Integrating Oral Health into Primary Care Francis E Rushton, MD, FAAP Medical Director SC QTIP

Transcription

1 Integrating Oral Health into Primary Care Francis E Rushton, MD, FAAP Medical Director SC QTIP Introduction and Acknowledgements This oral health integration training was developed for MORE Care. It was adapted from the following sources: Connecting Smiles Initiative, a collaborative project with the U of SC s South Carolina Rural Health Research Center and the Department of Health and Human Services. The training was adapted from the American Academy of Pediatrics A Pediatric Guide to Oral Health Flip Chart and Reference Guide, Copyright 2012 Smiles for Life Oral Health Curriculum, Module 6.Access at: Christine Veschusio, DrPH, MUSC, Oral Health Policy Consultant Raymond F. Lala, DDS, Director DHEC Division of Oral Health Mary Kenyon Jones, Med, DHEC Education and Outreach Lynn Martin LLSW, Project Director, QTIP 1

2 What primary care physicians need to convey about pathogenic oral health disease Early Childhood Cavities A transmissible, infectious, chronic disease that affects can begin in infancy Can lead to inability to chew food, and to pain and infection. Some feeding habits are strongly implicated in ECC Progresses Fast Starts in upper front teeth moves to posterior as teeth erupt 2

3 Mother to baby? YES, cariogenic bacteria can be transferred from the mother or primary caregiver to baby through saliva contact. The more untreated cavities in the mouth of the mother, the more likely the child will be have higher levels of bacteria, increasing the child s risk for tooth decay. Key Message: To reduce the risk of passing bacteria to their children, mothers can: Receive regular dental care Limit frequency of sugar in the diet brush with fluoridated tooth paste Limit activities in which saliva can be shared Tip: reinforce message by giving parent handout as part of their visit pack + Cavity Causing Germs + Sugar Cavity causing bacteria or germs breaks down sugar (formula, fruit juice, cookies, sweet tea, etc ) into acid Acid stays for minutes after Sugar eaten Acid demineralizes or breaks down the tooth surface Key Message: your teeth need breaks between meals and snacks to prevent cavities limit constant eating & drinking of sweets and complex carbs 3

4 What is the one factor for getting a cavity? if CYCLE of ACID production & DEMINERALIZATION occurs frequently over TIME Enamel weakens & breaks down into a CAVITY if SUGARS are consumed INFREQUENTLY, REMINERALIZATION can take place as the acid is buffered by the saliva, halting the decay process. Understand how to assess a child s risk for tooth decay 4

5 Using the AAP Oral Health Risk Assessment Tool The child is at an absolute high risk for caries if any risk factors or clinical findings, marked with a, are documented yes. In the absence of a risk factors or clinical findings, the clinician may determine the child is at high risk of caries based on one or more positive responses to other risk factors or clinical findings. Answering yes to protective factors should be taken into account with risk factors/clinical findings in determining low versus high risk. High Risk One or more of the following: Presence of white spots and/or cavities History of cavities and/or fillings in last 3 years Presence of plaque/tartar Family members have cavities particularly mother No dental visit in last year Child with Special Health Care Needs 5

6 Low Risk No history of fillings No what spots or cavities present No plaque or tartar present No family history of untreated cavities particularly mother Had dental visit in past year Describe key Anticipatory Guidance/Oral Health Counseling messages for the prevention of tooth decay in children 6

7 + The Importance of Early Oral Health Care Begins with infants After feeding, an infant's teeth and gums should be wiped with a moist cloth or gum cleaner to remove any remaining liquid that coats the teeth and gums Tip: reinforce message by giving parent handout as part of their visit pack & gum cleaner + Toothbrushing Tip: reinforce message by giving parent handout as part of their visit pack Infants and Toddlers should be soft with a small head and large handle. Supervision: until the child has proper coordination and can reliably rinse and spit out excess toothpaste which usually occurs at about 6 years of age. 7

8 Toothbrushing and Toothpaste As soon as teeth appear, parents & caregivers need to begin brushing children s teeth with fluoride toothpaste 2 minutes 2 times a day. Under 3 years, use smear Over 3 years, use pea sized amount American Dental Association Council on Scientific Affairs (2014) Fluoride toothpaste use for young children. Journal of the American Dental Association. 145(2): Oral Health Counseling: Feeding Habits and Nutrition Impact Oral Health 8

9 + Information on Breastfeeding & Bottle Feeding Bottle Feeding: Associated with a higher risk of dental caries. Only breast milk, formula, or water in a bottle. Babies should be held when bottle-fed Bottle & Breast Feeding: Limit constant feeding Wipe their infant s mouth and teeth clean after feeding. Tip: reinforce message by giving parent handout as part of their visit pack + Sippy Cups Potential Misuse: Used continuously throughout the day. Filled with juice and other sugary beverages. Used a as pacifier to calm and appease. Tip: determine current use & reinforce positive message by giving parent handout as part of their visit pack 9

10 + Dietary Counseling Food guidance for dental health often mirrors food guidance for obesity prevention. Encourage: healthy foods such as fruits and vegetables or whole grain snacks. Encourage: regular meal times for breakfast, lunch and dinner Discourage: sticky foods such as raisins, fruit leather, and hard candies. Discourage: grazing behavior where the child is eating and drinking very frequently throughout the day. Tip: reinforce message by giving parent handout as part of their visit pack Fluoride Assessment: Component of the Risk Assessment: Describe how to implement the fluoride assessment in a primary care practice Demonstrate the appropriate application of fluoride varnish Determine if fluoride supplements are needed 10

11 1/19/ Fluoride Assessment Determine source of child s main source of drinking water. Questions for parents: What is the source of your family s drinking water? Where do you live? Where does your child stay most of the time? Does your child drink well water? Does your child drink bottled water? 11

12 + Community Water Fluoridation Topical Main Effect: Fluoride can strengthen the tooth surface and protect teeth from decay. Also works systemically, for children as their teeth are forming. 70 years of scientific research confirms that Community Water Fluoridation is proven to be the most Safe, Effective and Cost Effective way to prevent tooth decay. + American Dental Association Dietary Fluoride Supplement Schedule for Children at High Caries Risk Child s Source of Drinking Water is not fluoridated Public Water System not fluoridated or Private Well does not contain natural fluoride at a level to prevent tooth decay Age of Child Birth to 6 Months 6 months to 3 years <0.3 ppm ppm >0.6 ppm None None None 0.25 mg/d None None 3 to 6 years 0.5 mg/d 0.25 mg/d None 6 to 16 years 1.0 mg/d 0.5 mg/d None 12

13 + Primary Source: Well Water If the child s primary source of drinking water is wellwater, determine the level of fluoride in the water by having a water sample tested by DHEC Contact SC DHEC for well-water testing program for the presence of fluoride. Access at: sting.htm. Care Pathway Primary & Secondary Prevention: Integrating Fluoride Varnish into the Practice Thinking through the process 13

14 + Rationale - Standard of Care: Fluoride Varnish in Primary Care Topical Effect of Fluoride 2014 Apply Fluoride Varnish to the teeth of all infants and children starting at the eruption of the first tooth At least every 6 months in the primary care office Higher risk children should receive every 3-4 months Evidence-based Dental Prevention White Spots Varnish applied to teeth Remineralized Enamel Safe and effective way to prevent tooth decay by strengthening enamel Recent studies report fluoride varnish application in baby teeth resulted in a 30-35% reduction in tooth decay Can reverse early decay white spots, and slow enamel destruction in active decay 14

15 The why fluoride varnish? for parents Tip: handout can be given to the parent/caregiver in the waiting room or at any time during visit in order to help them understand why fluoride varnish is applied to children s teeth. Reimbursement from SCDHHS Medicaid Reimbursement for Fluoride Varnish in Primary Care as of 7/1/2015 Former Fluoride Varnish policy SCDHHS Medicaid 2007 to June 30, 2015 only delivered at EPSDT visit 0 to 36 months of age only 15

16 Develop a Process for Identifying Opportunities for Delivery of Fluoride Varnish Can be delivered at any visit Be mindful that the interval must be greater than 180 days since the child s last fluoride varnish service in the medical setting 6 months X 9 months X 12 months X 15 months X 18 months X 24 months X 36 months X 4 years X 5 years X 6 years X 7 years X 8 years X 9 years X 10 years 11 years 12 years EPSDT Oral Exam Fluoride Varnish X X X d a y I n t e r v a l r e q u i r e d Other Visits Thinking through the process of delivering fluoride varnish Step by Step 16

17 Step 1 Set up for Fluoride Varnish Set up on paper towel: Fluoride Varnish single dose with applicator brush Gauze Square Gloves Step 3 Position the child Provider behind child s head in knee to knee and on exam table Parent holds hands Older child can apply with child standing or sitting Knee to knew work well for babies and young children Can also use the exam table Older children can stand in front of you 17

18 Use gauze to dry the teeth off Step 4 Applying Fluoride Varnish Apply varnish to dried teeth starting in posterior Apply a thin layer to all teeth Apply to front teeth last Saliva contamination after application is fine since varnish sets in contact with saliva 5. Fluoride Varnish After Care Instructions for Parents SC DHEC will have the Spanish version of their instructions soon. AAP has instructions available in multiple languages: arnish-instructions-all.pdf Do not brush the child s teeth until the next morning The child s teeth may be slightly yellow until they are brushed. The child can eat and drink right away but should avoid hot liquids. sticky or hard foods 18

19 How do I develop a plan to integrate fluoride varnish into the practice? What changes will be needed to deliver fluoride varnish in our practice? Health Records/Billing: Determine a procedure for documenting and billing fluoride varnish SCDHHS Medicaid Reimbursement for Fluoride Varnish in Primary Care 2015 Use Procedure Code: for billing fluoride varnish every 6 months up to 13 th birthday month Interval between Fluoride Varnish Services: greater than180 days Complete approved Training (e.g. Smiles for Life) Private Insurance: one peds has reported billing for private insurance is going well. Only payer not reimbursing is federal BCBS Representatives identified from to develop a plan to include fluoride varnish and other oral health documentation into Health Records Billing 19

20 + Determine a Protocol for the Delivery of Fluoride Varnish Every Office is Different! What works best for your office! 1. Assemble fluoride varnish, gauze, gloves on paper towel 2. Position: place child in knee to knee position or other position that works for you 3. Check child s mouth for White spots or cavities Oral hygiene status Other clinical findings If child does not open, slide finger into buccal sulcus and open mouth gently 4. Apply Fluoride Varnish & give after care instructions. 5. Record findings & document delivery of fluoride varnish How do we engage South Carolina pediatric offices in promoting optimal oral health? What changes will be needed to deliver fluoride varnish and expanded oral health prevention in our practices? 20

21 How Pediatric Practices 18 practices selected Each practice identified a QI team lead: practitioner, nurse and office manager 4 year commitment Plan-Do-Study-Act cycles Practices document quality improvement work Maintenance of Certification Physicians can earn Part IV MOC credit on QI work Regular Contact Monthly conference calls Blog (where data and QI minutes are also posted IP Worked with Practices and Stakeholders Learning Collaborative Semi-annual sessions attended by QI team Quality measures presented, expert speakers, PCMH and behavioral health concepts, information sharing, etc. Site Visits QTIP team technical assistance site visits Peer reviewer participation Academic detailing Mental Health education and community resource meetings Quality Improvement coaching 41 July 1, 2015 QTIP practices main and satellite offices satellite satellite 21

22 Documentation of work on core measures PDSA Jan Dec 31, 2014 N= 1, Introduced: Jan 11 July 11 Jan 12 July 12 Jan 13 July 13 Jan 14 July Oral HealthRESULTS 167 PDSA Cycles have been documented a. Performing and documenting an oral health risk assessment (20%) b. Referral of the patient to a dental home (20%) c. Application of fluoride varnish (47%) d. Fluoride in the family s drinking water (6%) e. Other interventions/focus 18% (some PDSAs had more than 1 focus) All original QTIP practices have documented PDSA Preventive Oral Health Preventative Oral Health is the 4 th most frequently documented QI project. (11% of all PDSA cycles) QTIP trained 369 staff in fluoride varnishing (from 21 practices) 44 22

23 MOC (Maintenance of Certification) Part IV Credit for American Board of Pediatrics On at least 2 of the 5 following criteria. New and/or existing patients seen in the office over the previous 30 days can be included in each 10-chart sample. Chart documentation of an oral health home or referral to such in practice well child visit notes. Documentation of an Oral Exam at each well child visit Risk Assessment documented for each child at the time of the well child visit to include: Presence of Medicaid insurance, family oral health status, prematurity and special health care need. Provision of Fluoride varnish every 6 months between ages 6 months and 3 years of age in high risk children in the pediatrician s office Documentation of anticipatory guidance around oral health issues including exposure to fluoride in the diet. July 2011 Learning Collaborative National and State Topic Experts Oral Health and Primary Care Lessons from the Tooth Fairy Suzanne Boulter, MD Overview of Early Childhood Caries: Prevalence and Significance Pathophysiology of Caries Demographics of Caries Risk Oral Health Risk Assessment Anticipatory Guidance Recommendations and Referral 46 23

24 National and State Experts Paul Hlecko, MD Georgetown Pediatrics Understand the biologic mechanism of fluoridation Understand the benefits, possible adverse effects and fluoride dosing Understand the community and well water fluoride content issues in SC Examples of PDSA cycles 47 Oral Health Results: QTIP practice staff trained to administer fluoride varnish; 14/18 QTIP practices are now eligible to provide fluoride varnish. A 507% increase in fluoride varnish application in the pediatric office(d1206) (as of June 2012 and compared with 2015) Patients at QTIP practices statistically more likely to go to a dentist than patients at non QTIP practices Increased collaborative with DHEC on oral heath toolkits and water testing. 24

25 PDSA cycle dental home P: Develop a list of Dentists in Anderson D: Contacted all dentist in area and asked: if they accepted Medicaid? seeing new patients? what age did they start preventive care? S: List collated. Lots of local dentists accept Medicaid: 6 start preventive dental care at age 1, 1 starts with first tooth A: Give the list to all patients at well child visits and encourage dental home engagement 49 PDSA cycles Risk Assessments P: Want an oral health screening tool to use with our EMR to identify children high risk for dental disease and track oral health advice D:Used AAP oral health screening instrument, incorporated it in to our well child templates, educated MDs S: Baseline data shows 0 screened for oral health risk as we just started initiative A: Further tracking of oral health risk assessment, make tool more visible in EMR, train doctors 50 25

26 Practice reports new procedures implemented Fluoride, Oral Health Risk Computer Templates (including notations with well child checks) Expand patient education packets to include oral health material Distributing infant toothbrushes Oral Health Goody Bags containing toothbrushes, toothpaste and educational material Distributing a list of local dentists. A practice held a "dental summit" with area dentists and hygienists to discuss oral health issues and increasing efficacy in promoting oral health. Posted DHEC oral health posters in every exam room Investigated fluoride status of local wells. Changing from candy to stickers 51 Blog headlines Christine Veschusio, DrPH MUSC, CDM Oral Health Policy Consultant 52 26

27 Preventative Oral Health Fluoride Varnish in Non-Dental Settings for Medicaid children (10 mos) QTIP ALL 702% Improvements in Pediatric Office Dental Varnish Application 7000 d1206 all non dental (excluding FQHC) FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 qtip non qtip total 27

28 Preventative Oral Health 10 of 10 (99.4%) eligible children visited a Physician Only 4 out of 10 (43%) eligible children visited the dental provider Only 5% eligible Medicaid children (0 5) received fluoride Varnish by a Physician Only 41% of Medicaid children (0-5) received fluoride varnish from a dental provider Only 8% of Medicaid children seen by a physician received fluoride varnish more than 1 application in a calendar year Impact: DHHS reviewing policy about Fluoride varnishing frequency Physician intervention important and where children are first and most frequently seen Continued education is needed Data source: with Medicaid physician Claims data SFY16 and dental community 55 Challenges Reimbursement for Dental Varnish: MCO, FQHC, private insurance amount not sufficient for some Dental Homes various dentist accept at patient s at various ages not in congruence with national recommendations Push back from many pediatricians and their office in not wanting to provide dental varnish some sense this is not their area of expertise. Requirement by SC Medicaid that each practitioner complete a DHHS approved oral health course before being allowed to bill for fluoride varnish. A long way to go before we are adequately meeting the need 56 28