Quality Initiatives in Quality Initiatives in Oral HealthOral Health

A topic you can sink your A topic you can sink your teeth into!!teeth into!!

Suzanne Boulter, MDSuzanne Boulter, MD

South Carolina Chapter MeetingSouth Carolina Chapter Meeting

July 23, 2011July 23, 2011

Bright Futures Bright Futures RecommendationsRecommendations

•Oral health risk assessment performedOral health risk assessment performed

•Anticipatory guidance givenAnticipatory guidance given

•Fluoride modalities addressedFluoride modalities addressed

•Referral to dental home makeReferral to dental home make

Measures for SC ProjectMeasures for SC Project

1.1. Was an oral health risk assessment done and Was an oral health risk assessment done and documented between 12 and 36 months?documented between 12 and 36 months?

2.2. Did you refer the patient to a dental home?Did you refer the patient to a dental home?

3.3. Did you apply fluoride varnish to a high risk patient Did you apply fluoride varnish to a high risk patient between 12 and 36 months of age?between 12 and 36 months of age?

4.4. Have you documented a discussion about fluoride in Have you documented a discussion about fluoride in the family’s water source?the family’s water source?

                                               

   

Opportunities for Microsystems Improvement

THE PDSA CYCLE

Defining an Aim: Defining an Aim: Examples in Oral Health Examples in Oral Health for SCfor SC

•By December 1By December 1st st 2011, using an oral 2011, using an oral health risk assessment tool, screen health risk assessment tool, screen 100% of 12 to 36 month old patients at 100% of 12 to 36 month old patients at health supervision visits to identify health supervision visits to identify those at high risk.those at high risk.

•By December 1By December 1stst 2011, refer 100% of 2011, refer 100% of high riskhigh risk patients to a dental home patients to a dental home with tracking of compliancewith tracking of compliance

More ExamplesMore Examples

•By December 1By December 1stst 2011, perform fluoride 2011, perform fluoride varnish application on 75% of high risk varnish application on 75% of high risk children as identified by the oral health risk children as identified by the oral health risk assessment.assessment.

•By December 1By December 1stst 2011, test and document 2011, test and document all well water fluoride levels in households all well water fluoride levels in households without public water supplywithout public water supply

Pick a Measurement then Pick a Measurement then Brainstorm and Map ProcessBrainstorm and Map Process• Oral Health Risk Assessment screening doneOral Health Risk Assessment screening done

• Fluoride varnish appliedFluoride varnish applied

• Referral to dental homeReferral to dental home

• Order and track well water fluoride test resultsOrder and track well water fluoride test results

Example of Mapping ProcessExample of Mapping Process

Patient calls For appt.

Patientarrives

MA roomspatient

Provider visitwith patient

Fluoride varnishapplied if OHRA

positive Patient leaves

Provider does

screening

MA putsmaterials in room

List ofDentists

given

MA givespatient

informationabout OHRA

Using Tools to Address Your Using Tools to Address Your QuestionsQuestions

1) Was Oral Health Risk 1) Was Oral Health Risk Assessment Done?Assessment Done?

• Caries Risk Caries Risk Assessment Tools:Assessment Tools: - Bright Futures CAT tool- Bright Futures CAT tool– AAPD CAT AAPD CAT

www.aapd.org– American Dental American Dental

Association CAT (not Association CAT (not finalized yet) finalized yet) www.ada.org

• AAP Policy AAP Policy Statements on Oral Statements on Oral HealthHealth– Pediatrics May Pediatrics May 20032003– Pediatrics December, Pediatrics December,

20082008

On line trainings:

•www.aap.org/oralhealth/smilesforlife

– Free on line trainingFree on line training– Endorsed by AAPEndorsed by AAP– Six chapters; 3 of Six chapters; 3 of

importance for importance for pediatricianspediatricians

• www.aap.org/oralhealth/pact/index

RISK FACTORSPROTECTIVE

FACTORSCLINICAL FACTORS

Has mother or primary caregiver had active decay in the past 12 months? Yes □ No □ Does mother have a dentist? Yes □ No □ Other Risk Factors: Yes No□ □ Continual bottle/sippy cup use with fluid other than water□ □ Frequent snacking □ □ Special health care needs□ □ Low SES or health literacy/Medicaideligible

Yes No□ □ Existing dental home□ □ Drinks fluoridated water or takes F supplements□ □ F varnish in the last 6 months□ □ Child has teeth brushed daily   

□ White spots or visible decalcifications

□ Obvious decay□ Restorations present□ Visible plaque

accumulation□ Gingivitis

(swollen/bleeding gums)

□ None □ No Teeth Present 

Caries Risk: Low High Completed: Anticipatory Guidance Fluoride Varnish Referral to_________________

Goals: 

Oral Health FlipchartOral Health Flipchart

eQIPP Module on Bright eQIPP Module on Bright FuturesFutures

• Released August 2010Released August 2010

• QI areas recommendedQI areas recommended– Elicit and Address Patient/Family Concerns and Elicit and Address Patient/Family Concerns and

NeedsNeeds– Perform Risk Assessment and Medical ScreeningPerform Risk Assessment and Medical Screening– Perform Developmental Surveillance and ScreeningPerform Developmental Surveillance and Screening– Address maternal depression (birth -36)Address maternal depression (birth -36)

– Promote Oral Health (birth -36)Promote Oral Health (birth -36)

eQIPP Module on Bright eQIPP Module on Bright FuturesFutures

– Screen for Screen for ChlamydiaChlamydia– Implement a strength based approachImplement a strength based approach– Provide Anticipatory GuidanceProvide Anticipatory Guidance– Utilize a Recall Reminder SystemUtilize a Recall Reminder System– Promote Community Relationships and Promote Community Relationships and

ResourceResource– Case Studies: Case Studies: Oral HealthOral Health, Teen , Teen

Driving, Foster CareDriving, Foster Care

Data Collection Tools – Some Data Collection Tools – Some ExamplesExamples

• Paper chart toolsPaper chart tools

• Electronic MedicalElectronic Medical

Record toolsRecord tools

Healthy Teeth for Tots: Pediatrician Risk Assessment Tool

Age:_________ Screening Site: Peds / WIC / Other:__________________ Race / Ethnicity: White Asian Mexican/Hispanic Black Other:___________ Child’s Primary Care Physician (if applicable):_______________________________ PARENTAL QUESTIONS Family Dental History / Access Y / N Does your child have any cavities or problems in his / her mouth? (if yes,

explain) Y / N Have any of your other children experienced cavities or problems with their

mouth when they were younger than 6 years? Y / N Has your child even been to see a dentist? Y / N Have you had experience with cavities or other problems with your mouth? Feeding Y / N Does your child still carry around a bottle / sippy cup? If YES, what is in it? __________________________ Y / N Does your child go to bed with the bottle? If YES, what is in it?__________________________ Y / N Does your child snack on cookies or candy often? Does your child drink TAP or BOTTLED water? (circle appropriate answer) Brushing / Fluoride Y / N Does an adult help to brush your child’s teeth each day? Y / N If YES, do you use toothpaste with fluoride in it?

INTRAORAL FINDINGS: How many teeth are present? __________ Check all observed conditions: ___ Chalky-white spots ___ Excessive plaque @ gum-line Early childhood caries (ECC)**: ___ MISSING

___ DECAYED ___ FILLED

** Child is HIGH-RISK if any ECC conditions OR chalky white spots are present** RECOMENDATIONS Child has been evaluated & determined: ___ At-Risk, Anticipatory guidance given, follow-up scheduled for preventive measures Needed (circle): Gum/tooth cleaning, Fluoride varnish application ___ High-Risk, Anticipatory guidance given, referred to pediatric dentist for more extensive treatment (fillings, tooth extraction, sealants, etc.) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Following evaluation, Parent / Child given: ____ Anticipatory Giudance ____ Toothbrush, etc. ____ Oral Health fact sheet NOTES:

Revised: 11/8/04 (jdd)

2) Was the Patient Referred 2) Was the Patient Referred to a Dental Home?to a Dental Home?• First dental visit should take place at 1 year; earlier First dental visit should take place at 1 year; earlier

if patient is at high riskif patient is at high risk

• Develop list of dentists who will accept patients this Develop list of dentists who will accept patients this ageage

• Include office phone numbers and addressesInclude office phone numbers and addresses

• Refer Medicaid patients to state web site or phone Refer Medicaid patients to state web site or phone line if no accessline if no access

3) Was Fluoride Varnish 3) Was Fluoride Varnish Applied?Applied?• Offer to patients at high riskOffer to patients at high risk

• Evidence for up to 35% decreased cariesEvidence for up to 35% decreased caries

• Apply and bill per your state Medicaid Apply and bill per your state Medicaid guidelinesguidelines

• Give information sheet about what to do after Give information sheet about what to do after applicationapplication

Office Tools for OHRA and Office Tools for OHRA and Varnish Application Varnish Application

Medicaid Codes and Medicaid Codes and ReimbursementReimbursement

• Fluoride varnish D 1206 $12 - $53Fluoride varnish D 1206 $12 - $53

• Oral evaluation new pt D 0145 $29 - $56Oral evaluation new pt D 0145 $29 - $56

• Oral evaluation est pt D 0120 $20 - $27Oral evaluation est pt D 0120 $20 - $27

• Age limit – varies; ages 6 months to 5 yearsAge limit – varies; ages 6 months to 5 years

• Number of varnish applications reimbursed Number of varnish applications reimbursed annually – 2- 4annually – 2- 4

• Training required – varies; state specificTraining required – varies; state specific

• Delegation of procedure (NP, RN, LPN, CMA) Delegation of procedure (NP, RN, LPN, CMA) about 2/3 of states allow about 2/3 of states allow

4) Did You Document a 4) Did You Document a Discussion About Fluoride in Discussion About Fluoride in the Patient’s Water Source?the Patient’s Water Source?

Identify Potential Systems Identify Potential Systems SolutionsSolutions

• Train everyone in practice on OHRATrain everyone in practice on OHRA

• Choose coordinatorChoose coordinator

• Determine staff roles for screening, Determine staff roles for screening, counseling, referral and varnishcounseling, referral and varnish

• Have supplies in kitHave supplies in kit

• Store kit in central locationStore kit in central location

• Screen for needed services at every visitScreen for needed services at every visit– Close K, Rozier G, Zeldin L, Gilbert A.Barriers to the adoption and Close K, Rozier G, Zeldin L, Gilbert A.Barriers to the adoption and

implementation of preventive dental services in primary medical implementation of preventive dental services in primary medical care. care. PediatricsPediatrics 2010;125:509-517 2010;125:509-517

Pilot Study ResultsPilot Study Results

•Brightening Oral Health Brightening Oral Health Bright Futures Bright Futures Implementation Project Implementation Project 20102010

• Funded by Proctor & GambleFunded by Proctor & Gamble

Project DetailsProject Details

• Initial QUINN practice pilot doneInitial QUINN practice pilot done

• 10 sites chosen to test OHRA tool as 10 sites chosen to test OHRA tool as part of QI Brightening Oral Health part of QI Brightening Oral Health project project

• Pre test survey of practicesPre test survey of practices

• Post project survey of data Post project survey of data completedcompleted

Clinician Agreement on Oral Clinician Agreement on Oral HealthHealth

100 100

57

71

86

71

0

20

40

60

80

100

Pre Test Post Test

Assess 6, 9, 12 month oldchildren f or dental caries

Assess maternal oral health

Ref er all 12 month olds toa dental home

Practice Has a System to Practice Has a System to Document OHRADocument OHRA

• Our practice has a system in place Our practice has a system in place to document oral health to document oral health risk assessmentrisk assessment..

75%

11%

25%

89%

0

20

40

60

80

100

Pre Test Post Test

Yes

No

Practice Has a System and Can Practice Has a System and Can Identify High Risk PatientsIdentify High Risk Patients

• My practice has a system to My practice has a system to identify high risk patientsidentify high risk patients for an oral health referral for an oral health referral

11%

87.5%

12.5%

89%

0

20

40

60

80

100

Pre Test Post Test

Yes

No

System to Apply Fluoride VarnishSystem to Apply Fluoride Varnish

Pre Test Data

33%Yes

No

Post Test Data

50%Yes

No

Easily Accessible Dental Referral Easily Accessible Dental Referral List in my OfficeList in my Office

Pre Test Data

22%

78%

Yes

No

Post Test Data

13%

87%

Yes

No

Responsible for Regularly Responsible for Regularly UpdatingUpdating

Pre Test Data

67%

33%Yes

No

Post Test Data

62%

38%Yes

No

Someone responsible for regularly updating practice’s oral health list

Brightening Oral Health Study Brightening Oral Health Study ConclusionsConclusions

• Practice teams employing a system Practice teams employing a system to document oral health risk to document oral health risk assessments assessments increasedincreased significantly significantly

• Practice teams utilizing a system to Practice teams utilizing a system to identify high risk patients for an oral identify high risk patients for an oral health referral health referral increasedincreased significantly significantly

SummarySummary

• Bright Futures and AAP Policy Statements Bright Futures and AAP Policy Statements recommend:recommend:– OHRAOHRA– Anticipatory guidanceAnticipatory guidance– Assessment of fluoride modalitiesAssessment of fluoride modalities– Referral to dental homeReferral to dental home

South Carolina data will help South Carolina data will help determine feasibility of including determine feasibility of including oral health recommendations in a oral health recommendations in a busy practice setting!!!busy practice setting!!!