You Can’t Have Good Health if You · integrating oral health into primary care practice...

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You Can’t Have Good Health if You Have Bad Teeth 26 th Annual Midwest Stream FORUM FOR AGRICULTURAL WORKER HEALTH November 1, 2016 Irene V. Hilton, DDS, MPH NNOHA Dental Consultant

Transcript of You Can’t Have Good Health if You · integrating oral health into primary care practice...

Page 1: You Can’t Have Good Health if You · integrating oral health into primary care practice Understand the systems that must be created to successfully integrate oral health into primary

You Can’t Have Good Health if You Have Bad Teeth

26th Annual Midwest Stream

FORUM FOR AGRICULTURAL WORKER HEALTH

November 1, 2016

Irene V. Hilton, DDS, MPH

NNOHA Dental Consultant

Page 2: You Can’t Have Good Health if You · integrating oral health into primary care practice Understand the systems that must be created to successfully integrate oral health into primary

Objectives

Explain why oral health should be integrated into primary care

Determine organizational readiness for engaging in integrating oral health into primary care practice

Understand the systems that must be created to successfully integrate oral health into primary care practice

Describe solutions to common challenges in integration

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Why Integrate Healthcare Disciplines? Triple Aim

Increase communication and collaboration

Improve quality

• Better health outcomes

• Increased patient satisfaction

Reduce costs

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20 months

9 months

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Diabetes

Adverse

Pregnancy

Outcomes

Coronary Heart

Disease

Respiratory

Infections

Periodontitis

Periodontal Disease Associations

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Pregnancy Presents an Opportunity

Introduce risk reduction & self management strategies

Stabilize maternal periodontal status & lower transmission of cavity causing bacteria

Only time some women have dental coverage

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Our Goal

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Undiagnosed Diabetes

Prevalence diabetes U.S. adults 12-14 %

Prevalence pre-diabetes 37-38%

Half U.S. adult population either diabetic or pre-diabetic [JAMA, 2015; 314 (10)]

27.8% of people with diabetes are undiagnosed

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Periodontitis and…

Cardiovascular Disease

Many studies show known periodontal pathogens found in coronary & carotid artery walls (Ford 2006, Lalla 2003,

Dorn 2001)

Respiratory Disease

Oral bacteria found in lower airways

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Oral Manifestations of Treatment

Xerostomia (dry mouth from lack of saliva)

Common drug side effects (HTN, DM, asthma, psychotropic)

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Oral Manifestations of Treatment

Mucositis

• Chemotherapy

• Radiation therapy

Gingival Hyperplasia

• Dilantin

• Ca+ blockers

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Reduced Cost & Improved Outcomes

Recent study compared medical costs of diabetic patients who received periodontal treatment vs. no treatment over three years

Commercial medical and dental insurance

Periodontal treatment was associated with a significant decrease in hospital admissions, physician visits and overall cost of medical care in diabetics. Savings averaged $1,814 per patient in a single year independent of age and sex

Jeffcoat M, Blum J, Merke F. Periodontal Therapy Reduces

Hospitalizations and Medical Care Costs in Diabetics. J Dent Res 91(Spec Iss A):753, 2012

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Tooth Loss Older Adults: Detrimental Changes in Food Choices

Fruits

Vegetables

Dietary and crude fiber

Carotene

Saturated fat

Cholesterol

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Integration in Health Centers

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2000 Surgeon General & 2011 IOM Reports:

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2005- Oral Health Disparities Collaborative Pilot

2011- Oral Health & the Patient Centered Health

Home: Action Guide

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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

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2015- A User’s Guide for Implementation of Interprofessional Oral Health Core Clinical Competencies

PCPs deliver oral health interventions

Standardization of training, clinical protocols

Measures/QI

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Primary Care Providers

MD/DO

Certified Nurse Midwives

Nurse Practitioners

Physician Assistants

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Oral Health Core Clinical Competency Domains

1. Risk assessment

2. Oral health evaluation

3. Preventive interventions

4. Communication & education

5. Interprofessional collaborative practice

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Clinical Practice

Primary care providers perform oral health assessments, apply FV, screen for depression, refer patients

Dental providers screen for HIV, diabetes, depression, BP, monitor child immunizations

Behavioral health providers screen for obesity, BP, perform oral health assessments

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Readiness Assessment

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Characteristics of Success

Leadership Vision & Support

Integrated HC Executive Team

Co-location

Organizational Culture of Quality Improvement

Staff Buy-in: Understanding the “Why”

Champions

Bonus: Integrated EHR system

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Leadership Vision & Support

Starts with ED/CEO

Insure same message throughout organization

“Treating the patient as a whole is part of the mission and culture of the Health Center”

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Integrated HC Executive Team

Not personal relationships- part of organizational structure

Included in all operations team meetings, committees and communications

Present when planning and clinical policy and protocol decisions made to advocate and give input and perspective

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Co-location

Bi-directional referral

“warm hand-off”

Positive attributes of having multiple services in one location.

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Organizational Culture of Quality Improvement

In-depth user’s knowledge of the terminology and methodology of quality improvement

Culture permeated all levels of the Health Center- part of how dental conducted daily functions

Focus on outcomes - of using outcome measures to drive change, of improving from a baseline

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Staff Buy-in: Understanding the “Why”

Continuous process

Resistance to change addressed not by telling staff what to do, but rather explaining the "why”

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Champions

Proactive, sure of the importance of their discipline in improving the health status of patients

Confidence to advocate

Long-term vision, taking time to develop influence, relationships and grow credibility

“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.”

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Turn & Talk: Where is your Organization?

What characteristics of early adopter are present in your organization?

What characteristics of early adopter are not present in your?

Discuss how you might develop one missing/low level characteristic at your organization?

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Steps to Success for Integration Project

Planning

Training system

Health information system

Clinical care system

Evaluation system

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Planning

Establish a Team

Select a population of focus

Create timeline

Figure costs

Gear up test cycle process

Identify champions

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Training Systems

Online training

In-person training (interdisciplinary collaboration opportunity)

On-boarding new health professionals

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Health Information Systems

EHR revision

To implement the core competency domains, an EMR must be able to:

• Provide screening tool—ideally one that automatically scores risk level for individual patients

• Document evaluation, interventions, self-management goals, and education

• Print educational handouts and post-visit instructions

• Refer the patient for care

• Collect data

EMR-EDR relationship

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Clinical Care System

Workflow

• Who & during what part of the care visit?

Screening/Risk assessment

Evaluation

Interventions

Communication & education

• Take home materials

• Motivational interviewing

Interprofessional collaborative practice

• Referral & follow-up

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Evaluation Systems

Number screenings/assessments performed

Number of interventions for high-risk patients.

Number patients linked to definitive care and treatment

Changes in quality of care/outcome indicators

Knowledge and skills of providers

Patient experience and knowledge

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Turn & Talk: Where is your Organization?

What integration projects has your organization implemented?

What might be the first/next integration project your organization could implement?

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Challenges & Strategies

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Competing Needs/Resistance to Change

Competing needs/issues- existing practice management issues

“One more thing”

Normal resistance to change

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Reimbursement Issues

Unable to bill same day medical/dental/behavioral FQHC visit- varies by state

Not able to capture FFS enhancements for PCP delivering OH prevention

State Medicaid not covering dental treatment, especially periodontal treatment for adults

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Capacity & Co-location

Norm is to not have dental co-located with medical at the same site

2015 UDS data

• 1.5 million behavioral health users

• 5.2 million dental users

• 20.6 million medical users

Dental capacity for 25% of medical users

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Strategies

Pilot integration at one co-located site

Develop systems

Expand to non-co-located sites

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Training System

Time

Incentive

Standardized content

Supervised clinical practice

Self-paced online curricula

Free CE units

Use endorsed, recognized curricula

Interprofessional collaboration

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Health Information Technology Systems

All Paper

Electronic Medical Record

Only

Electronic Dental Record

Only

Separate Electronic Medical

and Dental

Records

Electronic Medical Records

with Dental

Templates

Home Grown

Electronic Medical &

Dental Records

Interfaced Electronic Medical &

Dental Record

Fully Integrated Electronic Medical &

Dental Record

Fully Integrated Electronic Medical &

Dental Record +

Electronic Health Record

No integration Full integration

1 2 3 4 5 6 7 8 9

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Strategies

Use Excel/Access/i2i for databases

Fax alternative to eReferral

Extra resources must be allocated to develop work-arounds

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Clinical Care System

Implementation

Forms/templates

Data entry

Clinic flow

Use QI/PDSA to test

Develop written clinical protocols/policies

Incorporate into orientation/on-boarding/clinical mentoring

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Turn & Talk: Where is your Organization?

What challenges to integration are present in your organization?

What is going to be your first Action Step next week to works towards increasing integration in your organization?

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Conclusion

YOU CANNOT HAVE GOOD HEALTH IF YOU HAVE BAD TEETH

Page 60: You Can’t Have Good Health if You · integrating oral health into primary care practice Understand the systems that must be created to successfully integrate oral health into primary

Interdisciplinary Collaboration…

Is the future

Creates access to oral health services

Improves health status

Contributes to Triple Aim

The right thing to do

Page 61: You Can’t Have Good Health if You · integrating oral health into primary care practice Understand the systems that must be created to successfully integrate oral health into primary

Medical Assistant & Dental Assistant Providing Education in Waiting Shared Room

Page 62: You Can’t Have Good Health if You · integrating oral health into primary care practice Understand the systems that must be created to successfully integrate oral health into primary

Contact Us!

Irene V. Hilton, DDS, MPH, FACD NNOHA Dental Consultant [email protected]

National Network for Oral Health Access 181 East 56th Street, Suite 501

Denver, CO 80216

Phone: (303) 957-0635

Fax: (866) 316-4995

[email protected]


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