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Integrating Oral Health Into Patient Centered Primary Care That’s Disruptive! MPCA 2015 Annual Conference August 31, 2015 Irene V. Hilton, DDS, MPH NNOHA Dental Consultant

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Page 1: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Integrating Oral Health Into Patient Centered Primary Care

That’s Disruptive!

MPCA 2015 Annual Conference

August 31, 2015

Irene V. Hilton, DDS, MPH

NNOHA Dental Consultant

Page 2: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Objectives

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 barriers to integrating oral health into primary care practice

Page 3: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Current Initiatives to Incorporate Oral Health into Primary Care Practice

What’s Going on out There?

Page 4: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

20 months

9 months

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2011 IOM Report: Improving Access to Oral Health Care

Recommended HRSA developing oral health competencies for non-dental professionals

Page 6: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

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

NEW! 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

Page 7: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

MediCaid & Private Insurer Payment

Medicaid in 48 states reimburse PCPs for assessment and/or FV placement

99188 App Topical Fluoride Varinish

Kaiser Northwest

Health Partners

United Health Care

Page 8: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Statewide Efforts

North Carolina: Into the Mouth of Babes/ Connecting the Docs

• Reduces caries incidence in high risk children after 8 years (Achembong LN, Kranz AM, Rozier RG. Office-based preventive dental program and

statewide trends in dental caries. Pediatrics. 2014 Apr;133(4):e827-34.)

Massachusetts (Isong IA, Silk H, Rao SR, Perrin JM, Savageau JA, Donelan K.

Provision of fluoride varnish to Medicaid-enrolled children by physicians: the Massachusetts experience. Health Serv Res. 2011 Dec;46(6pt1):1843-62.)

Washington (Lewis C, Lynch H, Richardson L. Fluoride varnish use in primary care:

what do providers think? Pediatrics. 2005 Jan;115(1):e69-76.)

Page 9: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

HRSA PCM/HH Initiatives

Encouraging Health Centers to undertake the practice changes that will enable them to gain NCQA Patient-Centered Medical Home (PCMH) recognition

Health Home vs. Medical Home

Page 10: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

1998

2005 2011

Page 11: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

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

http://www.hrsa.gov/publichealth/clinical/oralhealth/primarycare/integrationoforalhealth.pdf

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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

http://www.nnoha.org/nnoha-content/uploads/2015/01/IPOHCCC-Users-Guide-Final_01-23-2015.pdf

Page 13: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

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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Health Partners Western Ohio

Bronx Community

Health Center

Family HealthCare

Page 16: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Characteristics of Success

1. Leadership Vision & Support

2. Integrated Clinical Team

3. Culture of Quality Improvement

4. Understanding the “Why”

5. Champions

6. Relationships with oral health providers

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Steps to Success

Planning

Training systems

Health information systems

Clinical care systems

Evaluation systems

Page 18: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Planning

Establish team

Timeline- which competency 1st?

Reimbursement

Cost

Synergy with other practice initiatives (PCHM)

Refresh quality improvement technique

Page 19: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Training Systems

Page 20: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Training

Primary care staff needs

• Importance oral health to systemic health

• Clinical competencies

• Referral protocols

Dental staff needs training in clinical skills & latest guidelines

• Children 0-5

• Perinatal

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Page 22: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Training Systems

Online training

In-person training (interdisciplinary collaboration opportunity)

On-boarding new health professionals

Page 23: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

What it Looks Like Clinically

HPWO FHC BCHN

Population > 18 0-5 0-3

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

Page 24: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

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!)

On-boarding new providers Incorporate into orientation

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Page 26: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

HIT Systems

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Health Information Systems

Risk-assessment

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

Page 28: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

What it Looks Like Clinically

HPWO FHC BCHN

Population > 18 0-5 0-3

EMR-EDR Configuration

Greenway Prime Fully integrated

Centricity Dentrix

Centricity QSI

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Page 30: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk
Page 31: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Clinical Care Systems

Page 32: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

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

Page 33: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Barriers in the Literature

#1- perception no time, logistics Disruption!

(Close K, Rozier RG, Zeldin LP, Gilbert AR. Barriers to the adoption and

implementation of preventive dental services in primary medical care. Pediatrics.

2010 Mar;125(3):509-17.

Lack of OH knowledge/perceived difficulty applying FV

No reimbursement

Risk assessments too long

EMR not capturing data

Dental referral issues

Page 34: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

What it Looks 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

Page 35: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

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.

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Oral Evaluation

Challenge Strategy

Assuring correct elements incorporated

Online training followed by in person training

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

Page 37: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk
Page 38: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk
Page 39: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

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

Page 40: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk
Page 41: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

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. Include as part of visit summary

PCP staff resistance to performing OH education

Relate to general health concerns i.e. obesity, diabetic control

Page 42: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk
Page 43: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

What it Looks Like Clinically

HPWO FHC BCHN

Inter-professional

Collaborative

Practice (e.g.

referral)

Provider (EMR

check-off box),

yellow tooth patient

takes to front desk.

Provider (EMR

check-off box),

“passport” sheet

with follow ups (e.g.

lab, radiology)

includes dental

Provider (EMR

check-off box).

Work around-can’t

see dental appts.

Inter-professional

Collaborative

Practice (e.g.

appointment

scheduling)

Reserved dental

exam slots

accessible by front

desk at checkout.

No reserved dental

exam slots. Primary

care front desk staff

at checkout.

Reserved dental

exams. Manual

entry.

Page 44: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

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

Page 45: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk
Page 46: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Evaluation System

Page 47: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

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 quality of care/outcome indicators.

Knowledge and skills of primary care medical providers.

Patient experience and knowledge of oral health.

Page 48: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Conclusion

Page 49: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Integrating Oral Health into Patient Centered Care

Is the future

Improves health status

Contributes to Triple Aim

The right thing to do

Page 50: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Medical Assistant & Dental Assistant Providing Education in Waiting Shared Room

Page 51: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

Join NNOHA

NNOHA member ($50 individual / $350 organization) benefits include: • Publications

• Technical Assistance

• Job Bank

• Newsletter

• Discount to annual conference

http://www.nnoha.org/join/overview/

Save the Date!

2015 NNOHA

Conference

November 15-18, 2015

Indianapolis, Indiana

http://www.nnoha.org/join/overview/
http://www.nnoha.org/join/overview/
http://www.nnoha.org/join/overview/
Page 52: Integrating Oral Health Into Patient Centered Primary Care · Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk

www.nnoha.org

Irene V. Hilton, DDS, MPH NNOHA Dental Consultant [email protected] San Francisco Department of Public Health 1525 Silver Avenue San Francisco, CA 94134 (415) 657-1708

mailto:[email protected]

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