Open Wide –Mouth is the window to the body. HEENT to HEENOT€¦ · Primary Care Practice (IOHPCP) initiative with three inter‐ related components. ‐Creation of a HRSA prepared

Open Wide – Mouth is the window to the body.

HEENT to HEENOT

Dr. Vinod Miriyala BDS, MPH, CAGS, DDSDr. Anna Novais DMD

Make the case that oral health is an essential component of primary care.

Present a practical framework for how to deliver preventive oral healthcare as a component of routine medical care.

Share resources and information about existing practice in the state to implement this in your health center.

Objectives

Lack of access to basic dental services contributes to profound and enduring oral health disparities in the United States.

Millions of children and adults do not receive needed clinical and preventive dental services. In 2011, 6.1 percent of children and 16.4 percent of adults under the age of 65, did not receive needed dental care because their families could not afford it.

Children are only one of the many vulnerable and underserved populations that face persistent, systemic barriers to accessing oral health care.

Understanding the problem

Dental caries (cavities) and periodontal disease (gum disease) are largely preventable.

Yet nationwide, among all ages, incomes, and life experiences, we have an unacceptably high burden of these chronic diseases.

We’ve seen little improvement in oral health status over the past 20 years, and pervasive disparities remain: Poor and near‐poor 5‐year‐olds are more than two times as likely to have tooth decay than their middle‐income peers.

Understanding the Problem

The Burden of Oral Disease: ChildrenDecay: Tooth decay is the most common chronic disease of childhood.

• Pain and infection can result in impaired nutrition and growth.

• Untreated decay puts children at risk for dental disease in adulthood.

Ages 2–525%

Ages 12–1550%

The Burden of Oral Disease: Adults

Cumulative result? 25% of adults 65 and older have no teeth.

25% ages 20–64 have untreated caries.

19% ages 35–44 have destructive periodontal diseases.

Oral cancer kills over 8,000 people each year, the number who die of cervical cancer, a major preventive care focus.

2.0x

Access and Affordability Challenges In most communities, dental care is the most common unmet health need.

40% of the population lacks dental insurance, the percentage of those lacking medical insurance.

Many patients turn to the ER as a last resort; most are sent home with painkillers and antibiotics, but their problem hasn’t been solved.

Late‐stage interventions (e.g., extractions) waste valuable healthcare resources and introduce unnecessary risksfor patients.

2.5x

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Oral health is essential to general health and well‐being at every stage of life.

A healthy mouth enables not only nutrition of the physical body, but also enhances social interaction and promotes self‐esteem and feelings of well‐being.

The mouth serves as a “window” to the rest of the body, providing signals of general health disorders.

Why Oral health is important

Mouth lesions may be the ‐ first signs of HIV infection, ‐ aphthous ulcers are occasionally a manifestation of Coeliac disease

or Crohn’s disease, ‐ pale and bleeding gums can be a marker for blood disorders, ‐ bone loss in the lower jaw can be an early indicator of skeletal

osteoporosis, and ‐ changes in tooth appearance can indicate bulimia or anorexia.

The presence of many compounds (e.g., alcohol, nicotine, opiates, drugs, hormones, environmental toxins, antibodies) in the body can also be detected in the saliva.


Bacteria from the mouth can cause infection in other parts of the body when the immune system has been compromised by disease or medical treatments (e.g., infective endocarditis).

Systemic conditions and their treatment are also known to impact on oral health (e.g., reduced saliva flow, altered balance of oral microorganisms).


Periodontal disease has been associated with a number of systemic conditions. Though the biological interactions between oral conditions such as periodontal disease and other medical conditions are still not fully understood, it is clear that major chronic diseases – namely cancer and heart disease – share common risk factors with oral disease.


Recognition that oral health and general health are interlinked is essential for determining appropriate oral health care programs and strategies at both individual and community care levels.

That the mouth and body are integral to each other underscores the importance of the integration of oral health into holistic general health policies and of the adoption of a collaborative “Common Risk Factor Approach” for oral health promotion.

Common Risk Factor Approach

The United States health care system is able to provide acute care but continues to struggle to address the need for ongoing care, especially for vulnerable populations such as the elderly, disabled, mentally ill, and special needs populations.

Safety net organizations like FQHC’s that provide health services to uninsured, low‐income, and vulnerable persons continue to look for ways to coordinate services among providers to improve access to quality care.

What can we do

The 2011 Institute of Medicine (IOM) reports, Advancing Oral Health in America and Improving Access for Oral Health for the Vulnerable and Underserved, recommended that the Health Resources and Services Administration (HRSA) address the need for improved access to oral health care through the development of oral health core competencies for health care professionals.

IOM Report – Oral Health in America

HRSA developed the Integration of Oral Health and Primary Care Practice (IOHPCP) initiative with three inter‐related components.

‐ Creation of a HRSA prepared draft set of oral health core clinical competencies appropriate for primary care clinicians.

‐ Presentation of a systems approach to delineate the interdependent elements that would influence the implementation and adoption of the core competencies into primary care practice.

‐ Characterization and outline of the basis for implementation strategies and translation into primary care practice in safety net settings.

HRSA Response to IOM Report

HRSA provided the following five domains as part of a starter set. Each domain contains a core set of clinical competencies:

• Risk Assessment• Oral Health Evaluation• Preventive Interventions• Communication and Education• Inter professional Collaborative Practice

HRSA’s Response

How Can We Improve This Picture?

Expand the oral disease prevention workforce by engaging primary care teams in the

fight against oral disease.

Why Us?We have regular contact with high‐risk groups:

•Children•Pregnant women

•Adults with diabetes

We are well equipped for the work:We routinely assess risk, screen for disease,

offer preventive interventions, and refer patients to specialists when treatment is needed.

We can apply these core competencies to oral disease.

Population receiving regular medical careTotal population at

risk for caries and periodontal disease

Population receiving regular dental care

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• Provide information about healthy diet, measure BMI. • Advise on sunscreen, look for suspicious moles.

• Oral disease is a common problem with serious health impacts.

• Patient and family behavior (self-care) is key.• Most problems can be recognized early and treated

to reduce impact.

This Is a Natural Extension of What We Already Do…

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Oral Health Delivery FrameworkFive actions primary care teams can take to protect and promote their

patients’ oral health. Within the scope of practice for primary care, possible to implement in diverse practice settings.

Citation: Hummel J, Phillips KE, Holt B, Hayes C. Oral Health: An Essential Component of Primary Care. Seattle, WA: Qualis Health; June 2015

Preventive interventions: Fluoride therapy, dietary counseling to protect teeth and gums, oral hygiene training, therapy for substance use, medication changes to address dry mouth.

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Health care providers have performed physical assessment of the head, ears, eyes, nose, and throat (HEENT) in the same fashion since its inception centuries ago. For the majority of primary care providers, the traditional HEENT examination excludes examination of the oral cavity, as well as omitting oral health and its linkages to overall health in the health history.

A simple solution to this problem is to introduce a paradigm shift to teaching the HEENT examination by using the “HEENOT” approach. Incorporating “O,” for oral cavity assessment, adds a comprehensive focus on the oral‐systemic history and examination of the teeth, gums, mucosa, tongue, and palate. The HEENOT approach means that educators and clinicians can “NOT” omit oral health and intraoral assessment from the history and physical examination performed by DO’s, MDs, PAs, NP’s and other health professionals.

HEENT to HEENOT

This strategy will increase oral health screenings, detection of oral health comorbidities, and preventive interventions, including referrals to dental colleagues by primary care providers in community‐based settings for acute or chronic health problems commonly seen in primary care practice.

HEENT to HEENOT

Decide on a population of patients to target: adults with diabetes, pediatrics, pregnant women, other?

Clinical assessment Workflow analysis: current and future state Planning for structured referrals EHR modifications and report creation

Plan

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Additional Resources

Oral Health Implementation Guide

Sections 1 and 2: Introduction and the Case for Change

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Oral Health: An Essential Component of Primary Care

• White paper, published June 2015

• A call to action:

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: http://www.safetynetmedicalhome.org/change‐concepts/organized‐evidence‐based‐care/oral‐health

Hummel J, Phillips KE, Holt B, Hayes C. Oral Health: An Essential Component of Primary Care. Seattle, WA: Qualis Health; June 201525

Smiles for Life: A National Oral Health Curriculum was originally developed in 2005 by the Society of Teachers of Family Medicine Group on Oral Health. It consisted of four modules, and was based in part on materials developed by regional consortia of family physicians, dentists, and educators between 2001 and 2004 including:

Washington Interdisciplinary Oral Health Project (ICOHP) University of Texas Health Science Center San Antonio Project Smile Physician Oral health Education in Kentucky (POHEK) University of Connecticut Schools of Medicine and Dental Medicine

Smiles For Life™

Smiles For Life™

https://www.smilesforlifeoralhealth.org/buildcontent.aspx?tut=555&pagekey=62948&cbreceipt=0

46 highlighted dental counties40 out of 55 FQHCs

Elevated Blood Pressure ‐Metrics

As partners in patient‐centered care, the integration of oral health and primary care is a priority in Ohio’s FQHCs. Screening for hypertension by the dental team during daily intake is an effective method to educate and appropriately refer patients to their physician. To date, 18% of all patients screened in the dental setting have been identified as having elevated blood pressure and referred for follow‐up care.

Ohio’s FQHC – Blood Pressure Metric

Dental sealant measure – UDS measure Patient no show rate Treatment plan completion rate Caries risk assessment rate

Inter collaborative projects:‐ Fluoride varnish applications in medical settings‐ Elevate Blood pressure screenings in dental settings

OACHC – Oral Health Metrics

Shared Patient’s data and other quality metrics in Ohio’s FQHC –

Cincinnati Health Department data

* Treatment completed, caries risk assessment,Sealantutilization data (UDS required),Denta and Medical shared users, Broken appointments.

Anna Novais, DMDDenise Saker, MD, MPH, FAAP

March 6th, 2019

A Collaborative Action to Integrate Oral Health with Primary Care in Health Centers

Presentation Title HereAdditional Line if Needed

Date Here

The following personal financial relationships with commercial interests relevant to this presentation

existed during the past 12 months:

No Relationships to Disclose

Anna Novais, DMDDenise Saker, MD, MPH, FAAP

PRESENTATION OBJECTIVES

1- Describe critical steps for the successful implementation of an integrated medical-dental care practice in a community health center.

2- Describe the role of each medical and dental team member in the establishment of an interprofessional practice.

3- Demonstrate how oral health care services have been incorporated into pediatric care visits by both medical and dental teams.

Interprofessional CollaborationBACKGROUND STORY

● Bobbie Sterne Health Center

(formerly Elm Street Health Center)

● Urban Community Health Center

● City of Cincinnati Primary Care (Cincinnati Health Department)

All Children Thrive CollaborativeCincinnati Children’s Hospital

• Multi-disciplinary initiative

• Address an area of great need which has an impact on the health of children in poverty

• Dental caries and oral health deficit

• We wanted to work towards establishing a Dental Home for our patients.

Interprofessional CollaborationAll Children Thrive

TEAM MEMBERSLast Name First Name Role

*Saker Denise Pediatrician*Wadhwa Gauri Health Center ManagerChildress Toshia Medical AssistantRobinson Sharma RN (PHN-2)

Novais Anna DentistMcClanahan Kelsey Dental Assistant

Carter Nancy Associate Dental DirectorFunk Hollin RN (PHN-3)

Hallums VaLinda Administrative Technician

SMART AIM

Increase the number of patients age 9 to 27 months establishing a dental home at Elm Street Health Center from 24% to 50% by 12/31/18.

Interprofessional CollaborationAN INTEGRATED DENTAL HOME

• Use the Electronic Health Record to document the dentist as part of the child’s care team

• Refer our patients to the dental office IN OUR HEALTH CENTER – (cards/improved tracking)

• Dr. Novais learned about efforts to integrate oral health and primary care at the NNOHA (National Network for Oral Health Access) meeting and remembered that Dr. Saker is ALWAYS trying to have her patients seen for dental care at Bobbie Sterne.

• We HAVE AN IDEA!!! An integrated health home

Interprofessional CollaborationEstablished Practice

.

Interprofessional CollaborationAmerican Academy of Pediatrics

• Oral Health should be part of primary care

• How to do it? Practice Tools

• Resource:

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Oral-Health/Pages/Oral-Health-Practice-Tools.aspx

American Academy of PediatricsCampaign for Dental Health

• Resources in English and Spanish• Addresses fluoride questions

Interprofessional CollaborationHow to Make it Happen?

• Enlist the expertise of the health center manager to organize meetings

• Discuss schedule coordination, common goals

• Develop a workflow (using the EHR, workstations, fluoride administration, signaling)

• Have a practice session (or 2!)

• Tweak the workflow (PDSAs)

• Create a workstation for dental

• Set a date to start regular sessions

High Level Process Map Template

Process:

Beginning Boundary:

Ending Boundary:

Establishment of Dental Home

Patient Arrives in Clinic

Patient Leaves Clinic

Patient

Arrives

Patient Leaves

START STOP

Patient registered

RN/MA rooms patient

Dental provider enters for knee to knee visit

Provider assesses patient

RN/MA Exits Patient



AND HERE WE GO!

Interprofessional CollaborationCare Team Update/Dental Home

Interprofessional CollaborationIntegrated Care: Medical-Dental Pediatrics

• Pilot program: started at Elm Street Health Center and expanded to the Northside Health Center.

• 6mo-5yo age focus on “Dental Peds Days”

• Dental utilizes medical facility (3 medical rooms); oral exams provided in conjunction with well-child visits.

• Medical schedule accommodated to serve similar age group

• Medical/dental visits from 8am-12pm twice a month (usually 12 pts scheduled)

• Integration may improve fiscal sustainability and contributes to the IHI Triple Aim: improves care, population health, and reduces cost.


● Early oral health education for parents

● Early detection of caries for high-risk kids

● Early establishment of a dental home

● Early exposure to a dental provider

● Fluoride, SDF for caries prevention

● Convenient multi-purpose patient visits

● Increased dental patients and encounters

● Ability to intervene in the oral health of parents


● Dental Exams: 112● Dental Preventive treatments: 103● Treatment Complete: 65● Dental NPs: 50● Dental Center Referrals: 25● Hospital Referrals: 2

Productivity● Average pts/day: 10● Time: 8‐12AM→ 2.5 pts/hr● Separate encounters for medical and dental

Better outcomes: early intervention, improved access, and a facilitated referral system.

Interprofessional CollaborationMedical-Dental Pediatric Care

Dental Armamentarium

Interprofessional CollaborationsBrush, Book, and Bed Program

Interprofessional CollaborationsBrush, Book, and Bed Program

Bobbie Sterne Dental CenterIntegrated Care: Medical-Dental Pediatrics

STAFF EQUIPMENT

• 2 FT Dentists/2 PT Dentists

• 1 Hygienist

• 1 Front Office Dental Assistant

• 1 Expanded Functions Dental

Assistant (EFDA)

• 2 Certified Dental Assistants

(CDA)

• 3 Dental Assistants (DA)

• 8 fully plumbed, operational dental operatories

• 1 Dental Lab

• Nitrous Oxide Sedation

• Health center offers comprehensive dental treatment and co-located with medical (Primary care, Peds, OB/GYN) and WIC services.

Chronic Disease ManagementInnovative Interventions Making a Positive Difference

1- Silver Diamine Fluoride (SDF 38%)

● Multiple SDF applications● Prevention focus (remineralization) ● Arrests lesion (tooth preservation)● Antimicrobial and reduces pain● Non-invasive procedure● Positive dental experience● Sealants placed on occlusal fissure● (cost-effective vs. restorations)● Less OR (GA) and pediatric referrals● Maximizes prevention and restorative appointments

○ Can be applied by DAs, EFDAs, DHs

Chronic Disease ManagementInnovative Interventions Making a Positive Difference

2- SDF-modified Atraumatic Restoration (SMART)

Interprofessional Oral Health Competencies








THANK YOU!!!

Oral Health Isn’t Optional !!

Open Wide and Ask Questions

Thank you

Documents

Open Wide –Mouth is the window to the body. HEENT to HEENOT€¦ · Primary Care Practice (IOHPCP) initiative with three inter‐ related components. ‐Creation of a HRSA prepared