YOUR VALUE-BASED ORAL HEALTH PROGRAM: STRATEGIES FOR SUCCESS

South Carolina Primary Care

Association

January 24, 2019

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Pre-Training Evaluation & Download Materialswww.surveymonkey.com/r/SCPRE

Go to https://www.dentaquestinstitute.org/learn/online-

learning-center/resource-library/south-carolina-pca-2019 to

download today’s training materials

Download the presentation, activities and handouts

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Oral Health Value-Based Care Training

Academy

The DentaQuest Partnership for Oral Health Advancement’s Oral Health

Value-Based Care (OHVBC)team is a nationally recognized leader in

practice management consulting and training.

For the last several years, the OHVBC team, operating as Safety Net

Solutions under the former DentaQuest Institute, has been offering

customized training opportunities for national, regional and local

organizations dedicated to professionals working in the oral health

safety net

These trainings have led to the development of a new program, the Oral

Health Value-Based Care Academy.

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SNS has worked with over 500 dental programs

in 45 states & DC

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Oral Health Value-Based Care Team

Mark

Doherty,

Executive

Director

Danielle

Apostolon,

OHVBC

Training

Specialist

Dori

Bingham,

Practice

Improvement

Specialist

Caroline

Darcy,

Technical

Assistance

Project

Manager

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DentaQuest Partnership

The DentaQuest Partnership, a not-for-profit organization,

engages in grantmaking, research, care delivery

improvement programs, and collaborations that transform

the current broken system to achieve better health through

oral health.

By prioritizing the transition to person-centered health, the

DentaQuest Partnership will drive forward as a leading

voice for positive change at the local, state and national

levels in support our common mission to improve the oral

health of all.

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Today’s Objectives:

After this training, participants will:

• Recognize the top ten areas for defining FQHC dental program

success and identify essential components to developing a business

plan for FQHC dental programs.

• Establish key dental policies and procedures for managing an

efficient and effective FQHC dental program.

• Measure dental program capacity and understand its impact on

access to care.

• Set realistic and achievable financial and productivity goals.

• Continuously monitor dental program performance.

• Develop effective policies and procedures for managing broken

appointments and emergencies.

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Today’s Objectives Cont.

• Design a strategic scheduling template to maximize access and

dental program financial viability.

• Develop strategies to achieve integrated care.

• Develop an improvement plan for success.

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AgendaSession One: Laying the Groundwork –

Fundamentals of Operating an FQHC Dental

Program

Dr. Scott Wolpin, Chief Dental Officer,

Eastern Shore Rural Health System, Inc.

Session Two :Measuring Dental Program

Productivity in Access and Finance

Danielle Apostolon, OHVBC Training

Specialist

BREAK

Exercise: Developing Financial and

Productivity Goals

Danielle Apostolon, OHVBC Training

Specialist

Session Three: Strategic Scheduling and

Managing Chaos

Dori Bingham, Practice Improvement

Specialist

LUNCH

Session Four: Comprehensive Health Center

Integration to Improve Overall Health

Dr. Scott Wolpin, Chief Dental Officer,

Eastern Shore Rural Health System, Inc.

Session Five: Creating the Improvement Plan

for Success

Danielle Apostolon, OHVBC Specialist

CLOSING/WRAP UP

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SESSION 1: LAYING THE GROUNDWORK

Dr. Scott Wolpin

Redesign Dental for Maximum Efficiency

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Chief Dental Officer of Eastern Shore Rural Health System

Expert Advisor for Safety Net Solutions

Health Center Dental Director for more than 25 years

Scott Wolpin, DMD

Safety Net Solutions Expert Advisorswolpin@mchsi.com

President, Board of Directors, National Network for Oral Health Access (NNOHA)

Past President, Board of Directors, Association of Clinicians for the Underserved

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LEARNING OBJECTIVES

•Discuss the key elements to success for a FQHC dental

program.

•Outline the essential components of developing a business

plan for a FQHC dental program.

•Review national data that demonstrates what other safety

net dental programs are doing.

•Review key dental policies and procedures for managing

an efficient and effective FQHC dental program.

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What we don’t want today to be…

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Dental Leadership is really about you knowing

where you are going and

how you are going to lead your team there.

“Extreme ownership requires leaders to look at organization challenges through an objective lens, without emotional attachments to agendas or plans. It mandates that a leader set ego aside, accept responsibility for failures, tackle the challenges, and consistently work to build a better and more effective team. Such a leader, however, does not take credit for his or her team’s successes but bestows that honor upon rising leaders and team members.”

Concept of Dental Leadership

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What does Success look like?

“The ability to generate resources to meet the needs of the

present without compromising the future”

So …Success = Financial Sustainability

from Our Common Future, also known as the Brundtland

Report: International Institute for Sustainable Development

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Success =

• Happy, healthy patients and staff

• Providing quality oral health care, managing chaos

• Assuring a budget neutral bottom-line: with or without

grant funding?

• Collaborating with others in the community to meet

patient needs

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So how do we get there?

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Top Ten Priorities for Dental

1. Understanding What Success Should Look Like in Dental

2. Compiling data that is: Accurate, Meaningful and Timely

3. Computing and understanding your actual “Capacity”

4. Setting clear Goals, Roles, Responsibilities and Timelines

5. Utilizing the dental schedule strategically

6. Having the right policy for “Everything”

7. Owning management of Broken Appointments and Emergencies

8. Creating a “Culture of Accountability”

9. Executing a CQI and QA System

10. Teaching Executive Leadership how to best enable and support Dental

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MEDICAL DENTAL

Are Different!

Different Care Plan and Different

Business Plan

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Medical

20% of clinic volume

80% of visits = varied

80% of visits = longer

80% of billing varied

80% of visits treatment

80 % of RVU different

0% of governance is designed around dental

EDR silo

Not familiar with dental model

Lack of confidence

80% of clinic volume

80% of visits = similar

80% of visits = shorter

80% of billing similar

80% of visits diagnostic

80% of RVUs similar

100% of governance is designed around medical

EMR silo

Familiar with medical model

Confident leadership

Dental

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Capacity=Quality

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Defining Capacity

We are limited by our structure

o Chairs-Rooms-Operatories, Dentists,

RDHs, DAs, Staff, Hours of Operation

Our structure determines our capacity, not our hearts

We cannot be all things to all patients

We only have 20% of the capacity of Medicine

Understanding and defining capacity is essential to the

creation of the dental business plan

We need to decide WHO gets the care by creating priority

populations

Equitable, quality care mandates that

we work within our capacity

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DentaQuest Online Learning Center

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Defining Capacity

• We are limited by our structure

• Chairs-Rooms-Operatories, Dentists,

RDHs, DAs, Staff, Hours of Operation

• Our structure determines our capacity, not our hearts

• We cannot be all things to all patients

• We only have 20% of the capacity of Medicine

• Understanding and defining capacity is essential to the creation of

the dental business plan

• We need to decide WHO gets the care by creating priority

populations

Equitable, quality care mandates that

we work within our capacity

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2,500-3,200encounters/year/FTE dentist

2,700 encounters/year with 1,100 patient

base/dentist

1.7 patients/houror 13.6 patients/day/dentist

Access Benchmarks

2.6 Visits/Year/Patient

2 Chairs/dentist (3:1 is ideal)

1.5 Assistants/dentist (1 DA per chair is ideal)

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1,300-1,600encounters/year/FTE hygienist

230 work days/year (or 1,600 work hours/year after

holidays and vacations)

2 ADA coded servicesas the diagnostic part of a recall or comprehensive visit (exam, FMX)

1.2patients/hour/hygienist

or 10 patients/day/hygienist

5 days/week x 46 weeks = 230 work

days/year

Access Benchmarks

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15% Broken Appointment Rate

<10% Emergency Rate

33% Comp TX. Plan is Fair

#New Patients = #Completed Treatment

Plans

Access Benchmarks

Booking out 30-45 days

Designated AccessScheduling

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$200 average cost per encounter (UDS 2017)

330 Allocation = Average of 15%

Gross Charges =

>$500K-$600K per dentist per year

% of total A/R due past 90 days =

10-15%

95% Collection Rate

Financial Benchmarks

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$40Nominal fee

3 Slide Categories100-199% FPG

Full Fee Schedule70-80% of UCR

Financial Benchmarks

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FQHC Budget Breakdown

Total Budget: 100%• Dental Practice Overhead: 70-85%

• See breakdown below*

• Allocation for Administrative Costs: 5-10%

• Costs for CEO, CFO, COO, etc.

• Health Center Support Allocation: 10-20%

• Costs for Human Resources, Security, Medical records, IT, etc.

Breakdown of the 70-85% Dental Practice Overhead:• Payroll (salary, taxes, & fringe benefits): 68%

• Lab fees: 5%

• Office Supplies: 2%

• Depreciation: 4%

• Dental Supplies: 7%

• Repairs: 2%

• Marketing/Promotion: 1%

• Recruitment: 1%

• Building, Utilities, telephone: 9%

• Continuing Education: 1%

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• 27.1 million unduplicated FQHC patients

• 84.2% accessed medical services (22.9 million patients)

• 22.5% accessed dental services (6.1 million patients)

– Dental capacity is a little over 1/4th of medical capacity

• 2,599 visits/year/FTE Dentist

• 1,180 visits/year/FTE Dental Hygienist

• 902 visits/year/FTE Dental Therapist

• 2.6 visits/year per unduplicated dental patient

• Average cost/visit in dental = $200 per visit

• Average admin cost allocation to dental = 12.8%

• Sealant metric average = 50.7%

2017 FQHC UDS National Averages

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The Business Plan

GOVERNANCE

QUALITY

Productivity in Access-Finance-Outcomes

We get what we measure

We get the results we tolerate

We now establish productivity goals for the

program as a unit and for each individual

Remembering: Clarity around Goals, Roles,

Responsibilities and Timelines establishes how

we will hold the program and each individual

Accountable

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Strategies to Set Goals

Defining Capacity

Utilizing Benchmarks

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Setting Goals

AccessTotal

number of visits

Number of unduplicated

patients

Number of new patients

Provider Productivity

Visits/dayProcedures/

visit

Expected net revenue/day

Quality Outcomes

Percentage of completed Phase 1 treatment plans

Percentage of high and moderate risk children ages 6-

9 who received at least one sealant

Financial Outcomes

Gross charges

Net revenue & expenses

Bottom line

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Scope of Service Benchmarks

Service Type Procedure Codes % of

Total

Diagnostic D0100-D0999 (excluding

D0140)

30-40%

Preventive D1000-D1999 25-35%

Restorative D2000-D2999 18-25%

Endodontics D3000-D3999 1-2%

Periodontics D4000-D4999 2-5%

Removable Prostho D5000-D5899 1-3%

Fixed

Prosthodontics

D6200-D6999 <1%

Oral Surgery D7000-D7999 5-10%

Emergency D0140, D9110 2-6%

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Access is everything associated with the visit:

VisitMeasures

Services: Type – diagnostic, preventive, therapeutic, specialty

How many services by ADA code?

Charges for the services

Revenue received for the charges

Health Outcomes as a result of the services

Quality of the services and of the customer service

Compliance with Governance

Safe-Equitable-Efficient-Effective-Timely-Patient Centric

AccessOutcomes

Health Outcomes

Oral Health Outcomes

Financial Outcomes

HRSA Goal Outcomes

Treatment Plan Completion Outcomes

Focus Population Care Outcomes

Access

Not Just Visits!

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Creation of a high-quality, affordable, oral health program

that documents the improvement of the oral health status

of the patients we treat while being financially responsible

Finance

Vision

What the dental practice needs to accomplish

to be financially sustainable, maximize patient access and

provide meaningful quality outcomes

Financial Plan

REMEMBER: Knowing who you are and being able

to define that with data; defining who you want to be and

what success looks like for you; creating a simple and

clear plan to achieve that success and then

communicating that plan to the team and thus creating a

culture of accountability is the road to accomplishing

financial success

The Profitand Loss

If I had only one report!

Success in Finance, Outcomes & Quality

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• HRSA Sealant Measure Compliance for FQHCs

• Completion of phase 1 treatment plans

• Children seen 0-5 years old

• Children seen getting a preventive service

• #Fluoride Varnish applications

• Pregnant women seen and treated

• Diabetic patients with HbA1C > 7 seen

• Patients seen who have not been seen for 12 months

• Patients seen getting a Risk Assessment

• Patients with moderate or high risk who lower risk at recare

• #Sealants provided

http://www.nnoha.org/nnoha-content/uploads/2015/12/Demystifying-HRSA-SEALANT-PRESENTATION_FINAL.pdf

Outcomes

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• Quality Management System

• Quality Assurance Policy and Tool

• Continuous Quality Improvement Policy

• Dental Quality Compliance Officer

• Dental Representation on FQHC CQI team

• Credentialing Policy

• Privileging Policy/Competencies

• Policy and Procedure Manual

• Patient Satisfaction Survey (At least 1X year)

Quality

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• Compliance with Federal, State and Local Regulations

and with the State Practice Act

• Credentialing Policies and CEU Compliance

• Privileging Policy/Competencies

• Annual Safety/Infection Control/Hazardous Waste

Training

• Preparation for a OSV/Regulatory Site Visit

• After Hours Coverage Policy

• Extended Service Hours

• Malpractice, Liability Policies & Coverage/Gap Insurance

• FTCA Deeming/Annual Redeeming/Compliance

Governance

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Aligning with HRSA Governance

Accessibility to Patients

• Provides services at times and locations that assure accessibility

and meet the needs of the population to be served.

• Provides professional coverage for medical emergencies during

hours when the center is closed.

Fees and Sliding Fee Schedule Discounts

• System in place to determine eligibility for patient discounts

adjusted on the basis of the patient’s ability to pay.

Quality Management

• Ongoing Quality Improvement/Quality Assurance (QI/QA) program

that includes clinical services and management, and that maintains

the confidentiality of patient records.

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Aligning with HRSA Governance

Program Performance

• Systems which accurately collect and organize data for

program reporting & which support management decision

making.

Billing and Collections

• Systems in place to maximize collections and reimbursement

for its costs in providing health services, including written

billing, credit and collection policies and procedures.

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We Get the ResultsWe Tolerate

What We Measure

Gets Done

Remember……..

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QUESTIONS/DISCUSSION

SESSION 2: PLANNING FOR DENTAL PROGRAM SUCCESS Access and Finance

Danielle Apostolon

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LEARNING OBJECTIVES

• Recognize the key practice

• Learn the calculations to use with the

data

• Setting access, financial & outcome

goals

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What Does Success Look Like to

You?• Serve our community by providing access to high quality,

affordable dental services

• Generate enough revenue to cover our expenses

• Patients and staff are satisfied

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Data to Evaluate Program

Performance• Number of visits • Number of unduplicated

patients• Number of new patients• Procedures by ADA code• Procedures per visit• Broken Appointment rate• Emergency rate• Gross charges• Total expenses (direct and

indirect) • Net revenue (including all

sources of revenue)

• Expense per visit• Revenue per visit• Aging report past 90 days• Payer and patient mix• Percentage of completed

treatments• Percentage of children

needing sealants who received sealants

• HRSA Sealant metric

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Capacity=Quality

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Define Capacity

Capacity is defined by Structure:

• Number of operatories

• Hours of operation

• Number and types of staff

• Utilization of Benchmarks and SNS Tools

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Benchmark Guide

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Example

Staff and Operatories:

• 2 FTE General Dentists

• 3.0 FTE Dental Assistants

• 1 FTE Hygienist

• 5 Operatories

• Each Dentists works out of 2 Ops

Hours:

• Monday through Friday 8:00-5:00 (1 hour lunch)

• 8 clinical hours per day

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Determining Capacity Goals Based

on Our Structure

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# of

Providers

# of total

clinical hours

worked

x recommended

# of visits/

clinical hour

Potential

Daily Visit

Capacity

Mon. 2 16 1.7 27

Tues. 2 16 1.7 27

Wed. 2 16 1.7 27

Thurs 2 16 1.7 27

Fri 2 16 1.7 27

Potential Weekly Capacity = 135 Dentist Visits

Actual

Visits

% of

Capacity

Achieved

20 74%

26 96%

19 70%

18 66%

10 37%

*At least two operatories and 1.5 dental assistants

Setting Productivity/Access Goals: Visits

Potential vs. Actual – FTE Dentists

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# of

Providers

# of total

clinical hours

worked

x recommended

# of visits/

clinical hour

Potential

Daily Visit

Capacity

Mon. 1 8 1.2 9

Tues. 1 8 1.2 9

Wed. 1 8 1.2 9

Thurs 1 8 1.2 9

Fri 1 8 1.2 9

Potential Weekly Capacity = 45 Hygiene Visits

Actual

Visits

% of

Capacity

Achieved

7 77%

8 89%

6 66%

7 77%

6 66%

*Benchmark of 1.2 is ideal for a practice with a patient mix of both adults and children

Setting Productivity/Access Goals: Visits

Potential vs. Actual – FTE Hygienists

WHY?

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GOAL CALCULATION TARGET

Visits/Day 27 Dental Visits + 9 Hygiene Visits = 36 visits

per day *same for each day

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Visits/Week 135 Dental Visits + 45 Hygiene visits = 180

visits per week

180

Visits/Year 180 weekly visits x 46 weeks = 8,280 Visits 8,280

Dental Visits Based on Capacity

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Only fill in peach

colored cells Provider Type

General

Dentist A

General

Dentist B

General

Dentist C

Pediatric

Dentist Resident RDH A RDH B

Visit per Hour Benchmark 1.7 1.7 1.9 1

Daily Clinical Provider Hours 7 7 8 7 Monday 46 50 4

Visits 11.9 11.9 0 15.2 0 7 0

Daily Clinical Provider Hours 7 7 7 Tuesday 30.8 32 1.2

Visits 11.9 11.9 0 0 0 7 0

Daily Clinical Provider Hours 7 7 7 Wednesday 30.8 33 2.2

Visits 11.9 11.9 0 0 0 7 0

Daily Clinical Provider Hours 7 9 7 Thursday 34.2 35 0.8

Visits 11.9 15.3 0 0 0 7 0

Daily Clinical Provider Hours 7 7 7 Friday 30.8 32 1.2

Visits 11.9 11.9 0 0 0 7 0

Daily Clinical Provider Hours 4 4 Saturday 10.8 11 0.2

Visits 6.8 0 0 0 0 4 0

Weekly Visits per Provider 66.3 62.9 0 15.2 0 39 0 Weekly Visit Goal 183.4

Enter number of

weeks/year 46

Yearly Visit Goal 8436.4

Daily Provider Visit Goals Clinic Productivity Goals

Day of the Week Daily Visit Goal Actual Visits Variance

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

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# of

Providers

# of total

clinical

hours

worked

x recommended

# of visits/

clinical hour

Potential Daily Visit

Capacity

Mon. 2 16 1.4 22

Tues. 2 16 1.4 22

Wed. 2 16 1.4 22

Thurs 2 16 1.4 22

Fri 2 16 1.4 22

Potential Weekly Capacity = 110 Dentist Visits

2 Dentists each working out of 2 Operatories with 1 dental assistant

Model 1

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Potential Weekly Capacity = 135 Dentist Visits

2 Dentists each working out of 2 Operatories with 1.5 dental

Model 2

# of

Providers

# of total

clinical

hours

worked

x recommended

# of visits/

clinical hour

Potential Daily Visit

Capacity

Mon. 2 16 1.7 27

Tues. 2 16 1.7 27

Wed. 2 16 1.7 27

Thurs 2 16 1.7 27

Fri 2 16 1.7 27

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Cost of Adding Dental Assistant

$16/hour x 40 hrs = $640/week

Fringe benefits @ 25% = $160

Total cost = $800/week

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Additional 25 Visits per week

• 20% Self pay visits = 5 @ $40 = $200

• 65% Medicaid visits = 17@ $135 = $2,295

• 10% Commercial Insurance = 3 @ $165 = $495

• 5% Homeless (Free Care) = $0

• Total Revenue = $2,990 - $900 (cost of adding a Dental Assistant)

Weekly profit = $2,090

Yearly profit = $108,680

Increases access by providing nearly 1,150 additional visits for the year!

Cost vs. Benefit of Adding Dental

Assistant

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Dental Procedures

Benchmark for Procedures per Visit: 2.5

Total the number of procedures by ADA code and divide that by the total number of yearly visits

• Total annual visits = 3,600

• Total procedures by ADA/CDT code = 4,000

• 4,000/3,600 = 1.1 procedures per visit

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Scope of Service BenchmarksService Type Procedure Codes % of

Total

Diagnostic D0100-D0999 (excluding

D0140)

30-40%

Preventive D1000-D1999 25-35%

Restorative D2000-D2999 18-25%

Endodontics D3000-D3999 1-2%

Periodontics D4000-D4999 2-5%

Removable Prostho D5000-D5899 1-3%

Fixed

Prosthodontics

D6200-D6999 <1%

Oral Surgery D7000-D7999 5-10%

Emergency D0140, D9110 2-6%

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What Happens at the Visit

TimeProviders level of competency

Patient need

Patient tolerance

Reimbursement

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Balancing the Mission and Margin:

Expenses Revenue

• Visits

• Payer mix

• Grants and donations

• Staff and Resources

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Define what Financial Success

Looks Like:• Create a profit?

• Break even or zero variance?

• With grants or without grants?

• Willing to accept a loss? If so how much?

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Net Revenue

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Individual Production GoalsProvider FTE Gross

Charges

Net

Revenue

(60%)

Annual

Days

Worked

Charges/Day Revenue/Day

Dr. D 1.0 $541,667 $325,000 230 $2,355 $1,413

Dr. G 1.0 $541,667 $325,000 230 $2,355 $1,413

Total

Dentist

2.0 $1,083,333 $650,000 460 $4,710 $2,826

RDH 1.O $291,667 $175,000 230 $1,268 $761

RDH 1.0 $291,667 $175,000 230 $1,268 $761

Total

RDH

2.0 $583,333 $350,000 460 $2,536 $1,522

TOTAL $1,666,666 $1,000,000

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Predictability is Key

Ability to predict expected reimbursement based

on:

• Payer Mix

• 3rd Party insurance reimbursement

• Sliding fee discounts and nominal fees

• Visits

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Payer Mix

• Huge impact on financial sustainability

• Big challenge to manage

• Determine the average revenue per visit per payer type

• Use that information to create a payer mix that ensures

financial sustainability while preserving access for all

patients

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Impact of Payer Mix on Sustainability

7,500 visits

35% Medicaid =2,625 visits x $100 = $262,500

55% Self-Pay/SFS =4,125 visits x $30 = $123,750

10% Commercial =750 visits x $125 = $93,750

Total revenue = $480,000

Total expenses = $500,000

Operating loss = ($20,000)

7,500 visits

40% Medicaid =3,000 visits x 100 = $300,000

50% Self-Pay/SFS =3,750 visits x $30 = $112,500

10% Commercial=750 visits x $125 = $93,750

Total revenue = $506,250

Total expenses = $500,000

Operating surplus = $6,250

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Average Reimbursement by Payer

Type

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Financial Projections Projected Visits

Actual Visits

Difference -6500

Patient/Insurance mix: Yearly visits

Percent Medicaid -

Percent Self Pay -

Percent Commercial Insurance -

Percent Other -

Total 0% -

Reimbursement Rate (per visit): Yearly Revenue

Medicaid -$

Self Pay -$

Commercial Insurance -$

Other -$

Total Projected Revenue -$

Total Expenses

Projected Bottom Line -$

Payer Mix Tool

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Obstacles to Success

• Unfavorable Payer Mix• Working under or over capacity• Lack of goals and accountability

• High broken appointment rate

• Scheduling issues (types of patients)

• Insufficient support staff (dental assistants)

• Staff turnover

• Insufficient instruments, supplies

• Equipment issues (chairs, outdated, missing, broken)

• Lack of EDR/PMS (or not being fully utilized)• Billing and collections • Fees are set too low

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Obstacles to Success, Cont.

Change in Healthcare Environment

83

Cost of Healthcare

2017 U.S.

Healthcare Costs:

3.5 Trillion/22% of GDP

U.S. spends

6-11% more on healththan other countries

The U.S. is ranked

37th in health

outcomesby the WHO

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30% of Health Care Resources are Wasted

Source: Institute of Medicine Report – The Healthcare Imperative

Unnecessary Services

$210 Billion

Fraud

$75 Billion

ExcessiveAdministrative Costs

$190 Billion

Inefficiently Delivered Services

$130 Billion

Prices That Are Too High

$105 BillionMissed Prevention

Opportunities$55 Billion

= 1 Billion

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30% = $37.2Bthat could have been spent

on care

30% = $4.47Bthat could have been spent

on care

2016 Dental Expenditures =

$124B2016 Medicaid Dental Costs

= $14.9B

Oral Health Care Dollars Wasted

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Access to Care

Environment

Genetics

Health

Behaviors

Influence on

Health

10%

20%

20%

50%

Access to Care

OtherHealth Behaviors

National Health Expenditures$3.5 Trillion

88%

8%

4%

Health Status: Determinants of Health

and Health Care Expenditures

Source: Centers for Disease Control and Prevention, University of California at San Francisco,

Institute for the Future, http://www.cdc.gov/nchs/fastats/health-expenditures.htm

87

Value-based healthcare is a

healthcare delivery model in which

providers are paid based upon

making patients healthier while

reducing costs of care.

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OHVBC : Not yet created!

The fact that an alternative payment model

is different from fee-for-service does not

necessarily mean it is better.

www.chqpr.org/downloads/WhyVBPIsNotWorking.pdf

DESIGN

Fee-For-ServiceWhat Works What Does not Work

• Providers are only paid when they provide a service

• Pays for more care when patients need it (volume)

• Payment does not depend upon variables the provider can’t control

• Predictable payment, Providers know what they will be paid before they provide a service

• Care is not linked to quality or results

• Care provided is not predictable

• Cost of care can exceed the payment for care

• No fees for many needed services

• Costs for care are not predictable or comparable

www.chqpr.org/downloads/WhyVBPIsNotWorking.pdf

Pay For PerformanceWhat Does not Work

• P4P services provided may not be the ones that a particular patient needs

• Payments may not be enough to cover the costs of care

• There may be needed services that are not covered by the P4P plan

• Costs for care are not predictable or comparable

• Providers still have to deliver services to be paid. P4P is just an adjustment to FFS provided

• Providers could get paid less for treating patients with greater needs

• Providers could get paid less for things they can’t control

www.chqpr.org/downloads/WhyVBPIsNotWorking.pdf

92

OHVBC is Not:

• Simple

• One size fits all

• Guaranteed to work

• Going away

• Instant

93

OHVBP: An Opportunity

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Opportunity to be at the Table

and not on the Menu

Domains of VBC• Leadership, Vision and Will

• Structure, Systems and Operations

• Care Pathways and Provider Buy-In

• Data and Analytics Technology and Personnel

• Financial Viability

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QUESTIONS/DISCUSSION

97

98

EXERCISEDeveloping Financial and Productivity Goals

99

Open the Financial and Productivity Goals Tool Excel spreadsheet (1st tab –Productivity Goals Exercise)

Using the Productivity Benchmark Guide & Data Sheet for Financial and Productivity Goals Exercise (both in word), we are going to identify the following productivity goals:

• Visits per day

• Weekly visits per provider

• Visits per week

• Visits per year

Exercise: Creating Capacity and Productivity in Access Goal

Financial and Productivity Goals Tool1st Tab

Sample Data

102

Answers

SCHEDULING FOR SUCCESS

South Carolina Primary Care

Association

January 24, 2019

104

LEARNING OBJECTIVES

• Provide information on the basics of successful

dental scheduling

• Discuss the common scheduling pitfalls

• Provide guidance in effective scheduling for

various provider types

• Talk about how to schedule new adult patient visits

• Discuss strategies for overcoming schedule

busters

105

Associate Vice President, Morton Hospital and Medical Center, 1992-2006

Publications Coordinator, Norwood Hospital, 1986-1992

Freelance Editor, 1982-1986

President, Board of Directors, Taunton Oral Health Center, 2008-present

Member, National Network for Oral Health Access

Member, American Association of Public Health Dentistry

Associate Member, Association of State and Territorial Dental Directors

Dori Bingham, Practice Improvement

Specialist

DentaQuest Partnership for Oral Health

Advancement

106

GUIDING PRINCIPLES

The dental schedule should be used to achieve three key

strategic objectives:

1. Improved oral health status for patients

2. Maximum access to care for patients

3. Financial viability of the dental program

107

MAXIMUM PATIENT ACCESS

• All patients

• Priority populations (eg, children, pregnant women)

108

MAXIMIZING OUTCOMES: COMPLETION OF

PHASE 1 TREATMENTS

• What is Phase 1 Treatment?

109

FINANCIAL VIABILITY

• Net revenue = total direct and indirect expenses

• Patient revenue plus grants/other

110

DEFINE THE SCHEDULING PROCESS

• How far out to schedule?

• How many appointments at a time?

• How to use available operatories?

• Define appointment lengths for various procedures

• Who is needed when in each appointment?

• What types of appointments can be double-booked?

111

THE SCHEDULE PROCESS (CONT.)

• Start and end times for appointments each day

• Who can schedule appointments?

• Providers should always be working to the top of their

licenses

112

COMMON SCHEDULING PITFALLS

• Scheduling appointments out too far

• Scheduling multiple appointments for patients

• Putting too many new patients into the schedule

• Appointments that are too long or too short

• Not using provider time strategically

• Not being strategic about how and when to double-book

• Open time in the daily schedule (10 minutes here and

there adds up!)

• Not being strategic about who can schedule

appointments

113

COMMON SCHEDULING PITFALLS (CONT.)

• Hygiene appointments

in the dentists’

schedules

• Not maximizing the

potential of auxiliary

staff with expanded

functions

• Not identifying focus

populations or using

designated access to

preserve appointments

for focus populations

114

DEFINING PROGRAM CAPACITY

• Capacity is finite

• Capacity = structure and resources

115

# of

Providers

# of total

clinical hours

worked

x recommended

# of visits/

clinical hour

Potential

Daily Visit

Capacity

Mon. 2 16 1.7 27

Tues. 2 16 1.7 27

Wed. 2 16 1.7 27

Thurs 2 16 1.7 27

Fri 2 16 1.7 27

Potential Weekly Capacity = 135 Dentist Visits

Actual

Visits

% of

Capacity

Achieved

20 74%

26 96%

19 70%

18 66%

10 37%

*At least two operatories and 1.5 dental assistants

SETTING PRODUCTIVITY/ACCESS GOALS: VISITS

POTENTIAL VS. ACTUAL – FTE DENTISTS

116

# of

Providers

# of total

clinical hours

worked

x recommended

# of visits/

clinical hour

Potential

Daily Visit

Capacity

Mon. 1 8 1 8

Tues. 1 8 1 8

Wed. 1 8 1 8

Thurs 1 8 1 8

Fri 1 8 1 8

Potential Weekly Capacity = 40 Hygiene Visits

Actual

Visits

% of

Capacity

Achieved

7 87%

8 100%

6 75%

4 50%

6 75%

SETTING PRODUCTIVITY/ACCESS GOALS: VISITS

POTENTIAL VS. ACTUAL – FTE HYGIENISTS

117

GOAL CALCULATION TARGET

Visits/Day 27 Dental Visits + 8 Hygiene Visits = 35 visits

per day

35

Visits/Week 135 Dental Visits + 40 Hygiene visits = 175

visits per week

175

Visits/Year 175 weekly visits x 46 weeks = 8,050 Visits 8,050

DETERMINING ANNUAL POTENTIAL VISITS

FOR THE DENTAL PROGRAM

This shows how to take the daily visit capacity and

determine weekly and annual goals for the dental

program. 46 weeks is the standard number of weeks

we use in a health center year to account for holidays

118

FOCUS POPULATIONS

• Children

• Pregnant women

• Patients with chronic diseases such as diabetes, heart disease

and HIV/AIDS

119

DESIGNATED ACCESS

• The daily schedule ensures access

for all patients

• But a certain number of

appointments are reserved

• These reserved appointments

can’t be filled with other patient

types until the day before

120

PHASE 1 TREATMENT COMPLETION

• Treatment or procedures that lead to the “Elimination of dental disease”

• Oral cancer prevention and early diagnosis

• Prevention education and services

• Emergency treatment

• Diagnostic services and treatment planning

• Restorative treatment

• Basic periodontal therapy (nonsurgical)

• Basic oral surgery that includes simple extractions

121

WHY TRACK PHASE 1 TREATMENT COMPLETION?

• Important quality metric

• Promotes continuous coordinated care

• Enables balance of new and existing patients

122

FINANCIAL GOALS

• Gross charges

• Net patient-generated

revenue

• Bottom line (revenue after

expenses)

123

DETERMINING THE DAILY REVENUE GOAL

Total direct and indirect expenses ÷ Number of clinic days per year = daily net revenue goal to break even

For example:

Total expenses = $950,000

5 days per week x 46 weeks = 230 clinic days per year

$950,000 ÷ 230 = daily net revenue goal of $4,131

124

DAILY REVENUE GOAL (CONT.)

• Gross Charges – Contractual Adjustments = Adjusted Net Revenue

125

SCHEDULING BASICS

• Ideal patient mix

• Available practice resources

• Hourly visit goals for each provider type (general dentists,

specialists, residents/externs, hygienists, EFDAs)

• Appropriate appointment lengths for various visit types

• Build and test the templates

• Use 10-minute increments if possible

126

COMMON STAFFING BENCHMARKS

• General dentist, 2+ operatories, 2 assistants = 1.7 visits/hour

• General dentist, 1-2 operatories, 1 assistant = 1 visit/hour

• General dentist, 3+ operatories, 1 EFDA and 1-2 assistants = 2.5

visits/hour

• 4th year dental students = 0.5 visit/hour

• GPR Resident, Q1 = 1 visit/hour

• GPR Resident, Q2 = 1.2 visits/hour

• GPR Resident, Q3 = 1.5 visits/hour

• GPR Resident, Q4 = 1.7 visits/hour

• Hygienist, 1 operatory, unassisted = 1 visit/hour (typically, unless lots

of kids)

• Hygienist, 2 operatories, assisted = 1.5 visits/hour

127

SCHEDULING FOR DENTISTS

• Minimum of two operatories and ideally two assistants

• Staggered appointments in two columns (possible use of 3rd

column for overflow)

• Define workflow for each standard visit - where and for how

long the dentist is needed

• Line up the blocks so the dentist’s time is maximized

• Consider each dentist’s individual characteristics but aim for

standardization

128

SAMPLE TEMPLATE, DENTIST

Morning Schedule: Afternoon Schedule:Time Op1 Op2

Op3 (Overflow for

emergencies)

8:00 Emergency

8:10

8:20

8:30

8:40

8:50

9:00

9:10

9:20

9:30

9:40

9:50

10:00

10:10

10:20

10:30

10:40

10:50

11:00

11:10

11:20

11:30

11:40 Emergency

11:50 HOLD

12:00

12:10

12:20

12:30

12:40

12:50

Time Op1 Op2Op3 (Overflow for

emergencies)

1:00 Emergency

1:10

1:20

1:30

1:40

1:50

2:00

2:10

2:20

2:30

2:40

2:50

3:00

3:10

3:20

3:30

3:40

3:50

4:00

4:10

4:20

4:30

4:40 Emergency

4:50 HOLD

5:00

Intake10-minute appointments for medical hx review, blood pressure, etc.

Operative

40-minute appointments for Fillings/extractions. Can expand to 60 minutes for more procedures

Anesthesia

First 10 minutes of operative appointment, if anesthesia is provided, where the dentist might be available for a brief side-booked appointment (eg, denture try-in, suture removal) or to provide a POE or LOE

Lunch 30 minutes

Color Code:

129

SCHEDULING FOR HYGIENISTS

• Easiest schedules to fill; hardest to KEEP full!

• Broken appointments can wreak havoc

• Limit 6-month recall appointments

• Limit new patients in the daily schedule

• Develop tasks for hygienists whose patients fail to show

• Assisted hygiene may be a fit

130

ASSISTED HYGIENE

• Requires two operatories and dedicated hygiene assistant

• Hygienist can see 1.5 patients/hour or 12-13 patients in an 8-

hour day

• Assistant facilitates visit

• Eliminates RDH waiting for dentist to do exam

• Must rigorously manage broken appointments

• Must have demand for hygiene

131

COMPARISON:Unassisted vs. Assisted Hygienists

Unassisted

Hygienist

Assisted

Hygienist

Visits/hour 1 1.5

Visits/day 8 12-13

Visits/week (factors in

25% BA rate)

30 45

Revenue ($140/visit) $4,200 $6,300

Salary costs (includes

22% fringe)

$1,464 $2,149

Net revenue after salary $2,764 $4,151

Annual net revenue $127,144 $190,946

132

SAMPLE TEMPLATE, ASSISTED HYGIENE

Time Room 1 Room 28:00 greet, seat, update, BP (Patient 1)

8:10 x-rays

8:20 Prophy greet, seat, update, BP (Patient 2)

8:30 OHI review, disclose, anesth

8:40 OHI/dentist exam SRP (one quad)

8:50 Unseat patient/clean OP

9:00

9:10

9:20 greet, seat, update, BP (Patient 3)

9:30 Prophy Unseat patient/clean OP

9:40

9:50 greet, seat, update, BP (Patient 4)

10:00 Unseat patient/clean OP Prophy

10:10

10:20 greet, seat, update, BP (Patient 5)

10:30 x-rays

10:40 Prophy OHI/dentist exam

10:50 Unseat patient/clean OP

11:00 Greet, seat, update, BP (Patient 6)

11:10 OHI/dentist exam Prophy

11:20 Unseat patient/clean OP

11:30 Greet, seat, update (Patient 7)

11:40 Sealants x 4 OHI/dentist exam

11:50 Unseat patient/clean OP

12:00 Unseat patient/clean OP

The Result: 7 patients in 4 hours! Patients have the same amount of time in

the dental chair, the work is just redistributed to provide more access.

133

SCHEDULING ADULT NEW PATIENT VISITS:

REASONS FOR NOT BREAKING VISITS UP• Can be red flag for insurance audits

• Not patient-focused care

• Clogs the schedule

134

RATIONALE FOR BREAKING UP VISITS

• Oral health status unknown

• How much calculus in mouth?

• May not be able to complete exam until calculus removed

• Not enough time to do all required work in one visit

135

TWO POSSIBLE SCENARIOS Scenario A:

Unable to Do Comp Exam due to Heavy Calculus/Plaque

Visit 1: D0210 (FMX) and either D1110 (prophy) or D4355 (full mouth debridement)

Visit 2: D0150 (comp exam) and either PSR or full perio charting (likely needed)

Scenario B:

Able to Do Comp Exam

Visit 1: D0210 (FMX), D0150 (comp exam) and D1110 (plus PSR or full perio charting)

136

RECOMMENDATIONS

• 60 minutes with hygienist

• Scenario A or B depending on how patient presents

• Practice policy: as much care as possible in time allotted

• Document why if patient needs separate exam visit with the dentist

• Exam visits 30 minutes in dentist’s overflow chair

• PSR first and comprehensive periodontal exam if indicated

• Pilot, test and tweak as necessary

137

DOCUMENT THE SCHEDULING PROCESS

• Create a formal scheduling policy

• Include scheduling templates as attachments

• Review the policy with entire staff

• Train staff how to use the templates

• Monitor, provide feedback and tweak as necessary

138

SCHEDULE BUSTERS

• Last minute cancellations

• No-shows

• Late patients

• Too many emergencies/walk-ins

• Too many new patients

• Overbooking

• Logjams at check-in or out

• Providers who fall behind

• Not enough support staff

• Wrong appointment types

• Wrong appointment lengths

• Insufficient instruments

• Technology issues

139

STRATEGIES FOR RESOLVING SCHEDULE

BUSTERS

• Attack broken appointments

• Be strategic with double-booking

• Control emergencies/walk-ins

• Limit new patients

• Revisit capacity

• Resolve logjams at check-in/out

• Determine why providers/practice fall behind

• Resolve scheduling errors

• Ensure sufficient instruments

• Tackle technology issues

140

QUESTIONS/DISCUSSION

141

MANAGING CHAOS:BROKEN APPOINTMENTS AND EMERGENCIES

South Carolina Primary Care

Association

January 24, 2019

143

LEARNING OBJECTIVES

• Understand the negative impact of BAs and

emergencies on the practice

• Learn strategies for managing emergencies

• Learn strategies for reducing BAs

144

MANAGINGEMERGENCIESEmergency care important

but capacity must be

managed

145

WHY DOES THIS MATTER?

• Dental ER or Dental Home?

• Unpredictability

• Extra Work

• Reimbursement

• Disruption

• Patient/Staff Satisfaction

146

OPERATIONAL EMERGENCY MANAGEMENT

• Quantify demand for emergency care

• Develop system to meet demand

• Create an emergency policy and triage tool

147

QUANTIFY DEMAND

• Average Per Day

• Reality vs. Perception

• Tracking

148

WHEN DEMAND EXCEEDS CAPACITY

• Patients of record

• Patients in service area

• Waivered patient policy

• Are all area safety nets doing their part?

149

HAVE A SYSTEM IN PLACE

• Where do emergencies fit?

• Who will provide care?

• What care will be provided?

• Morning huddle

150

BEWARE OF WALK-INS

151

THE ROLE OF TRIAGE

• What constitutes an emergency?

• Who decides?

• Objective criteria

152

Ask the Patient MUST BE SEEN

TODAY!See tomorrow or this

week

See when available

“On a scale of 1

to 10 how badly

are you hurting?”

Pain level 7 to 10 Pain level 4 to 6 Pain level 3 or below

“How long have

you been

hurting?”

This level for a

week or less This level of pain for a

month or less Had these symptoms for

over a month

“Describe the

type of pain or

discomfort you

feel.”

Throbbing Broken tooth, lost a filling Chip tooth, broken filling

“How are you

sleeping at

night?”

Keeps me awake

at night Able to sleep with

medication Able to sleep

“What occurred to

make the tooth

begin to hurt?”

Unknown or bit

down on

something hard

Bit down on something or

other cause Sweets; candy causes it to

hurt

“Have you

noticed any other

symptoms?”

Fever and

swelling ------ ------

Two or more

checkmarks in this

section results in the

patient needing to be

seen today

Three or more checkmarks in

this section results in the

patient needing an

appointment this week

Three or more checkmarks in

this section results in the patient

being given the next available

standard appointment time

Sample Triage FormPatient Name: ___________________________________ Date: _____________________Last Dental Visit: ________________________ Location of Pain: Bottom left, Bottom right, Top left, Top right________Patient Address: __________________________________ Contact Number: ____________________________________

153

DEFINITIVE VS. PALLIATIVE CARE

• Definitive whenever possible

• Time

• Impact on BAs

• Patient/provider satisfaction

154

HAVE A POLICY

• Define it all

• Share with staff

• Communicate to patients

155

REDUCING BROKENAPPOINTMENTSBroken Appointment

Rate Goal: 15%

156

157

BROKEN APPOINTMENTS:

#1 cited problem for all safety net dental clinics

5 Key Areas Negatively Impacted:

Access to Care

Oral Health Outcomes

Staff Satisfaction

Patient Satisfaction

Financial Sustainability

158

WHY DOES THIS MATTER?

• Lost productivity

• Lost revenue

• Wasted chair time

• Diminished access

• Incomplete treatment

• Chaos/unpredictability

• Staff/provider frustration

• Patient frustration

159

FACTORS LIKELY TO INCREASE BA

RATES• No policy

• Policy weak or not enforced

• No understanding of why keeping

appointments matters

• Misinterpretation of governance related to no-

shows

• No culture of accountability (staff or patients)

• No consequences for broken appointments

160

BROKEN APPOINTMENTS DEFINED

No-Show:A patient is scheduled for an appointment and they do not show up for that appointment.

Late Cancellation:

A patient cancels an appointment less than 24 hours prior to the start of the appointment.

Late Arrival:A patient does not arrive by 10 minutes after the start of their appointment.

161

MANAGING MOST LIKELY TO “NO-SHOW”

New Patients

Recare Visits

• Require new (non-emergent) patient registration prior to scheduling 1st appt.

• Limit the number of new patients/day

• Book new patient visits within 2 weeks

Emergency Follow-up

• Teach patients to value the hygiene visit

• Consider moving to a “designated access” 2-5 week schedule for hygiene patients

• Require emergency patients who need follow-up care to call to schedule their next visit

162

PUNISHMENT VS. CONSEQUENCES

EVERY time the policy is breached:

• Call, letter, document/flag account

STRIKE ONE• Reminder and (only) warning

STRIKE TWO• Consequence occurs; requires a

proactive response from patient

STRIKE THREE• Strongest consequence

implemented by dental staff

163

“PROACTIVE RESPONSE” CONSEQUENCES:

Broken Appointment

Retraining Session

Write a Letter to the

Dental Director1. Explanation

2. Understand the impact

3. Promise never again

164

“STRONGER” CONSEQUENCES

Dismissal letter

• 30 days of emergency

care access

Same-Day-Only Scheduling Status

• Quick call lists

• Patient required to call

165

LESS FAVORABLE CONSEQUENCES

Charging for No-Shows

• Rarely works

• Can’t charge Medicaid

patients

Double-Booking

• Feast or famine

https://www.medicaid.gov/medicaid/benefits/downloads/policy-issues-in-the-delivery-of-dental-services.pdf (see question 11a)

166

Source: http://www.aapd.org/media/Policies_Guidelines/D_DentalNeglect.pdf

CONSIDERATIONS FOR CHILDREN UNDER AGE 18

167

STRATEGIES FOR SUCCESS

▪Provide reminder messages for upcoming

appointments

✓ Text/e-mail plus phone

✓ 48 hours in advance

✓ What if: Non-working numbers

✓ What if: Voice mail

168

▪ 30-45 days out

▪ One appointment at a time

▪ New (nonemergent) patients register in advance

▪ Limit appointments for multiple family members

▪ Limit new hygiene patients

▪ Ask emergency patients to call for follow-up

appointment

▪ Use alerts to warn schedulers

169

THE BIG FIVE BEST PRACTICES FOR EVERY

PROGRAM

• Strong policy with clearly communicated consequences

• Consistent enforcement

• Patient education

• Culture of accountability for patients and staff

• Track and evaluate BA rate

170

CDT TRACKING CODES FOR BROKENAPPOINTMENTS D9986:

Missed Appointment

D9987: Cancelled

appointment

D9991: Dental Case Management – addressing appointment compliance

barriers

171

NO-SHOW RATE CALCULATION

• Formula is: Number of broken appointments (numerator) divided by the Number of scheduled appointments (denominator)

• The number of scheduled appointments (denominator) is defined as the number of broken appointments + the number of visits.

• For example, if 20 patients broke, and 80 patients came, the percentage of broken appointments = 20/100 = 20% broken appointments

• Target is 15%

172

QUESTIONS/DISCUSSION

SESSION FIVE:COMPREHENSIVE HEALTH CENTER INTEGRATION TO IMPROVE OVERALL HEALTH

Dr. Scott Wolpin

174

OBJECTIVES

Session Objectives:

• Identify the benefits and barriers to integration

• Discuss the various aspects of integration

• Provide examples of integrated care

175

176

Why is session relevant?

• Oral health is a critical component of patient-centered,

comprehensive healthcare and well-being

• Better health outcomes = reduced costs

• PCAs are a great network to share tools, resources, and best

practices needed for improving oral health

177

What is integrated care?

Collaboration = primary care and oral health working with one another

Integration = oral health working within and as part of primary care or vice versa….provision of oral health services within

primary care

178

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179

180

How do we get to Level 6?

Oral

Health

181

Integration efforts need to occur around three key

areas:

• Administration

• Clinicians

• Infrastructure

182

Administration

➢ Does the health center leadership believe in the

importance of integrating oral health into primary care?

➢ Is health center leadership not just supportive but

actively involved in making integration happen?

➢ Is the health center willing and able to allocate the

resources necessary to implement integration? (staff

time and funding)

➢ Is there an dental program representative on the health

center’s leadership team?

➢ Is oral health an important priority in the strategic plan

for the health center?

It starts with the CEO reinforcing the same message throughout the

organization “Treating the patient as a whole part is the mission and

culture of our health center”

183

Clinicians

➢ Providers and support staff must be able to communicate

both formally and informally across disciplines

➢ Providers need to participate in health center

committees, meetings, in-services together

➢ Mutual respect must exist with warm handoffs

➢ Providers must be willing to practice transdisciplinary

care:

Medical staff provides caries risk assessments, fluoride varnish

Dental staff provides diabetes, depression screenings, BPs

184

185

Infrastructure

➢ Sharing and access to patient information across

disciplines is necessary, are EMR and EDR systems

integrated?

➢ Are care coordination and other patient-enabling services

available for the dental program?

➢ Bilateral referrals must be supported (i.e. non-medical

user presenting with a toothache but his pre-operative BP

is extremely high)

➢ The health center’s system (policies and procedures)

must support standardized processes, forms, and

tracking of medical consults

186

Creating the Integration Plan

1. Forming the team

2. Creating the action steps and timeline

3. Strategic plan

4. Business plan- operations and systems

5. Policies and procedures

6. Goals

7. Evaluation plan - metrics

187

Who is on the Integration Team?

o Primary Care Providers

o Clinical Support Staff

o Front Office Staff

o Care Management Staff

o Quality Management

o Informatics

o Senior Leadership

188

The Primary Care Team’s Role

➢ Screen for dental disease and assess caries risk

➢ Educate patients on the nature of dental disease and self-

care strategies to prevent/reverse disease

➢ Provide primary (Fluoride) and secondary

(remineralization) prevention

➢ Triage emergent dental concerns

➢ Make appropriate referrals for oral health care - the

medical health history form should determine whether the

patient has a dental home (especially for vulnerable

populations like pregnant women, diabetics, etc.)

Be the primary oral health care provider for low risk pre-school

children??

189

➢ The oral health history should determine whether the

patient has an ongoing medical home

➢ Incorporate screening for common health

problems (e.g., high blood pressure, diabetes)

➢ The oral health health history should ask about

chronic and special conditions affected by oral

health disease (e.g., diabetes, heart disease,

HIV/AIDS, pregnancy)

➢ Substance Use screenings, Behavior Health

screenings

➢ Provide continuous (trending) health

information to patient’s medical providers

Oral Health Provider’s Role

190

191

Challenges of Integration

• Capacity – will the dental program’s physical capacity

accommodate increased visits resulting from referrals

from medical?

• Health Information Technology – how do we create caries

risk assessment tools for the EMR? Are the electronic

dental and medical records connected?

• Training - how can we assure timely completion of oral

health assessment and fluoride varnish during a medical

visit?

• Reimbursement – does the state Medicaid plan permit

both dental and medical visits to occur on same date of

service? Does the state Medicaid plan offer dental

benefits for adult patients?

192

Examples of Medical- Dental Integration Efforts at

Eastern Shore Rural Health System (ESRHS)

o Embedding a Dental Hygienist in the pediatric wing of

Onley Community Health Center

o Combined 9 month well child check/initial dental visits at

Franktown Community Health Center

o Quarterly Provider Meeting Case Study Exercises

193

Eastern Shore

Rural Health

System (ESRHS)

A federally qualified,

community health center

Five medical centers

and four dental

locations serving

residents of the eastern

shore of Virginia.

WWW.ESRH.ORG

Chesapeake

Bay

Chincoteague CHC

Atlantic CHC

Onley CHC

ESRHS Corporate Office

Franktown CHC(with Dental Services)

Bayview CHC

ESRHS &

Accomack County

School Dental

Program

The Hermitage on

The Eastern Shore

ESRHS &

Accomack County

School Dental

Program

Riverside Shore

Memorial Hospital

Chesapeake Bay

Bridge Tunnel

194

➢ DH joins the daily medical huddles

➢ Provides oral health assessments for vulnerable, target populations (i.e. diabetics, pregnant, children)

➢ Provides risk-based, evidence-based prevention interventions: Primary (fluoride varnish) secondary (SDF) and oral health education

➢ Makes referrals to the dental program for patients with untreated dental disease requiring restorative or surgical care

DH = The primary oral health care provider for low risk adult patients???

Embedding a Hygienist in Medical

195

ESRHS Vision for Population Health - Oral

196

Combined well child check/initial dental

visits

• An in-service was provided for the medical providers using online curriculum (http://smilesforlifeoralhealth.org) that provides guidance on how to perform oral health screenings and fluoride treatment in the medical setting

• Hands-on fluoride varnish demonstration was provided

• Determined that the 9 month old well check visit is the best visit to incorporate an initial dental visit because children have teeth and do not receive vaccines at this visit

• The dentist/DH sees the child at nine months and the medical team serves as the dental home for the first two years unless the child has treatment needs

• Has increased number of new insured patients for the dental program and decreased OR referrals

197

198

6-36 Month Olds with a Dental Visit(there are approximately 1400 ESRHS Medical Users < 36 months)

1

1524

32

38

40

0

20

40

60

80

100

120

2013 2014 2015 2016 2017 2018

Column1 Linear (Column1)

%

199

Interdisciplinary Case Studies

200

Mrs. J

201

202

203

204

5 Simple Implementation Steps for

Achieving Integration at your Health

Center

First:Add questions to patient medical history about oral health.

➢Do you have a regular dentist?

➢When was your last oral health visit?

➢Have you ever been told your gums bleed?

205

Implementation Steps for Integration in

your health center (cont.)

Second:Perform a workflow analysis to see what works best in your

practice.

➢Do you have a small practice or a large practice?

➢Are medical and oral health co-located?

➢What types of providers/support staff do you have to provide

integration?

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Third:Choose a provider (RDH, DA,CDHC, MA, MD) who will integrate oral

health into medical.

➢Which days of the week?

➢Which hours per day?

➢Which patient population will you begin with?

Regardless of where or how your integration practice

begins, the goal is to pursue progressively higher levels

of integration, so that over time all patients can expect to

receive oral health preventive services and structured

referrals from their primary care team.

Implementation Steps for Integration

in your health center (cont.)

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FourthProvide a Structured Referral

• A “structured” oral health referral should include the

information the dentist needs to participate appropriately in

the patient’s care, for example: the patient’s problem list,

current medication and allergy lists, the specific reason for the

referral, and a statement that the patient is healthy enough to

undergo routine oral health procedures.

Implementation Steps for Integration

in your health center (cont.)

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Fifth

Develop a Referral Network

A Care Coordinator is a good liaison to work between medical

and oral health, to complete and follow through on all referrals

and to make sure target patients are seen in the dental program –

they can trouble soot barriers to accessing care

Implementation Steps for Integration

in your health center (cont.)

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The cost of not providing integrated care…

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At Risk Reversible Irreversible

Primary Prevention Secondary Prevention Tertiary Prevention

Primary Care Specialty

• Dietary counseling

• Behavior

modification

• Fluoride varnish

• oral health sealant

Remineralization • Restorations

• Pulpotomy

• Simple endodontics

• Simple extractions

• Endodontics

• Perio surgery

• Complex

prosthodontics

• Oral surgery

• Orthodontics

• oral health Assistant

$17.13

• Medical Assistant

$14.80

• Nursing Assistants

$12.51

• Dietetic Tech $13.74

• oral health Hygienist

$34.39

• Physician Assistant

$45.36

• Nurse Practitioner

$45.71

• General Dentist

$79.12

• Pediatric Dentist

• Oral Surgeon

$105.27

• Orthodontist $94.36

Non-Dentist oral health Surgeon

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Questions ?

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Helpful Resources

National Network for Oral Health Access

www.nnoha.org

DentaQuest Institute Online Learning Center (free Disease Management Modules)

www.dentaquestinstitute.org

Health Resources and Services Administration

www.hrsa.gov

National Interprofessional Initiative on Oral Health www.niioh.org

U.S. National Health Alliance

www.usalliancefororalhealth.org

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QUESTIONS/DISCUSSION

CREATING THE IMPROVEMENT PLAN

Danielle Apostolon

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The Improvement Plan (IP)

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Recipe to a Successful IP

Identify and state the Problem or Problems

Apply Strategies to address each of the problems

Define the Actions Steps to execute each strategy

Assign a Person or Person’s responsible

Attach Due Dates

Set goals and performance Metrics

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Step 1: Identify the Area in Need of

Improvement

Observation

Data

Staff Meetings

Patient Satisfaction Survey

Environmental Changes

Organizational Changes

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Examples

The broken appointment rate is 30%

Providers are working late and somedays do not get a lunch break

High number of walk-ins and emergencies

Patients have been complaining about the long waits

Providers feel burnt out

Patients cannot schedule an appointment for at least another 3 months

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Step 1: State the Problem

The no show rate is 30%

No-shows and last-minute cancelations are negatively impacting access

to care and productivity. The policy is not consistently enforced.

• By reducing the no-show rate the practice can increase revenue

and decrease chaos and stress for dental staff. A major impact will

be an increase in the percentage of patients who complete their

phase 1 treatment within 12 months.

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Step 2: Identify Strategies

Revise and distribute a strong, no-tolerance Broken Appointment policy

to establish accountability with the patient and staff. Post signs

prominently within the practice explaining the policy.

Flag patient charts of those who breach the policy and send letters

reminding those patients of the policy they agreed to abide by.

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Step 3: Create Action Steps

1. Revise the current policy

2. Obtain Board approval

3. Educate staff and patients about the new policy

4. Require all new patients to sign the policy

5. Monitor the BA rate and access policy after 3 months

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Step 4: Assign Due Dates & Responsibilities

Action Steps Due Date Person(s) Responsible

Revise the current policy 6/30/17 Dental Director and Practice

Manager

Obtain Board approval 7/15/17 Dental Director and CEO

Educate staff and patients about the

new

8/1/17 All staff

Require all new patients to sign 8/30/17 Front Desk

Monitor the BA rate and access policy

after 3 months and report to leadership

Ongoing Practice Manager

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Step 5: Set a Target Goal for the Metric

Current BA rate = 30%

Year 1: 20%

Year 2: 15%

Every quarter the broken appointment will be monitored to ensure:

• Policy is effective

• Everyone is consistent with enforcing the policy

• BA’s are being documented accurately

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Step 6: Execute and Monitor Results

Create Buy-In and Accountability among staff

Collect data to monitor result; have a measurable goal for everything!

Regular meetings to discuss the progress in executing the actions steps

Discuss barriers that arise

Brainstorm ways to overcome barriers as a team

Celebrate successes

Recognize and award staff

Coach and offer feedback when there are setbacks

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Resources

Improvement plan template

Best Practice Manual

Tools to create goals

Sample policies

DQI Resource Library

Online Learning Modules

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Next Steps

Utilizing the Best Practice Manual and Improvement Plan Template

1. Download the Best Practice Manual (pdf)

2. Download the Improvement Plan Template (Word)

3. Identify 1 area for improvement that your clinic can work on in the

short term (next 3 months)

4. Decide on at least 1 strategy

5. Create specific actions steps for each strategy

CLOSING/WRAP-UP

Da-Nell Pedersen

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Sample Policies & Tools

• Dental Policy & Procedure Manual Template

• Sample Clinical Protocols

• Sample Dental Job Descriptions

• Sample Broken Appointment Policies

• Scripting for CHC Dental Staff

• Profit & Loss Budget Variance Tool

• Sample Scheduling Policy

• Sample Emergency Policy

• Sample Quality Assurance Policy

• Dental Clinic Performance Monitoring/Tracking Tool

• And much, much more!

https://www.dentaquestinstitute.org/learn/safety-net-solutions/sns-sample-policies-and-tools

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Online Practice Management

Courseware • Developing Billing Excellence

• Fee Schedules, Sliding Fee Scales, & Management of

the Self-Pay Patient

• Safety Net Dental Program Finance and Productivity:

Your Mission and Your Margins

• Front Desk Customer Service

• The Front Desk: Creating Your Dream Team

• Managing Chaos in the Dental Program

• Scheduling by Design

Free continuing dental education credits!

https://www.dentaquestinstitute.org/learn/online-learning-center/online-courseware/safety-net-dental-

practice-management-series

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Additional Online Learning Center

Resources Other Learning Modules/Online Courseware

• Disease Management Series

• Special Topic Series (e.g. Payment Reform in Oral

Health)

Resource Library

• Best Practices Manual

Dental Caries Management Virtual Practicum

Instructional Webinars/SNS Lunch & Learn Webinars

PrevenTips Videos

https://www.dentaquestinstitute.org/learn/online-learning-center

https://www.dentaquestinstitute.org/learn/safety-net-solutions/sns-webinars

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Post-Training Evaluation

www.surveymonkey.com/r/SCPOST

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