Maura EdwardsConsultant in Dental Public Health

Chair of National Older People’s Oral Health Improvement Group

NHS Ayrshire and Arran

Overview of

for Oral Health Improvement

Initiatives for Older People

Maura Edwards Consultant in Dental Public Health

NHS Ayrshire & Arran

01292 885936maura.edwards@nhs.net

2005Scottish Dental Action Plan

Targets for older people“All NHS Boards will have oral health care and support programmes for care homes”

National Groups

Scottish Dental Needs Assessment Programme (2006)

Subgroup on domiciliary dental careMulti-disciplinary membership

Role of care staff in preventing dental disease Establish National Older People’s Oral Health

Improvement Group (NOP OHIG) Focus on preventive rather than service aspects

Each has effect on the other, both are required to improve oral health

Public Health Researcher – for evaluation

Equally Well

Ministerial Task Force Report - June 2008 Implementation Plan – Dec 2008 Improve dental health of vulnerable groups

(older people, prisoners and homeless people)

“NHS AA will determine good practice in the oral health of older people”

NHS QIS (2005) Best Practice Statement (BPS) Working with Dependent Older People to Achieve Good Oral Health

Raising nurses’ awareness of the need to promote good oral health

Assessment Care of the mouth and teeth Education and training

MPH Study on BPS (2006-7)Aim To describe current levels of oral care in care

homes

Explore Use that homes make of QIS BPS

Oral health assessments undertakenRole of care staff in oral assistanceStaff training Importance of oral health to managers

MPH Study on BPSResults Homes less aware of oral health BPS Assessments

Only half did within week Only quarter said staff trained

Assistance Less than half of staff trained in oral care

Care homes with Registered Nurse more likely to do assessments/training

MPH Study on BPS Overwhelming requests for:

better access to dentists to provide: “screening” emergency treatment

training on: oral health assessments oral care

Further work to be undertaken to support homes to implement current guidance

Poster

Consultants in Dental Public Health

Quality Improvement Group (QIG)Audit (2006) Older people in local oral health strategy? Oral health improvement activity?

Most areas Oral health in Single Shared Assessment? Engaging with Care Commission locally?

Most not Focus on care homes – most vulnerable

Oral health improvement activity Local projects in Scotland

Lothian - Lifesmile Fife – Care Home Award Ayrshire & Arran – North Ayrshire Pilot Highland – MSc – Home Carers

1. Establish facts about population

2. Establish facts about health status

3. Develop pilot

4. Evaluate

5. Refine project

NHS Ayrshire & Arran Oral Health Needs Assessment (2006)

North Ayrshire Pilot Project

Running since late 2007

Aims of North Ayrshire Pilot

To make referral pathway to primary care salaried dental service clearer

A5 laminated cards with phone numberCarbonised referral pads

To develop oral health risk assessments for nurses and carers

For initial and ongoing assessment

To deliver OHP training to care home and hospital staff

Include information on how to access salaried dental service Denture marking kitDaily oral care recording charts

Evaluation Ayrshire Central Hospital Phase

• Audit paperwork Aug & Dec 2007

• All initial oral assessments completed

• Compliance with 4-weekly reviews reduced over time

• Referral of patients to SDS also fell

• Documentation of daily mouthcare only partially implemented

Interim Conclusions

One-off training not sufficient Must be part of ongoing programme

All staff require trainingCascade not fully effective

Staff positive about changesBut takes time to be fully adopted

Amending and refining procedures as a result

Highland MSc - Remote and Rural Fellowship

Myra Morrison (nee O'Boyle) Lorna Macpherson Petrina Sweeney

Highland – home carers

Assessed baseline and post-oral health training knowledgeattitude behaviour

Assessed oral health status of 60 older people receiving care

Highland – home carers

Findings Little difference post-training in knowledge,

attitude or behaviour of home carers in relation to oral care

Older people receiving care showedhigh levels of edentulism - xerostomia, fungal

growth, poor denture hygieneamong dentate individuals - high levels of

plaque and caries

Highland – home carers Conclusions Despite high levels of disease, many older

people not receiving help with oral care Many reported they did not want

assistance Further work required with older people

and carers to increaseawareness of oral health understanding of attitudes

SQA Donna Kirk - NOP OHIG All care staff required to be qualified and

registered with Scottish Social Services Council (SSSC) by 2012

Potential for oral health training to be included in their generic training

Add oral health to SVQ level 2 Currently, oral health not included until

level 3

National Oral Health & Nutrition Reference Group Agree common messages

e.g. cheese, crisps Life stages – older people

MalnutritionDehydration vs. growing population of dentate older people

Mitigation – increase prevention High fluoride toothpaste, more intensive oral care

Poor OH can lead to nutritional problems

National OH & N Reference GroupDiet and nutrition advice for older people

Best practice advice for snacks and drinks in relation to oral health may not be appropriate for older people in care homes.

Oral health advice given with understanding ofdietary needs of older people risks to older people

Inappropriate advice could compromise hydration, nutrition and social enjoyment

Dehydration Loss of fluid from the body, through illness or not

drinking enough Serious consequences for health and wellbeing

of older people. Can contribute to: increased confusionconstipationpressure ulcersurine infections

Older people in care homes at increased risk of dehydration

Care Commission report - dehydration made up largest number of complaints received about eating and drinking The Care Commission (2009). Eating well in care homes for older people

Under-nutrition and unplanned weight loss Under-nutrition often unrecognised and

untreated in care homes Not enough calories unplanned weight loss. Survey - nutrition screening among people

admitted to hospitals and care homesoverall risk of under-nutrition - 28%.

BAPEN (2007). Nutrition Screening Survey in the UK in 2007: Nutrition Screening Survey and Audit of Adults on Admission to Hospitals, Care Homes and Mental Health Units.

But….could this be due to oral health problems?

Care Commission receives complaints about unplanned weight loss The Care Commission (2009). Eating well in care homes for older people

Social enjoyment

Important to take into account that eating and drinking is one of life’s pleasures

Key social opportunity for older people in care homes.

Marjorie Thomson, Nutrition Adviser, Care Commission

Care Commission Highlighted in CDPH QIG audit Meetings to discuss joint working “Three questions”

What should Care Commission staff expect to see re oral health at inspection

What does the carer need to know? What does the nurse need to know?

External Quality & Consistency Forum

Single Shared Assessment

From CDPH QIG audit Joint health and social work documentation

Wash hair?Cook meal?

Not oral health! Next national revision - 2012 SG suggested pilot in East Renfrewshire – ongoing

East Renfrewshire is test site for electronic SSA

Single Shared Assessment Oral health questions

Does the person have any of their own natural teeth?

Does the person have full and/or partial dentures?

Does the person have any problems with their mouth or teeth?

Has the person been seen by a dentist? Is the person housebound?

Single Shared Assessment Personal Care Score

A: Without difficultyB: Without difficulty using equipment or an

adaptationC: Has difficulty even if using equipment or

adaptationD: Requires prompting, guidance, supervision

or encouragementE: Cannot do without assistance from others

East Renfrewshire are evaluating

In conclusion….

Lots of work ongoing Need to keep joined up Training is important, but only first step Determine good practice Roll into National Programme