Addressing Tobacco Control Addressing Tobacco Control In Dental NetworksIn Dental Networks

Eric E. Stafne, D.D.S., M.S.D.Eric E. Stafne, D.D.S., M.S.D.

Director Tobacco Cessation ProgramDirector Tobacco Cessation Program

University of MN School of DentistryUniversity of MN School of Dentistry

Shelley Steen, M.S.Shelley Steen, M.S.

HealthPartners, Center for Health PromotionHealthPartners, Center for Health Promotion

Addressing Tobacco ControlAddressing Tobacco Controlin Physician & Dental Networksin Physician & Dental Networks Grant from: Grant from: Alliance of Community Health PlansAlliance of Community Health Plans

and the and the Robert Wood Johnson FoundationRobert Wood Johnson Foundation

6 HMO’s throughout the country6 HMO’s throughout the country HealthPartners was the only dental networkHealthPartners was the only dental network

Why dentistry should be involvedWhy dentistry should be involvedwith tobacco dependence with tobacco dependence

treatmenttreatment Tobacco useTobacco use is a is a significant risk factorsignificant risk factor for for

oral cancers, periodontal diseases and other oral cancers, periodontal diseases and other oral conditionsoral conditions

There is impaired wound healing and There is impaired wound healing and less-favorable clinical outcomesless-favorable clinical outcomes for for periodontal therapy and dental implants in periodontal therapy and dental implants in smokerssmokers vs. nonsmokers vs. nonsmokers

Dental Office InterventionsDental Office Interventions

Dental office team membersDental office team members emphasize preventionemphasize prevention have educating & motivating skillshave educating & motivating skills see patients on a regular basis for fairly long see patients on a regular basis for fairly long

appointmentsappointmentsAnd are therefore And are therefore ideal settingsideal settings to encourage, to encourage,

support, assist and follow-up their tobacco users support, assist and follow-up their tobacco users to help them through the stages of changeto help them through the stages of change

Dental hygienistsDental hygienists play a key role in an office program play a key role in an office program

PurposePurpose

To implement system changes to include routine brief tobacco cessation interventions using the 5 A’s (through training of the dental office team)

To increase referral patterns to resources for tobacco cessation and increase the use of pharmacotherapy

Project EnvironmentProject EnvironmentHealthPartners Dental NetworkHealthPartners Dental Network

Number and Affiliation of Dental ClinicsNumber and Affiliation of Dental Clinics

HPDG17

Park Dental

27

Other Affiliates

16

Total60

0

10

20

30

40

50

60

70

Clinic Affiliation

Nu

mber

of

Cli

nic

s

Across the system, the total number of dental providers includes:• 206 dentists• 300 dental hygienists• 150 dental assistants.

Project ApproachProject Approach

Pilot project implemented: 4 staff model clinics (HPDG) 4 contracted clinics (Park Dental)

Intervention Provider trainings (entire office team) Ongoing clinic support

weekly e-newsletter (sharing data) quarterly staff meetings new staff training

Project ApproachProject Approach

Evaluation Baseline and post-training (12 Months) staff

surveys Chart reviews for documentation of 5A’s Dental coding data review

ADA 1320 code HP I1321 code HPDG perio risk assessment codes Park 0007 code

Pharmacy prescriptions written and filled Referrals and enrollment to

HealthPartners Partners for Better Health (PBH) Phone Line

Office Team TrainingOffice Team TrainingCurriculumCurriculum

First 2 hour session:First 2 hour session: IntroductionsIntroductions Why dentistry should be involvedWhy dentistry should be involved

risks of tobacco use (general & oral effects)risks of tobacco use (general & oral effects) benefits of a tobacco-free lifestylebenefits of a tobacco-free lifestyle

Nicotine addiction – Nicotine addiction – the mechanism involvedthe mechanism involved Stages of change – Stages of change – determines type of interventiondetermines type of intervention Cessation techniques – Cessation techniques – successful interactionssuccessful interactions

Office Team TrainingOffice Team TrainingCurriculumCurriculum

First 2 hour session:First 2 hour session: The 5 A’sThe 5 A’s

use of 5 A’s stickers on patient progress notesuse of 5 A’s stickers on patient progress notes follow-up stickers and call reminder index cardsfollow-up stickers and call reminder index cards

Changes in clinic flowChanges in clinic flow must fit into clinic routinemust fit into clinic routine roles and expectations of the dental teamroles and expectations of the dental team

Office Team TrainingOffice Team TrainingCurriculumCurriculum

First 2 hour session:First 2 hour session: Resources and referralsResources and referrals

Telephone-based tobacco counselingTelephone-based tobacco counseling

Pharmacotherapy – Pharmacotherapy – start brief overviewstart brief overview

Patient scenario – role playPatient scenario – role play examples of scriptingexamples of scripting

Office Team TrainingOffice Team TrainingCurriculumCurriculum

Second 2 hour session:Second 2 hour session: PharmacotherapyPharmacotherapy

when and how to suggest various optionswhen and how to suggest various options insurance coverageinsurance coverage

Patient interactionsPatient interactions low key, nonjudgmental, sensitive, respectfullow key, nonjudgmental, sensitive, respectful

Patient scenariosPatient scenarios role play patients in various stages of changerole play patients in various stages of change walk through process using clinic forms and codeswalk through process using clinic forms and codes

0102030405060708090

100

HPDG Pre HPDG Post Park Pre Park Post

Provider Survey ResultsProvider Survey ResultsKnowledge and Practices of Behavior Knowledge and Practices of Behavior

Change and “5-A’s” in Tobacco CessationChange and “5-A’s” in Tobacco Cessation

% * **

**

* = p<0.05 - HPDG

# = p <0.05 - Park Dental

# # ##

# #

0102030405060708090

100

Health

Hist

ory F

orm

Progr

ess N

otes

Dental

Exa

m Cha

rting

Perio R

isk A

ssess

ment

Other

No Doc

umen

tation

HPDG Pre

HPDG Post

Park Pre

Park Post

Provider Survey ResultsProvider Survey ResultsDocumentation of Tobacco StatusDocumentation of Tobacco Status

%

*

#

#

* = p<0.05 - HPDG

# = p <0.05 - Park Dental

Current Use of Types of Current Use of Types of Tobacco Cessation Tobacco Cessation

Resources Resources Baseline to 12 MonthsBaseline to 12 Months

0102030405060708090

100

Self-h

elp

Pam

ph

lets

Gro

up

Pro

gra

m

Tele

ph

on

eC

ou

nseln

g

NR

T R

x

Zyban

Rx

Oth

er

HPDG Pre HPDG Post Park Pre Park Post

% *

#

* = p<0.05 - HPDG

# = p <0.05 - Park Dental

#

## #

HealthPartners Members coded as 1320 or I1321 (-overlap)

0

20

40

60

80

100

120

140

160

180

Training

Training

Park Dental Patients with 0007 code

0102030

40506070

May-02

Jun-02

Jul-02

Aug-02

Sep-02

Oct-02

Nov-02

Dec-02

Jan-03

Feb-03

Mar-03

Apr-03

May-03

Training

Total Number of HPDG Members Documented with Risk Assessment Codes (R12.1,

R12.2,R12.3)

0

50

100

150

200

Training

Number of HPDG Members Referred and Enrolled in PBH Phone Line Course

0

2

4

6

8

10Referralnumber

Enrollmentnumber

Training

Number of HPDG HealthPartners Members with a Rx written & filled

02468

101214

HPDG

HPDG Control

Training

HPDG- Chart Audit 5As Breakdown

0%

20%

40%

60%

80%

100%

120% Ask

Advise

Assess

Assist

Arrange

Program ImpactProgram ImpactHPDGHPDG

Survey Results Knowledge and awareness improvement Increase in tobacco status documentation Increase in use of telephone-based counseling as a tobacco

cessation resource

Coding Data and Referral Data Results Coding improvement using ADA and HPDG codes Improvement in risk assessment coding Improvement in referrals to the phone line

Pharmacy Data Review Increase in prescriptions written and filled

Chart Review Data Difficult to interpret – may be related to new 5-A’s chart form

Program ImpactProgram ImpactPark DentalPark Dental

Survey Results Significant increase in knowledge of 5A’s, except

for Ask May indicate an increase in follow-up for already

identified patients Significant increase in use of health history form

(with addition of tobacco status) Increase in use of 5-A’s form Significant increase in use of tobacco cessation

resources (phone line & pharmacotherapy)

Lessons LearnedLessons Learned Importance of clinic buy-in with leadership

involvement

Importance of agreement on project processes, work plans, and data collection Responsibility and accountability for doing work

Importance of role clarification Medication prescribing practices

Dealing with time limitations Limitations—what’s doable at the time of the visit?