Integrating Oral Health Into Primary Care Practice An Overview of NNOHA s New IPOHCCC User Guide February 23, 2015 Irene V. Hilton, DDS, MPH NNOHA Dental Consultant
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Objectives Describe previous & current HRSA/BPHC medical-dental integration initiatives Explain the five oral health core clinical competency domains Learn the different approaches used by Health Center primary care departments to implement oral health clinical competencies Understand some of the strategies to address common barriers to integrating oral health into primary care practice
A Brief History of Medical- Dental Integration in Health Centers Where are we & how did we get here?
1998- HRSA BPHC Health Disparities Collaboratives PDSA/QI/Chronic Care model Diabetes collaborative Dental component/measure
2005- Oral Health Disparities Collaborative Pilot 4 Health Centers Children 0-5 & pregnant women PCP education Referral to dental
2011- Oral Health & the Patient Centered Health Home: Action Guide Described levels of integration Revealed organizational characteristics of early adopter Health Centers Documented promising practices
2011 IOM Report: Improving Access to Oral Health Care Recommendations included HRSA developing oral health competencies for nondental professionals
2014 HRSA Integration of Oral Health and Primary Care Practice (IOHPCP) Initiative Develop oral health core clinical competencies for primary care clinicians Translate into primary care practice in safety net settings Goal: Improve access for early detection and preventive interventions leading to improved oral health
2015- A User s Guide for Implementation of Interprofessional Oral Health Core Clinical Competencies 3 Health Centers PCPs deliver oral health interventions Standardization of training, clinical protocols Measures/QI
U.S. Preventive Services Task Force Recommendations May 2014 Primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride Primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the time of primary tooth eruption to prevent dental caries in children from birth through age 5 years
IPOHCCC
Primary Care Providers MD/DO Certified Nurse Midwives Nurse Practitioners Physician Assistants
Oral Health Core Clinical Competency Domains 1. Risk assessment 2. Oral health evaluation 3. Preventive interventions 4. Communication & education 5. Interprofessional collaborative practice
IPOHCCC Pilot Project Objectives Increase oral health screening and preventive services Increase oral health integration and primary care practice Increase interprofessional collaborative practice Increase care coordination between medical and dental Identify sustainable approach to practice changes
Health Partners Western Ohio Total Users 14,787 Dental Users 7,151 Primary Care sites 3 Dental sites 2 PCP FTEs 8.5 Dentist FTEs 3.2 Small city surrounded by rural 38,339
Family HealthCare, Fargo, ND Total Users 11,694 Dental Users 3,951 Primary Care sites 1 Dental sites 2 PCP FTEs 6.4 Dentist FTEs 2.6 Medium city surrounded by rural 109,779
Bronx Community Health Network Total Users 81,784 Dental Users 20,658 Primary Care sites 15 Dental sites 3 PCP FTEs 36 Dentist FTEs 20 Urban metropolis 1.4 million Health Center without walls operated under contract by Montefiore Medical Center, Albert Einstein College of Medicine
Implementation Guide
Readiness Assessment
Types of Integration Administrative- mtgs, org chart Clinical infrastructure- bilateral EHR, referrals, tracking Clinical practice- bilateral screenings, prevention Evaluation/Quality- cross discipline measures In the same building, silos Know a little about other discipline, refer populations Standardize training, clinical protocols to deliver interventions, measure & track
Characteristics of Success Leadership Vision & Support Integrated HC Executive Team Co-location Organizational Culture of Quality Improvement Staff Buy-in: Understanding the Why Patient Enabling Services Champions Bonus: Integrated EHR system
Steps to Success Planning Training systems Health information systems Clinical care systems Evaluation systems
Planning Establish a team Select a population of focus Create timeline Explore reimbursement Figure costs Look for synergy with existing Health Center initiatives
Training Systems Online training In-person training (interdisciplinary collaboration opportunity) On-boarding new health professionals
Health Information Systems EMR revision To implement the five IPOHCCC domains, an EMR must be able to: Provide a risk-assessment tool ideally automatically scores Document oral health evaluation, preventive interventions, selfmanagement goals, and education Print educational handouts and post-visit instructions Refer the patient for oral health care Collect data EMR-EDR relationship
Clinical Care System Workflow Who & during what part of the primary care visit? Risk assessment Oral health evaluation Preventive interventions Communication & education Take home materials Motivational interviewing Interprofessional collaborative practice Referral & follow-up
Evaluation Systems Number oral health assessments performed by PCPs. Number fluoride varnish applications for high-risk patients. Number patients linked to definitive oral health care and treatment. Changes in patient experience.
Clinical System Results
What it Looked Like Clinically HPWO FHC BCHN Population > 18 0-5 0-3 EMR-EDR Configuration Greenway Prime Fully integrated Centricity Dentrix Training Smiles for Life Smiles for Life, state specific for Medicaid reimbursement Dental department participation in training Inservices, demonstrations Inservices, demonstrations Centricity QSI Smiles for Life Inservices, demonstrations
What it Looked Like Clinically- Workflow HPWO FHC BCHN Risk Assessment 100% Support staff 10% Support staff Oral Evaluation (e.g. clinical oral screening) Preventive Interventions (e.g. fluoride varnish) Communication & Education 50% Support staff 90% Provider 50% Provider Provider Provider Provider Support staff (prior to oral evaluation) Provider and takehome materials Support staff (after oral evaluation) Provider and takehome materials Support staff (after oral evaluation) Provider and takehome materials
What it Looked Like Clinically- Workflow Inter-professional Collaborative Practice (e.g. referral) Inter-professional Collaborative Practice (e.g. appointment scheduling) HPWO FHC BCHN Provider (check-off box in the EMR), yellow tooth patient takes to front desk. Reserved dental exam slots (4 per day) accessible by front desk at checkout. Provider (check-off box in the EMR), passport sheet with follow ups (e.g. lab, radiology) includes dental No reserved dental exam slots. Primary care front desk staff at checkout. Provider (check-off box in the EMR). Can print out a list of community dental providers from EMR. Reserved dental exam slots (4 per day). Primary care front desk cannot access dental appointment system.
Challenges & Strategies
PCP Training Challenge Time for training Incentive for training Standardizing content Obtaining supervised clinical practice Strategy Self-paced online curricula Free CE units Use endorsed, recognized curricula Collaborate with HC dental clinic providers to observe and provide clinical training for PCP (Build competency & foster interprofessional practice!)
Risk Assessment (RA) Challenge Assuring correct RA elements incorporated Assuring RA performed at PC visit Incorporating RA into PC visit flow PC staff resistance to additional tasks Strategy Utilize well-known risk assessment tools such as CAMBRA/ADA/AAP Embed OH risk assessment into the EMR template Make procedural and workflow changes, use QI methodology to monitor and improve Identify PCP champion, start small. Make official clinic policy.
Oral Evaluation Challenge Assuring correct elements incorporated Assuring oral evaluation performed at PC visit Incorporating oral evaluation into PC visit flow PC staff resistance to additional tasks Strategy Online training followed by in person training with dental staff Embed OH evaluation into the EMR template Make procedural and workflow changes, use QI methodology to monitor and improve Identify PCP champion, start small
Preventive Intervention Challenge Assuring competency in application of Fluoride Varnish (FV) Adult patient resistance to FV color & taste Concerns about excessive applications PCP staff resistance to performing procedures inside patient s mouths Strategy Online training followed by in person training with dental staff Try different colors & brand tastes Develop immunization card to track Let patients (adults) self administer
Communication & Education Challenge Obtaining oral health education materials in multiple languages Patient resistance to OH education in the PC setting PCP staff resistance to performing OH education Strategy Online resources, Smiles for Life Include as part of visit summary Relate to general health concerns i.e. obesity, diabetic control
Interprofessional Practice Challenge Inability of PC staff to make direct dental appointments using HIT system Lack of capacity in the dental clinic for PC referrals Patient resistance to dental treatment citing cost and/or fear led to No Shows Strategy Develop work-around Dedicated appointments Motivational Interviewing
Conclusion & NNOHA Next Steps Spread IPOHCCC User Guide Help primary care practices ensure that all patients have access to oral health services and referral http://www.nnoha.org/nnoha - content/uploads/2015/01/ipo HCCC-Users-Guide-Final_01-23-2015.pdf
Medical Assistant & Dental Assistant Providing Education in Waiting Shared Room
Contact Us! Irene V. Hilton, DDS, MPH NNOHA Dental Consultant irene@nnoha.org National Network for Oral Health Access 181 E. 56 th Ave, Suite 501 Denver, CO 80216 Phone: (303) 957-0635 Fax: (866) 316-4995 info@nnoha.org