Iatro-Compliance

An unintended consequence for oral health of excessive autonomy in long term care

facilities.

OBJECTIVES

1. Relationship between oral pathogens and lower

respiratory infections (LRI) in long term care

facilities (LTCFs).

2. Cost hospitalization for LRIs versus that of

preventive plaque control in LTCFs.

3. The autonomous resident

4. Oral Health Care Director (OHCD) in LTCFs.

Cherin C. Pace, & Gary H. McCullough, 2010

Dysphagia (2010) 25:307–322 DOI 10.1007/s00455-010-9298-9

Oral Pathogens LRIs

• What has been established in literature• Oral health

• “Mouth-body connection”• Oral pathogen-pneumonia correlation

“Aspiration pneumonia is a leading cause of illness and death in persons who reside in long-term-care facilities and, combined with the lack of proper oral health care and services, the risk of aspiration pneumonia rises.”

S. Paju & F.A. Scannaopieco 2007Oral Diseases (2007) 13, 508–512. doi:10.1111/j.1601-0825.2007.1410a.x

PMID:17944664

• Pneumonia: • “an infection of the lungs caused by bacteria, mycoplasma,

viruses, fungi or parasites”• “bacterial being the most common and a significant cause of

mortality and morbidity in human populations”• with influenza, together are leading cause of death in elderly

long term care residents• Results in:

• morbidity• decline in quality of life• Increased medical costs

• Nosocomial pneumonia (NHAP)• Often caused by organisms that populate the oral cavity in

institutional settings• Mortality rate can be as high as 25%

S. Paju & F.A. Scannaopieco 2007Oral Diseases (2007) 13, 508–512. doi:10.1111/j.1601-0825.2007.1410a.x

PMID:17944664

Oral Cavity• Dental Plaque:

• Tooth-borne biofilm (hard surfaces)• Initiates periodontal disease• “persistent reservoir for potential pathogens”

• (oral & respiratory bacteria)• Can shed into saliva then aspirated into LR tract/lungs• Organisms NHAP

• Pseudomonas aeruginosa, Prophyromonous gingivalis• Staphylococcus aureus• Enteric gram negative bacteria

• Periodontal enzymes and cytokines• From periodontally inflamed tissues also transferable• Stimulate local inflammatory processes that precede infection

Factors

• In Health:• Respiratory tract can defend against aspirated pneumonia

• Factors in elderly• Diminished salivary flow• Decreased cough reflex• Swallowing disorders (dysphasia)• Poor oral hygiene• Physical / cognitive disabilities

• Dysphasia and Aspiration Pneumonia• Significant risk factor• Predictor

• (Langmore et al, 1998-PMID:9513300)

Modifiable Risk FactorsModifiable Risk Factors for Nursing Home-Acquired Pneumonia. V. Quagliarello,

et.al. Clinical Infect Dis 2005;40:1-6 PMID 15614684

• This study identified two modifiable risk factors in NHAP • Inadequate oral care• dysphagia

Improved oral care indirectly improved swallowing reflex

Single intervention may reduce NHAP

Strategies to improve OH in LTCOral care reduces Pneumonia in Older patients in Nursing Homes

T. Yoneyama, et. al, J. Am. Geriatr Soc. 50:430-433, 2002 PMID:11943036

• Seminal Article:

Findings: those who received daily oral care: had fewer febrile days reduction in risk for pneumonia mortality rate ½ half that of without oral care

OBJECTIVES

1. Relationship between oral pathogens and lower

respiratory infections (LRI) in long term care

facilities (LTCFs).

2. Cost hospitalization for LRIs versus that of

preventive plaque control in LTCFs.

3. The autonomous resident

4. Oral Health Care Director (OHCD) in LTCFs.

Hospitalizations

• 4.3% of Americans >65 years old reside in nursing homes• Develop pneumonia at rate of 1 / 1000 days of care (CDC)

• Centers for Disease Control and Prevention. National Center for Health Statistics. National nursing home survey. Available at: http://www.cdc.gov/nchs/about/major/nnhsd/nnhsd.htm.

• By 2030, there will be an estimated 1.9 million episodes of nursing home—acquired pneumonia annually • Muder R. Management of nursing home acquired pneumonia: unresolved issues and priorities for future investigation. J Am

Geriatr Soc 2000;48:95-6. http://www.serialssolutions.com/images/AL_Button_grey.gif

• Hospital inpatient care• Number of discharges: 1.1 million• Average length of stay: 5.2 days• Number of residents with pneumonia: 33,700• Percent of residents with pneumonia: 2.3%

Modifiable Risk Factors for Nursing Home–Acquired Pneumonia

Quagliarello et al, 2005. Clin Infect Dis. 2005 Jan 1;40(1):1-6. Epub 2004 Dec 1

PMID:15614684

Costs

Healthcare utilization and cost of pneumococcal disease in the United States.

S.S. Huang et al. Vaccine Volume 29, Issue 18, 18 April 2011, Pages 3398–3412 PMID:21397721

• 2004• 4.0 million illness episodes• 22,000 deaths• 445,000 hospitalizations• 774,000 emergency department visits• 5.0 million outpatient visits• 4.1 million outpatient antibiotic prescriptions• Direct medical costs totaled

• $3.5 billion. • accounted for 22% of all cases • 72% of pneumococcal costs.

Costs of Admissions for NHAPShould I Hospitalize My Resident With Nursing Home–Acquired Pneumonia?

David Dosa, MD, MPH. DOI: 10.1016/j.jamda.2005.06.005

• A single patient with NHAP transferred to an acute care hospital can average well over $1000 a day or $10,000 per admission.

• Much of this cost• involves expenditures for transportation to and from the

hospital,• emergency room evaluation, hospital admission, and• nursing home readmission

• Treatment within the LTC• Estimated to by $458.00 above the cost of usual care• Medicare disincentives

• MDs benefited at higher rate for hospital care than for LTC• LTC supplies and nursing staff

Estimated cost of provision of care

• Estimated annual salary of a RDH52,000.00 (ADHA)

• Estimated cost of hospitalization for pneumonia• $1,000.00- $10,000.00 / hospitalization (up to 5 days)

• Transportation costs (EMS), ER costs, Medication costs,• Physician fees, readmission to LTC

• Reduction in febrile days (not assoc. w/ UTI)• Medications, supplies,

David Dosa, MD, MPH, 2005

How to pay for care

• Incurred Medical Expense• Currently enrolled in Medicaid• Have Retirement Income (for non-Medicaid covered services)

• Social Security• Personal

• Available dental benefits are based on the State regulations• Are those services not covered by

• State Medicaid program• Third party payer

• Determined to be medically necessary

• Not administratively simple

Strategies in literature• Strategies

• Dr. M. MacEntee et.al. 1999 Six strategies in Canada1. On-sight FFS DDS and assistant

2. On-sight Salaried DDS and RDH

3. On-sight FFS DDS, RDH and assistant

4. RDH referring for emergency care (on-sight) elective off-sight

5. On-sight Independent DDS with mobile equipment

6. Staff, resident and family seeking services off-sight

Conflicting priorities: oral health in long term careM.I .MacEntee, et al. Spec.Care Dent., Vol. 19 No 4 1999

Strategies (findings)

• Success:• Must include a formalized routine

• for periodic examinations • daily oral hygiene • easy access to dental professionals

• On site facilities• care staff took minimal responsibility for oral care

• Minimal access• Care staff assumed full responsibility for oral care

Conflicting priorities: oral health in long term careM.I .MacEntee, et al. Spec.Care Dent., Vol. 19 No 4 1999

Oral Health Coordinator

• Utilized Nursing Assistants (NA)• In house training

• One hour didactic course• Basic oral health, brushing techniques, oral/systemic connection• Dental / root caries, behavior management

• Shadowing/training• Trainer shadows NA while provided care

Oral health coordinators in long-term care—a pilot studyGilda J. Pronych. Spec Care Dentist 30(2): 2010

• “Training alone may be insufficient in ensuring that improved mouth

care actually takes place.”

• Poor background in health care sciences, lack of understanding

• “The OHC sets the tone for how seriously mouth care of the resident

was taken.”

• Does not acquire competency associated with understanding

• “While the OHC held a position of authority they did not feel they

could act on it.”

• Were not significantly different from co-worker CNA is administrative

structure of LTC

OHC (findings)

Oral health coordinators in long-term care—a pilot studyGilda J. Pronych. Spec Care Dentist,(30)2, 2010

OBJECTIVES

1. Relationship between oral pathogens and lower

respiratory infections (LRI) in long term care

facilities (LTCFs).

2. Cost hospitalization for LRIs versus that of

preventive plaque control in LTCFs.

3. The autonomous resident

4. Oral Health Care Director (OHCD) in LTCFs.

The current Equation of Care

• Direct Care staff: • Certified Nursing Aide (CNA), Licensed Vocational Nurse (LVN),

Registered Nurse (RN)• Little time / understaffed• Little knowledge• Low skill level• Little desire to perform oral hygiene care

• Resident:• Autonomous, non intubated, non ventilated

• Developed kinship-style relationships• Guard independence• Aware of time constraints on staff• Lack confidence in care staff knowledge and skills• Low oral health literacy due to lack of professional contact• Refuse assistance

Leads to Iatro-compliance = benign neglect

Exploring Daily Oral Hygiene Tasks in a Long Term Care FacilityMelanie Taverna MS, RDH Thesis presentation 2011

Themes about relationships• Ageism

• Discriminating against an older person on the grounds of age. In society, is negative In closed environment is preferred by resident

Themes (continued)

• Respect:• Is reciprocal and involves showing regard and

consideration for one another.• Initial respect of elders• Must be continually reinforced by actions and words

“There are certain things I should be able to by myself. But if not, I’ll

ask for help” (Resident).

“If they can do it on they own they

should. If the patient can do it we let them do it” (Care staff).

Themes (continued)

• Time Constraints:• Based on work requirements, affecting the amount of time

available for each resident.• Residents were very aware of care staff time constraints• Care staff take advantage of that awareness

“I mean like I’m not against it. Anything pertaining to the wellbeing of the patient, that’s what I’m here

for. I would say though if I were super-duper crunched for time it’s

not a priority” (Care Staff).

Direct Care Staff: CNA

• Barriers to improving oral health

“ I don’t what kind of course they give (them),

but I bet its one a fifth grader could pass!”

(Resident)

The Resident• Higher level of education than direct care staff

• Majority of residents = two years of College• Majority of care staff = high school diploma or GED

• Despite the respectful relationships• Residents

• Lacked confidence in the oral hygiene knowledge and skills of care staff• Refused intervention in oral hygiene

• Placed a low priority on oral hygiene• “ a simple task”• Did not perceive the need for professional care• Excessive autonomy

The Resident

“It’s a simple task I have done all my

life.”

“ I usually do everything myself”

• 50% did not have a dentist/hygienist

• Lack perceived need for professional dental care.

• Lack education in oral changes

OBJECTIVES

1. Relationship between oral pathogens and lower

respiratory infections (LRI) in long term care

facilities (LTCFs).

2. Cost hospitalization for LRIs versus that of

preventive plaque control in LTCFs.

3. The autonomous resident

4. Oral Health Care Director (OHCD) in LTCFs.

Cost of provision of care

“ The time taken to evaluate and develop an oral care plan may prevent an individual from moving to a more medically expensive environment such as a hospital.”

Health benefits and reductions in bacteria from enhanced oral care.

Fozia Ferozali et.al. Spec. Care Dent. 2007

Proposal• Oral Health Care Director (OHCD)

• Mediator in the equation• Resident:

• Supports autonomy with oral hygiene education• Interaction focusing or oral health issues • Improve resident confidence in care staff• Reduce refusal of assistance

• Care staff • Hands on education• Daily reinforcement of skills• Have more confidence in the skills of resident• Motivated to provide more oversight

Oral Health Care Director• On-sight intake oral evaluations/electronic transfer to

contract dentist for treatment diagnosis and planning• Validated oral health evaluations and impact forms• Financial information• Health and demographic information• Dental and periodontal charting• Intra-oral photos and radiographs

• Provide:• Dental hygiene diagnosis • Professional hygiene care plan • Daily care plan• Referrals for dental treatment

Oral Health Care Director (OHCD) MS, RDH

• Coordinate:• Physician(s) – multiple systemic diseases• Dentist – coordinate and follow-up on referrals• Pharmacy – Polypharmcy and oral adverse effects• Care staff – daily care, in-service and support of knowledge• Occupational and physical therapy – physical issues• Dietitian – diet / nutrition influences on oral cavity• Social Director – coordinate education of residents• Family / Legal Guardian – support of referrals, resident

education and daily care plans

Oral Health Care Director

• Oral Health Care Director• An MS, RDH

• Added skills sets • Oriented to the geriatric population • Decrease Iatro-compliance of staff• Increase care staff oral health literacy care skills• Enhance the oral hygiene autonomy of the resident

Conclusion• Beneficial:

• to support and encourage the oral hygiene autonomy of residents

• Not beneficial• care staff often allows excessive autonomy to occur.

• Oversight • must remain a component of care.

• OHCD • Improved oral health can be delivered to this population

under the supervision of an onsite oral health care prof.

References:

• Cherin C. Pace, & Gary H. McCullough, 2010 Dysphagia (2010) 25:307–322 DOI 10.1007/s00455-010-9298-9

• S. Paju & F.A. Scannaopieco 2007 Oral Diseases (2007) 13, 508–512. doi:10.1111/j.1601-0825.2007.1410a.x PMID:17944664

• Modifiable Risk Factors for Nursing Home-Acquired Pneumonia. V. Quagliarello, et.al. Clinical Infect Dis 2005;40:1-6 PMID 15614684

• Oral care reduces Pneumonia in Older patients in Nursing Homes. T. Yoneyama, et. al, J. Am. Geriatr Soc. 50:430-433, 2002 PMID:11943036

References:

• Healthcare utilization and cost of pneumococcal disease in the United States. S.S. Huang et al. Vaccine Volume 29, Issue 18, 18 April 2011, Pages 3398–3412 PMID:21397721

• Should I Hospitalize My Resident With Nursing Home–Acquired Pneumonia? David Dosa, MD, MPH. DOI: 10.1016/j.jamda.2005.06.005 PMID:16500288

• Conflicting priorities: oral health in long term care. M.I. MacEntee, et al. Spec.Care Dent., Vol. 19 No 4 1999 PMID:10765882

References:

• Oral health coordinators in long-term care—a pilot study Gilda J. Pronych. Spec Care Dentist 30(2): 2010 PMID:20415802

• Exploring Daily Oral Hygiene Tasks in a Long Term Care Facility. Melanie Taverna MS, RDH Thesis presentation 2011

• Health benefits and reductions in bacteria from enhanced oral care. Fozia Ferozali et.al. Spec. Care Dent. 2007 PMID:17990475

References:

• Centers for Disease Control and Prevention. National Center for Health Statistics. National nursing home survey. Available at: http://www.cdc.gov/nchs/about/major/nnhsd/nnhsd.htm

• Muder R. Management of nursing home acquired pneumonia: unresolved issues and priorities for future investigation. J Am Geriatr Soc 2000;48:95-6. http://www.serialssolutions.com/images/AL_Button_grey.gif