Integration of Oral Health and Primary Care Practice. Candace Owen, RDH, MS, MPH NNOHA Education Director Wyoming PCA Meeting September 19, 2018

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1 Integration of Oral Health and Primary Care Practice Candace Owen, RDH, MS, MPH NNOHA Education Director Wyoming PCA Meeting September 19, 2018

2 Objectives Explain the 5 oral health core clinical competency domains for integration of oral health and primary care practice (IOHPCP). Describe the background of medical and dental integration initiatives with NNOHA and HRSA. Learn strategies to integrate medical and dental within community health centers.

3 About NNOHA Founded in 1991 by FQHC Dental Directors who identified a need for peer-to-peer networking, collaboration, research, and support Membership now includes more than 3,000 dentists, dental hygienists, supporters, and partners

4 HRSA NCA Grantee T/TA Learning Collaboratives IOHPCP, UDS Sealant Measure, quality improvement Operations Manuals Webinars NNOHA Listserv Promising Practices Resources dental forms library, education materials nnoha.org or

5 Wyoming Access to Dental Care Medical users: 27,024 Dental users: 2,678 Dental capacity to medical: 9.9%

6 A Brief History of Medical- Dental Integration in Health Centers Where are we and how did we get here?

7 2011 IOM Report: Improving Access to Oral Health Care Recommendations included HRSA developing oral health competencies for non-dental professionals

8 2014: HRSA IOHPCP Initiative Develop oral health core clinical competencies for primary care clinicians Translate into primary care practice in safety net settings

9 2015: A User s Guide for Implementation of Interprofessional Oral Health Core Clinical Competencies 3 Pilot Health Centers PCPs deliver oral health interventions Standardization of training, clinical protocols Measures/QI

10 IOHPCP Framework

11 Strategic Goal 2: Promote and Advance Quality of Care 100% Healthy People 2020 Goals Chronic Disease Management: Patients with controlled diabetes and hypertension 80% 60% 40% 20% 68% 55% 53% 62% National Average UDS % Diabetes Conrolled Blood Pressure Controlled National Average Sources: National Committee for Quality Assurance. The State of Health Care Quality Report Hypertension prevalence and control among adults: United States, NCHS data brief, no 220. Hyattsville, MD: National Center for Health Statistics

12 Strategic Partners Technical Assistance Strategies to Prevent and Manage Diabetes Improving Health Systems & Infrastructure Optimizing Provider & Multidisciplinary Teams Facilitating Behavior Change in Patients EHRs with Diabetes Modules Diabetes Informatics Health Information Exchange (HIE) & Telemedicine Patient Centered Medical Home (PCMH) Use Patient Portals Team Based Care Promote National Standards New Techniques for Early Detection Screening Case Management Sharing of Diabetes Management Promising Practices Eye, Foot, Dental, & Kidney Screening Provider Counseling of Patients CHW Directed Patient Education Lifestyle/Self- Management Promote Physical Activity and Healthy Diets Address Childhood & Adult Obesity Increase Patient Health Literacy 12

13 IOHPCP Improve access for early detection and preventive interventions by expanding oral health clinical competency of primary care clinicians, leading to improved oral health Why integrate? Improve communication and collaboration Improve quality Reduce costs

14

15

16 Steps to Success

17 Planning Establish a Team Select a population of focus Create timeline Look for synergy with existing Health Center initiatives Gear up test cycle process Identify champions

18 Strategies Pilot integration at one co-located site Develop systems Expand to non-co-located sites

19 Training Systems Online training In-person training (interdisciplinary collaboration opportunity) On-boarding new health professionals

20 Online Training Smiles for Life: Nation s most comprehensive and widely used oral health curriculum for PCP American Academy of Pediatrics Oral Health Nursing Education and Practice (OHNEP)

21

22 In-Person Training Provided by dental staff at health center Training options: minute mini-sessions during primary care staff meetings 1 hour presentation 1-2/yr Lunch and learn Provide ongoing learning opportunities

23 Things to Learn 1. Risk assessment 2. Oral health evaluation 3. Preventive interventions 4. Communication & education 5. Interprofessional collaborative practice 1. What to ask? 2. What to look for? 3. What to do? 4. What to say? 5. How to refer?

24 Interdisciplinary Practice Interprofessional clinical observation and practice can be used as a training tool Allows professionals to gain competence in competency domains (risk assessment and oral health evaluation) Once a group of PCP are competent, they can train other PCP

25 On-Boarding New Health Professionals Develop a system to on-board future PCP in the five domains Require online curriculum as part of employee orientation process Oral health in-service presentations can be recorded and uploaded onto online modules Medical director or other champions can preceptor newly hired PCP in oral health competencies Clinical rotations at least 1 full day observing the other clinic

26 HIT Systems All Paper Electronic Medical Record Only Electronic Dental Record Only Separate Electronic Medical and Dental Records Electronic Medical Records with Dental Templates Home Grown Electronic Medical & Dental Records Interfaced Electronic Medical & Dental Record Fully Integrated Electronic Medical & Dental Record Fully Integrated Electronic Medical & Dental Record + Electronic Health Record No integration Full integration

27 EMR Revision To implement the five IPOHCCC domains EMR must be able to: Provide a risk-assessment tool ideally automatically scores Document oral health evaluation, preventive interventions, self-management goals, and education Print educational handouts and post-visit instructions Refer the patients for oral health care Collect data

28 Referral to Dental

29 RA and Clinical Eval in EMR

30 EMR and EDR Relationship Ideal: EDR/EMR should be integrated and should communicate with each other Ability to see patient information and visit notes Shared e-prescribing Shared appointment making Track referrals across systems Track procedures across systems Can use workarounds to create referral and data-collection systems

31 Strategies Generating population lists from other database Convert & track through Excel or Access In general, it is true that resources must be allocated to develop workarounds Training sessions for PCP and Dental from HIT staff

32 Workarounds Track referrals using a spreadsheet Access to EDR and EMR Assign dedicated dental appointments for medical referred patients

33 Clinical Care Systems Who performs what? During what part of the PC visit? Clear division of labor Develop a workflow Test cycles Document procedures and clinical protocols

34

35 Evaluation Systems Needed to drive system changes to implement an oral health and primary care practice integration program Evaluate program success

36 Developing an Evaluation System Determine what data to collect What information is important to drive system changes? Most data can be collected through EMR/EDR Other data sources Patient surveys Provider surveys

37 IPOHCCC Minimum Core Set of Measures 1. # and % of OH assessments/screening performed by PCP 2. # and % of FL varnish applications for highrisk patients 3. # and % of patients receiving OH preventive interventions 4. # and % patients referred from medical to dental 5. # and % of patients that are linked to definitive OH care and treatment

38 IPOHCCC Minimum Core Set of Measures 6. Changes in quality of care/outcome indicators 7. Knowledge and skills of primary care providers 8. Patient experience and knowledge for oral health

39 Peer Review Assess compliance with new policies and protocols Incorporate oral health criteria into primary care provider peer review tool Ensures that staff recognizes oral health as a priority

40

41 Data Collection Data collection can be the most cumbersome aspect of the project Focus on collecting data to determine if the project is successful

42 Considerations Accountability comes from 1 year of progress At 1 year mark, review data, evaluate for areas of improvement # of patients with referred dental visit Use exam codes same as UDS Sealants Measure D0191, D0120, D0145, D0150, D0180

43 Final Considerations Do not underestimate planning Include a champion from medical, dental, and operations/it Meet regularly as a team Start small! Be prepared to run test cycles Success takes time don t be discouraged!

44

45 Questions? Candace Owen, RDH, MS, MPH NNOHA Education Director National Network for Oral Health Access 181 E 56th Avenue, Suite 401 Denver, CO Phone: (303) Fax: (866) info@nnoha.org

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