Prevention Focused Patient Care in the Dental Practice

DentaQuest©DentaQuest©

Prevention Focused Patient Care in the Dental Practice

Robert Compton, DDSExecutive DirectorDentaQuest Institute

October 2013

DentaQuest©

One of the largest dental benefits administrators in the United States

DentaQuest Benefits Company Serve nearly 20 million members

in both government and commercial business sectors nationwide

Subcontract with over 70 health plans in 19 states

Contract with ten state agencies

DentaQuest Foundationwww.DentaQuestFoundation.org

DentaQuest Institutewww.DentaQuestInstitute.org

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Disclosure About DentaQuest


www.DentaQuestInstitute.org

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DentaQuest©

Untreated Decay in 5 to 19 year olds

Income/Poverty Level Race & Ethnicity

CDC: Selected Oral Health Indicators in the United States, 2005-2008, May 2012

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Health Disparities

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“The occurrence of caries in the permanent dentition is clustered: A

quarter of the children and adolescents ages 5 to 17 with at least one

permanent tooth accounted for about 80% of the caries experienced

in permanent teeth. Differences in caries experience were found

among race and race-ethnicity subpopulations”

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Kaste LM, et al. Coronal caries in the primary and permanent dentition of children and adolescents 1-17 years of age: United States, 1988-1991. J Dent Res. 1996 Feb; 75 Spec No:631-41

25% of Children Have 80% of Caries


• A human health condition or disease that is persistent or otherwise long-lasting in its effects. The term chronic is usually applied when the course of the disease lasts for more than three months.[1]

• A growing body of evidence supports that prevention is effective in reducing the effect of chronic conditions; in particular, early detection results in less severe outcomes. [2]

• Chronic Disease is a long-lasting condition that can be controlled but not cured.[3]

1. World Health Organization2. Kenkel DS “Prevention” “Handbook Of Health Economics”3. The Center for Managing Chronic Disease http://cmcd.sph.umich.edu/what-is-chronic-disease.html

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Chronic Disease

http://en.wikipedia.org/wiki/Chronic_disease#cite_note-WHO-1

http://en.wikipedia.org/wiki/Chronic_disease#cite_note-WHO-1

http://cmcd.sph.umich.edu/what-is-chronic-disease.html

http://cmcd.sph.umich.edu/what-is-chronic-disease.html

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Determinants of Health

Adapted from: McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood) 2002;21(2):78-93

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Chronic Care Model

Delivery System Design

Self- Management

Support

CommunityHealth System

http://www.improvingchroniccare.org

Informed Active Patient

Prepared Proactive Practice Team

Productive Interactions

Decision Support

Clinical Information

Systems

Improved Outcomes


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Restorative Costs by Tooth Type

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20$0.0

$500,000.0

$1,000,000.0

$1,500,000.0

$2,000,000.0

$2,500,000.0

$3,000,000.0

$3,500,000.0

$4,000,000.0

$4,500,000.0

$5,000,000.0

D 2nd MolarD 1st MolarD CanineD Lateral IncisorD Central Incisor2nd Molars1st Molars2nd Premolars1st PremolarsCaninesLateral IncisorsCentral Incisors

Age of Beneficiaries

P = Permanent or adult teethD= Deciduous or primary teeth

Restorative Costs by Age

PreventistrySM Sealant Program

PreventistrySM Fluoride Program

ECC Disease Management Disease Management


Evidence-based clinical recommendations for the use of pit-and-fissure sealants. A report of the American Dental Association Council on Scientific Affairs. JADA, Vol. 139. March 2008

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ADA Sealant Recommendation


Evidence from ADA Dental Sealant Recommendation• Reduction of caries incidence in children and adolescents after

placement of resin-based sealants ranges from 86 percent at one year 78.6 percent at two years 58.6 percent at four years.

• Sealants are effective in reducing occlusal caries incidence in permanent first molars of children by

76.3 percent at four years, when reapplied as needed. Caries reduction was 65 percent at nine years with no

reapplication during the last five years

Evidence-based clinical recommendations for the use of pit-and-fissure sealants. A report of the American Dental Association Council on Scientific Affairs. JADA, Vol. 139. March 2008

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Effectiveness of Sealants

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Most Restorations Could Have Been Prevented

First Permanent Molars


Healthy People 2010 Healthy People 2020Age 8 14 6 to 9 13 to 15Baseline 23% 15% 25.5% 19.9%Target 50% 50% 28.1% 21.9%Method Better than the best 10% Improvement

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National Goals for Dental Sealants

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UT IN MI WI AR PA GA MT NJ LA WY SD MS IA VT NC SC DC TN CO NE ME NVWA IL TX

0%5%

10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%

100%

17%

FY11 Goal

US National Average

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Medicaid 6-9 Y.O. Receiving Sealants in 2011


Organize patient and population data to facilitate efficient and effective care• Provide timely reminders for providers and patients• Identify relevant subpopulations for proactive care• Facilitate individual patient care planning• Share information with patients and providers to coordinate

care• Monitor performance of practice team and care system

Chronic Care Model: Clinical Information Systems

http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

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0

100

200

300

400

500

600

700

800

900

1000

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percent of 6 and 7 Year Olds Receiving Dental Sealant on First Molars

Count of Ages 5, 6 & 7 Percent 5-7 w/ Seal

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Monitor Performance of Practice Team


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Identify Relevant Subpopulation for Proactive CareProvide Timely Reminders for Providers & Patients


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Monitor Performance of Care Team


Professional applied topical fluoride: Evidence-based clinical recommendations. ADA Council on Scientific Affairs. JADA 2006;137;1151-1159

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Fluoride Recommendation


• Many patients presenting with recurrent gingivitis without additional attachment loss after definitive periodontal therapy may be adequately maintained with PM performed semiannually.

• In general, data suggest that most patients with a previous history of periodontitis should obtain PM at least four times per year, since that interval will result in a decreased likelihood of progressive disease, compared to patients receiving PM on a less frequent basis

Periodontal Maintenance (2003) J Periodontol 2003;74:1395-1401

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Frequency for Periodontal Maintenance


6%

18%

43%

75%

25%

0%

10%

20%

30%

40%

50%

60%

70%

80%

0 Clean 1+ Clean 2+ Clean 3+ Clean 4+ Clean

First goal is to increase the percentage of perio patients receiving at least 2 maintenances per year

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Perio Patients Receiving Perio Maintenance

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Identify Relevant Subpopulation for Proactive CareProvide Timely Reminders for Providers & Patients

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Health System: Provide Incentives Based on Quality

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Fluoride Perio Maintenance0%

10%

20%

30%

40%

50%

60%

70%

46.3%49.1%

59.9% 61.8%61.0%63.6%

Jan-Jun 2011Jul-Dec 2011Jan-Jun 2012

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Results for Populations

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%Jan-Jun 2011 Jul-Dec11 Jan-Jun 2012

Names of Providers on X Axis

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Fluoride Results for Network Providers

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan-Jun11 Jul-Dec11 Jan-Jun12

Names of Providers on X Axis

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Perio Results for Network Providers


• The highest bonuses are in $7,000 - $8,000 range

• Around 60% of dentist achieve the fluoride goal

• Around 75% of dentists achieve the perio goal

• Around 85% of dentists receive a financial bonus

• Improved quality of care• Improved our Program Quality Score• Reimbursed for quality not just quantity (P4P)

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Overall Results for Network Providers

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20$0.0

$500,000.0

$1,000,000.0

$1,500,000.0

$2,000,000.0

$2,500,000.0

$3,000,000.0

$3,500,000.0

$4,000,000.0

$4,500,000.0

$5,000,000.0

D 2nd MolarD 1st MolarD CanineD Lateral IncisorD Central Incisor2nd Molars1st Molars2nd Premolars1st PremolarsCaninesLateral IncisorsCentral Incisors

Age of Beneficiaries

P = Permanent or adult teethD= Deciduous or primary teethECC Disease Management

Early Childhood Caries and Severe ECC


• The disease of ECC is the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child under the age of 6.

• In children younger than 3 years of age, any sign of smooth-surface caries is indicative of severe early childhood caries (S-ECC).

• From ages 3 through 5, 1 or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of ≥4 (age 3), ≥5 (age 4), or ≥6 (age 5) surfaces also constitutes S-ECC.

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AAPD Early Childhood Caries


Empower and prepare patients to manage their health and health care• Emphasize the patient’s central role in managing their health• Use effective self-management support strategies that include

assessment, goal-setting, action planning, problem-solving and follow-up

• Organize internal and community resources to provide ongoing self-management support to patients

Chronic Care Model: Self Management Support

http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

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INITIAL OR RECALL APPT• Medical history• Caries Risk Assessment (CRA)• Exam/X-rays• Behavioral assessment VISIT 1

• Self-management goals (diet, oral hygiene, home fluoride)• Fluoride varnish• Indicated clinical care

DISEASE MANAGEMENT VISIT• Caries Risk Assessment• Clinical/X-ray exam• Fluoride varnish• Re-define or re-emphasize self-management goals• Behavioral assessment

RESTORATIVE ITR VISIT(S)• Provide restorative care as

indicated• Provide ITR as indicated• Schedule OR time if indicated

CHILDREN AT HIGH RISK• Schedule next Disease

Management visit in 1 month

CHILDREN AT MEDIUM RISK• Schedule next Disease

Management visit in 3 months

CHILDREN AT LOW RISK• Schedule next Disease

Management visit in 6 month

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Risk-Based Disease Management Protocols

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ECC disease management approach based on premise that a patient’s caries risk status is not static, but can be managed and improved over time.

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Patient’s Caries Risk Status is Not Static


Refer to OR New Cavitation Pain0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

48%

65%

38%40% 42%

77%

36%28% 27%

CHBSJHPhase II

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Improved Outcomes and Patient Experience


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www.dentaquestinstitute.org


Contact information

Robert Compton, DDSExecutive DirectorDentaQuest Institute

October 2013

[email protected]

Documents

Prevention Focused Patient Care in the Dental Practice