TELEDENTISTRY: PROVIDING ALTERNATIVE CARE ......Barriers drive up costs and worsen the chronic...
Transcript of TELEDENTISTRY: PROVIDING ALTERNATIVE CARE ......Barriers drive up costs and worsen the chronic...
TELEDENTISTRY:PROVIDING ALTERNATIVE CARE DURING APUBLIC HEALTH CRISISDentaQuest Partnership Continuing Education WebinarApril 6 & 8, 2020
DOI: 10.35565/DQP.2020.3003
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Learning Objectives
By the end of this webinar, participants will be able to:1. Recognize Teledentistry as a mode to increase access to dental care in
urgent situations.2. Describe policy issues around Teledentistry and the potential solutions for
policymakers.3. Understand examples of how Teledentistry has been used to improve access
to care.
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Housekeeping
• All lines will remain muted to avoid background noise.• A copy of the slides and a link to the recording will be shared after the webinar
concludes. • In order to receive CE credit you must fill out the webinar evaluation, which
will be shared at the end of the presentation. The evaluation must be completed by EOD Friday, April 17 to receive CE credit. CE certificates will be distributed a few days after the webinar takes place.
The DentaQuest Partnership is an ADA CERP Recognized Provider. This presentation has been planned and implemented in accordance with the standards of the ADA CERP.
*Full disclosures available upon request
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Q&A Logistics
After the presentations we hope to have some time for Q&AWe will be monitoring the chat box through the entire presentation and we will do our best to answer all questions.• Type your question in the chat box
and make sure you send it to allpanelists.
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Presenters:
TELEDENTISTRYProviding access to care during the COVID-19 crisis April 6, 2020
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• New HHS policy statement allows for reductions or waivers of cost-sharing obligations by people enrolled in Medicare and Medicaid
• Many governors have issued executive orders promoting telehealth
• In this crisis, dental providers can use telehealth to consult with patients, triage their needs and offer limited emergency services
As the COVID-19 pandemic intensifiedFederal and state leaders have taken steps advancing telehealth
Office of Inspector General, U.S. Dept. of Health and Human Services, policy statement regarding telehealth services during the coronavirus (COVID-19) outbreak, March 17, 2020; IL Executive Order No. 2020-09, KS Executive Order No. 20-08, NH Emergency Order No. 8, and TX statement on payment parity posted on gov.texas.gov, March 17, 2020.
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Some states’ executive orders (EOs) are fairly limited in scope:• The Arkansas EO no longer requires a “real time” patient encounter to
establish a professional relationship
• The Florida EO enables state employees to receive free telehealth services during the COVID-19 crisis but covers less than 1% of Floridians
• The Maryland EO allows health director to permit “real time” audio-only remote consultation between patients and providers
• The Texas EO focused on payment parity and it covers 16% of Texans
State executive orders vary in their scopeGovernors were focused on the immediate COVID-19 crisis
Arkansas Governor’s Exec. Order 20-05; Florida Governor’s Exec. Order 20-85; Texas Governor’s Statement issued March 17, 2020; Maryland Governor’s Executive Order No. 20-03-20-01;
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The duration of these EOs is limited:• Kansas EO expires no later than May 1
• Massachusetts EO expires whenever its “state of emergency” ends
• New Hampshire EO expires when its “state of emergency” ends
• North Dakota EO expires when its “state of emergency” ends
• Rhode Island EO expires on April 17
State executive orders vary in their durationGovernors were focused on the immediate COVID-19 crisis
Kansas Governor’s Exec. Order 20-08; Massachusetts Governor’s Exec. Order on Telehealth Services, March 15, 2020; New Hampshire’s Emergency Order No. 8; North Dakota Governor’s Exec. Order 2020-05.01; Rhode Island Governor’s Exec. Order 20-06.
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Where states stand on teledentistryOnly a few states have a truly supportive policy environment
Data from three interactive maps on the Scope of Practice Policy website, designed by NCSL and ASTHO, was used to gauge state-based environments on teledentistry based on three parameters: 1) dental hygienists with direct access, 2) status of dental therapists as part of the oral health team, and 3) states allowing the practice of teledentistry. Information provided in the maps was used to evaluate each state on these parameters on a scale of 1-5, with 1 = the most unsupportive environment and 5 = the most supportive environment.
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Both documents can be accessed at https://bit.ly/Teledentistry2020Access DQP’s Communications Brief and White Paper
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States have a unique opportunity to:• Enable dental providers and patients to
connect remotely in compliance with social-distancing and other guidance
• Help people with important oral health needs consult with providers, deterring them from visiting hospital EDs, which are overwhelmed
• Build a more accessible and connected system that remains after the immediate crisis ends
As COVID-19 cases continue to growTeledentistry gives states a chance to improve access
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Over 56 million people live in a dental professional shortage area
Even outside shortage areas, many people face barriers, including:• Seniors with limited mobility
• People with complex medical issues
• People facing transportation barriers
• People on the autism spectrum
Barriers to care are persistent, even for many who are insuredDental access is much more than a rural problem
OIG Policy Statement Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal Health Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus (COVID-19) Outbreak March 17, 2020
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Oral health access also impacts overall healthGrowing research links oral health with chronic health conditions
Teeuw, WJ et al., Diabetes Care, Feb 2010; Sen S, Sumner R, Hardin J, et al., Journal of Stroke and Cerebrovascular Diseases, 2013; Wang C-W, McCauley LK. Current Osteoporosis Reports, Dec 2016; Müller F, Journal of Dental Research, Oct 2014.
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• These ED visits are very costly for consumers, insurers and states
• These ED visits can disrupt more urgent needs at a time when COVID-19 has overwhelmed many hospitals
Most of the 2 million annual ED dental visits could be handled in dental offices and/or through teledentistry
Slow progress on teledentistry hurts efforts to improve accessBarriers drive up costs and worsen the chronic disease burden
Vanderbilt Univ. Medical Center, Lack of oral care can lead to life-threatening situation, VUMC Reporter, Sept 2016; Wall T, Nasseh K, and Vujicic M, Majority of Dental-Related Emergency Department Visits Lack Urgency and Can Be Diverted to Dental Offices, Aug 2014, Health Policy Institute, American Dental Association.
A lack of access can lead to untreated tooth decay or other infections, leaving people with no viable options other than visiting hospital EDs
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• During the COVID-19 crisis, it’s crucial for EDs to be free for patients who are acutely ill
• This is an added concern for states with high percentages of seniors — and teledentistry can allow older adults to access providers while safely at home
The numbers in Florida:
Dental-related visits to Florida’s hospital EDsThese visits can disrupt or delay care for more urgent conditions
489,000+ Number of dental-related hospital ED visits in Florida over a three-year period
1 in 4
Serna CA, Arevalo O, and Tomar SL. Dental-Related Use of Hospital Emergency Departments by Hispanics and Non-Hispanics in Florida. American Journal of Public Health. 2017.
The share of these Florida hospital ED visits that were billed to Medicaid
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The 4 modalities of teledentistry
Live video (synchronous): Two-way, real-time interaction between two or more people
Store-and-forward (asynchronous): Photos, X-rays or other patient info are transmitted through a secure system to a dental provider
Remote patient monitoring (RPM): Personal health or medical data are gathered from a person in a different location, allowing a provider to monitor blood pressure or another vital sign or condition
Mobile health (mHealth): Making health data or education accessible to smartphones or other mobile devices
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• Medicaid reimburses live video services for telehealth in all 50 states
• 2/3 of Americans say they are open to using telehealth
• Experts: Oral health is “lagging behind” other health disciplines in utilizing telehealth
Telehealth initiatives are steadily growingHowever, teledentistry is expanding more slowly
Center for Connected Health Policy, State Telehealth Laws & Reimbursement Policies, Fall 2019; American Well’s Telehealth Index: 2019 Consumer Survey, July 2019; Teledentistry: How Technology Can Facilitate Access To Care, a white paper by the Association of State and Territorial Dental Directors, March 2019.
19American Hospital Association. Telehealth Use Surges in Rapidly Changing Market, April 4, 2019; Minemyer P, article in FierceHealthcare, Dec 5, 2018.
Telehealth use is accelerating in medical and behavioral healthOral health is trailing behind these efforts
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• California’s Virtual Dental Home (VDH) delivered much more preventive and early intervention services at a lower cost per patient than the Medicaid program
• 2/3 of children and 1/2 of adults in VDH with complex health conditions were able to obtain all the care they needed at the community site
Teledentistry: Promising initiatives in a variety of statesThese programs demonstrate the ability to improve access
Univ. of the Pacific. “Virtual dental homes” prove safe, effective in six-year statewide study. Aug 2, 2016; Glassman P, Teledentistry Improving Oral Health Using Telehealth-Connected Teams, Pacific Center for Special Care, Aug 2016.
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Teledentistry: A promising impact on improving access
Pelto I. A Reason to SMILE(S): Dental Care for Thousands of Coloradans, Colorado Health Institute, 2018; Minemyer P. The missing piece in telemedicine? Dentistry. FierceHealthcare. 2018 Dec 5.
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Teledentistry: A promising impact on improving access
Pelto I. A Reason to SMILE(S): Dental Care for Thousands of Coloradans, Colorado Health Institute, 2018; Minemyer P. The missing piece in telemedicine? Dentistry. FierceHealthcare. 2018 Dec 5.
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1. Dental workforce
2. Reimbursement policies
What can states do to seize the opportunity of teledentistryHere are the 4 key areas that need to be addressed
As of 2019, all states have Medicaid policies that reimburse live video services for medical or behavioral health encounters.
State Practice Acts should allow care in community settings by non-dentists while having appropriate regulations to ensure oversight, instead of imposing direct supervision rules.
Both public and private insurers should reimbursement teledentistry provided via live video or a store-and-forward mechanism. In addition to payment parity, there should be no discrimination based on the type of dental provider.
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3. Legal clarity
4. Sharing patient information
What can states do to seize the opportunity of teledentistryHere are the 4 key areas that need to be addressed
NOTE: Health Level 7 is an international network of experts developing consensus standards for the exchange, integration, retrieval or sharing of electronic health records (EHRs). The ADA is among the key stakeholders lending their expertise to these efforts to achieve interoperability.
States should help to bring clarity to legal issues that discourage providers and health systems from engaging in teledentistry. These issues include liability coverage for dental providers, getting “credentialed,” data security, and rules of HIPAA compliance.
Experts and key stakeholders are working to make electronic health records (EHRs) “interoperable” or shareable. States should support efforts to achieve interoperability and mandate that certified health IT products adopt the dental exchange standard.
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• Creating telehealth-friendly policies now can ensure that patients are able to receive oral health and other services away from settings where potential for contracting COVID-19 is higher
• States can leverage the federal CARES Act, which includes telehealth provisions
This is an ideal time for states to act States can address immediate and long-term health care needs
National Consortium of Telehealth Resource Centers, COVID-19 Telehealth Toolkit, March 18, 2020. The Coronavirus Aid, Relief and Economic Security Act (CARES) was enacted by Congress and signed by the President in March 2020.
• Making permanent changes to laws and policies that promote teledentistry would better prepare states for similar crises in the future
California Northstate University College of Dental Medicine
Paul Glassman DDS, MA, MBAProfessor and Associate Dean for Research and Community EngagementCalifornia Northstate UniversityElk Grove, [email protected]
California Northstate University College of Dental Medicine
Disclosures
The presenter has consulting arrangements with the following entities:• DentaQuest Partnership, Inc.• Virtual Dental Care• Idaho Department of Health• Rhode Island Department of Health• Multiple dental care providers
California Northstate University College of Dental Medicine
California Northstate University College of Dental Medicine
DeliverySystems
Measurement and Payment
Systems
Preventionand Behavior
Science
California Northstate University College of Dental Medicine
Preventionand Behavior
Support Science
California Northstate University College of Dental Medicine
The Declining Role for the Dental Drill
California Northstate University College of Dental Medicine
Behavior Change Principles
• Messages delivered by trusted members of the community• Multiple people delivering the same message• Small incremental behavior changes• Ongoing reinforcement, coaching• Peer support
California Northstate University College of Dental Medicine
DeliverySystems
California Northstate University College of Dental Medicine
Teledentistry
Dentist to dentist interactions: share records, patients
Real time video surgical support
Real time video consultation – dentist to dentist/patient
Store-and-forward record review
Patient to dentist interactions
mHealth data collection
Telehealth-connected team delivery systems
California Northstate University College of Dental Medicine
California Northstate University College of Dental Medicine
Space and Equipment
California Northstate University College of Dental Medicine
EHR: Radiographs
California Northstate University College of Dental Medicine
EHR: Photographs
California Northstate University College of Dental Medicine
California Northstate University College of Dental Medicine
California Northstate University College of Dental Medicine
Community-based Prevention and Early Intervention Procedures
California Northstate University College of Dental Medicine
California Northstate University College of Dental Medicine
California Northstate University College of Dental Medicine
The Virtual Dental Home Sites
California Northstate University College of Dental Medicine
• Reach people, emphasize prevention, and lower costs• Majority of people kept and verified healthy on-site
– About 2/3 of children had all needed services completed by dental hygienist
• Continuous presence• Community organization integration• Dentist integration
California Northstate University College of Dental Medicine
The Virtual Dental Home Current Trainees8- DentalQuestLearning Collaborative
19- DHCS DentalTransformation Initiative
1- Delta Dental
5- HRSA
1 – CA Wellness
2 – Regional Centers
2 – Hawaii3 – Oregon5 - Colorado
Total = 46 entities
California Northstate University College of Dental Medicine
States Adopting Virtual Dental Home Systems2010
VDH Funded Projects
VDH Systems
VDH Discussions
California Northstate University College of Dental Medicine
States Adopting Virtual Dental Home Systems2020
VDH Funded Projects
VDH Systems
VDH Discussions
California Northstate University College of Dental Medicine
Community EngagedOral Health Systems
California Northstate University College of Dental Medicine
California Northstate University College of Dental Medicine 52
Maintaining Services and Contact with Patients During the time of COVID‐19 Physical Distancing
Using Teledentistry Tools and Strategies
California Northstate University College of Dental Medicine 53
• People cut off from sources of dental care• Practices trying to limit services to emergent/urgent services• Need to:
– Establish communications– Provide advice, consultation, triage– Provide limited and efficient in-person services when needed.
necessary• Must keep people from seeking care for oral health concerns in
other components of health care system – Emergency Rooms
Physical Distancing
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1. Optimized systems: Integrated teledentistry systems that include all needed tools
2. Combining available tools:– Email and text + patient generated photographs– Off-the shelf/low-cost/free separate tools:
• scheduling/video/forms/payment– Copy and paste all activity into one record/EDR
Solutions for current physical distancing environment
California Northstate University College of Dental Medicine 55
• Notify• Plan• Advice/Consultation/Triage• In-person – minimal interventions• Secure complete record of all components of the patient
interactions
Optimized System: Components
California Northstate University College of Dental Medicine 56
• Notify• Plan• Advice/Consultation/Triage• In-person – minimal interventions• Secure complete record of all components of the patient
interactions
Optimized System: Components
California Northstate University College of Dental Medicine
California Northstate University College of Dental Medicine 58
Patient:• Notify• Register – create patient portal• Choose level of response• Pay or enter insurance/Medicaid number• Fill out forms• Upload – photos, text, records• Schedule – type, urgency
Optimized System: Workflow
California Northstate University College of Dental Medicine 59
Provider:• Notified of patient registration and uploads• Respond via message –portal/chat• Secure videoconference• Advice/consultation/triage• Next steps:
– Advice– Prescription– Follow-up appointment– In-person treatment
Optimized System: Workflow
California Northstate University College of Dental Medicine
California Northstate University College of Dental Medicine 61
Provider:• Telehealth system
– Notifications/Appointments– Consent/signatures/explanations/instructions
• In-person– No waiting room– Text or call when ready– No paperwork, no explanations, no signatures– Short visit – in and out
• Follow-up: Teledentistry system
Optimized System: In-person visit
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California Northstate University College of Dental Medicine 63
• Patient– Secure, one-stop access to provider
• Oral health provider– Maintain contact with patients– Full ability to provide advice, consultation, triage– Plan for in-person visits if needed– Complete record of images, forms, consent, payment all in one record
tied to practice EDR• Health care system
– Help people with dental conditions to receive advise or care outside of other components of the health care system – especially ER
Optimized System: Advantages
California Northstate University College of Dental Medicine
Live Video
Schedule
PatientInformation
Forms
ConsentExplanation/Information
Integrated Permanent
Record
Registration
Messaging
Chat
Optimized Systems for COVID-19 ERA: All-in-One
California Northstate University College of Dental Medicine 65
Paul Glassman DDS, MA, MBAProfessor and Associate Dean for Research and Community EngagementCollege of Dental Medicine, California Northstate [email protected]
Maintaining Services and Contact with Patients During the time of COVID‐19 Physical Distancing
Using Teledentistry Tools and Strategies
A COVID-19 SNAPSHOT OF TELEHEALTH AND ORAL HEALTHSean G. Boynes, DMD, MSVice President, Health ImprovementDentaQuest Partnership for Oral Health Advancement
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Emergent and Urgent Care, Reducing Exposure, & Finding Health
The covid-19 pandemic is accelerating the transition to a new model of remotely delivered health care that embraces the benefits of digital and data technologies.
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Proportion of All Dental Encounters that are Unplanned
DQ Partnership Preliminary Analysis - NHANES
14%
5%
17% 17%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Total Children (<21) Adults (21-64) Elderly (65+)
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Proportion of All Dental Encounters that are Unplanned, by Insurance Type
16%
19%
29%
10%
16%
12%
24%
0%
5%
10%
15%
20%
25%
30%
35%
Medicaid only Medicare only Dual Eligibles PrivateInsurance only
Other insurers Multipleinsurers
Uninsured
DQ Partnership Preliminary Analysis - NHANES
70
10%
6%
19%
0%
5%
10%
15%
20%
25%
Total Children Adults
2017
Proportion of All Dental Encounters that are due to a Emergency
Truven IBM –Marketscan – DQ Partnership Preliminary Analysis
9% 9% 10% 10% 10%
6% 6% 6% 6% 6%
20% 20% 20% 20% 19%
0%
5%
10%
15%
20%
25%
2013 2014 2015 2016 2017
2013-2017 Trend
Total Children Adults
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# of Days Between Dental Emergency Visit and Next Dental Visit
32%
15% 15%
9%
15% 14%
44%
20%17%
7% 8%4%
16%
11%14%
11%
27%
20%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
1-15 16-30 31-60 61-90 91-180 181-365Number of Days
Emergency Dental Treatment Routine Dental
Truven IBM –Marketscan – DQ Partnership Preliminary Analysis
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Fragmented guidance…
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Emergency BundleTeledentistry CDT Codes Variations of the following CDT Codes:D9995 teledentistry – synchronous; real-time encounter Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service.
-or-
D9996 teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service.
D0140 - Limited oral evaluation, problem focused
D0160 - Detailed and extensive oral evaluation
D0170 - Re-evaluation - limited, problem focused (established patient; not post-operative visit)
D0171 - Re-evaluation – post-operative office visit
D0190 - screening of a patient
D0191 - assessment of a patient
D9992 - Dental case management – care coordination.
D9994 - Dental Case Management – patient education to improve oral health literacy.
D9311 - Consultation with a medical health care professional.
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Follow Current State Orders & CDC / ADA Recommendations
Initiate Patient-DMD/DDS/RDH
Teledental Encounter
Patient Self-Help
OTC or Rx Medication
In DMD/DDS Office-Follow current CDC/ADA
guidance to minimize need for aerosol producing procedures
Access, Review,
Update and/or create pt.
record, med hx
Initiate triage protocol
(ADA, CDC, etc.)
Collect records via interview,
patient photos/video
Document and treat
Virtual care
Urgent +
Emergency
Patient Education
Use most current ADA Guidance for Triaging and Screening Patients
Refer to Medical Professional or ED
only if warranted
include COVID-19 Screening
Consultation with medical
professional
Bill Codes:
D1330,D9992, D9994, and/or D9311
Bill Code:
D0140, D0160D0170
D0171, orD0190
Dental Professional Follow-Up:Decide If Follow-up Contact Needed
Notate definitive treatment priority once business and
operations have returned to normal
Constant monitor community and state
recommendations related to COVID-19
By phone, telehealth, video as approved
Teledental Emergency Flowchart for COVID-19 Impacted Dental Coverage
Bill for procedures
provided
Bill Code:
D0995(D0996 only if asynchronous)
Bill Code:Limited use:
D0350
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A few things to ponder….
• Limited teledental or virtual visit services for new patients only• “My dentists phone is just ringing and no one is picking up, can you help me?”
– 19% closed and not seeing any patients (ADA HPI: N≈11,000 ADA Members)
– State level reports of dentists closing offices permanently due to loss of lease
• Requiring patients to activate the tele-visit • Limitations of cold calling for a billable procedure
• Telehealth is not applicable to dentistry because it is a surgical sub-specialty only• In Medicaid (2017), 25% of all dental claims and 43% of all costs were for surgical
procedures (restorative care, oral surgeries, periodontal care, and anesthesia)
• In Commercial Insurance (2017), 24% of all dental claims and 49% of all costs were for surgical procedures
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Re-designing the pathway to oral surgical intervention
Grocott et al. Perioperative Medicine 2017; 6:9
Encounter. An interaction between a patient and a healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.
HEALTH
DISEASE
Opportunities of health-oriented patient engagement
Traditional focus on disease-oriented patient engagement
What gets done to the patient?What gets done
with the patient?
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Re-designing the pathway to oral surgical intervention
Grocott et al. Perioperative Medicine 2017; 6:9
Encounter. An interaction between a patient and a healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.
HEALTH
DISEASE
Opportunities of health-oriented patient engagement
• Collaborative (shared) decision-making
• Collaborative behavioral change (lifestyle modification)
• Comorbidity and risk management
• Expectation management and psychological preparedness
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Re-designing to Assess Health and Risk of Disease
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Risk Stratified Annual Surgical Dental Intervention Costs
MORE Care: Preliminary Analysis
0
10
20
30
40
50
60
70
High Risk Moderate Risk Low Risk
Surgical Intervention Rate by Risk
Surgical Intervention Rate
Medicaid, 2017 – 0.33% CRA reportsCommercial, 2017 – 0.28% CRA reports
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14% 13%
88%
29%
24%
78%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Emergency Dental Visit Surgical Intervention Preventive Procedure
Patie
nts
Rec
ievi
ng S
ervi
ce
Relationship between “Oral Health Visit” in 2018 on Oral Health in 2019
Had Oral Health Visit in 2018 No Oral Health Visit in 2018
MORE Care: Preliminary Analysis
QUESTIONS?
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Webinar Evaluation
https://www.dentaquestpartnership.org/node/193990*Must complete by EOD Friday, April 17 in order to receive CE credit
Upcoming Webinar:• Wednesday, April 8th at 1:00 PM – Teledentistry: Providing Alternative Care
During a Public Health Crisis
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