Early Childhood Oral Health: Improving Collaborative Care in Clinical Practice Rocio Quiñonez Q ez, DMD, MS, MPH UNC Schools s of Dentistry and a Medicine Vegas, 2017 Objectives Trends in early childhood oral health Rationale and evidence of collaborative care in early childhood Opportunities to promote collaborative oral health care in clinical practice 1
Spring 2000 Pediatric Medical Guidelines 2003: American Academy of Pediatrics - Oral health screening in the first year of life. If high-risk, referral to a dentist. 2
2006 New York State Prenatal Oral Health Guidelines Caries Progression Cavity-free smile White spots Cavities Cavities with abscess 3
How can we break the cycle of poor oral health? Early interventions are key 4
Heckman Equation: Return to a Unit Dollar Invested Interprofessional and collaborative systems approach to care http://heckmanequation.org/content/resource/presenting-heckman-equation Institute te of Medicine ne- 2011 A successful oral health care system: Include collaborative and multidisciplinary teams working across the health care system Two principles to guide its deliberation: 1. Oral health is an integral part of overall health- essential to comprehensive care. 2. Oral health promotion and disease prevention are key 5
Changing landscape of health care delivery 2011 All preventive interventions graded A or B- Fully Covered $ 6
Primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption (B). NEW CPT CODE 99188 7
Changing landscape CARE COORDINATION 8
Lessons from NC 1990 s- NC ranked: 47th in the number r of all dentists 45th in the number of pediatric dentists 44th in dentists participation in Medicaid 1st in percent growth in its Hispanic population between 1990 and 2000 had a child born into poverty every 23 minutes 9
Percentage of NC Medicaid Recipients Utilizing Medical and Dental Services in 1998 Percent 100 90 80 70 60 50 40 30 20 10 0 < 1 yr 1-5 yrs 6-14 yrs 15-20 yrs Age Dental Medical 1999 Recommendation #18: develop new service package and payment method to cover early caries screening, education and administration of fluoride varnish provided by physicians and physician extenders to children between the ages of 9 to 36 months. 10
Goals of Into the Mouths of Babes (IMB) Increase access to preventive dental services Reduce the prevalence of ECC Reduce the burden for treatment on dentists CONTROVERSY! Who s practicing dentistry? 11
October 2001 SO HAS IT WORKED? 12
North Carolina Adoption of Oral Healthh Preventivee Caree Package November 2005 * Asheville Raleigh Charlotte Pediatric practice (N=157) Family Physician practice (N=153) Health Department (N=83) Wilmington * The Family Physician practice in Virginia provides care to NC Medicaid patients. Annual number of visits with preventive oral health services in NC medical offices: 2000-2014 45-50% of well-child visits Source: NC DMA. 13
Physician Screening & Referral Identify disease presence or absence: 93% accuracy Pierce et al. Pediatrics. 2002;109:E82-2. 14
Effect of IMB on Dental Caries es-related Treatments per 1,000 Medicaid id-enrolled Children Number of IMB Visits Age in Months at IMB Visit Change in CRTs (95% CI) % Change 1 2 3 4 >4 12 12, 24 12, 15, 18 12, 18, 24, 35 12, 15, 18, 24, 35-7 (-85, 84) 19 (-82, 124) 49 (-88, 163) -281 (-469, -58) -458 (-623, -204) -0.3% 0.7% 2.9% -10.9% -17.7% Number of children with 0 IMB visits = 194,730. Number of children with 1 IMB visit = 55,561. Number of children with 2 IMB visits = 37,353. Number of children with 3 IMB visits = 21,353. Number of children with >4 IMB visits = 13,424. Number of children with 5 or 6 IMB visits = 4,327. Confidence intervals generated based on 200 bootstrap iterations. Impact of IMB on Oral Health Status Kindergarten Students, NC 4+ medical visits was associated with better overall oral health than 0 visits. No significant reduction on amount of untreated caries. Kranz AM, Preisser JS, Rozier RG. Effects of Physician-Based Preventive Oral Health Services on Dental Caries. Pediatrics 2015;136(1):107-14. N=29,173 15
Successes and Opportunities Into the Mouth of Babes has been very successful >1000 providers trained Increased access by 30-fold More than 140,000 visits per year Reduction in caries-related treatment needs But CHALLENGES REFERRING TO A DENTAL HOME Quinonez RB, Kranz A, Lewis CW, Barone L, Boulter S, O Connor KG, Keels MA. Oral health opinions and practices of pediatricians: Updated results from a national survey. Acad Pediatr. 2014;14(6):616-23. 16
GD willingness to accept a pediatrician s referral of an 18 month old Low-risk: No caries High-risk: WSL High risk: Cavitation Long M, Quinonez RB, Rozier RG, Kranz A, Lee JY. Barriers to Pediatrician s Adherence to AAP Oral Health Referral Guidelines: NC General Dentists Opinions. Pediatr Dent. 2014:36. NC General Dentists Acceptance of Pediatrician Referrals (N=423) 80% 70% 60% 50% 40% 30% 20% 10% 0% 75% 44% 35% Low Risk & No caries High Risk & WSL High Risk & Cavitation 17
COMFORT Train future dental workforce Improve access to care 18
2013 www.babyoralhealthprogram.org 19
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Tablet Friendly 21
bohp Report Card Clinical Exam 22
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bohp business card 30
Promoting bohp 31
Review website Lunch and Learn/Staff Meeting Training Videos (2) Provider Training Role Play Caregiver Interview Talking points Resources www.prenataloralhealth.org 32
www.prenataloralhealth.org 33
www.prenataloralhealth.org Prenatal Oral Health Infant Oral Health 34
Prenatal Messages Oral and Systemic Health 35
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3 min videos for moms 41
Initiatives in North Carolina 2000 - Into the Mouths of Babes 2006-09 Carolina Dental Home 2009 - PORRT Initiative 2010 - Connecting the Docs 2009 - ZOE Educate teachers in oral health and communication Link families with providers Evaluate how it works Pilot: Federally Qualified Community Health Centers 1 2 Practice/Financial Business Assessment Efficiency & & Enhancement Plan 1 2 3 Baby and Prenatal Oral Health Clinic Flow 3 Implement Changes Using Quality Improvement Phase 1 Phase 2 42
Coordinated Care How Can We Work Hand in Hand? New CDT 2017 codes Consultation with medical professional Dental Case Management - Care coordination - Addressing appointment compliance barrier - Motivational interviewing - Patient education to improve oral health literacy 43
Effectiveness ess s of Physicians Dental Referrals 0-36 m olds ECC N=1,204 (4.9%) (Total N = 24,403) Referred N=396 (32.9%) Not referred N=808 (67.1%) Dental Visit N=141 (35.6%) No Dental Visit N=255 (64.4%) Dental Visit N=97 (12.0%) No Dental Visit N=711 (88.0%) BED TIME ROUTINES 44
Body Mass Index 45
Electronic Health Record 46
FDA and General Anesthesia 31% of day surgery for preschoolers 19,000 surgeries per year 47
RESOURCES American Academy of Pediatrics http://www2.aap.org/oralhealth/coha.html 48
Summary Era of health care transformation Important time for our profession to help define the role of dentistry in this transformation Don t stop balls that are already rolling Be a steward of change! 49
Thank-you! 50