Interprofessional Oral Health Core Clinical Competencies: What They Mean for Your ... ·...
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Interprofessional Oral Health Core Clinical Competencies: What They Mean for Your Dental Program Findings from the IPOHCCC Project
Transcript of Interprofessional Oral Health Core Clinical Competencies: What They Mean for Your ... ·...
Interprofessional Oral Health Core Clinical Competencies: What They Mean for Your Dental Program
Findings from the IPOHCCC Project
Objectives
Describe current efforts in interprofessional education
Understand the goals of the Integrating Oral Health in Primary Care Practice initiative (IOHPCP)
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
Background
Where are we & how did we get here?
History
2000 Surgeon General’s Report on Oral Health
Highlighted disparities in oral health status & access to oral health care
1st IOM Report: Advancing Oral Health in America
Recommended oral health workforce innovation as one strategy to improve oral health/ increase access
2nd IOM Report: Improving Access to Oral Health Care
Recommendations included HRSA developing oral health competencies for non-dental professionals
HRSA increasing capacity of FQHC dental programs
Interprofessional Educational (IPE) Efforts
Trend in health profession education to develop programs and curricula that incorporate shared or integrated learning experiences
Revising accreditation requirements to mandate interprofessional experiences.
• CODA Standard 2-19: Graduates must be competent in communicating and collaborating with other members of the health care team to facilitate provision of health care.
Family Medicine first medical specialty to include oral health competencies as part of residency requirements
Interprofessional Educational Efforts
National Coordinating Center for Interprofessional Education and Collaborative Practice
• HRSA funded
• Coordinate dissemination of IPE efforts
Integrating Oral Health in Medical Education Model Curriculum
• HRSA funded in collaboration with the Association of American Medical Colleges
• Instructional resources disseminated through MedEdPORTAL
Interprofessional Educational Efforts
Smiles for Life- Online oral health teaching curriculum developed by Society of Teachers of Family Medicine
• Nation’s most comprehensive and widely used oral health curriculum for primary care clinicians
• Endorsed by 13 national organizations, and is in wide use in professional schools and post-graduate training programs.
Children’s Oral Health- American Academy of Pediatrics oral health website includes online training
Interprofessional Educational Efforts
NYU College of Nursing- Teaching Oral-Systemic Health- curricular (TOSH) model for primary care advanced practice nurses
Oral Health Nursing Education and Practice (OHNEP)- website- advocates, educates, creates and promotes resources for primary care clinicians
Physician Assistant Education Association- oral health initiative- Oral Health Summit and education through publications and website
Other Initiatives
The National Interprofessional Initiative on Oral Health (NIIOH)- maintains the Smiles for Life curriculum. Engages primary care clinicians
Qualis Health- Safety Net Medical Home Initiative. “Oral Health in Primary Care: PCMH Implementation Tools” project. Help primary care practices ensure that all patients have access to oral health services and referrals
State Medicaid Oral Health Programs with Primary Care Providers - Published Evaluations
Washington
Massachusetts
North Carolina
Colorado (coming soon)
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
Where Do I Fit In?
2014 HRSA Integration of Oral Health and Primary Care Practice (IOHPCP) Initiative
Develop oral health core clinical competencies for primary care clinicians
Delineate elements that influence implementation and adoption
Translate into primary care practice in safety net settings
IOHPCP
Improve access for early detection and preventive interventions by expanding oral health clinical competency of primary care clinicians, leading to improved oral health
Focus on the clinical practice of primary care practitioners in safety net community
• Members of existing delivery system who could incorporate oral health core clinical competencies into their existing scope of practice
• Most likely to see vulnerable and underserved populations without, or with limited access to dental services
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 Goal
Implementation of Oral Health Core Clinical Competencies using a sustainable systems approach that results in integrating oral health and primary care through 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
Could these things be done in your Health Center primary care clinic?
Health Partners Western Ohio Lima, OH
Health Partners Description
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
Family HealthCare Description (2011 UDS)
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 CENTER
BRONX, NY
BCHN DESCRIPTION (2011 UDS)
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
Which IPOHCCC Health Center do you feel you are most closest to?
BCHN
FHC
HPWO
Other
Results
Comprehensive Project Evaluation
In collaboration with Thomas Keifer Consulting
Quantitative and qualitative data
Evaluation Advisory Board meetings (3 for project)
• Provide feedback on evaluation plan, data collection instruments, data interpretation, content expertise
• Members: Dr. Huong Le, Dr. Jim Sutherland, Dr. Patty Braun, Tena Geis, Dr. Mark Deutchman, and pilot health center representatives
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
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
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.
Results: PCP Oral Health Training
Health Center # PCP Trained Post Test Scores % correct
HPWO 25** 96%
FHC 7 95%
BCHN 48* 88%
* Includes pediatric residents
**Includes new expansion staff
Results: # Patients with Risk Assessment in Primary Care
Health Center Objective Results
HPWO 1,800 2,458
FHC 390 476
BCHN 500 488
Results: Preventive Intervention- % of Patients with Risk Assessment Receiving Fluoride Varnish in Primary Care
Health Center % objective % results
HPWO 67 59
FHC 90 57
BCHN 80 75
Results: Communication & Education- % of Patients with Risk Assessment Receiving OH education
Health Center % Receiving OH Post Test Scores % correct
HPWO 86% 74%
FHC 85% 77%
BCHN 31% n/a
Results: Interprofessional Practice- % Patients with Completed Medical-to-Dental Appointment Through Primary Care
Health Center % Objective % Results
HPWO 67 17
FHC 80 62
BCHN 80 51
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 and 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
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
Relate to general health concerns i.e. obesity, diabetic control
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
Patients reporting existing dental home
Document
Patient resistance to dental treatment citing cost and/or fear
Motivational Interviewing
Characteristics of Success
Leadership Vision & Support
Starts with ED/CEO
Insure same message throughout organization- primary care, dental, behavioral
“Treating the patient as a whole is part of the mission and culture of the Health Center”
Integrated HC Executive Team
All disciplines integrated into the administrative structure
Part of organizational structure
Integrated operations team meetings, committees and communications
Co-location
Bi-directional referrals, same day assessments
“warm hand-off”
Organizational Culture of Quality Improvement
In-depth user’s knowledge of the terminology and methodology of quality improvement
Culture permeated all Health Center departments
Focus on outcomes - of using outcome measures to drive change, of improving from a baseline, and using these concepts for all aspects of clinic operations
Staff Buy-in: Understanding the “Why”
Progress the result of a continuous process
Resistance to change from staff addressed not by telling staff what to do, but rather explaining the "why”
Patient Enabling Services
Patient navigators, family support workers, health coaches
Assist in making appointments, engaging patients, motivational interviewing, goal setting
Available to all disciplines & departments
Champions
Proactive, sure of the importance of oral health in improving the health status of the patients they serve
Confidence to advocate for oral health
“Remember the reason for doing this is not for a piece of paper of recognition but to better serve our patients and improve their quality of life.”
Where is your Health Center?
What characteristics of success are present in your organization at high levels?
What characteristics of success are present in your organization at low levels?
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
Future
NNOHA Next Steps
IPOHCCC User Guide in review. Will be available online
Disseminate results via webinars, presentations, newsletter
Conclusion
Interprofessional education
HRSA focus on collaborative practice in Health Centers
YOU are a vital part!
“Dental had felt separate, someplace you sent a patient to. Now, I know them better. I can talk to them about a dental issue, and they talk with me more about medical issues.”
Primary care provider
“I think it's great that you care so much about the health of your patients that you are willing to go to such steps to better care for them. P.S. I think you are all great!”
Primary care patient after OH education by PC staff
Medical Assistant & Dental Assistant Providing Education in Waiting Shared Room
Contact Us!
Irene V. Hilton, DDS, MPH NNOHA Dental Consultant
National Network for Oral Health Access PMB: 329
3700 Quebec Street, Unit 100
Denver , CO 80207-1639
Phone: (303) 957-0635
Fax: (866) 316-4995
