Interprofessional Oral Health Core Clinical Competencies: What They Mean for Your Dental Program. Findings from the IPOHCCC Project

Transcription

1 Interprofessional Oral Health Core Clinical Competencies: What They Mean for Your Dental Program Findings from the IPOHCCC Project

2 Objectives Describe current efforts in interprofessional education Understand the goals of the Integrating Oral Health in Primary Care Practice initiative (IOHPCP) Explain the five oral health core clinical competency domains Learn the different approaches used by Health Center primary care departments to implement oral health clinical competencies

3 Background Where are we & how did we get here?

4 History 2000 Surgeon General s Report on Oral Health Highlighted disparities in oral health status & access to oral health care

5 1 st IOM Report: Advancing Oral Health in America Recommended oral health workforce innovation as one strategy to improve oral health/ increase access

6 2 nd IOM Report: Improving Access to Oral Health Care Recommendations included HRSA developing oral health competencies for nondental professionals HRSA increasing capacity of FQHC dental programs

7 Interprofessional Educational (IPE) Efforts Trend in health profession education to develop programs and curricula that incorporate shared or integrated learning experiences Revising accreditation requirements to mandate interprofessional experiences. CODA Standard 2-19: Graduates must be competent in communicating and collaborating with other members of the health care team to facilitate provision of health care. Family Medicine first medical specialty to include oral health competencies as part of residency requirements

8 Interprofessional Educational Efforts National Coordinating Center for Interprofessional Education and Collaborative Practice HRSA funded Coordinate dissemination of IPE efforts Integrating Oral Health in Medical Education Model Curriculum HRSA funded in collaboration with the Association of American Medical Colleges Instructional resources disseminated through MedEdPORTAL

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11 Interprofessional Educational Efforts Smiles for Life- Online oral health teaching curriculum developed by Society of Teachers of Family Medicine Nation s most comprehensive and widely used oral health curriculum for primary care clinicians Endorsed by 13 national organizations, and is in wide use in professional schools and post-graduate training programs. Children s Oral Health- American Academy of Pediatrics oral health website includes online training

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14 Interprofessional Educational Efforts NYU College of Nursing- Teaching Oral-Systemic Healthcurricular (TOSH) model for primary care advanced practice nurses Oral Health Nursing Education and Practice (OHNEP)- website- advocates, educates, creates and promotes resources for primary care clinicians Physician Assistant Education Association- oral health initiative- Oral Health Summit and education through publications and website

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16 Other Initiatives The National Interprofessional Initiative on Oral Health (NIIOH)- maintains the Smiles for Life curriculum. Engages primary care clinicians Qualis Health- Safety Net Medical Home Initiative. Oral Health in Primary Care: PCMH Implementation Tools project. Help primary care practices ensure that all patients have access to oral health services and referrals

17 State Medicaid Oral Health Programs with Primary Care Providers - Published Evaluations Washington Massachusetts North Carolina Colorado (coming soon)

18 U.S. Preventive Services Task Force Recommendations May 2014 Primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride Primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the time of primary tooth eruption to prevent dental caries in children from birth through age 5 years

19 Where Do I Fit In?

20 2014 HRSA Integration of Oral Health and Primary Care Practice (IOHPCP) Initiative Develop oral health core clinical competencies for primary care clinicians Delineate elements that influence implementation and adoption Translate into primary care practice in safety net settings

21 IOHPCP Improve access for early detection and preventive interventions by expanding oral health clinical competency of primary care clinicians, leading to improved oral health Focus on the clinical practice of primary care practitioners in safety net community Members of existing delivery system who could incorporate oral health core clinical competencies into their existing scope of practice Most likely to see vulnerable and underserved populations without, or with limited access to dental services

22 Primary Care Providers MD/DO Certified Nurse Midwives Nurse Practitioners Physician Assistants

23 Oral Health Core Clinical Competency Domains 1. Risk assessment 2. Oral health evaluation 3. Preventive interventions 4. Communication & education 5. Interprofessional collaborative practice

24 IPOHCCC Pilot Project Goal Implementation of Oral Health Core Clinical Competencies using a sustainable systems approach that results in integrating oral health and primary care through interprofessional collaborative practice.

25 IPOHCCC Pilot Project Objectives Increase oral health screening and preventive services Increase oral health integration and primary care practice Increase interprofessional collaborative practice Increase care coordination between medical and dental Identify sustainable approach to practice changes Could these things be done in your Health Center primary care clinic?

26 Health Partners Western Ohio Lima, OH

27 Health Partners Description Total Users 14,787 Dental Users 7,151 Primary Care sites 3 Dental sites 2 PCP FTEs 8.5 Dentist FTEs 3.2 Small city surrounded by rural 38,339

28 Family HealthCare Fargo, ND

29 Family HealthCare Description (2011 UDS) Total Users 11,694 Dental Users 3,951 Primary Care sites 1 Dental sites 2 PCP FTEs 6.4 Dentist FTEs 2.6 Medium city surrounded by rural 109,779

30 BRONX COMMUNITY HEALTH CENTER BRONX, NY

31 BCHN DESCRIPTION (2011 UDS) Total Users 81,784 Dental Users 20,658 Primary Care sites 15 Dental sites 3 PCP FTEs 36 Dentist FTEs 20 Urban metropolis 1.4 million Health Center without walls operated under contract by Montefiore Medical Center, Albert Einstein College of Medicine

32 Which IPOHCCC Health Center do you feel you are most closest to? BCHN FHC HPWO Other

33 Results

34 Comprehensive Project Evaluation In collaboration with Thomas Keifer Consulting Quantitative and qualitative data Evaluation Advisory Board meetings (3 for project) Provide feedback on evaluation plan, data collection instruments, data interpretation, content expertise Members: Dr. Huong Le, Dr. Jim Sutherland, Dr. Patty Braun, Tena Geis, Dr. Mark Deutchman, and pilot health center representatives

35 What it Looked Like Clinically HPWO FHC BCHN Population > EMR-EDR Configuration Greenway Prime Fully integrated Centricity Dentrix Training Smiles for Life Smiles for Life, state specific for Medicaid reimbursement Dental department participation in training Inservices, demonstrations Inservices, demonstrations Centricity QSI Smiles for Life Inservices, demonstrations

36 What it Looked Like Clinically HPWO FHC BCHN Risk Assessment 100% Support staff 10% Support staff Oral Evaluation (e.g. clinical oral screening) Preventive Interventions (e.g. fluoride varnish) Communication & Education 50% Support staff 90% Provider 50% Provider Provider Provider Provider Support staff (prior to oral evaluation) Provider and takehome materials Support staff (after oral evaluation) Provider and takehome materials Support staff (after oral evaluation) Provider and takehome materials

37 What it Looked Like Clinically Inter-professional Collaborative Practice (e.g. referral) Inter-professional Collaborative Practice (e.g. appointment scheduling) HPWO FHC BCHN Provider (check-off box in the EMR), yellow tooth patient takes to front desk. Reserved dental exam slots (4 per day) accessible by front desk at checkout. Provider (check-off box in the EMR), passport sheet with follow ups (e.g. lab, radiology) includes dental No reserved dental exam slots. Primary care front desk staff at checkout. Provider (check-off box in the EMR). Can print out a list of community dental providers from EMR. Reserved dental exam slots (4 per day). Primary care front desk cannot access dental appointment system.

38 Results: PCP Oral Health Training Health Center # PCP Trained Post Test Scores % correct HPWO 25** 96% FHC 7 95% BCHN 48* 88% * Includes pediatric residents **Includes new expansion staff

39 Results: # Patients with Risk Assessment in Primary Care Health Center Objective Results HPWO 1,800 2,458 FHC BCHN

40 Results: Preventive Intervention- % of Patients with Risk Assessment Receiving Fluoride Varnish in Primary Care Health Center % objective % results HPWO FHC BCHN 80 75

41 Results: Communication & Education- % of Patients with Risk Assessment Receiving OH education Health Center % Receiving OH Post Test Scores % correct HPWO 86% 74% FHC 85% 77% BCHN 31% n/a

42 Results: Interprofessional Practice- % Patients with Completed Medical-to-Dental Appointment Through Primary Care Health Center % Objective % Results HPWO FHC BCHN 80 51

43 Challenges & Strategies

44 PCP Training Challenge Time for training Incentive for training Standardizing content Obtaining supervised clinical practice Strategy Self-paced online curricula Free CE units Use endorsed, recognized curricula Collaborate with HC dental clinic providers to observe and provide clinical training for PCP (Build competency and foster interprofessional practice!)

45 Risk Assessment (RA) Challenge Assuring correct RA elements incorporated Assuring RA performed at PC visit Incorporating RA into PC visit flow PC staff resistance to additional tasks Strategy Utilize well-known risk assessment tools such as CAMBRA /ADA/AAP Embed OH risk assessment into the EMR template Make procedural and workflow changes, use QI methodology to monitor and improve Identify PCP champion, start small

46 Oral Evaluation Challenge Assuring correct elements incorporated Assuring oral evaluation performed at PC visit Incorporating oral evaluation into PC visit flow PC staff resistance to additional tasks Strategy Online training followed by in person training with dental staff Embed OH evaluation into the EMR template Make procedural and workflow changes, use QI methodology to monitor and improve Identify PCP champion, start small

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48 Preventive Intervention Challenge Assuring competency in application of Fluoride Varnish (FV) Adult patient resistance to FV color & taste Concerns about excessive applications PCP staff resistance to performing procedures inside patient s mouths Strategy Online training followed by in person training with dental staff Try different colors & brand tastes Develop immunization card to track Let patients (adults) self administer

49 Communication & Education Challenge Obtaining oral health education materials in multiple languages Patient resistance to OH education in the PC setting PCP staff resistance to performing OH education Strategy Online resources, Smiles for Life Relate to general health concerns i.e. obesity, diabetic control Relate to general health concerns i.e. obesity, diabetic control

50 Interprofessional Practice Challenge Inability of PC staff to make direct dental appointments using HIT system Lack of capacity in the dental clinic for PC referrals Patients reporting existing dental home Patient resistance to dental treatment citing cost and/or fear Strategy Develop work-around Dedicated appointments Document Motivational Interviewing

51 Characteristics of Success

52 Leadership Vision & Support Starts with ED/CEO Insure same message throughout organization- primary care, dental, behavioral Treating the patient as a whole is part of the mission and culture of the Health Center

53 Integrated HC Executive Team All disciplines integrated into the administrative structure Part of organizational structure Integrated operations team meetings, committees and communications

54 Co-location Bi-directional referrals, same day assessments warm hand-off

55 Organizational Culture of Quality Improvement In-depth user s knowledge of the terminology and methodology of quality improvement Culture permeated all Health Center departments Focus on outcomes - of using outcome measures to drive change, of improving from a baseline, and using these concepts for all aspects of clinic operations

56 Staff Buy-in: Understanding the Why Progress the result of a continuous process Resistance to change from staff addressed not by telling staff what to do, but rather explaining the "why

57 Patient Enabling Services Patient navigators, family support workers, health coaches Assist in making appointments, engaging patients, motivational interviewing, goal setting Available to all disciplines & departments

58 Champions Proactive, sure of the importance of oral health in improving the health status of the patients they serve Confidence to advocate for oral health Remember the reason for doing this is not for a piece of paper of recognition but to better serve our patients and improve their quality of life.

59 Where is your Health Center? What characteristics of success are present in your organization at high levels? What characteristics of success are present in your organization at low levels?

60 Characteristics of Success Leadership Vision & Support Integrated HC Executive Team Co-location Organizational Culture of Quality Improvement Staff Buy-in: Understanding the Why Patient Enabling Services Champions

61 Future

62 NNOHA Next Steps IPOHCCC User Guide in review. Will be available online Disseminate results via webinars, presentations, newsletter

63 Conclusion Interprofessional education HRSA focus on collaborative practice in Health Centers YOU are a vital part!

64 Dental had felt separate, someplace you sent a patient to. Now, I know them better. I can talk to them about a dental issue, and they talk with me more about medical issues. Primary care provider I think it's great that you care so much about the health of your patients that you are willing to go to such steps to better care for them. P.S. I think you are all great! Primary care patient after OH education by PC staff

65 Medical Assistant & Dental Assistant Providing Education in Waiting Shared Room

66 Contact Us! Irene V. Hilton, DDS, MPH NNOHA Dental Consultant National Network for Oral Health Access PMB: Quebec Street, Unit 100 Denver, CO Phone: (303) Fax: (866)