Health Literacy as a key driver for Integration of Dentistry into Primary Care

Transcription

1 Health Literacy as a key driver for Integration of Dentistry into Primary Care Kathryn A. Atchison, DDS, MPH Professor, UCLA Schools of Dentistry and Fielding School of Public Health R. Gary Rozier, DDS, MPH University of North Carolina at Chapel Hill Jane A. Weintraub, DDS, MPH University of North Carolina at Chapel Hill December 6, 2018

2 Drivers for Advancing Professional Efforts Integrating Oral Health 1926 Geis Report recommended integration of oral health 1995: IOM dental education report recommended integration 2000: Surgeon General s Report on Oral Health launched medicine s involvement in pediatric care 2005: Smiles for Life online training launched, includes CE 2006: Macy Study - shared professional responsibility needed 2009: Interprofessional Education Collaborative (IPEC) launched by 6 health profession education associations led to core competencies for IPP, updated in : AAMC partners with HRSA to support integration or oral health concepts to medical education 2014: HRSA report includes oral health competencies for primary care

3 Overview: Purpose of the environmental scan was to assess: Types of oral health integration into primary care programs in the U.S. How health literacy is included in the integration efforts Types of oral health training and education provided to nondental health professional students and through continuing education Prepare 4 Case Studies (some organizations to present today)

4 Developed relevant search criteria for U.S. articles Gathered broad amount of information from peer reviewed and grey literature. Identified experts from conference programs, dental and health professions schools with IPE programs, foundation representatives who funded integration programs, and government representatives from DHHS and NIDCR. Posted on listservs; then contacted people directly to learn about unpublished integration programs. Excluded: o o o Methods intra-disciplinary demonstration programs (adding midlevel providers to dental programs); Stand-alone demonstration programs of primary care into dental practice; and, Stand-alone public health programs with no connection to primary care practice.

5 Purpose of the environmental scan was to assess: The types of U.S. programs integrating oral health into primary care. How health literacy is included in the integration efforts The type of oral health training and education provided to other health professional students and through continuing education

6 Determined the Scope of Practice Reviewed Guidelines, Consensus statements of oral health integration US Preventive Services Task Force reviewed 3 services: ü Pediatric care provided by MDs (2014). Issued recommendation! ü Coronary Heart Disease (2009). Insufficient evidence to assess harms and benefits of clinical screening for periodontal disease to prevent CHD events. ü Oral Cancer (2014). Insufficient evidence to issue make a recommendation.

7 Reviewed Models of Integration of Care: from Linear.. Isolation Mutual Awareness Cooperation and Collaboration Primary Care Provider Service Focus Co-location Fully Integrated Source: Adapted from IOM 2012

8 Rainbow Model of Integrated Care (M-RMIC) Ref: Valentijn et al., 2013.

9 Conceptual Model of Integration with 6 Levels FIGURE 1-1 Simple Modified-Rainbow Model of Integrated Care (M-RMIC) Ref: Valentijn et al., 2013.

10 4 Clinical Categories of Integration used for the Environmental Scan Preventive oral health services provided by medical providers (POHS) Preventive health services (PHS) provided by dental providers in primary care clinics or nontraditional settings Case management, coordination and referral. Note used only if accompanies one of the above. Preventive health (non-dental) services by a dental provider (PHS) in dental settings

11 Literature Found 32 publications (15 peer-reviewed and 17 grey literature) Programs represent 28 states plus Washington DC and the National Head Start Association Represented statewide and countywide programs, urban and rural programs, focused on clinical & systems-level quality improvement Multi-site programs by age group, type of practice (e.g. pediatric), setting (e.g. FQHCs, private practice), etc.

12 POHS by medical providers 37 Reports: A report could have > 1 example 33 - Pediatric preventive OH services 10 - Pregnant women 5 - Patients with chronic diseases 2 - Emergency Dept. dental services (e.g. extractions by MDs)

13 Preventive (& other) oral health services provided by dental providers in primary care clinics or non-traditional settings 16 examples Dental services offered by hygienists to children in schools, pregnant women in primary care clinics, PH & community clinics Limited dental screening performed by dental assistants Other: Triage of dental emergency needs

14 Case manager and coordination of care service and referral 22 examples Increase access to dental services, community, & social services support. Increase access to health education & prevention through navigation to dental clinics. Divert people from E.D. to primary care dental treatment. Use of electronic tools to enhance care coordination.

15 Preventive Medical service by dental providers (PHS) 16 examples Dentists screen & refer for medical home, hypertension, HIV, and blood glucose levels. Dentist reviews care plans to find gaps in preventive services (e.g. immunizations). Development of periodontal quality metrics for diabetic patients.

16 In summary, there is much interest in integration. However Little peer-reviewed literature on integration Few guidelines for establishing such a program (mostly in direction of MDs doing POHS) Some pilot studies on implementing a program, but few studies discuss effectiveness or outcomes in improving oral and general health Wide variety of information about programs, but little consistency in what is presented Variety in purpose: e.g. educate representatives about integration models in primary care, determine best practices for integrating oral health into ACOs.

17 Purpose of the environmental scan was to assess: The types of U.S. programs integrating oral health into primary care. How health literacy is included in the integration efforts The type of training and education provided to health professional students and through continuing education

18 Health Literacy as a Facilitator to Integration FIGURE 1-1 Simple Modified-Rainbow Model of Integrated Care (M-RMIC) Ref: Valentijn et al., 2013.

19 Develop health literate educational materials in relevant languages. Utilize anticipatory guidance during OH screening of chronic disease patients. Develop & utilize case management and patient navigation. Ask patient about dental symptoms (i.e., toothache, bleeding gums, loose teeth, trouble chewing). Ask patient about medical and dental home and last medical/dental visit. Health Literacy Applications at the Clinical Level of Integration Develop &/or coordinate individualized multidisciplinary care plans. Interact in a culturally competent manner. Track & follow up on referrals.

20 Health Literacy Applications at the Professional Level of Integration Train primary care team on how to conduct an oral assessment and caries risk assessment. Develop a shared culturally appropriate vision for department. Develop/foster interdisciplinary collaborations. Develop & follow clinical guidelines/protocols. Develop an inter-professional governance for the collaboration. Create value for FQHC s providers and patients.

21 Health Literacy Applications at the Organizational Level of Integration Assure all providers have buy-in to planned integration collaborations. Develop performance metrics for screening, caries prevention, dental sealant, etc. Develop a dental referral network. Demonstrate supportive leadership. Make cultural competency training available to all providers and staff.

22 Health Literacy Applications at the System Level of Integration Interface with public health & community organizations. Determine Community s needs. Seek available resources to initiate needed programs. Develop & implement programs that meet the community s needs. Demonstrate good community-participatory governance. Develop a positive climate.

23 Health Literacy Applications at the Functional Level of Integration Develop accessible, integrated electronic record systems with clinical decision tools. Develop systems monitoring & benchmarks. Apply resource management. Develop needed support systems & services. Provide regular feedback on performance.

24 Health Literacy Applications at the Normative Level of Integration Visionary leadership to develop a dental home initiative. Create a shared vision for optimal oral health for all. Develop a collective attitude with the community. Let community come to know you are a reliable, trustworthy partner. Create a sense of urgency about the community s total health (including oral health). Build quality features of the collaboration at the operational, tactical & strategic levels.

25 Purpose of the environmental scan to assess: The types of U.S. programs integrating oral health into primary care. How health literacy is included in the integration efforts The type of training and education provided to health professional students and through continuing education

26 Health Profession Education Programs and Integration Methods included reviewing: ü English language published literature, 1995-July ü Surveys of oral health curriculum content in non-dental profession programs & IPE curriculum in dental programs. ü HRSA government-funded training grants. ü 43 Non-dental health professional association websites for evidence of enduring oral health content and continuing education opportunities. Contacting key individuals and organizations.

27 Challenges to Integrating Oral Health in nondental education & practice Siloed dental education programs: o More than twice as many US medical schools as dental schools o Many academic health centers lack a dental school o Even where co-located, implementation challenges: time, scheduling, space, cost, culture, attitudes, faculty were unprepared to implement. Prior to 2000, oral health was almost non-existent in primary care provider education. Until fairly recently, little oral health training in predoctoral primary care or residency training, generally < 5 hours; sometimes none. Little published literature on integration. Little research on patient outcomes.

28 Continuing Education (CE) Critical for post-licensure clinicians. Search included enduring, archived, relevant CE for practitioners: Challenging! o Difficult to access and determine CE content and quality. Joint Accreditation for Interprofessional Continuing Education includes medicine, pharmacy and nursing but not dentistry! Of 43 non-dental health professions association websites reviewed, 42% had minimal or no oral health information on their website or could not be determined.

29 Favorable Changes Occurring in Education & Training Recognition that non-dental health providers can have a key role in improving oral health, especially for vulnerable and underserved populations. Rise of curriculum initiatives, toolkits, train-the-trainer programs, webinars. Integration Examples: o HEENT becomes HEENOT adding oral cavity assessment o Nurse-Practitioner-Dentist Model o Referral networks built with local dental practices. o Prenatal Oral Health Program (pohp). o National Interprofessional Initiative on Oral Health & Oral health Nursing Education and Practice o New England s Transforming Clinical Practice Initiative training programs and practices o Smiles for Life online curriculum. Some organizations (AAP, AAPA, GSA, STFM) educating members about oral health.

30 Facilitators for Education and Training IPE accreditation standards across professions. Oral health integration throughout existing primary care curriculum o Not separated time blocks; not just sitting in classroom together o IPE focus on clinical activities and different types of professional students learning from each other, team-based. Networks established with local dentists for help with teaching and referrals (if dentistry not co-located in institution). Non-dental oral health champions; university/institutional leadership. Internal and external funding to initiate and sustain educational activities. Growth of large group, multidisciplinary delivery systems o Employers want graduates to be practice ready to work in teams.

31 Summary & Conclusions Few guidelines or published surveys of reported practice integrating oral health (except early childhood). Little peer-reviewed literature on studies of integration of oral health and within this most are pilot demonstrations and do not discuss effectiveness or outcomes in improving oral and/or general health. Professional education is developing systems to advance IPE, but little action at the practice-level. Health literacy applications are seen, with intent by ACOs with Normative, System, and Organizational levels, more intuitively in other settings. Integration of oral health into primary care is in its infancy!

32 Thank you to all those who provided knowledge, articles, projects, input! Citations Atchison KA, Rozier RG, Weintraub JA Integrating oral health, primary care, and health literacy: considerations for health professional practice, education and policy. Commissioned by the Roundtable on Health Literacy, Health and Medicine Division, the National Academies of Sciences, Engineering, and Medicine. hliteracy/commissioned%20papers%20- Updated%202017/Atchison%20K%20et%20al%202017%20Integrating%20oral%20healt h%20primary%20care%20and%20health%20literacy.pdf Atchison KA, Rozier RG, Weintraub JA Integration of oral health and primary care: Communication, coordination, and referral. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. Atchison KA, Weintraub JA, Rozier RG. Bridging the dental-medical divide. J Am Dent Assoc. 2018;149(10): Atchison KA, Weintraub JA. Integrating Oral Health and Primary Care in the Changing Health Care Landscape. N C Med J. 2017;78(6):

33 Survey Reports of POHS Integration Category of Integration Preventive oral health services (POHS) provided by medical providers Report of Service Provision Pediatrics (11): screen for caries, counsel on oral health, including diet & mother s OH, provide fluoride varnish; Referral practices: 7% - 94%. All ages (1): oral assessment Primarily state-level surveys Periodontal and Systemic Diseases (2): Diabetes: Endocrinologists rarely screen, provide materials in office. Cardiologists: rarely or never examine OH (67%) OB-GYN (4): Oral assessment, Use oral health screening questions, diet counseling; Refer or recommend to get dental visit. Oral Cancer (6): Oral assessment/screening, assess risk factors including smoking & alcohol, cancer history, refer suspicious lesion

34 Guidelines/Consensus statement support of POHS integration Pediatric Primary Care American Academy of Pediatrics Policy Statement (2014) US Preventive Services Task Force. (2014) AAP/ Bright Futures. (Hagan et al., 2017) Pregnancy American College of Obstetricians & Gynecologists, 2013 National Maternal & Child Oral Health Resource Center, 2012 Statewide Public Health Departments or Dental Associations Coronary Heart Disease U.S. Preventive Services Task Force, Insufficient evidence to assess harms and benefits of clinical screening for periodontal disease to prevent CHD events Diabetes International Diabetes Federation Task Force on Clinical Guidelines, European Federation of Periodontology & American Academy of Periodontology (2013) American Diabetes Association, 2017 Oral Cancer US Preventive Services Task Force, (Moyer, 2014). Insufficient evidence American Cancer, Society, 2016 Check oral cavity during adult examinations American Academy of Family Physicians, 2017 Insufficient evidence

35 Survey Reports of Preventive Health Services by Dentists Category of Integration Preventive (non-dental) health services provided by dental provider 7 surveys, all focused on chronic conditions & their risk factors. Report of Service Provision by Dentists Smoking / Alcohol: Sometimes record information about use, inquire interest on quitting, refer to program to quit. Diabetes: Most include in medical history; Rarely note under M.D. care, complications, taking medications, perform inoffice blood glucose measures, consult with physician before treatment; provide written education materials, or use inoffice glucometer, Sometimes advise about periodontal disease risk. Nutrition/Obesity: Sometimes/rarely offer diet counseling, advise to keep diary; refer or call MD to coordinate treatment; provide written education materials; Rarely take weight & height/bmi

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