medical /dental collaborations - nnoha · medical /dental collaborations ... patricia braun md, mph...
TRANSCRIPT
Medical /Dental Collaborations
Dennis Lewis DDS - Director of Dentistry, Dental Aid Inc.
Patricia Braun MD, MPH – Denver Health, Children’s Outcomes Research Program
Educational Objectives
Discuss the use of Caries Risk Assessment by medical providers
Demonstrate the positive effect of perinatal oral health care on the oral health of children
Discuss the use of Fluoride varnish in busy medical practices
Educational Objectives
Demonstrate the utilization and outcomes of dental hygienists working in medical practices
Examine restorative options in the very young child
Demonstrate we CAN affect the caries rates of high risk populations
Cavity Free At Three Program Overview
History of CF3 in Colorado
Multiple Foundation Support
Multidiscplinary Technical Assistant Team
Year One Grants and Presentations
Early focus was on Medical Providers
Problem – Dental Support
What does it look like today
Colorado Statistics
18% of children ages 2-4 have dental caries; 16% have untreated decay
45.7% of children in kindergarten have dental caries; 26.9% have untreated decay
57.2% of third graders have dental caries; 26.1% have untreated decay
By the age of 17 years, 78% of children have had at least one cavity: 7% have lost a permanent tooth to dental decay
Cavity Free at Three Model
Child Oral Health Integrated into well child care and dental visits
Caries risk assessment
Anticipatory guidance
Parent counseling and goal setting
Establishment of a dental home
Fluoride varnish application
Cavity Free at Three Model
Perinatal Oral Health Special emphasis on pregnant women
Assessing oral health of the mother
Patient counseling and education
Referral to a dentist during pregnancy
Education of oral health professions to increase access to care for pregnant women
Prevention of oral disease in the infant begins before birth
Cavity Free at Three
What we teach
The role of fluoride in prevention of early childhood caries
How to apply fluoride vanish as a tool in oral disease prevention
Proper procedures for Medicaid reimbursement for oral evaluation and fluoride varnish application
Role playing and anticipatory guidance
Hands on practice with infants and toddlers for oral exam and varnish application
Contact Information
WWW.CAVITYFREEATTHREE.ORG
Karen Savoie, RDH, BS
Director of Education
Cavity Free at Three Program
University of Colorado, Denver
Area Health Education Center
303-724-4750
Dr. Patricia Braun
Does this model really work in a busy medical Practice?
Co-locating dental hygienists in medical practices
Cavity Free At Three Program Evaluation
Patty Braun MD, MPH
Associate Professor of Pediatrics Children’s Outcomes
Research Program
Financial Disclosures
The authors do not have any significant financial interest or relationship with either the manufacturer of any commercial products or services or any commercial supporters of any activity.
Surgeon General’s Report
2000-U.S. Surgeon General David Satcher
2003-National Call to Action to Promote Oral Health
1. Change perceptions of oral health
2. Overcome barriers by replicating effective programs and proven efforts
3. Build the science base and accelerate science transfer
4. Increase workforce diversity, capacity and flexibility
5. Increase collaborations
Mouradian WE et al. Progress in Children’s Oral Health Since the Surgeon General’s Report on Oral Health. Academic Pediatrics 9(6), November-December
2009
Background-National
North Carolina-Into the Mouth of Babes
Questionnaire administered 12 months after training
Medical providers at well child care visits
28 family physician offices/49 pediatric offices
70% of participants providing dental services on regular basis
Major barriers integration of dental procedures into practice (42%)
difficulty in applying varnish (29%)
staff resistance (26%)
dental referral difficulties (21%)
Close K, Rozier G, Zeldin LP, Gilbert AR. Barriers to the Adoption and Implementation of Preventive Dental Services in Primary Medical
Care. Pediatrics 125 (3), March 2010
Background-National
Washington-Access to Infant and Childhood Dentistry (ABCD)
Focus group themes
PCPs influenced by their concerns for their patients’ oral health
Being part of decision making process helped adoption
Logistics to identify eligible patients were helpful
Lewis C, Lynch H, Richardson L. Fluoride Varnish Use in Primary Care: What Do Providers Think? Pediatrics 115 (1), January 2005
Background-Colorado
2007-2009: CF3 Technical Assistance Team comes together to build initiative
2008-2009: CF3 awards 10 grantees training, supplies, support
July 2009: Colorado Medicaid allows medical providers to deliver oral preventive care to children birth at well child care visits (up to age five)
States with Medicaid funding for physician oral health screening and fluoride varnish
Background-Colorado
Medicaid mandates that providers must receive oral health training (CF3 or Smiles for Life online)
2009-2010: 100’s requests for CF3 training
CF3 training refined to a
2 hour infant oral health
2 hour perinatal health
Hands-on
Methods
RE-AIM Conceptual Framework (F. Glascoe)
Reach
Effectiveness
Adoption
Implementation
Maintenance
Methods
Subjects-Training:
Grantees-10
Providers- 332 (medical, dental, public health nurses, home health nurses)
Denver Health- Colorado’s largest safety-net health care system (8 FQHCs)
Methods
CF3 Training:
Outcomes (RE-AIM): evaluation of the training
change of behavior after training
Administrative records
Risk Assessment Forms
Survey
Methods
CF3 Training:
Administrative records (Reach) Denver Health
Fluoride Varnish (1206) + Well Child Check (V20.2)
Risk Assessment Forms Survey
Methods
CF3 Training: Administrative records
Risk Assessment Forms (Reach) Collected from sites using them
Survey
Methods
CF3 Training: Administrative records
Risk Assessment Forms
Survey on-line
all trainees
validated questions
Piloted
Results-Reach of Services
Administrative Records: >3000 (as of June 2010)
Children at Denver Health who received oral preventive visit with fluoride varnish at well child care visits: 1510
Risk assessment forms collected= 1538 (year 1)
Reach of Training
Survey - 70% response rate (N = 175/248) Gender - 80% female
Year of profession graduation – 1967-2008
Provider type
24% medical providers 16% dental providers 17% public health nurses 21% RNs/medical assistants 22% administrative/other roles
Workplace 37% public health clinic 20% federally qualified medical health center 8% medical school/university setting 4% private dental 2% federally qualified dental clinic
0 25 50 75 100
I can change the oral health
behaviors of my patients
Fluoride varnish is safe
ECC is a problem for my patients
I have a role in preventing ECCAll
Dental
Non-Dental
Knowledge, Attitudes and Beliefs
p = ns
Strongly/Somewhat Agree
How confident do you feel with
examination of teeth?
0
20
40
60
80
100
% o
f re
sp
on
da
nts
Dental Non-Dental
Already Confident Before Training
Effectiveness of Training
p > 0.0001
0
20
40
60
80
100
Dental Non-Dental
Confident After Training
% o
f re
sp
on
da
nts
p = 0.44
N = 104
How confident do you feel with
demonstration of brushing of child’s teeth?
0
20
40
60
80
100
% o
f re
sp
on
da
nts
Dental Non-Dental
Already Confident Before Training
Effectiveness of Training
p > 0.0001
0
20
40
60
80
100
Dental Non-Dental
Confident After Training
% o
f re
sp
on
da
nts
p = 0.18
N = 104
How confident do you feel with
measuring child’s risk for caries?
0
20
40
60
80
100
% o
f re
sp
on
da
nts
Dental Non-Dental
Already Confident Before Training
Effectiveness of Training
p > 0.0001
0
20
40
60
80
100
Dental Non-Dental
Confident After Training
% o
f re
sp
on
da
nts
p = 0.28
N = 104
How confident do you feel with
application of fluoride varnish?
0
20
40
60
80
100
% o
f re
sp
on
da
nts
Dental Non-Dental
Already Confident Before Training
Effectiveness of Training
p > 0.0001
0
20
40
60
80
100
Dental Non-Dental
Confident After Training
% o
f re
sp
on
da
nts
p = 0.01
N = 104
How confident do you feel with
providing anticipatory guidance?
0
20
40
60
80
100
% o
f re
sp
on
da
nts
Dental Non-Dental
Already Confident Before Training
Effectiveness of Training
p = 0.005
0
20
40
60
80
100
Dental Non-Dental
Confident After Training
% o
f re
sp
on
da
nts
p = 0.32
N = 104
How confident do you feel with
caregiver goal setting?
0
20
40
60
80
100
% o
f re
sp
on
da
nts
Dental Non-Dental
Already Confident Before Training
Effectiveness of Training
p = 0.0003
0
20
40
60
80
100
Dental Non-Dental
Confident After Training
% o
f re
sp
on
da
nts
p = 0.11
N = 104
Have provided oral preventive care in past two work weeks to ≥ 75% of children
Adoption of CF3 care
0 20 40 60 80 100
Goal Setting
Anticipatory Guidance
Fluoride Varnish
Measuring Risk
Exam Teeth
Demonstrate Brushing
All
Dental
Non-Dental
p = 0.02
p = 0.002
p = ns
Have provided oral preventive care in past two work weeks to ≥ 50% of children
Adoption of CF3 care
0 20 40 60 80 100
Goal Setting
Anticipatory Guidance
Fluoride Varnish
Measuring Risk
Exam Teeth
Demonstrate Brushing
All
Dental
Non-Dental
p = 0.001
p = ns
Barriers to Adoption of CF3 care to children
0 25 50 75 100
Time
Obtaining
Fluoride
Lack of
Reimbursement
Forget
Difficulty
obtaining risk
All
Dental
Non-Dental
Definitely/Somewhat of a Barrier
*
*
*
*
* p>0.05
As a result of CF3, has your workplace done any of the following? YES % (N = 104)
Changed medical record/billing 51
Billed Medicaid 60
Planned for future training 58
Made arrangement for getting own fluoride 67
Made arrangement for getting own oral health supplies 75
Established referral system to dental home 79
Implementation/Maintenance of Training
Maintenance of Training
0 20 40 60 80 100
Children 0-36 mo
Pregnant Women
Dental
Non-Dental
In the future….very/somewhat likely to provide oral preventive care to ….
p = 0.03
p = 0.67
CF3 care reached almost 5000 children in first year
The CF3 training model is effective at providing necessary skills
Variety of providers are willing to adopt new behavior
Providers can assess a child’s risk for caries
Lack of time to provide care is most reported barrier to providing care
Oral health kits help with adoption and implementation
Trainees request updates
Conclusions
1. Change perceptions of oral health
2. Overcome barriers by replicating effective programs and proven efforts
3. Build the science base and accelerate science transfer
4. Increase workforce diversity, capacity and flexibility
5. Increase collaborations
Summary
Cavity Free at Three Program Evaluation
Thanks to CF3 Technical Assistance Team
Co-investigators Matt Daley Elaine Morrato Sarah Ling Katina Widmer
Funds Caring for Colorado Foundation The Colorado Health Foundation The Colorado Trust Delta Dental Foundation of Colorado Kaiser Permanente Rose Community Foundation
Thank you for collaborating!
Early Childhood Caries Prevalence Rates and Parent Oral Health
Knowledge, Attitudes, Beliefs and Behaviors
Children’s Outcomes
Research Program
Co-located Dental Hygienist Project
Background: Early Childhood Caries
Most common chronic disease of children 18% of Colorado’s Head Start children have caries
experience Large disparity exists
80% of disease occurs in 25% of children AAP and AAPD recommend first oral health visit by 12
months of age Innovative models of care delivery necessary Colorado Head Start Basic Screening Survey, 2004
The Impact of Oral Disease on the Health of Coloradans, CDPHE, 2005
Background: Co-location
General Considerations
Placing multiple services in same physical space
Premise that proximity will enhance access to necessary services
Continuum of care
co-location > collaboration> integration
S. Ginsburg, The Commonwealth Fund, July 2008
Goal
Overarching goal of project is to test feasibility of co-locating registered dental hygienists into medical practices.
Objectives
Objective 1: Using co-located dental hygienists in medical practices, measure baseline early childhood caries prevalence in young children, 0-36 months of age
Objective 2: Describe the baseline oral health knowledge, attitudes, beliefs and behaviors of primary parents/caregivers of young children
Methods: Study Setting
Five medical offices purposefully selected
All offices serve predominantly low income children
Registered Dental Hygienists (RDH) hired from 10/08 through 4/09
Dual function exam rooms built
RDH care specifically directed to children 0-36 months of age
Dual Function Exam Room
Methods
Recruitment Efforts Letters mailed to parents at practices Open recruitment by hygienists in offices Direct referral of patients by medical staff
Services Oral examination, rubber tip prophy, assessment of
caries, fluoride varnish application and oral health instruction
All children referred to dentist Business Model
RDH practice independently Do own scheduling and billing
Measurement of Cavities
Decayed, missing, filled surfaces (d1d2mfs) RDHs calibrated to caries measurement NIDCR and DRURY criteria (white spot lesions) Visualized on dried teeth, overhead light source, no probing
or x-rays
USDHHS, PHS, NIH, NIDR. NIH Publication No. 91 (1991) Drury TF. et al. J Public Health Dent 59. 1999
Measurement of Parent/Caregiver Variables
Parent/Caregiver knowledge, attitudes, beliefs, behaviors
Hand written paper-based survey
Health Belief Model
Validated questions (e.g. BRFSS)
Piloted
Administrated at first visit, 12 month visit
Results
Total = 2,101
Nov. 2008 to June 2010
0
50
100
150
200
250
300
350
400
450
500
Aurora(0
.1FTE) 11/08
Fort Collin
s(1.0FTE) 02/09
Montrose
(0.3FTE) 0
2/09
Delta(va
riable) 0
2/09
Thornton(0
.2FTE) 04/09
Num
ber
of patie
nts
Target children
<36 months
(N=525)
Non-target
children >36
months (N=805)
Baseline Characteristics of Study Population
N=528
Age (mean)
Range
18 months
(6-36)
Insurance
Medicaid
CHP+
67%
11%
Household Income
<= $29,999
55%
Caries
d1s only
d2mfs
9.6%
3.9%
Baseline Characteristics of Target Population
Yes
‘Has your child ever been received care by a dental provider?’
9%
‘Do you have a dental provider you plan on taking your child to?’
27%
‘Have you (parent) seen a dental provider in the past 2 years?’
51%
Baseline Parent Attitudes about Co-location
How much do you agree or disagree with the following statements?
Strongly
Agree
Somewhat Agree
Convenient to get dental care in same office as child’s medical provider
84% 15%
More likely to take my child to a dental provider located in doctor’s office than one in the community
63% 29%
Getting dental care at the same time as getting medical care makes sense
78% 17%
Perceived Barriers to Taking Children to Dental Provider
How much are the following a problem for you to take your child to a dental provider?
A Big Problem Somewhat a Problem
Cost 14% 25%
Finding a dentist that takes child’s insurance
13% 23%
Finding a dentist close to my house 10% 14%
Child afraid of the dentist 9% 19%
Too busy to take child to dentist 5% 14%
Parent Knowledge Regarding Provision of Dental Care
Has medical provider told you when to take child to see dental provider
Yes- 40%
Has dental provider told you to take child to see dental provider
Yes - 26%
By what age…
By age 1
By age 1 and before age 3
..did medical provider tell you to take child to dental provider (n=210)
65% 32%
…did dental provider tell you to take child to dental provider (n=137)
62% 31%
…do you think you should take child to dental provider (n=525)
51% 42%
Other Important Attitudes and Behaviors
47% brush child’s teeth once a day
22% use toothpaste when brushing child’s teeth
47% agree child won’t let them brush teeth
44% agree that most children eventually get cavities
Other Important Attitudes and Behaviors
47% of children currently use a bottle
23% reported putting child to bed with a bottle (milk, formula, juice) daily
However, 87% described taking child to dental provider as “very important” to preventing cavities
12 Month Parent Attitudes about Co-location
N = 48
How much do you agree or disagree with the following statements?
Strongly
Agree
Somewhat Agree
Convenient to get dental care in same office as child’s medical provider
83% 15%
More likely to take my child to a dental provider located in doctor’s office than one in the community
48% 44%
Getting dental care at the same time as getting medical care makes sense
73% 21%
12 Month Perceived Barriers to Taking Child to Dental Hygienist
How much of a problem? Big/Somewhat of Problem
Not a Problem
Dental hygienist is not in the office at
convenient times
13% 87%
Takes too much time to see both the medical provider and the dental hygienist on the same day
23% 77%
Dental hygienists don’t fill cavities 21% 79%
12 Month Perceived Barriers to Taking Child to Dental Hygienist
How much of a problem? Big/Somewhat of Problem
Not a Problem
Dental hygienist is not in the office at
convenient times
13% 87%
Takes too much time to see both the medical provider and the dental hygienist on the same day
23% 77%
Dental hygienists don’t fill cavities 21% 79%
Too busy to take my child to the dental hygienist
15% 85%
My child is afraid to see the dental hygienist 29% 71%
12 Month Parent Attitudes about Co-location
Really Like Like
What is your opinion about having your child see the dental hygienist in the medical office?
73% 25%
12 Month Parent Attitudes about Co-location
Yes No Not sure
Do you plan on taking your child to the dental hygienist in this office in the future?
87% 0.2% 12%
Would you recommend this doctor’s office to others because a dental hygienist works here?
90% 0.2% 10%
Key Informant Interviews
Positive Theme: Access to services
Medical Director:
“[It was] something we had always tried to do. To co-locate anything we can… It's kind of like this- what is this new term, Medical Home that we've done for a long time. So it just makes sense - the one stop shop being the Medical Home issue.”
RDH:
“I thought it was a great idea to help the kids out and help them find a dental office. Because it is really hard to find an office who will take - like in their case, a lot of our children have Medicaid and some of them don't have any insurance. So helping them find where to go…Finding a resource for them.”
Key Informant Interviews
Challenge Theme: Medical buy-in
Medical Director:
“The biggest thing for my consideration was selling it to my own staff… Trying to get buy-in was probably the one biggest thing.”
RDH:
“At the beginning it was kind of rough. Only because we…had conferences with the pediatricians there and their assistants because of scheduling and getting the patients in and having them know and be aware that we are there to help them out… part of it was educating PA's and pediatricians who worked there to work together.”
Challenges and Limitations
Challenges to Co-location
Medical practices lack space for new providers
Getting medical providers to refer patients slow
Incorporating dental hygienists into scheduling of clinics difficult
Limitations
RDH assessing for caries
Generalizability
Selection Bias
Conclusions
Co-located dental hygienists seeing both targeted and non-targeted children
Young children are receiving preventive oral health services
Few targeted children previously seen by dental provider
and already are developing white spot lesions and cavities
Reported barriers are less common/haven’t been encountered yet
Conclusions
Most parents think child should see dental provider by age 3
Most parents report that dental visits prevent cavities
Co-locating dental hygienists into medical practices is
feasible and expands dental access
Acknowledgements
Delta Dental Foundation
Barbara Springer
Helene Kent
C0-Investigators
Matt Daley
Shelby Kahl
Sarah Ling
Katina Widmer
Dental Hygienists
Maria Matias,
Mike Bennett
Ginnette Trujillo
Mary Vigil
Suzi Shada
Conclusions
Co-located dental hygienists seeing both targeted and non-targeted children
Few targeted children previously seen by dental provider and already are developing white spot lesions and cavities
Parents support receiving dental care in the medical office Reported barriers are less common Parents think child should see dental provider by age 3 Parents report that dental visits prevent cavities Co-locating dental hygienists into medical practices is feasible and
expands dental access
Why Treat Moms?
Improving Children’s Oral Health Through Perinatal treatment and Education
Dental Aid Inc.
What is Dental Aid?
History and Location
Scope of Services
Who comes to Dental Aid
Funding
Current size
# of providers
Patients per year
Visits per year
Bright Smiles Program
Purpose
History
Number of women Participating Per year
Logistics of the Program
Funding For Bright Smiles
What treatments are Provided
ALL Aspects of General Dentistry
New York Guidelines August 2006
California Guidelines February 2010
Priority of treatment
Does treating Mom help?
The children have less decay
They have less SEVERE decay – fewer hospital cases
They have their first dental visit earlier
Their parents are more active in providing home care and good nutrition
Decay rates dmfs
BS kids dmfs ages 2 to 3 = 3.4 all other kids 6.3
BS ages 3 to 4 = 8.4 15.0
Bs kids ages 4 to 5 = 12.6 21.5
Decay Rates dmft
Ages 2 to 3 BS = 1.0 2.7
Ages 3 to 4 2.9 5.1
Ages 4 to 5 3.15 5.4
Hospitalizations
Bright Smiles children under age 5 18%
All other children under age 5 50%
Bright Smiles children are treated with general anesthesia at 1/3 the rate or frequency of our general population of children
Other Outcomes
We see the children earlier in life and the parents are more involved.
14% of Bright Smiles babies are seen by age one. Of 250 audited charts of children in our patient population under age 5, NONE were seen before 30 months.
Parents are more involved in the child’s home care. Parents are brushing the child’s teeth. BS = 66% vs. 19%
What Next?
Xylitol Interventions
Cost Savings Analysis
Talk to Dentists Too many won’t see young children
Apprehension about treating women during pregnancy
THANK YOU
QUESTIONS