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
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
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
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 25 44 have severe periodontal disease Photo: ICOHP Photo: Robert Henry, DMD, MPH
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 12,546 25.4% 34.7% Cascade Pacific Action Alliance 77,762 44,336 14,863 19.1% 33.5% WA State 815,123 515,012 161,105 19.8% 31.3% Pierce 103,547 60,130 18,791 18.1% 31.3% Greater Columbia 130,893 93,235 28,826 22.0% 30.9% King 175,952 105,323 32,552 18.5% 30.9% North Sound 123,965 73,086 22,421 18.1% 30.7% Better Health Together 82,711 53,700 16,178 19.6% 30.1% Olympic 33,137 17,322 5,017 15.1% 29.0% SW WA Regional Health Alliance 63,060 35,801 10,210 16.2% 28.5% Other/Out of State 3,343 177 40 1.2% 22.6%
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
Periodontal Treatment Reduces Medical Costs? Jeffcoat et al. Am J Prev Med 2014;47(2):166 174
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
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
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
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.
Collaborative Care
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: www.qualishealth.org/white-paper Hummel J, Phillips KE, Holt B, Hayes C. Oral Health: An Essential Component of Primary Care. Seattle, WA: Qualis Health; June 2015
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
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
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
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
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
Standard of Care in a Protocol
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
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.
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)
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
Dx Codes for Caries Severity Clinical Concept ICD-10 Severity Sound Tooth Dummy code 0 Caries involving enamel only K02.51; K02.61 1 Caries into dentin K02.52; K02.62 2 Caries extending into pulp K02.53; K02.63 3 Qualis Health, 2017
Dx Codes for Periodontal Disease Clinical Concept ICD-10 Severity Sound periodontium Dummy code 0 Attachment loss with healthy periodontium K05.30 1 Mild periodontitis K05.311; K05.321 2 Moderate periodontitis K05.312; K05.322 3 Severe periodontitis K05.313; K05.323 4 Qualis Health, 2017
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 500 500 400 400 300 300 200 200 100 100 0 Sound Controlled Mild Moderate Severe 0 Sound Controlled Mild Moderate Severe
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
The Medicaid Waiver Project Toolkit Project 3C: Access to Oral Health Services
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
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 2013. 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 2015. Source: Washington State Health Care Authority, Apple Health Dental Services Enrollment and Utilization Data
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 2014. 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
FY 2016 Apple Health Dental Utilization by County: Adults Ages 21 and over Statewide Utilization Total 22.1%
Apple Health FY 2016 Utilization of Restorative Services Adults Age 21 and Over Users' Region Eligibles Users % Users Greater Columbia 127,391 14,503 11.4% Better Health Together 120,610 10,896 9.0% North Central 46,728 4,036 8.6% WA State (unduplicated) 1,120,265 95,302 8.5% King 292,574 24,585 8.4% North Sound 174,185 13,596 7.8% Pierce 142,735 11,109 7.8% SW WA Regional Health Alliance 76,473 5,450 7.1% Cascade Pacific Action Alliance 122,530 7,888 6.4% Olympic 58,428 3,518 6.0% Other/Out of State 3,694 19 0.5% Children Age 20 and Under Users' Region Eligibles Users % Users North Central 59,948 13,970 23.3% Greater Columbia 159,253 32,487 20.4% Better Health Together 101,334 18,836 18.6% WA State (unduplicated) 994,555 179,710 18.1% Cascade Pacific Action Alliance 95,540 16,427 17.2% King 215,881 35,909 16.6% Pierce 126,201 20,728 16.4% North Sound 151,386 24,750 16.3% SW WA Regional Health Alliance 76,208 11,391 14.9% Olympic 40,656 5,554 13.7% Other/Out of State 3,909 47 1.2%
Apple Health FY 2016 Utilization of Preventive Services Adults Age 21 and Over Users' Region Eligibles Users % Users Greater Columbia 127391 13485 10.6% Better Health Together 120610 10872 9.0% King 292574 24407 8.3% WA State (unduplicated) 1,120,265 89,743 8.0% North Central 46728 3692 7.9% Pierce 142735 10458 7.3% SW WA Regional Health Alliance 76473 5099 6.7% North Sound 174185 11456 6.6% Olympic 58428 3592 6.1% Cascade Pacific Action Alliance 122530 6722 5.5% Other/Out of State 3694 8 0.2% Children Age 20 and Under Users' Region Eligibles Users % Users North Central 59,948 36,452 60.8% Greater Columbia 159,253 95,842 60.2% Better Health Together 101,334 53,206 52.5% WA State (unduplicated) 994,555 513,228 51.6% King 215,881 105,128 48.7% North Sound 151,386 72,730 48.0% SW WA Regional Health Alliance 76,208 35,227 46.2% Pierce 126,201 57,798 45.8% Cascade Pacific Action Alliance 95,540 42,994 45.0% Olympic 40,656 16,891 41.5% Other/Out of State 3,909 141 3.6%
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 286,637 134569 46.9% Greater Columbia 127391 32202 25.3% North Central 106,674 49573 46.5% Better Health Together 120610 29354 24.3% Better Health Together 221,942 87733 39.5% WA State (unduplicated) 1,120,265 247,169 22.1% WA State (unduplicated) 2,114,778 807,366 38.2% North Central 46728 9982 21.4% SW WA Regional Health Alliance 152,678 54531 35.7% King 292574 61588 21.1% North Sound 325,566 113755 34.9% Cascade Pacific Action Alliance 122530 25414 20.7% Pierce 268,932 93603 34.8% Pierce 142735 29042 20.3% King 508,445 175619 34.5% SW WA Regional Health Alliance 76473 15283 20.0% Cascade Pacific Action Alliance 218,065 74106 34.0% North Sound 174185 34680 19.9% Olympic 99,081 29671 29.9% Olympic 58428 11057 18.9% Other/Out of State 7,603 555 7.3% Other/Out of State 3694 361 9.8% Children Age 20 and Under Children Age 6 and Under Users' Region Eligibles Users % Users Users' Region Eligibles Users % Users North Central 59,948 39,591 66.0% North Central 19,608 12,341 62.9% Greater Columbia 159,253 102,369 64.3% Greater Columbia 52,209 31,110 59.6% Better Health Together 101,334 58,381 57.6% Better Health Together 33,887 18,244 53.8% WA State (unduplicated) 994,555 560,202 56.3% WA State (unduplicated) 329,820 173,530 52.6% King 215,881 114,032 52.8% Cascade Pacific Action Alliance 31,647 15,992 50.5% North Sound 151,386 79,075 52.2% SW WA Regional Health Alliance 24,656 12,308 49.9% SW WA Regional Health Alliance 76,208 39,248 51.5% North Sound 50,676 24,393 48.1% Pierce 126,201 64,561 51.2% King 72,813 34,908 47.9% Cascade Pacific Action Alliance 95,540 48,692 51.0% Pierce 43,420 20,155 46.4% Olympic 40,656 18,614 45.8% Olympic 13,493 5,674 42.1% Other/Out of State 3,909 194 5.0% Other/Out of State 1,654 50 3.0%
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 549 507 186 North Sound 268 234 84 Greater Columbia 260 231 75 Better Health Together 225 206 58 Cascade Pacific Action Alliance 207 184 42 Pierce 181 164 49 SW WA Regional Health Alliance 118 107 5 North Central 86 75 45 Olympic 80 73 16 Other/Out of State 58 32 8 WA State (unduplicated) 1,930 1,717 532 Adults Age 21 and Over Providers' Region Non-FQHC Dental Providers 1-25 Clients Served 26-50 Client Served More than 50 Client Served King 343 213 20 110 Greater Columbia 166 93 14 59 Better Health Together 149 74 21 54 North Sound 144 99 8 37 Cascade Pacific Action Alliance 132 82 11 39 Pierce 117 67 10 40 SW WA Regional Health Alliance 102 62 6 34 Olympic 58 34 4 20 Other/Out of State 30 21 4 5 North Central 25 12 6 7 WA State 1,266 757 104 405
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