Integrating Oral Health Into Primary Care Practice · 3/2/2015 · 2014 HRSA Integration of Oral...
49
Integrating Oral Health Into Primary Care Practice An Overview of NNOHA’s New IPOHCCC User Guide February 23, 2015 Irene V. Hilton, DDS, MPH NNOHA Dental Consultant
Transcript of Integrating Oral Health Into Primary Care Practice · 3/2/2015 · 2014 HRSA Integration of Oral...
Integrating Oral Health Into Primary Care Practice
An Overview of NNOHA’s New IPOHCCC User Guide
February 23, 2015
Irene V. Hilton, DDS, MPH
NNOHA Dental Consultant
NNOHA Webinar Series Archived presentations from the NNOHA webinar series are available online at
www.nnoha.org.
Disclaimer: This speaker has been engaged for educational purposes only and does necessarily
reflect the opinions of NNOHA, its agents or employees, or the organization as a whole. NNOHA does
not endorse any specific claim(s) relative to the effectiveness of products or techniques suggested by
the speaker and does not accept any liability for actions taken based on the content of this webinar or
for any and all consequences resulting from the use of the information. NNOHA does not warrant that
this webinar will be presented uninterrupted or error-free, nor that the website or server which make
this webinar available are free from viruses or other dangerous conditions. NNOHA does not accept
any liability for damage which may ensue as a result of such potentially harmful elements. The viewer
and/or any entity using this information assumes all risk associated with its use.
Objectives
Describe previous & current HRSA/BPHC medical-dental integration initiatives
Explain the five oral health core clinical competency domains
Learn the different approaches used by Health Center primary care departments to implement oral health clinical competencies
Understand some of the strategies to address common barriers to integrating oral health into primary care practice
A Brief History of Medical-Dental Integration in Health Centers
Where are we & how did we get here?
1998- HRSA BPHC Health Disparities Collaboratives
PDSA/QI/Chronic Care model
Diabetes collaborative
Dental component/measure
2005- Oral Health Disparities Collaborative Pilot
4 Health Centers
Children 0-5 & pregnant women
PCP education
Referral to dental
2011- Oral Health & the Patient Centered Health Home: Action Guide
Described levels of integration
Revealed organizational characteristics of early adopter Health Centers
Documented promising practices
2011 IOM Report: Improving Access to Oral Health Care
Recommendations included HRSA developing oral health competencies for non-dental professionals
2014 HRSA Integration of Oral Health and Primary Care Practice (IOHPCP) Initiative
Develop oral health core clinical competencies for primary care clinicians
Translate into primary care practice in safety net settings
Goal:
Improve access for early detection and preventive interventions leading to improved oral health
2015- A User’s Guide for Implementation of Interprofessional Oral Health Core Clinical Competencies
3 Health Centers
PCPs deliver oral health interventions
Standardization of training, clinical protocols
Measures/QI
U.S. Preventive Services Task Force Recommendations – May 2014
Primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride
Primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the time of primary tooth eruption to prevent dental caries in children from birth through age 5 years
IPOHCCC
Primary Care Providers
MD/DO
Certified Nurse Midwives
Nurse Practitioners
Physician Assistants
Oral Health Core Clinical Competency Domains
1. Risk assessment
2. Oral health evaluation
3. Preventive interventions
4. Communication & education
5. Interprofessional collaborative practice
IPOHCCC Pilot Project Objectives
Increase oral health screening and preventive services
Increase oral health integration and primary care practice
Increase interprofessional collaborative practice
Increase care coordination between medical and dental
Identify sustainable approach to practice changes
Health Partners Western Ohio
Total Users 14,787
Dental Users 7,151
Primary Care sites 3
Dental sites 2
PCP FTEs 8.5
Dentist FTEs 3.2
Small city surrounded by rural 38,339
Family HealthCare, Fargo, ND
Total Users 11,694
Dental Users 3,951
Primary Care sites 1
Dental sites 2
PCP FTEs 6.4
Dentist FTEs 2.6
Medium city surrounded by rural 109,779
Bronx Community Health Network Total Users 81,784
Dental Users 20,658
Primary Care sites 15
Dental sites 3
PCP FTEs 36
Dentist FTEs 20
Urban metropolis 1.4 million
“Health Center without walls” operated under contract by Montefiore
Medical Center, Albert Einstein College of Medicine
Implementation Guide
Readiness Assessment
Types of Integration
Administrative- mtgs, org chart
Clinical infrastructure- bilateral EHR, referrals, tracking
Clinical practice- bilateral screenings, prevention
Evaluation/Quality- cross discipline measures
In the same
building, silos
Know a little
about other
discipline, refer
populations
Standardize
training, clinical
protocols to
deliver
interventions,
measure & track
Characteristics of Success
Leadership Vision & Support
Integrated HC Executive Team
Co-location
Organizational Culture of Quality Improvement
Staff Buy-in: Understanding the “Why”
Patient Enabling Services
Champions
Bonus: Integrated EHR system
Steps to Success
Planning
Training systems
Health information systems
Clinical care systems
Evaluation systems
Planning
Establish a team
Select a population of focus
Create timeline
Explore reimbursement
Figure costs
Look for synergy with existing Health Center initiatives
Training Systems
Online training
In-person training (interdisciplinary collaboration opportunity)
On-boarding new health professionals
Health Information Systems
EMR revision
To implement the five IPOHCCC domains, an EMR must be able to:
• Provide a risk-assessment tool—ideally automatically scores
• Document oral health evaluation, preventive interventions, self-management goals, and education
• Print educational handouts and post-visit instructions
• Refer the patient for oral health care
• Collect data
EMR-EDR relationship
Clinical Care System
Workflow
• Who & during what part of the primary care visit?
Risk assessment
Oral health evaluation
Preventive interventions
Communication & education
• Take home materials
• Motivational interviewing
Interprofessional collaborative practice
• Referral & follow-up
Evaluation Systems
Number oral health assessments performed by PCPs.
Number fluoride varnish applications for high-risk patients.
Number patients linked to definitive oral health care and treatment.
Changes in patient experience.
Clinical System Results
What it Looked Like Clinically
HPWO FHC BCHN
Population > 18 0-5 0-3
EMR-EDR Configuration
Greenway Prime Fully integrated
Centricity Dentrix
Centricity QSI
Training Smiles for Life Smiles for Life, state specific for Medicaid reimbursement
Smiles for Life
Dental department participation in training
Inservices, demonstrations
Inservices, demonstrations
Inservices, demonstrations
What it Looked Like Clinically- Workflow
HPWO FHC BCHN
Risk Assessment 100% Support staff 10% Support staff
90% Provider
50% Support staff
50% Provider
Oral Evaluation (e.g.
clinical oral
screening)
Provider Provider Provider
Preventive
Interventions (e.g.
fluoride varnish)
Support staff (prior
to oral evaluation)
Support staff (after
oral evaluation)
Support staff (after
oral evaluation)
Communication &
Education
Provider and take-
home materials
Provider and take-
home materials
Provider and take-
home materials
What it Looked Like Clinically- Workflow
HPWO FHC BCHN
Inter-professional
Collaborative
Practice (e.g.
referral)
Provider (check-off
box in the EMR),
yellow tooth patient
takes to front desk.
Provider (check-off
box in the EMR),
“passport” sheet
with follow ups (e.g.
lab, radiology)
includes dental
Provider (check-off
box in the EMR).
Can print out a list
of community
dental providers
from EMR.
Inter-professional
Collaborative
Practice (e.g.
appointment
scheduling)
Reserved dental
exam slots (4 per
day) accessible by
front desk at
checkout.
No reserved dental
exam slots. Primary
care front desk staff
at checkout.
Reserved dental
exam slots (4 per
day). Primary care
front desk cannot
access dental
appointment
system.
Challenges & Strategies
PCP Training
Challenge Strategy
Time for training Self-paced online curricula
Incentive for training Free CE units
Standardizing content Use endorsed, recognized curricula
Obtaining supervised clinical practice
Collaborate with HC dental clinic providers to observe and provide clinical training for PCP (Build competency & foster interprofessional practice!)
Risk Assessment (RA)
Challenge Strategy
Assuring correct RA elements incorporated
Utilize well-known risk assessment tools such as CAMBRA/ADA/AAP
Assuring RA performed at PC visit Embed OH risk assessment into the EMR template
Incorporating RA into PC visit flow Make procedural and workflow changes, use QI methodology to monitor and improve
PC staff resistance to additional tasks
Identify PCP champion, start small. Make official clinic policy.
Oral Evaluation
Challenge Strategy
Assuring correct elements incorporated
Online training followed by in person training with dental staff
Assuring oral evaluation performed at PC visit
Embed OH evaluation into the EMR template
Incorporating oral evaluation into PC visit flow
Make procedural and workflow changes, use QI methodology to monitor and improve
PC staff resistance to additional tasks
Identify PCP champion, start small
Preventive Intervention
Challenge Strategy
Assuring competency in application of Fluoride Varnish (FV)
Online training followed by in person training with dental staff
Adult patient resistance to FV color & taste
Try different colors & brand tastes
Concerns about excessive applications
Develop “immunization” card to track
PCP staff resistance to performing procedures inside patient’s mouths
Let patients (adults) self administer
Communication & Education
Challenge Strategy
Obtaining oral health education materials in multiple languages
Online resources, Smiles for Life
Patient resistance to OH education in the PC setting
Include as part of visit summary
PCP staff resistance to performing OH education
Relate to general health concerns i.e. obesity, diabetic control
Interprofessional Practice
Challenge Strategy
Inability of PC staff to make direct dental appointments using HIT system
Develop work-around
Lack of capacity in the dental clinic for PC referrals
Dedicated appointments
Patient resistance to dental treatment citing cost and/or fear led to No Shows
Motivational Interviewing
Conclusion & NNOHA Next Steps
Spread IPOHCCC User Guide
Help primary care practices ensure that all patients have access to oral health services and referral
http://www.nnoha.org/nnoha-content/uploads/2015/01/IPOHCCC-Users-Guide-Final_01-23-2015.pdf
Medical Assistant & Dental Assistant Providing Education in Waiting Shared Room
Contact Us!
Irene V. Hilton, DDS, MPH NNOHA Dental Consultant [email protected]
National Network for Oral Health Access 181 E. 56th Ave, Suite 501
Denver, CO 80216
Phone: (303) 957-0635
Fax: (866) 316-4995
