Shared Learning: Oral Health. Special Guest: Glenn Puckett, Director of Health Systems Integration with Washington Dental Service Foundation

Transcription

1 Shared Learning: Oral Health Special Guest: Glenn Puckett, Director of Health Systems Integration with Washington Dental Service Foundation SHARED LEARNINGS FUNDED BY THE ANTHEM FOUNDATION 55

2 Putting the Mouth Back in the Body: CPAA & The Medicaid Demonstration May 17, 2017 Glenn Puckett, Director, Health Systems Integration Washington Dental Service Foundation 56 I Putting the Mouth Back in the Body WDS Foundation March 2017

3 Agenda > The case for change: review of the current state & why oral health is an essential part of (whole person) wellbeing > Implementing evidence based models for oral health integration & population health > Using the Demonstration Toolkit to Address Oral Health

4 Oral Disease Prevalence Tooth Decay Most common chronic disease in childhood Nearly 40% of kindergarteners in WA have tooth decay Nearly 1 in 4 adults in the U.S. have untreated tooth decay Periodontal Disease 47% of U.S. adults have some form of periodontal disease (> with age) 19% of adults aged have severe periodontal disease Photo: ICOHP Photo: Robert Henry, DMD, MPH

5 Apple Health FY 2016 Children 1-17 with Dental Decay (cavities) Children 1-17 Users' Region Eligibles Accessing Care Children with Dental Decay % of Eligibles with Dental Decay % of Users with Dental Decay North Central 49,480 36,158 12, % 34.7% Cascade Pacific Action Alliance 77,762 44,336 14, % 33.5% WA State 815, , , % 31.3% Pierce 103,547 60,130 18, % 31.3% Greater Columbia 130,893 93,235 28, % 30.9% King 175, ,323 32, % 30.9% North Sound 123,965 73,086 22, % 30.7% Better Health Together 82,711 53,700 16, % 30.1% Olympic 33,137 17,322 5, % 29.0% SW WA Regional Health Alliance 63,060 35,801 10, % 28.5% Other/Out of State 3, % 22.6%

6 Oral Disease Systemic Diseases > People with serious gum disease are 40% more likely to have a chronic condition on top of it. 1 > Periodontal disease correlated with a variety of conditions with systemic implications > Cardiovascular disease, heart disease, respiratory infections, diabetes, HIV, adverse pregnancy outcomes > 91% of patients with heart disease have periodontitis, compared with 66% of people with no heart disease. > Systemic diseases can have an impact on oral health > Dementia > Chronic disease medications that cause xerostomia

7 Periodontal Treatment Reduces Medical Costs? Jeffcoat et al. Am J Prev Med 2014;47(2):

8 What is the problem we are trying to solve? A Prevention Gap > Caries and periodontal disease are preventable chronic infectious diseases > Unacceptably high burden of disease > Dental care is the most common unmet health need > The healthcare system, as currently configured, fails to reach the populations with the highest burden of disease resulting in pervasive health disparities and wasteful spending Qualis Health, 2016

9 We need an upstream solution a way to intervene earlier in the course of disease 25 % of children suffer from tooth decay The proposal? Expand the oral disease prevention workforce by engaging primary care teams in the fight against oral disease

10 Why enlist primary care teams? Total population at risk for caries and periodontal disease Population receiving regular medical care Access: Frequent contact with high-risk groups: Children, pregnant women, adults with diabetes Population receiving regular dental care Skills: > Disease prevention > Risk assessment, screening, case-finding > Help patients navigate the healthcare system > Engage patients in behavior change

11 Support for Oral Health Prevention in Primary Care Washington State Common Measure Set includes pediatric oral health services. 2011, Institute of Medicine (IOM) recommends expanding the role of non-dental healthcare professionals in oral health. The U.S. Preventive Services Task Force (USPSTF) Grade B recommendation for children, primary care providers should apply fluoride varnish to the teeth of all infants and children from the time of primary tooth eruption to age 5. The Health Resources and Services Administration (HRSA) issues core clinical competencies and recommendations for integrating oral health in primary care, healthcare education, and practitioner standards.

12 Collaborative Care

13 Oral Health: An Essential Component of Primary Care Published June 2015 Case for change Oral Health Delivery Framework Supporting actions from stakeholders Case examples from early leaders: Confluence Health, The Child and Adolescent Clinic, Marshfield Clinic Available at: Hummel J, Phillips KE, Holt B, Hayes C. Oral Health: An Essential Component of Primary Care. Seattle, WA: Qualis Health; June 2015

14 Field-Testing a Conceptual Framework 19 diverse healthcare delivery organizations: Private practices, Federally Qualified Health Centers; medical only and on-site dental Adults with diabetes (12), pediatrics (5), pregnancy (1), adult well visits (1) ecw (5), EPIC (8), NextGen (2), Centricity (2), Success EHS (2) Direct Technical Assistance Train-the-trainer with State PCAs Oregon Primary Care Assoc. Kansas Assoc. Medically Underserved (*) Massachusetts League of CHCs

15 Field-Testing Results Implementation Tools Oral Health Integration Implementation guide Toolkit for primary care teams (Published Oct 2016) Workflow maps Referral agreements Clinical training materials Patient engagement strategies Patient/family education resources EHR templates Case examples Impact data and more

16 A Workflow that Finishes the Work Before the Patient Leaves Insurance information Documentation of decision Clinical information Appointment information Process information MA reviews chart and Services Due Report to see if child has dentist noted in chart Confirm dental insurance & name of dentist and document in chart If no dentist, receptionist routes sticky note to alert MA MA asks OH questions, and if indicated Fills out order for Dental visit Schedules dental visit on dental schedule, which closes F/U order Provider reviews MA notes Examines Pt If referral to dental necessary checks to see if already done. If not, fills out F/U form and alerts MA MA checks to see if F/U order to Dental has been scheduled and schedules if needed If Pt unable to schedule MA sends Task to dental MA prints Plan that includes date of dental appointment or dental Qualis Health, 2017

17 Percent of Adults with Diabetes Assessed in past 12 Months 80% 70% 60% 50% 40% 30% 20% Pilot Clinic Formal spread kickoff 10% 0% Organic spread Qualis Health, 2017

18 Easy to Use Primary Care Oral Health Diagnostic Terms Clinical Concept ICD-10 Code Oral Health prevention Z29.3 Tooth decay K02.9 Gum inflammation K05.6 Oral Dryness K11.7 Unspecified lesion of oral mucosa K13.7 Qualis Health, 2017

19 Standard of Care in a Protocol

20 What does value look like in dental? Cost of care, utilization >Procedural approach >No consistent assessment of disease severity across population >Providers compensated for delivering services not population health

21 Imagine Dental is a valued partner in a healthcare system capable of using data and evidence to measure, finance and deliver whole person care and population health.

22 What Will It Take? Validated tools in dental for consistently measuring the oral disease severity in a population. > chronic diseases in medical Dental providers assessing and tracking disease severity in real time. > Retrospective claims analysis is not sufficient. Ability to easily share diagnostic data between dental and medical > Procedure codes (dental) vs diagnostic codes (medical)

23 Getting to Clinical Outcomes > Validated 4-point scales exist that can be mapped to ICD- 10 codes > Caries: ADA Caries Classification System (CCS) > Periodontal disease AAP/CDC > Both describe most severe tooth or tissue > No disease, mild, moderate, severe > Both can be adapted to population health > Caries add score for involvement of pulp > Periodontal disease add score for healthy gingiva

24 Dx Codes for Caries Severity Clinical Concept ICD-10 Severity Sound Tooth Dummy code 0 Caries involving enamel only K02.51; K Caries into dentin K02.52; K Caries extending into pulp K02.53; K Qualis Health, 2017

25 Dx Codes for Periodontal Disease Clinical Concept ICD-10 Severity Sound periodontium Dummy code 0 Attachment loss with healthy periodontium K Mild periodontitis K05.311; K Moderate periodontitis K05.312; K Severe periodontitis K05.313; K Qualis Health, 2017

26 A Population Approach to Oral Health Imagine 2 identical adult populations with diabetes > One receiving usual care > The other with integrated oral health 600 Usual Care 600 Integrated Oral Health Sound Controlled Mild Moderate Severe 0 Sound Controlled Mild Moderate Severe

27 Enabling Pay For Performance (Value) Outcomes > Quality of care: > Fluoride varnish for children & adults at risk > Sealants for children > Adults at greater risk screened > Population health > Caries: severity profile > Periodontal disease: severity profile > Utilization/Risk > ED utilization for dental disease > OR anesthesia for caries in kids

28 The Medicaid Waiver Project Toolkit Project 3C: Access to Oral Health Services

29 Oral Health Opportunities Focus Areas Populations Outcomes Evidence Based Approaches Preventive services Care Integration Care Coordination ED Diversion Maternal/Child Health Opioids Using population health dental data to detect, monitor and evaluate Medicaid Clients Focus on children, pregnancy, diabetes, older adults System Outcomes ED Diversion Project Outcomes Utilization Treatment plan completion Caries at recall Completed Referrals Data systems enabling population health: Dental diagnostic coding (ICD10) Disease severity Index Fluoride Varnish (USPSTF Grade B) Oral health in Primary Care Framework Use of diagnostic coding and disease severity assessments

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31 Medicaid Enrollees with at Least One Dental Service FY 2008 FY 2015 > The percentage of children using dental services has risen steadily from FY 2008 to FY In FY 2014, the total number of children accessing services increased but due to more enrollees, the percentage of children using dental services decreased slightly by 0.6%. In FY 2015, the utilization rates increased back to 55.5%. > With the restoration of adult dental program, the percent of adult enrolled using dental services increased from 13% in FY 2012 to 22% in FY Source: Washington State Health Care Authority, Apple Health Dental Services Enrollment and Utilization Data

32 Non-FQHC Providers and Number of Apple Healthinsured Adults Served, FY 2012 FY 2015 > Between FY 2012 and 2014, the majority (75%- 83%) of Non-Federally Qualified Health Clinic providers served 50 or less unique Apple Health-insured adults, while the remaining providers (18%-26%) served more than 50 unique Apple Healthinsured adults. Note: Adult dental benefits were restored in January FY 2014 data reflects 6 months of services, while FY 2015 data reflects one full year of adult dental services. Non-Federally Qualified Health Clinic providers include unique individual dentists identified through Service Provider s NPI (dentists may all be working at the same clinic) > In FY 2015, the number of Non-FQHC providers who served more than 50 adults increased by 34%. Nearly two thirds of Non-FQHC providers served 50 or less adults, while one third served more than 50 Apple Health insured adults. Source: Washington State Health Care Authority, Apple Health Dental Services Enrollment and Utilization Data

33 FY 2016 Apple Health Dental Utilization by County: Adults Ages 21 and over Statewide Utilization Total 22.1%

34 Apple Health FY 2016 Utilization of Restorative Services Adults Age 21 and Over Users' Region Eligibles Users % Users Greater Columbia 127,391 14, % Better Health Together 120,610 10, % North Central 46,728 4, % WA State (unduplicated) 1,120,265 95, % King 292,574 24, % North Sound 174,185 13, % Pierce 142,735 11, % SW WA Regional Health Alliance 76,473 5, % Cascade Pacific Action Alliance 122,530 7, % Olympic 58,428 3, % Other/Out of State 3, % Children Age 20 and Under Users' Region Eligibles Users % Users North Central 59,948 13, % Greater Columbia 159,253 32, % Better Health Together 101,334 18, % WA State (unduplicated) 994, , % Cascade Pacific Action Alliance 95,540 16, % King 215,881 35, % Pierce 126,201 20, % North Sound 151,386 24, % SW WA Regional Health Alliance 76,208 11, % Olympic 40,656 5, % Other/Out of State 3, %

35 Apple Health FY 2016 Utilization of Preventive Services Adults Age 21 and Over Users' Region Eligibles Users % Users Greater Columbia % Better Health Together % King % WA State (unduplicated) 1,120,265 89, % North Central % Pierce % SW WA Regional Health Alliance % North Sound % Olympic % Cascade Pacific Action Alliance % Other/Out of State % Children Age 20 and Under Users' Region Eligibles Users % Users North Central 59,948 36, % Greater Columbia 159,253 95, % Better Health Together 101,334 53, % WA State (unduplicated) 994, , % King 215, , % North Sound 151,386 72, % SW WA Regional Health Alliance 76,208 35, % Pierce 126,201 57, % Cascade Pacific Action Alliance 95,540 42, % Olympic 40,656 16, % Other/Out of State 3, %

36 Apple Health FY 2016 Utilization of Dental Services in CPAA Region All Ages Adults Age 21 and Over Users' Region Eligibles Users % Users Users' Region Eligibles Users % Users Greater Columbia 286, % Greater Columbia % North Central 106, % Better Health Together % Better Health Together 221, % WA State (unduplicated) 1,120, , % WA State (unduplicated) 2,114, , % North Central % SW WA Regional Health Alliance 152, % King % North Sound 325, % Cascade Pacific Action Alliance % Pierce 268, % Pierce % King 508, % SW WA Regional Health Alliance % Cascade Pacific Action Alliance 218, % North Sound % Olympic 99, % Olympic % Other/Out of State 7, % Other/Out of State % Children Age 20 and Under Children Age 6 and Under Users' Region Eligibles Users % Users Users' Region Eligibles Users % Users North Central 59,948 39, % North Central 19,608 12, % Greater Columbia 159, , % Greater Columbia 52,209 31, % Better Health Together 101,334 58, % Better Health Together 33,887 18, % WA State (unduplicated) 994, , % WA State (unduplicated) 329, , % King 215, , % Cascade Pacific Action Alliance 31,647 15, % North Sound 151,386 79, % SW WA Regional Health Alliance 24,656 12, % SW WA Regional Health Alliance 76,208 39, % North Sound 50,676 24, % Pierce 126,201 64, % King 72,813 34, % Cascade Pacific Action Alliance 95,540 48, % Pierce 43,420 20, % Olympic 40,656 18, % Olympic 13,493 5, % Other/Out of State 3, % Other/Out of State 1, %

37 Apple Health FY 2016 Dental Providers (All Providers vs Non-FQHC) Adults Age 21 and Over Providers' Region All Providers Dental Providers Only FQHC Providers King North Sound Greater Columbia Better Health Together Cascade Pacific Action Alliance Pierce SW WA Regional Health Alliance North Central Olympic Other/Out of State WA State (unduplicated) 1,930 1, Adults Age 21 and Over Providers' Region Non-FQHC Dental Providers 1-25 Clients Served Client Served More than 50 Client Served King Greater Columbia Better Health Together North Sound Cascade Pacific Action Alliance Pierce SW WA Regional Health Alliance Olympic Other/Out of State North Central WA State 1,

38 Table Break-out Learning on Oral Health Please answer the following questions: 1. What strategies would be most promising in the CPAA Region? 2. If you could do one thing to improve oral health in our region what strategy would you choose? 3. What else do we need to know? 92