Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral...

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Integrating Oral Health and Primary Care

Transcript of Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral...

Page 1: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

Integrating Oral Health and Primary Care

Page 2: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

Welcome & Announcements

Welcome – Ann Greiner,

PCPCC President & CEO

Upcoming PCPCC Webinars

Interested in

PCPCC Executive Membership?

Email Jenifer Renton

([email protected]) or v isit

www.pcpcc.org/executive-membership

PCPCC Annual

Conference

Save the Date: November 4-5, 2019

https://attendee.gotowebinar.com/register/2282911992299343117
http://www.pcpcc.org/executive-membership
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Moderator: Ann Greiner

PCPCC President & CEO

Anita Glicken, MSWExecutive Director, National

Interprofessional Init iative on Oral Health

Kelli Ohrenberger, MAManager of Interprofessional

Pract ice , DentaQuestPartnership for Oral Health Advancement

Kimberley Robbins

Administrator, Child and

Adolescent Clinic

Webinar Speakers

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Medicine and Dentistry – Fragmented Delivery SystemsHow Did We Get Here? 5

People visit a medical provider but not a dental provider

Visit a dental provider butnot a medical provider

Vujicic, M., H. Israelson, J. Antoon, R. Kiesling, T. Paumier, and M. Zust. 2014. A profession in transi- tion. Guest editorial. Journal of the American Den- tal Association 145(2):118-121.

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Primary Care physician

Diabetes Screening

Diabetes,

so endocrinologist

If heart attack, cardiologist

If stroke, neurologist

If chronic kidney disease, nephrologist

General DentistPeriodontal Screening

Periodontal disease,

so periodontist

If root canal, endodontist

Communication is tenuous, usually carried out by patient, if at all

?

?

Flow of Information in Patient Care for Providers

Adapted from Powell and Din 2008

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Health Professional Shortage Areas

62

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Who, What and Why – NIIOH 2009

Consortium: Funders, health professionals +national organizationsVision: Eradicate dental diseaseMission: Engage primary care teamFocus: Integrate oral health into primary care education + practice

The Short AnswerNIIOH is a systems change initiative that

provides“Backbone Support” and facilitates interprofessional agreement and alignment to ready an

interprofessional oral health workforce for whole person care

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The Opportunity for Change

Collective Impact

Interprofessional Competencies The “What” and

“How”

2020 Surgeon General Report

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10

InterprofessionalInitiative Activities

National Interprofessional Initiative on Oral HealthTheory of Change

Primary Care Clinicians

Ready• To deliver oral

health services

• To work with dentists

Optimal Oral

HealthDEVELOP TOOLS

(e.g., curriculum)

June 28, 2012

Oral Health Recognized

Through

• Accreditation• Licensure

• Certification

External Factors

•Access to Care•Patient Motivation

• Appropriate Reimbursement

CULTIVATELEADERSHIP

Curriculum Endorsements

Health Professional

Education Systems

• Teach Oral Health

• Adopt Interprofessional

CultureFACILITATE

INTER-PROFESSIONAL

LEARNING & AGREEMENT

Theory of ChangeCollective Impact

Support, align and connect partner efforts to integrate oral health into education and practice.

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Smiles For Life

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Resources

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Facilitate Interprofessional Agreement

20Endorsing organizations

representing

MedicinePA’s

NursingDentistry

Dental HygienePharmacy

Community Health CentersAnd More!

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Smiles for Life Discrete Site Visits1

SMILES FOR LIFE CROSSES THE ONE MILLION MARK FOR DISCRETE SITE VISITS!

Since the site launched in June 2010, there have been:

• 102,082 registered users• 299,0412 courses completed for CE credit• 51,872 modules downloaded by educators

Discrete Site Visits2010 - 2018

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Key Question:

• How does Smiles for Life influence practice?

Smiles for Life Survey

Clark M, Quinonez R, Bowser J, Silk H (2017). Curriculum influence on interdisciplinary oral health education and

practice. Journal Public Health Dentistry. 2017 Jun; 77(3):272-282. doi: 10.1111/jphd.12215.

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How Does SFL Influence Practice?

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Influence on 6 Key Activities

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Influence on 6 Key Activities

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Oral Health: An Essential Component of Primary Care

Published

June 2015

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19 diverse healthcare delivery organizations: Private practices, Federally Qualified Health Centers; medical only and on-site dental

Adults with diabetes (12), pediatrics (5), pregnancy (1), adult well visits (1) eCW (5), EPIC (8), NextGen (2), Centricity (2), Success EHS (2)

Field-Testing a Conceptual Framework

© Qualis Health, 2016

Population receiving

regular medical care

Population receiving

regular dental care

Total population at risk

for caries and

periodontal diseaseUsing population health to address

“missed opportunities”

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“Oral Health Integration Implementation Guide”

Toolkit for primary care teams (Released 10/10/16)

What’s in the Guide?

• Workflow maps

• Referral agreements

• Patient engagement strategies

• Patient/family education resources

• EHR templates

• Case examples

• Impact data and more

Field-Testing Results Informed the Creation of the Implementation Guide and Tools

© Qualis Health, 2016

Resources available at: http://www.safetynetmedicalhome.org/change-

concepts/organized-evidence-based-care/oral-health

http://www.safetynetmedicalhome.org/change-concepts/organized-evidence-based-care/oral-health
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Seven Principles of Person Centered & Team-Based Care

PERSON & FAMILY CENTERED

CONTINUOUS COMPREHENSIVE & EQUITABLE

TEAM-BASED & COLLABORATIVE

COORDINATED & INTEGRATED

ACCESSIBLE HIGH VALUE

Addresses the whole-personwith appropriate clinical and supportive services that include acute, chronic and preventivecare, behavioral and mental

health, oral health, health

promotion and more

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• Organizational change process requires system-wide intervention

• Having the right people, right place, right reason can change ideas and practice

• A key is having the right tools and strategies to impact knowledge, skills and attitudes of providers

• We cannot achieve our vision of “oral health for all” unless we change our approach to oral health care

• Integration and collaboration is key, we can’t do this alone!

What we have learned

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ORAL HEALTH INTEGRATION: THE MORE

CARE FRAMEWORKMarch 21, 2019

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The Oral-Systemic Connection

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Measurement Concepts

Fluoride

Application

Self-Management

Goal Setting

Oral Health Evaluation

(Risk Assessed)

Referral Initiated Referral Completed

MORE Care Pediatric Pathway

Oral Health at Well Child Visit

• Review medical/dental histories

• Perform Oral Health Evaluation (HEENOT)

• Document findings and management plan, including referrals

• Apply Fluoride

Disease Management

• Engage in shared decision making to decrease or maintain low oral health risk (risk factor identification)

• Set oral health self management goals

• Follow up and develop referral plan

• Engage in shared decision making aimed at prevention and/or stabilization of disease (self-management goals)

• Establish re-care appointments according to patients needs

• Initiate and sustain patient-centered interprofessional communication

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Cooperative Tasks

• Coordinate care with bi-directional referral system

• Initiate, develop and improve interprofessional communication

• Create shared outcomes through collaborative interprofessional practice

• Develop joint treatment planning and record keeping

MORE Care Adult PathwayDENTAL

Dental Care Appointment

• Review medical/dental histories

• Complete Oral Health Risk Assessment of gums and teeth and assign appropriate risk status

• Conduct Preventive Dental Care Appointment and full head and neck examination

• Create treatment plan focused on disease management

Disease Management

• Engage in shared decision making aimed atprevention and/or stabilization of disease (self management goals)

• Establish re-care appointments according to patient needs

• Initiate and sustain person-centered interprofessional communication

Measurement Concepts

Self-

Management

Goal Setting

Oral Health

Evaluation

(Risk Assessed)

Referral

Completion

Verification

MEDICALAdult Oral Health Opportunity

• Review medical/dental histories

• Perform Oral Health Evaluation (HEENOT) Document findings and management plan, including referrals

• Additional screening should occur for oral cancer and soft tissue anomalies

• Review current prescriptions for opportunities to optimize oral health and decrease dry mouth, as needed

Disease Management

• Engage in shared decision making to decrease or maintain low oral health risk(risk factor identification)

• Set oral health self management goals that align with systemic treatment or prevention

• Follow up and develop referral plan

IPP Pregnancy

% of patients seen by both care

teams with a preventive dental

care visit

IPP Adult

% of patients seen by both

care teams with oral cancer

screening

Page 29: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

MORE Care Process Fundamentals

1.) Training

• Smiles for Life/In-State Training

• Quality Improvement

• Effective Communication

2.) Testing

• Oral Health Evaluations

• Oral health Workflow

• Referral Communication

3. Sustainability and Spread

• Policies and documentation

• Staff turnover plans

• Consider new populations

Supported throughout by expert faculty, monthly data review/feedback, collaborative activities, as needed

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Tools for Success and Communication

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Integration

• Identify high-risk patients

• Tailor education to patient’s risk factors

% of patients with documented oral health

risk

• Guide patients to set their own goals

• Support healthy behaviors

% of patients with documented oral health self-management goals

• Provide preventive treatment

% of patients with documented fluoride varnish application in

conjunction with assessed risk and self-management

goals reviewed

• Patients who need dental careNumber of elevated

risk/pregnant patients referred to dental

• High-quality and coordinated care to improve patient oral health outcomes

% of patients with treatment

completion verification was received from

the dental provider

Coordination

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Improvement Data

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Lessons Learned: Creating an Interprofessional Oral Health Network

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Opportunities For the Future

• Improved coordination of care through HIT

• Integration of overall health into dental visits

• Shared oral health outcome measurement

• Business and care solutions for the next era of healthcare

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Dental Services in Primary Care

Implementation, Flow & Follow up in the Pediatric Practice

Kimberley [email protected]

Page 36: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

Oral Health Integration at Child & Adolescent Clinic

• University of WA clinical trial of fluoride application at Well Baby exams – 2001

• Arcora Foundation Oral Health Training – 2005 – full implementation 2009

• 12 pediatricians/2 ARNPs, independent practice, 2 sites in SW Washington

• 74% Medicaid

Page 37: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

Successes

• Local pediatric dentist reduced the number of caries restorations under anesthesia by 50% because there are many fewer patient with that level of dental disease

• Check community health statistics: Rate for kindergartners entering school with caries was drastically reduced 5 years after our program began

Page 38: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

Clinic Flow

• Handout at Check-in

• Family Oral Health education using Arcora supplied flip book on rooming patient

• FV applied on rooming, if accepted by parent

• CMA determines if have a Dental Home

• MD performs Oral exam during Well Child

• MD refers to local dentist if family doesn’t have Dental Home

• Services are auto-templated to document

• Services are auto-billed when marked “Complete”

Page 39: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

Early Challenges/Solutions

• “One more thing to do”

– Little buy-in and poor follow through

• Clinic-wide focus

• Champion for each department; reception, CMA, MD, Billing

• Share data

Page 40: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

Early Challenges/Solutions

• Timing of FV Application/ Parent Education

– If done prior to MD exam, the MD visit starts with a fussy child

– If done after the exam, the parent leaves before it is conducted

– With experience staff become for efficient, patient flow is more smooth with application at rooming patient

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Early Challenges/Solutions

• Satellite office with very low achievement rates

– Remote training and participation

– No on-site champion

• Weekly Clinical manager visits until established

• Published reports of #’s of procedures and revenues by MD and by CMA and site

Page 42: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

Early Challenges/Solutions

• Services provided inconsistently– Initially offered only to Medicaid Population

» Universal processes are much more consistently applied

• Universal task, templated through the EMR for all well child visits, all ages starting at 6 months

Page 43: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

Early Challenges/Solutions

• Billing challenges

– ACA not yet in place at start of program

– D (dental codes) and AMA CPT codes describe the same service

– Payers require different codes – not consistent in CPT or dx code requirement

– Payers inconsistent in what is covered – even different policies within the same carrier

• Test every combination with every carrier

Page 44: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

Lessons Learned

• Build flow first with input from all departments

• Consider universal application to improve consistency and staff buy in

• Identify and cultivate a champion in each department – and at each location

• Adjust frequently based on input so team doesn’t get discouraged

• Share your statistics, including revenue with the team

Page 45: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

Financially Supported Program- 15,000 Active Patients, 2 sites, 74% Medicaid:

• 2010 First full year- Applied to Medicaid only: $12,000

• 2012 Increased focus, required individual MD order $16,000

• 2014 Universally applied, auto-ordered at all well exams (PPACA implemented) $261,000

• 2017 $281,000

• 2018 $283,000

Page 46: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

Remaining Challenges

• Parents decline FV out of fear

• Commercial patients decline, unsure of coverage

Page 47: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

Implementation Resources

• Your State’s Dental Services Foundation

• Arcora Foundation

• www.kidsoralhealth.org

• www.healthychildren.org

• AAP Section on Oral Health

– Map of Medicaid coverage by State

• C&AC handouts as templates

http://www.kidsoralhealth.org/
Page 48: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

Supplies Resources

• Fluoride Varnish

– Henry Schein

– State Dental Foundation

– Partner Dentists

– Toothbrushes

• Partner Dentists

• Plaque Smackers

Page 49: Integrating Oral Health and Primary Care · Mission: Engage primary care team Focus: Integrate oral health into primary care education + practice The Short Answer NIIOH is a systems

Questions


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