UTILIZING NAVIGATORS TO ENHANCE MEDICAL/DENTAL INTEGRATION

WILLIAM DONIGAN DDS, MPH

OR GETTING MORE CHILDREN INTO YOUR DENTAL PROGRAM.

ZIG ZIGLAR

"THE 3 C'S OF LIFE:

WILLIAM DONIGAN DDS, MPH

• A clinic child

• Marquette University, BS Biology

• University of Illinois Chicago DDS

• University of Kansas MPH

• Private Practice 1983-2007

• Dental Director 1996 – Present

• No financial ties

• 1997 – Martin de Porres

• 2001 – Flint Hills Community Health Center

• 2007 – Gaston Family Health Services

• 2011 – NNOHA Clinician of the Year

• 2011 Safety Net Solutions Expert Advisor

• 2012 – Gaston County Public Health Hero

• 2016 North Carolina Provider of the Year

• MOM – Gastonia 2010,2012,2015,2017,2020 3500 patients, $1.5 M donated care

How many times have you thrown you call list away as

your contact information is no longer relevant?

Community Health Workers, can be the “eyes and ears”

of our colleagues out in the field, they are ready to

address the health care needs of individuals across the

lifespan, from babies to pregnant women to our

esteemed elders.

They can bring the relevance of good overall health to

the community and those living within it. Prevention and

education are their tools of the trade

BRINGING ORAL HEALTH INTO THE OVERALL HEALTH CARE CONVERSATION WILL ENHANCE EFFICIENCY, EFFECTIVENESS, PRODUCTIVITY AND PROFITABILITY (NO MARGIN, NO MISSION).

This integration will truly make a demonstrable

impact within the overall health of the

community, not just in the lives of individuals

who have been lucky enough to “break into the

system.”

BALANCE?

11

Uninsured

Patients

Medicaid Patients,

Commercial

Insurance Patients

Equals Sustainability

• The number of dental encounters

should produce 75% of revenue

for a Health Center dental

program

• How many uninsured patients is

enough for your center?

• How many uninsured patients do

we treat until the need is met?

• We need Medicaid and

Commercial insurance to help

pay for care for the uninsured.

BALANCE?

Where we

are and

who we

serve!

Primary

Care

Pharmacy

Medication

AssistanceBehavioral

Health

Dental

HIV

Case

Management

Disease

Management

SERVICES

Vision

(PHS330 = $7M)

IMPACT

Service Area Gaston County

Patients 45,000 31,000

Patient

Visits172,000 101,000

Staff 600 360

Budget $42M $27M

1 in 7Gaston County Residents

ECONOMIC

ENGINE

45%of Gaston County’s

Uninsured

GASTON FAMILY HEALTHSERVICES

DENTAL SERVICES

• Hudson Boulevard - 1996

• Summit Crossing Pediatric Dental Services – 2004 (Originally Aberdeen)

• Statesville Dental – 2009

• Catawba Dental – 2015

• Lexington Dental– 2015

• Mobile Dental Services (North) – 2016

• Lincolnton Dental – 2019

• Mobile Dental Services (South) – 2019

• Mocksville Dental - 2019

• Recommends that all

children receive an

oral health assessment

(screening) and

appropriate referral

by a trained health

care professional or

trained layperson

within 6 months after

the eruption of the

first primary tooth, but

no later than one year

of age;

AAPHD (AMERICAN ASSOCIATION OF PUBLIC HEALTH DENTISTRY)

18

• ….recommends that

children be seen by a

dentist following the

eruption of the first

tooth, but not later

than 12 months of

age.

AAPD (AMERICAN ASSOCIATION OF PEDIATRIC DENTISTRY)

19

SO WHAT SHOULD THE GOAL OF NAVIGATION BE?

• To increase the number of patients (children) in your dental program by

bringing oral health into the medical visit!

• To employ successful navigation from the medical program to the dental

program

• To create successful data collection (accurate, meaningful and timely)

• To be able to evaluate the integration and modify to meet our practice needs

WHAT’S WRONG IN AMERICA?• Oral diseases and disorders in and of themselves affect health and well-being

through life.

• There are safe and effective measures to prevent the most common dental diseases

dental caries and periodontal diseases.

• Lifestyle behaviors that affect general health such as tobacco use, excessive alcohol

use, and poor dietary choices (soda, juice, sports drinks) affect oral and craniofacial

health as well.

• There are profound and consequential oral health disparities within the American

population.

• The mouth reflects general health and well-being.

• Oral diseases and conditions are associated with other health problems.

Medical-Dental Integration

WHAT’S WRONG IN AMERICA?

• Overall. Non-Hispanic blacks, Hispanics, and American Indians and Alaska

Natives generally have the poorest oral health of any racial and ethnic groups in the United States.

• Children and Tooth Decay. The greatest racial and ethnic disparity among children aged 2–4

years and aged 6–8 years is seen in Mexican American and black, non-Hispanic children.

• Adults and Untreated Tooth Decay. Blacks, non-Hispanics, and Mexican Americans aged 35–

44 years experience untreated tooth decay nearly twice as much as white, non-Hispanics.

• Tooth Decay and Education. Adults aged 35–44 years with less than a high school education

experience untreated tooth decay nearly three times that of adults with at least some college education.

• Adults and Oral Cancer. The 5–year survival rate is lower for oral pharyngeal (throat) cancers

among black men than whites (36% versus 61%).

• Adults and Periodontitis. 47.2% of U.S. adults have some form of periodontal disease. In adults

aged 65 and older, 70.1% have periodontal disease.

• Periodontal Disease is higher in men than women, and greatest among Mexican Americans and Non-Hispanic blacks, and those

with less than a high school education.

WHAT’S RIGHT (IN MISSISSIPPI) ?

• Percentage with a PCP Visit in the Past Year: Ages 25 Months-6 Years 88%

• Percentage with a PCP Visit in the Past Two Years: Ages 7-11 Years 91%

• Percentage with a PCP Visit in the Past Two Years: Ages 12-19 Years 88%

• Percentage with a PCP Visit in the Past Year: Ages 12-24 Months

99.4%

OPPORTUNITIES

• 2011 statistics

• 1/3 of adults age 35-64 who visit the physician have not seen a dentist in the last

12 months

• 10% of adults age 21-49 who visited the dentist had not seen a physician in the last

12 months

• Mutual benefit

• Both physician and dentist

• Use the registration form

Opportunities

6/17/2014NC Oral Health Collaborative 1

HRSA HAS ADOPTED THE FOLLOWING DEFINITION OF COMPREHENSIVE PRIMARY ORAL HEALTH CARE THAT HAS APPEARED IN POLICY AND PROGRAM GUIDANCE SINCE 1997:

• Comprehensive primary oral health services is defined as personal oral

health care, delivered in the context of family, culture, and community,

that includes all but the most specialized oral health needs of the

individuals being served.

Patients need to take some

responsibility for their own care!

Education!

Education!

Education!!!!!!!!!!!!!!!!!!

Break?

How about an increased

number of children

without caries. Which

should mean:

WHAT SHOULD THE BENEFITS OF NAVIGATION BE?

An increased

number of adult

patients without

caries andAn increased number

of patients having

treatment completed

Education, Education, Education Children - Diet, Soda, Sugars

• Transportation

• Car, Bus or use their feet?

• Childcare

• Isn’t it hard to treat patients

with other little ones in the

room

• Finances

• Can’t even afford the nominal

fee

• Medicaid reimbursement

• 3% loss (shared savings plan),

It has been about 9 years

since our last increase

• Telephone

• Usage, pay as you go, no

minutes, no messages

WHAT ARE THE BARRIERS FACED BY YOURPOPULATION?

32

• Oral Health Literacy

• Cooperation with

provider instructions

• Lack of care

• Many are first timers

or only came when in

pain

• Raised that way

• Lack of discretionary

funds

• Basics, medications

WHAT BARRIERS ARE BROUGHT BY YOUR POPULATION?

33

REMEMBER WE SHOULD ALL WANT TO:

1. Improve Access - Every infant and child is worthy of the

opportunity to benefit from contemporary knowledge and

measures that will improve his or her oral health, overall

health, and health trajectory.

2. Improve oral health outcomes - Oral health is the

window to the entire body.

FACTS ABOUT MEDICAL-DENTAL INTEGRATION

•All CHC Medical patients should be dental patients

•Probable not possible!

•High priority populations:

•Children

•Pregnant women

•HIV/RW

•Diabetics

•Cardiovascular disease

ALL OF OUR CLINICS SEE CHILDREN!

•Why?

•How do we attract more children?

• In this age of corporate dental clinics?

•What are your thoughts?

DAP (DENTAL ACCESS PROGRAM)

• 2007-2008 9 SCHOOLS 353 STUDENTS

• 2008-2009 20 SCHOOLS 900 STUDENTS

• 2012-2013 34 SCHOOLS 2,136 STUDENTS

• 2016 36 SCHOOLS 2,800 STUDENTS

• 2018 56 SCHOOLS 4,100 STUDENTS

• IREDELL COUNTY WAS ADDED IN SCHOOL YEAR 2010-2011

• MDU 2017

• Melissa Boughman RDH, Dental Access Coordinator

WHAT DOES A DAP NAVIGATOR DO?

• Makes appointment

• Verify eligibility

• Verifies parent and child make it to the appointment

• Assist with transportation if Medicaid and requested

• Contact parent within 24 hours

• If no contact

• Three times in next two weeks, different times of day

• No contact postcard

2012 CHOP (CHILD HEALTH OUTREACH PROGRAM)

• Priorities:

• 1. Educate caregiver and children about oral health, caries

transmission, pediatric dental specialty care and especially the one

year dental visit.

• 2. Relieve burden of accessing care by directly scheduling dental

appointments at the location of their choice for children and

caregiver while at their pediatric medical visit.

• 3. Integrate oral health into the medical visit.

CHOP (CHILD HEALTH OUTREACH PROGRAM)

• Components:

• 1. Full time bilingual staff member

• 2. Office space in the pediatric medical clinic

• 3. Laptop computer

• 4. Wireless internet (VPN), EDR capable

• 5. Salary, benefits, and equipment funded by dental

clinic

CHOP (CHILD HEALTH

OUTREACH PROGRAM)• Non-tangible components:

• 1. Hardworking and dedicated individual

• 2. Flexibility of liaison, clinicians and

staff

• 3. “Buy-in” of clinicians with whom the

liaison is working

CHOP (CHILD HEALTH

OUTREACH PROGRAM)• Training with pediatric & general

dentists in oral health

• Training with front office staff in Dentrix

• Training in data collection with PM

• Training in Fluoride Varnish placement

HOW DO YOU SCHEDULE IN YOUR CENTER?

• An hour per patient?

• Two columns per provider?

• How about hygiene patients?

• An hour?

• Hygiene assistant?

• Kids?

HYGIENE APPOINTMENT LENGTHS

• Child/New Patient over 12 treated as adult 60 minutes

• Child/New Patient over 8 50 minutes

• Child/New Patient under 8 40 minutes

• Child Recall no x-rays 30 minutes

• Child Lap to Lap <3 yoa 30 minutes

• Sealants 30-40 Minutes

depending on age/degree of difficulty

• Education! Education!! Education!!!!!!!!!!!!! Of staff

CHOP (CHILD HEALTH

OUTREACH PROGRAM)•Benefits to the patient:

• 1. Education about oral hygiene and diet

at medical visit

• 2. Education about the one year dental

visit

• 3. Convenience of scheduling for both

caregiver and child

CHOP (CHILD HEALTH

OUTREACH PROGRAM)

•Benefits to the dental clinic:

• 1. Constant influx of new patients

especially 1 year olds and special

needs patients.

• 2. Liaison has quick communication

with dentists if needed via e-mail or

Dentrix messenger.

• Benefits to medical clinic

• Time

• Money

DO OUR PRIORITIES MEET WITH OUR OBJECTIVES?

• Increase Patient Dental IQ

• Get children into clinic early (age 1)

• Create a broader patient base of

children

• Increase number of Patients with a

payer source

• Improve sustainability

PROJECT PLANNING PROCESS

• Timeline- CEO, GCHD director and

medical director, providers (medical and

dental)

• Unique and great relationship with HD,

CEO wants the dental clinic run as if my

own? So I took ownership!!!!!

• 75% treatment completion within 6 months,

sealants placed on all molars, premolars, and

primary molars that need placement

WHAT SUCCESS MIGHT LOOK LIKE?

No pain!

“I see in our patients a remarkable improvement in their oral health. The CHOP program is showing families that dental caries can be prevented as well as many other illnesses.”

Cindy TorresDental LiaisonGaston Family Health Services Pediatric DentistryGaston Family Pediatrics

CHOP (CHILD HEALTH OUTREACH PROGRAM)

• Success!!!!!!!!!!!!!!!!!!!!

• The income brought into our dental clinics due to the program far

exceeds the salary and benefits of the liaison (125-175 new

patient appointments monthly)

• Most are new patients or those who have not seen a dentist in

more than six months

• No parent has declined having the liaison provide oral health

education during the child’s medical visit

• The show rate of liaison scheduled patients is around 80-85%

which closely approximates our dental clinic show rate

Child Health Oral

Program 2016

Jan-

16

Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-

16

# Declines 0 0 0 0 0 0 0 0 0 0 0 0 0

# Uninsured appt

made

4 0 6 2 2 3 4 2 5 4 5 3 40

# Appointments

Kept

74 111 81 49 55 70 77 76 77 76 78 69 893

# Insured

appointment made

95 128 90 67 62 74 73 79 81 72 83 70 974

# Appointments

Made

98 129 96 69 64 77 84 81 86 87 88 82 1041

CFD WIC CHOP, 2017

Jan-

17

Feb-

17

Mar-

17

Apr-

17

May-

17

Jun-

17

Jul-

17

Aug-

17

Sep-

17

Oct-

17

Nov-

17

Dec-

17

Tot

al

Number of

Declines

0 0 0 153 151 148 181 221 304

Number of

uninsured appts

made

1 1 2 2 0 0 0 1 1 3 6

Number of

appointments Kept

17 24 50 51 42 28 44 55 48 29 212

Number of Insured

appointments

made

24 40 88 86 77 51 75 94 65 45 366

Total number of

appointments

Made

25 41 90 88 77 51 75 95 66 48 372

Percentage of

appt kept

68% 59% 56% 58% 55% 55% 59% 58% 73% 60% 59%

BUILD IT AND THEY WILL COME!

MAYBE??????????????????????

47 NEW PATIENTS FOR ALL OF

2016 AT STATESVILLE FAMILY

DENTISTRY REFERRED FROM

STATESVILLE CHILDREN’S CLINIC

HOW IMPORTANT IS OUR NAVIGATOR?

4584 new patients 2012 - 2016!

EDUCATION!!!

What Causes Cavities? SUGAR – From foods and drinks left on the teeth

PLAQUE – A bacteria which is on the teeth

ACID – Caused by sugar and plaque left on the teeth

SUGAR + PLAQUE + ACID = CAVITIES

(American Dental Association, 2011b)

EDUCATION!!

BABY ORAL HEALTH PROGRAM (BOHP)

•Cindy Cruz

•http://www.babyoralhealthprogram.org/

•http://www.prenataloralhealth.org/video/moth

ers1-english.mp4

EDUCATION!!!!!!!!!!!!!!!!!!!

But most general dentists, as a rule, only treat as emergency cases.

All dentists see pregnant patients!

Why don’t many general dentists treat pregnant patients?

Fear (recent ADA Journal article)https://www.ada.org/en/press-room/news-releases/2015-archive/august/new-study-shows-dental-treatment-during-pregnancy-is-safe

Lack of medical consultation

Phase I Dentistry (extractions, fillings, etc.)

Many have Medicaid- Regular Medicaid vs. Pregnancy Medicaid

DATA?HOW VITAL IS IT?ACCURATE, MEANINGFUL, TIMELY….

- 1/5 HEALTH CENTER PATIENTS SHOULD BE DENTAL PATIENTS……

- HOW MANY CHILDREN ARE THERE IN YOUR PROGRAM?

HOW ABOUT CLOSING THE LOOP?

• Referral from Medical

• Dental remediation of situation

• Acknowledgment of treatment back to

Medical

WHAT ARE THE CHALLENGES?

Keeping it Vibrant

Coordination of Services (billing)

Staff Turnover (pay scales &

Benefits)

Staff buy in

Parental buy in

WHAT LESSONS CAN WE LEARN?

• Collaboration is powerful

• Implementation phase

• Sustainability

THE AFFORDABLE CARE ACT AND BEYOND

•Where will we be?

•2002 45% utilization ages 25-45 versus

•2012 35% utilization same age group

Why?

Where will you be in 2020 and beyond?

How do we get there?

WHAT DOES IT ALL MEAN?

• 2002 – 287 million, ages 25-45 99.8 million, 173 thousand dentists 45%, 44 million

• 2012 – 314 million, ages 25-45 81.1 million, 190 thousand dentists 35% 28 million

• 2025 – trends, 201 thousand dentists

• 20% DSO

• 12% loss annually nationwide all practices

• New patients to make up for it? How

• Marketing (external)

• CHOP, DAP

• Internal

Ideas – what fits and can you

do it?

THINK

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Relationships – County with

FQHC, with DSS, WIC, etc.

PDSA’s – small incremental

changes for the better

Program evolution

You will always have

change

When the pain of staying the same becomes

greater than the pain of change you’ll change!

PATIENTS

William Donigan DDS, MPH

Dental Director

Gaston Family Health Services

(704) 862-5376

wdonigan@gfhs.info

CONNECTIONS