Dental Effectiveness of Physicians’
Dental Dental REffectiveness of Physicians’ Effectiveness of Physicians’ Effectiveness of Physicians’
RRRReferrals
0-36 m oldsB
ED
TIM
E R
OU
TIN
ES
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Body Mass Index
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Electronic Health Record
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FDA and General Anesthesia
•• 31% of day surgery for preschoolers•
31% of day surgery for preschoolers31% of day surgery for preschoolers31% of day surgery for preschoolers••• 19,000 surgeries per year
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RESOURCES
American Academy of Pediatrics
http://www2.aap.org/oralhealth/COHA.html
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• Era of health care transformation• Important time for our profession to help define
the role of dentistry in this transformation
• Don’t stop balls that are already rolling
Be a steward of change!
Summary
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ThankThank-Thank-you!