family medicine and community health making medical-dental collaboration work - lessons from across...

Family Medicine and Community Health

Making Medical-Dental Collaboration Work - Lessons

from Across the Country

Hugh Silk, MD, MPH

Clinical Associate Professor

April 13, 2012


Learning Objectives

By the end of this talk participants will be able to discuss:

• Some of the national efforts creating medical-dental momentum

• Educational opportunities for collaboration • Massachusetts - an example of a comprehensive

oral plan in evolution• Medical providers and fluoride varnish - a

gateway to more oral health and how we are making it work


Acknowledgment: Some materials today are used from Smiles for Life

8 annotated 50 minute PowerPoint modules

www.smilesforlifeoralhealth.org

4


National Medical-Dental Efforts

But first – why is this important

Family Medicine and Community Health 5

The Big Picture

“You are not healthy without good oral health…” David Satcher, Surgeon General 2000

• Dental care: the most common unmet health need • Oral disease can severely affect systemic health• Profound disparities in oral health and access to

care exist at all ages• Much oral disease is preventable or at least

controllable


Still Need to Know More!

• Dental caries is the most common chronic disease of childhood

• Severe gum disease affects 19% of adults aged 25-44 ~ links to DM, CAD

• 30,000 oral cancers diagnosed annually; 8000 die

• 50% of the elderly perceive their dental health as poor/very poor; 33% have untreated cavities


Photos: Donald Greiner DDS MS, ICOHP

8

And you know the Consequences• Mounting evidence of aggravating

effects on systemic conditions• Oral pain

– Poor school performance in children– Work loss in adults– Poor chewing and poor nutrition– Costly emergency department visits

• Dental decay and tooth loss– Aesthetics and self-image – Speech and language development– Costly restoration


The Disconnect• Children are 2.5 times more likely to

lack dental coverage than medical coverage

• > 50% of MDs had little or no oral health training

• Little communication and cooperation between medical and dental providers


More recently…

• 62% of OB-Gyn residency programs provide no prenatal oral health education

• < 50% of pediatric residencies have 2 hours or less of oral health education

• Only 32% of family medicine residency directors are satisfied with their residents' competency in oral health

• 1 in 10 medical school have no OH curriculum


Why is this such a big deal?Because…

• 50 million Americans live in rural or poor areas where dentist d o not practice

• Only 43% of elderly visit the dentist

• Preventable dental conditions were the primary reason for 830,590 ED visits (2009)

• Only 34% of pregnant women visit the dentist

The Medical Home is the Dental Home!


How we practice

• Prenatal visits - ~13 visits ~4 hours

• Infants (WCC) – 11 visits before age two

• Children & Teens – 18 visits, plus sick visits

• Adults – annually

• Geriatrics – admission to NH, every 30 days

• Specialty visits, ED visits, VNA, etc


However, some good news…

• >90% of physicians think oral health should be addressed at well visits

• 75% of OB/GYN directors “agreed” that residents should address oral health

• 95% of peds and FM programs have some oral health training

• 45% of peds programs teach fluoride varnish• 80% of medical schools teach about oral cancer;

70% about oral-systemic relationships


Since 20002001 American Academy of Pediatrics: Section on Oral Health

2003 Society of Teachers in Family Medicine: Smiles for Life

2006 NY DPH: Oral Health During Pregnancy and Early Childhood (2010 CDA Revised OH During Pregnancy Evidence Based Guidelines)

2009 American Dental Association: Access to Care Summit

2010 Dept. of Health and Human Services: Oral Health Initiative

2010 Physician Assistants Leadership Summit on Oral Health

2011 Healthy People 2020: Oral Health = Leading Health Indicators

2011 Institute of Medicine and Health Resources & Service Admin HRSA: Advancing Oral Health in America

2011 IOM: Improving Access to Oral Health Care for Vulnerable and Underserved Populations

2011 Assn. of American Medical Colleges: oral health curricula


Patient-Centered Medical Home• Personal physician: ongoing relationship with a personal physician trained

to provide continuous and comprehensive care • Physician directed medical practice: the personal physician leads a team

who collectively take responsibility for the ongoing care of patients.• Whole person orientation: provide for all the patient’s health care needs• Care is coordinated and/or integrated across specialists, hospitals, home

health agencies, and nursing homes. • Quality and safety are assured by a care planning process, evidence-

based medicine, clinical decision-support tools, performance measurement, participation of patients in decision-making, information technology, quality improvement activities

• Enhanced access to care is available (e.g., via "open scheduling, expanded hours and new options for communication").

• Payment should reflect the value of "work that falls outside of the face-to-face visit," should "support adoption and use of health information technology for quality improvement," and should "recognize case mix differences”

– Wikipedia


“Health Homes”Move beyond dental and medical homes:• Set up in same building and conduct

meetings together (e.g. a ‘good’ CHC)• Have a professional perform “visiting”

consults (e.g. hygienist in MD office once a week)

• Create lists for proper referrals – know who does what, what insurance they take, what patient sets they see, etc


Culture Change

• Change is difficult

• Change leads to creative solutions

• “Change your thoughts and you change your world”– Norman Vincent Peale


Work synergistically

• Support cross pollination of ideas:– Dental supporting fluoride varnish done by

medical providers– Medical supporting dental doing oral cancer

screens, blood pressure monitoring, nutrition advice

– More inter-professional health in schools/residencies

– And more!


Moving Beyond “Our Offices”• Medical and dental sitting on Head Start,

WIC, school health committees

• Work together on water fluoridation campaigns

• State Task Force; State Oral Health Plans

• Watch Your Mouth – trainings to learn the same media messages, social marketing


The Colorado Experience• Cavity Free at Three (cavityfreeatthree.org)• Training practicing oral health and medical

professionals together• Meet in CHCs, Health Department offices,

Community Centers• Giving joint faculty appointments in medical and

dental schools• Use AHEC (Area Health Education Centers)• “Train-the-trainer” model


Colorado: Cavity Free at Three

• Train medical and dental to do oral exams, anticipatory guidance and varnish for all children under three

• Medical need to learn dental elements; dental need to learn to be comfortable with young children and sometimes about varnish

• Also combine forces for community social marketing


Colorado Results• started in 2008• 54 Cavity Free at Three, Master Trainers throughout

Colorado• have had 89 training presentations since inception• over 1500 multi-discipline individuals trained• have requests for presentations at 100+ new sites• distributed over 22,434 fluoride varnish kits through the

trainings • We estimate the total number of children and families in

Colorado exposed to Cavity Free at Three to be 40,000!• educational materials have been translated to 8

languages, available at www.cavityfreeatthree.org.


Educational opportunities for collaboration


www.niioh.org


Third Edition


Aphthous StomatitisThree Clinical Forms • Minor: less than 7mm, most common• Major: greater than 7mm• Herpetiform

Symptoms• Recurring, painful, solitary, or multiple

ulcers• White/yellow pseudomemembrane,

surrounded by an erythematous halo

Treatment • Most mild aphthae require no treatment• Orabase, topical or intralesional

steroids• Avoid trigger foods and chemicals

Photos: Joanna Douglass, BDS, DDS

30


Physician Assistants – On the Move!


Association of American Medical Colleges


Massachusetts - an example of a comprehensive oral plan in

evolution


• State plan


• Backed by:


The Players

• Better Oral Health Committees

• Oral Health Advocacy Taskforce

• Oral Health Caucus

• Department of Public Health

• Massachusetts Medical Society

• Massachusetts Dental Society – CAPIR

• Dentaquest Foundation


CMOHI – a regional example1) Providing school-based dental services for underserved children

– screen, educate, fluoride and sealant applications– added Head Start centers

2) Increasing the amount of oral health care for underserved– Actively recruited Medicaid dentist – Expand/promote Community Health Centers, Dental Hygiene School

3) Advocacy for oral health policy– Change local legislative, administrative, and regulatory policies

4) Establishing a dental residency program– Used local health centers/med school– create interest in treating the underserved; pool of future local dentists

5) Educating health professionals on oral health– medical students, residents and practitioners using Smiles for Life– Educate on common issues; build confidence in referrals


Results

1) 28 schools; 4,423 children (40%);

>20 000 service visits

2) Medicaid dentists 14% -> 55%

Doubled CHC capacity

3) Reimbursement, “cap” policy; 3rd party payer

4) 9 or 15 residents in area, underserved

5) increase local residencies education – peds, FM, EM and Grand Rounds OB, IS, IM


Partners• Commonwealth of Massachusetts

Legislature• *Family Health Center of Worcester• *Great Brook Valley Health Center• Health Care for All and Health Law

Advocates• Massachusetts Coalition for Oral

Health• Massachusetts Delta Dental

Foundation• Massachusetts Dental Society• Massachusetts Department of Public

Health• Massachusetts Society for the

Prevention of Cruelty to Children (MSPCC)

• *Oral Health Initiative of North Central Massachusetts

• *Quinsigamond Community College Dental Hygiene School

• Southbridge Public Schools• Southern Worcester Neighborhood

Center• *The Health Foundation of Central

Massachusetts• *UMass Medical School's Office of

Community Programs• *UMass Memorial Health Care• United Way of Webster and Dudley• Webster Public Schools• Worcester City Council• Worcester Department of Public

Health• *Worcester District Dental Society• *Worcester District Hygienists'

Association• Worcester Public Schools• South Worcester Neighborhood Center

* Denotes member on steering committee


Medical Initiatives• MA Medical Society – Oral Health Summit

– OB, Peds, Fam Med, Int Med, Pub Health, ENT, Emerg Med, Cards, Endo, MDS, othr dental experts – DPH, DH, CHW

– The resolution – A Taskforce– The “hook”


Medical Education• Medical Schools

– One by one– UMass – “every course – spiral curriculum”

• Medical Residencies– Fluoride varnish = gateway– Emergency Medicine (procedures)– IM (lesions), OB (safety/referrals)

• PAs, Pharmacy, Nursing• CME – AAFP, AAP, on-line


UMMS Year 1

• Anatomy – saliva, teeth, mouth

• Genetics – cleft lip/palate

• Doctoring – physical exam

• Cancer concepts – ICE case – oral cancer

• Infections – strep, biofilm, herpes, thrush

• Host Defense – perio and inflammation


UMMS Year 2

• Cardiology – perio-CAD; SBE prophylaxis

• Pulmonology – aspiration pneumonia

• The Brain – oral pain

• Nutrition – sugar and cavities

• Population Health Clerkship – – 2 weeks in oral public health –

• Headstart, care mobile, prisons


UMMS Year 3• Oral Health Clerkship

– Geriatric– Prenatal– Pediatric– Urgent care– Systemic– Fluoride varnish

• Disabilities Clerkship– Special Needs Oral Health


UMMS Year 4

• Clinical Emergent Problem Solver– Sepsis from oral infection

• Elective – oral public health

• Oral Health Interest Group – – 2 talks per year– 1 community service event


Medical Providers and Fluoride Varnish

A gateway to more oral health and how we are making it work


Building Upon the Work Done by Others

• The Gurus– North Carolina– Washington– Maryland


• AAP 2008 – Preventive Oral Health Interventions for Pediatricians– 9 recs including risk history and FV

• 2011 National Quality Forum – includes FV during WCC as 1 of 43 measures

• In 2007 only 7.5 % of 2-4 year olds in the US had any fluoride treatment

• In 2009 only 5% of physicians self reported providing fluoride varnish in MA


Comprehensive program:tri-state (CT3.5, MA6.5, RI1.0)

• Preparation - Project Coordinator prior to site training to allow our trainer to enter a practice ready to implement change

• Commitment – ensure the office starts varnish use “same day”• Practice work flow – identify eligible patients; work it into visits• Clinical record – incorporate oral health prompts into the record • Billing –Add codes to encounter forms or EHR billing system• Train ALL staff – establish buy-in; use web-based training for those

who are absent• Hands on practice - hands-on patient experiences with hygienist • Supply provisions - comprehensive informational packet, patient

posters, laminated fact cards, carrying cases with 50 free varnish packets, patient handouts, gauze, gloves, billing stickers/information

• Follow-up – “adopt a practice”


Promotion

• Each state AAP, AAFP meeting – booths, talks, handouts

• Newsletters

• List serves

• Medicaid lists of biggest practices

• Local success stories

• Personal connections


Building Bridges

• Medicaid – promotion, data, “fixes”, lists

• State DPH – trainings

• state Dental Society – train age 1 visits

• Head Start – coordinate; messaging

• Dentaquest – hands on

• AAP – promotion, forum

• AAFP – presentation, forum


The next generation

• Training all pediatric and family medicine residents

• Leaving in place a plan for future training

• Converting offices – continuous education

• >50% of graduates stay in the state


Year One

• 16 residencies

• 100 offices

• Skilled trainers

• Residencies with future plan


Conclusions

• Medical providers have to be part of the oral health solution

• Education is a key area to focus on

• Learn from our success and mistakes in Massachusetts

• Takes a Village!

• Fluoride Varnish may be the entry way for many medical providers


Questions

[email protected]

family medicine and community health making medical-dental collaboration work - lessons from across...

Documents

dental health

community health slide

community health photos

prenatal oral health

oral disease

common unmet health

good oral health david

dental providers