Working Across Medical – Dental Professional Boundaries in the

Management of Diabetes or Why Physicians (and other Providers) and

Dentists Need to Work Together even if They are not Spouses

Betsy Rodriguez MSN, CDE (bjr6@cdc.gov) Deputy Director NDEP

CDC Division of Diabetes Translation The findings and conclusions of this presentation are those of the presenter and

do not necessarily represent views of the Centers for Disease Control and Prevention.

Incorporating oral health into team care for diabetes prevention and lifelong

management

• By monitoring any oral infections that affect your gums and jaw, the dentist may help detect signs of early onset diabetes.

Oral health problems associated with diabetes:

– Tooth decay

– Gum disease

– Dry mouth

– Fungal infections

– Lesions in the mouth

– Taste impairment

– Infection

– Delayed healing

Diabetes as a Risk Factor forPeriodontal Disease

In people with type 1 or type 2:

• Poor glycemic control results in more severe periodontitis than

those with good control

• May develop periodontal disease sooner

• More frequent and advanced attachment and bone loss may

occur with longer duration of the disease

• Children with diabetes have more gingivitis

AAP Position Paper, 2000

National Diabetes Fact Sheet, 2005

Periodontal Infection & Diabetes

• Emerging evidence shows that the periodontal infection may effect:– Glycemic control

– Incidence and severity of some diabetic complications• Cardiovascular• Renal

Periodontal disease in diabetic patients

1) increased incidence of periodontal abscesses

2) increase gingival inflammatory reaction to

plaque

3) increase risk of periodontal disease 2.8 to 3.4

increase

4) increase severity and rate of destruction.

• There is a greater increase risk for diabetic patients to develop periodontal abscesses due to increased gingival reaction to plaque and increased risk of periodontal disease. The arrow points to the abscess

• Poor diabetic control and length of time increase risk of periodontal breakdown and increase chances of poor response to therapy.

“Periodontal diseases...

• are serious infections that, left untreated, can lead to tooth loss. Periodontal bacteria can enter the bloodstream and travel to major organs...Research is suggesting that this may:

• Contribute to the development of heart disease, the nation’s leading cause of death.

• Increase the risk of stroke.

• Increase a woman’s chance of having a preterm, low-birthweight baby.

• Pose a serious threat to people whose health is compromised by diabetes, respiratory diseases, or osteoporosis.”

American Academy of Periodontology (AAP) web site

• This unique interrelationship between periodontal diseases and systemic diseases and conditions compels dentistry to establish and maintain a “team care” program for the patients treated.

Team care

• Integrates the skills of different healthcare professionals with those of the patient into a comprehensive, lifelong, periodontal disease-management program.

The need for a better system

• To achieve the best control of periodontal diseases, treatment must be as follows:

•continuous, not irregular;

•proactive, not reactive;

•planned, not sporadic; and

•patient centered rather than provider centered

Oral Health Providers

• Alone could not possibly treat all patients. It is clear that effective treatment of

periodontal diseases requires: the 4 Cs• Communication

• Cooperation

• Collaboration among all members of the team

• Coordination of care

A multidisciplinary team

• Brings together the particular skills, knowledge, and experience of several dental healthcare professionals and other health care providers to establish and maintain the periodontal health of its patients.

• Coordination of care presents many challenges when delivered by multiple providers in a variety of settings.

Team Care Guide Now Available!Www.YourDiabetesInfo.org/TeamCare

• Developed by the National Diabetes Education Program (NDEP)

• NDEP is a joint partnership of the NIH, the CDC, and more than 200 partner organizations

The Need for Team Care

• Diabetes management requires expertise from many disciplines for optimal care

• Team care is integral to health care reform initiatives such as the Medical Home

• Demonstration projects are assessing new payment structures with positive results

• Improved quality and costs for diabetes care

Benefits of Team Care

– reduced risk factors for diabetes

– improved diabetes management

– lowered risk for complications

– efficient patient education

– improved glycemic control

– increased patient follow-up

– higher patient satisfaction

– improved quality of life

– reduced hospitalizations

– decreased health care costs

Purpose & Topics of the Team Care Guide

• Purpose: To provide a practical resource to help health care professionals and organizations implement collaborative, multidisciplinary team care for adults and children with diabetes in a variety of settings

• Topics: – Chronic Disease & the Health Care Delivery System

– What Makes a Successful Team?

– Nontraditional Team Care Approaches

– Payment & Cost-Effectiveness Data for Diabetes Education & Services

– Collaborative Care in Practice

– Real-World Case Studies

– Appendices

– Related Resources and References

Team Care Content Advisory Group• W. Lee Ball, Jr., O.D., F.A.A.O. of the American Optometric

Association • Mary Jo Goolsby, Ed.D., M.S.N., N.P-C, F.A.A.N.P. of the

American Academy of Nurse Practitioners • Amy Nicholas, Pharm.D. of the American Pharmacists

Association • Amparo Gonzalez, R.N., C.D.E., F.A.A.D.E. of the

American Association of Diabetes Educators• M. Sue Kirkman, M.D. of the American Diabetes

Association• Patti Urbanski, M.Ed., R.D., L.D., C.D.E. of the American

Dietetic Association

The Basics of Team Care• Select a key person to coordinate

• Vary team according to patients’ needs/load, organizational constraints, resources, clinical setting, geographic location and professional skills

• Augment team with community resources and support

• Expand access to team care via nontraditional approaches

What Makes a Successful Team?• Commitment/support of

organizational leadership

• Active patient and health care professional participation

• Information tracking system

• Adequate resources

• Payment mechanisms for team care services

• Coordinated communication system

• Documentation and evaluation of outcomes and adjustment of services

Helpful Materials• Appendices:

– Stratifying Care According to Patient Population Needs

– Scope of Practice for Diabetes Educators & Board-Certified Advanced Diabetes Management Practitioners

– Quality Improvement Indicators for Diabetes Care– Medicare for People with Diabetes

• Related resources from 17 NDEP partners • 109 useful references

TM

1. Healthy eating

2. Being active

3. Monitoring

4. Taking medication

5. Problem-solving

6. Healthy coping

7. Reducing risks

The AADE7 tools– help with goal setting and patient behavior

change tracking,– help set benchmarks,– assess outcomes,– demonstrate the influence of DE on diabetes

control, – offer a framework for data compilation and

research,– advance best practices in DE,

• Preliminary analysis of AADE7 data indicates that Diabetes Educators need to focus more on coping and problem solving behaviors.

Patient Education Principles

• Inform patient that periodontal infection may make it difficult to control diabetes and conversely, that poor diabetic control may increase susceptibility to infection

• Patients who have diabetes should know that they may be more likely to get gum infections and that the infection may take longer to heal. Untreated infection may lead to loss of teeth.

Prevention

• Good glucose control

• Local factors: smoking, dentures, may promote candida

• Try to preserve natural dentition

• Plaque and calculus removal

• F/U every 6 months

Resources: National Diabetes Education Program

Awareness Campaigns

Special Populations

Community Interventions

Partnership Network

Health Systems

A joint initiative of CDC and NIH

What are we?What do we do?Why do we do it?

NDEP Structure and Goals

• Joint initiative of the National Institutes of Health and the Centers for Disease Control and Prevention

• Formed after evidence showed that better glucose control translated into fewer complications

• Public and private partnerships to improve diabetes treatment and outcomes

• Increased public awareness of the seriousness of diabetes, its risk factors, and strategies for preventing diabetic complications

• Partnership with over 200 others:– State Diabetes

Prevention and Control Programs

– Professional organizations

– Businesses– Groups with a high

burden of diabetes or at increased risk for developing diabetes)

– IDF, PAHO

Overarching Program Messages

• Diabetes is serious, common, costly, yet controllable and preventable.

• Control Your Diabetes. For Life.

• Be Smart About Your Heart.

• Control the ABCs of Diabetes: A1C, Blood Pressure, Cholesterol, Smoking

• Diabetes Prevention Program message: Small Steps, Big Reward

NDEP’s Control Your Diabetes. For

Life. Campaign

NDEP Campaign Materials: Control & Prevention

PPOD is NOT a Vegetable: A CDC Resource

What is a PPOD?

• Something healthy that goes with beef or chicken

• Endamame

• Something that promotes health like a workgroup of NDEP

• Pharmacists, Podiatrists, Optometrists, Dental Professionals

PPOD provider may be the first to see a person experiencing a problem

• Patients may consult a PPOD provider before the primary care provider

• All providers need “cross-training”• Perfect opportunity to keep diabetes on

the radar screen• All providers need to give consistent

messages, recognize early danger signs, and promote the team approach

• PPOD providers are well-positioned to advise and educate their patients about diabetes control and prevention

PPOD Role in NDEP

• Unique group, not just additional “health care providers

• True team care• Need and opportunity identified:• Many people with diabetes or at risk don’t

access a primary care provider• Many seek services of PPOD provider for

diabetes-related concerns• PPOD well-positioned to deliver NDEP

messages

Visits to PPOD providers (Pharmacy, Podiatry, Optometry and Dentistry)

• Nearly 84 million adults use prescription medicines

• Approximately 50% of adults have a personal pharmacist

• About 5% of the population visits a podiatrist each year

• More than half the US population wears corrective lenses

• Approximately 2/3 of Americans see a dentist at least once a year

Example

• Person with type 1 DM, well controlled, now has elevated blood glucose

• Usual causes (diet, activity etc- ruled out)

• New tooth ache, new dental abscess

• Dentist/Oral surgeon calls the Endo to consult on timing and ‘other considerations’ before procedure

• “Diabetes can lead to changes in the oral cavity”

• “Caring for the mouth is often overlooked when trying to control

other problems associated with diabetes.”

• “Good oral health can help control diabetes – and controlling the

blood glucose level can improve oral health.”

• Working Together to Manage Diabetes, produced by the

Pharmacy, Podiatry, Optometry and Dentistry Work Group of the

National Diabetes Education Program (NDEP)

http://ndep.nih.gov.materials/pubs/team-care/team-care.htm

PPOD Primer• Focus on comprehensive,

interdisciplinary diabetes care• Section on “What You As A

Health Care Provider Care Do” for all HCP

• Educate PPOD providers so they can educate patients in turn

• Sections specific to each discipline:– Key issues in each PPOD

discipline– Recommendations RE

referrals– Expanded information on

PPOD provider’s role

PPOD Primer Key Messages

• Recommend routine exams for

complication prevention: oral health,

comprehensive foot, dilated eye

• Reinforce self-exams

• Recognize danger signs

• Dentists’ role in diabetes care team

• Importance of metabolic control (ABCs)

Caveat!

• Quick “crash course” on each specialty and its relation to diabetes

• Each section is written for the OTHER providers to read.

• Your own section may seem “simplistic”.• Goal: Consistent messages across the

disciplines• Goal: Encourage collaboration, Team

approach

Primer dissemination• Work group members, State DCPCs

• Professional associations

• At continuing education programs

• Professional meetings

• Advertised in professional journals

• NDEP website

• NDIC Clearinghouse

• HIS, VA

PPOD Poster

Checklist

• Increase communication among multiple providers

• Educate people with diabetes about needed exams

• Do dentists play a role in diagnosis and treatment?

• Pay for performance measures

PPOD Checklist

PPOD Patient Checklist Pilot Testing

• The PPOD WG conducted a pilot test of a Multidisciplinary Patient Care Checklist.

• Individual WG members sent the checklist to co‐workers and colleagues, and invited them to comment via an online Survey Monkey questionnaire.

• The goal of the pilot was to gauge whether the checklist would be useful, and used, in a real‐world clinical setting.

PPOD Checklist Testing

• Most respondents agreed the content was appropriate and presented clearly.

• 74.3% responded that they were likely to change their practice to more of a team approach, incorporating the members of the team, or by referral.

• Survey responses revealed that the checklist is useful in actual practice, with many (30%) indicating its potential application in EMR/EHR systems.

How do I get NDEP materials?

All NDEP materials are copyright-free. Download from

www.yourdiabetesinfo.org

Visit all of the NDEP Web sites:

www.ndep.nih.gov www.betterdiabetescare.nih.gov

www.cdc.gov/diabetes/ndep

www.diabetesatwork.org