The OHS Journey – Year 1

Where we’ve been

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OHS

• By 2041, the senior population will be 23% (1995 only 12%) - 80,000,000 more teeth to care for!

• Literature indicates many barriers to care:– Financial, access, attitudes & beliefs, institutional,

education, physiological

• Oral health is marginalized from publicly funded health care

• Oral health impacts overall health and quality of life

Serving Seniors: Challenges for Oral Health

Purpose

To determine the key components of a health services model, based on continuity of care, which will help improve access to

oral health services for seniors.

What’s needed?

• A collaborative, integrated team approach

• Data

• Increased awareness of the issue

• Links to other research and initiatives

Nova Scotia: Our Project’s Playground

• High proportion of seniors: 128,333 seniors (65+) in NS; 13.6% of total population

• Many seniors living in rural communities, at home and with poor socio-economic conditions

• Currently, outside of our project, there is no information on the oral health services, barriers and facilitators

• No publicly funded dental services for seniors

Objectives – Year 1 (Data Collection/Planning)

Develop a survey for seniors and DCPDevelop 4 focus group guidesDevelop a research logic framework for the Best

Practices Identify resources and experts to consultDevelop a recruitment strategy and materialsBegin organizing the ForumDevelop a communication plan

MAWG

BPWG

RFCWG

Objectives – Year 2 (Analysis/Model Dev./ Dissem.)

Synthesize, design and prepare a final report and executive summary for the Focus Group findings and Best Practices Scan

Design Forum process, recruitment strategy, funding, and develop materials/presentations

Host Forum Assist with the development of proposals for future

projects/initiatives Develop a oral health services model for Nova Scotia Disseminate project findings

Research

Forum Planning

Team

Products/Wins Intersectoral team, 20+ working group meetingsA comprehensive evaluation frameworkCommunication Plan - 30 opportunitiesFacilitator training workshopRecruitment process and materials2 surveys and 4 focus groups guidesSurvey and Focus Groups findingsFramework for Best Practices ScanOver 266 literature referencesDetailed tracking of project progress

It takes a village to build a model

Insurance

Education

Dentistry societies

LTC facilities

Seniors

Researchers

Government

Researchers

Celebrating our Work

Today’s Agenda9:30am Welcome & Project Update (Mary & Liz)

10:00am Seniors’ Oral Health Services Evaluation: An Overview & Discussion of the Findings (Pam & Liz)

12:00pm Lunch

12:45pm Best Practices Scan: An Overview of Preliminary Findings (Pam)

2:30pm Building a Model: A Discussion to Plan Year 2 (Renée)

3:15pm Closing Remarks (Mary)

Please take a few minutes to complete the evaluation – thank you!

Challenge Today

• To receive an update of the OHS project’s Year 1 activities

• To share and discuss the research results we have to date

• Prepare recommendations and a plan for Year 2 activities including the Forum and model development

Research ObjectivesGoal: To determine the key components of a health services model, based on continuity of care, which will

improve the oral health status of seniors?

1) Seniors’ Oral Health Services Evaluation• Survey, Focus Group Sessions, Key Informant Interviews

2) Best Practices Scan• Review of literature, program scan, policy scan, professional

training scan, insurance scan, promotion & prevention scan

3) Oral Health Policy Forum• Review OHS project findings, develop strategies, clarify

sector roles

Seniors’ Oral Health Services Evaluation

Seniors’ Oral Health Services Evaluation

Senior Focus Groups

Northwoodcare Inc. - Halifax

Canso

Dartmouth

Margaree Forks

Saulnierville

Bridgetown

Bear River First Nations

7 focus groups Average # attending: 10 Range: 2-15

Dentists, Dental Hygienists and NursesFocus Groups

Sydney

Kentville

Yarmouth

Halifax

Truro

Antigonish

6 concurrent focus group sessions (18 in total)

Average # attending: DDS & DH = 7 Nurses = 4

Range: DDS & DH = 6-9 Nurses = 2-5

Survey FindingsSurvey Findings

Profile of the Senior Participants• 67 senior participants• Most:

– Female– Living 21+ years in their community– Perceived oral health and general health to be good– Partial or full dentures, only 73% had all their own teeth

• All but 3 of the seniors were able to care for their own teeth and/or dentures

• Slightly over half of the seniors visited a dentist, dental hygienist, or denturist in the last year

• Only 68% of the seniors have private dental insurance

Profile of Dentist and Dental Hygienist Participants

• 41 dentists and 44 dental hygienists participants• Most:

– 41+ years of age– 11+ years in practice

• 19 DDS and 22 DH had some form of geriatric training - either as a component of their degree or CE courses

• Seniors comprised less than 30% of their patient base• Like the seniors, most of the care providers perceived their senior patients’ oral health and

general health to be good• All but 10% indicated that their dental offices were wheelchair accessible• 26 DDS and 9 DH provide dental services to seniors outside of the traditional dental office:

– 16 DDS and 5 DH in nursing homes– 7 DDS in the hospital– 4 DDS and 2 DH serve homebound seniors

Focus Group FindingsFocus Group Findings

Profile of Nurse Participants• 21 nurses participated in the focus

groups• There were both general nurses

and nurse supervisors and working in homecare, long-term care and hospitals.

• Majority indicated no existing dental care policies or procedures in work place.

• No formal or informal geriatric dental care training either during nursing training or through their place of employment

Question #1: What are the existing dental services for seniors?

Type of Service Dentists Dental Hygienists

Nurses Seniors

Dental Office Dentist/Dental Hygienist Specialist/Hospital Nursing Homes MD

Note: Lack of services in rural areas

Key Findings - Services

Key Findings - Barriers

Question #2: What hinders seniors from accessing dental care (the barriers)?

– Financial (Rural)

– Lack of continuity –LTCF

– Attitudes Beliefs, & Practices (Rural/Communication)

Key Findings - Enablers

Question #3: What helps seniors access dental care (the enablers)?

– Supportive Measures

– Transportation

– Education/Awareness

– Initiatives Outside N.S.

Key Findings - Ideas

Question #4:What do you feel is needed to create a system of oral health care for seniors living in Nova

Scotia?

– Universal dental coverage

– Mobile clinics/equipment

– Policies/standards

– Geriatric education/awareness

– Dental Coordinator

Think Big and Dream Big!

The following is an example of storytelling

An Overview of the Seniors’ Oral Health Services Evaluation

                        

Welcome to Smileyville

Introduction

Gotta Research

Played by: Pam Magee

Our Representative

s

Shirley A. Senior

Played by: Liz Tait

Dr. Phil Yourtooth

Played by: Steve Creaser

Unida Scale

Played by: Jennifer Le

Ima Caregiver

Played by: Crystal Holly

Profile of the Senior Participants

• 67 senior participants, 7 focus groups

• Most:

– Female

– Living 21+ years in their community

– Perceived oral health and general health to be good

– Partial or full dentures, only 73% had all their own teeth

• All but 3 of the seniors were able to care for their own teeth and/or dentures

• Slightly over half of the seniors visited a dentist, dental hygienist, or denturist in the last year

• Only 68% of the seniors have private dental insurance Shirley A. Senior (Liz

Tait) will be travelling to Smileyville to speak on

behalf of the senior patricipants-

Profile of DDS and DH Participants

Dr. Phil Yourtooth (Steve Creaser) and Ms.Unida

Scale (Jen Le) will be travelling to Smileyville to

speak on behalf of the participants of

their sector

• 41 DDS and 44 DH participants• Most: - 41+ years of age

- 11+ years in practice• 19 DDS and 22 DH - some form of geriatric

training (component of degree or CE courses)

• Seniors comprised < 30% of patient base• Most care providers perceived senior oral

health and general health as good• All but 10% indicated that their dental

offices were wheelchair accessible• 26 DDS and 9 DH provide services to

seniors outside dental office:– 16 DDS and 5 DH in nursing homes– 7 DDS in the hospital– 4 DDS and 2 DH serve homebound

Profile of Nurse Participants• 21 nurse participants in the

focus groups, 6 focus groups• Nurse supervisors and general

nurses; working in homecare, long-term care and hospitals.

• Majority indicated no existing dental care policies or proceduresin work place

• No formal or informal geriatric dental care training either during nursing training or through their place of employment

Ms. Ima Caregiver (Crystal Holly) will be

travelling to Smileyville to speak on behalf of the

nurse patricipants

The Round Table Begins…

Question 1.

What are the existing dental services for seniors?

Key Point Recap – Question #1

Type of Service Dentists Dental Hygienists

Nurses Seniors

Dental Office Dentist/Dental Hygienist Specialist/Hospital Nursing Homes MD

Note: Lack of services in rural areas

Question 2.

What hinders seniors from accessing dental care (the

barriers)?

Key Point Recap – Question #2

– Financial (Rural)

– Lack of continuity –LTCF

– Attitudes Beliefs, & Practices (Rural/Communication)

Question 3.

What helps seniors access dental care (the enablers)?

Key Point Recap – Question #3

– Supportive Measures

– Transportation

– Education/Awareness

– Initiatives Outside N.S.

Question 4.

What do you feel is needed to create a system of oral health care for seniors living in Nova Scotia?

Key Point Recap – Question #4

– Universal dental coverage

– Mobile clinics/equipment

– Policies/standards

– Geriatric education/awareness

– Dental Coordinator

Discussion Questions

1) What key findings or issues stand out? What are the highlights?

2) Do you feel that story-telling would be a useful tool for dissemination of these findings at the Forum? Ideas for improvement?

Recap of Focus Group Findings

• Services: All / rural • Barriers: Financial, LTC facilities, attitudes,

beliefs and practices• Enablers: Supportive measures,

transportation, education / awareness• Think Big: Universal dental coverage,

mobile units / equipment, policies / standards, geriatric education / awareness, dental coordinator

Best Practices ScanBest Practices Scan

Literature Review

Prevention & Promotion

Scan

Program Scan

Policy Scan

Professional Training

ScanInsurance

Scan

BP ScanBP Scan

Best Practices Analysis

Scan of barriers and facilitators in oral health services for seniors’. Critical analysis of experiences and lessons learned

in Canada and elsewhere.

Objectives:Conduct a review of the literature relating to the Oral Health Care of Seniors’.

Conduct a scan for programs & services at 3 levels:

• Seniors’ dental programs

• Geriatric dental training programs

• Seniors’ oral health promotion/prevention services

Conduct a scan of existing policies that address seniors’ access to oral health care:

• gov’t, insurance

• national, international

Progress:Comprehensive search of existing literature completed

Oral Health Policy Scan –initial stages of search, on-going

•Seniors’ oral health program scan: completed

• Geriatric dental training scan: completed

• Promotion / prevention scan on-going

Next Steps:

Literature ReviewLiterature Review

Key Findings• 266 articles that address seniors’ oral health issues:

– Disparities in Oral Health Care and Access– Seniors’ Oral Health Status– Oral Health and Quality of Life– Oral Health and Medical Status– Oral Health and Nutrition– Barriers to Accessing Oral Health Care

• Seniors’ Barriers • Care Providers’ Barriers • System Barriers

– Long-term Care Facilities and Oral Health– Oral Health Prevention/Promotion– Geriatric Oral Health Education/Training– Policy and Seniors’ Oral Health– Recommendations and Future Directions

Attitudes, beliefs and practices

Policy ScanPolicy Scan

What is a Policy?

A policy is “a broad direction or course of action that has been endorsed by a body with authority to both implement it and resource it.”

HEAL Policy and Initiatives Scan, 2003

Types of Policies

• Care/Access- Those which state the level of care one must receive, and also the level of access to which one is entitled

• Coverage- The policies which outline the coverage of dental care and treatment to which individuals are entitled

• Advocacy- The policies of authoritative bodies which advocate for better or changed Oral Health Policies

Profile of Policies (total = 18)Canada: 73 Coverage4 Care/Access

US: 42 Advocacy2 Care/Access

International: 71 Advocacy6 Coverage

Canadian Policies (total = 7)

Federal: 22 Coverage

Ontario: 22 Care/ Access

BC: 11 Care/ Access

Yukon: 11 Coverage

NWT/ Nunavut: 11 Coverage

Policy- Canada

Policy Level Addressing

Veterans Health Care Regulation Federal Coverage

Non Insured Health Benefits Federal Coverage

Community Care Facility Act Provincial Care/Access

Extended Health Benefits for Seniors Provincial Coverage

Ontario Nursing Homes Act Provincial Care/Access

Long Term Care Facility Oral and Dental Care Program (Halton)

Regional Care/Access

Health Care Insurance Plan Act Provincial Care/Access

Policy- InternationalPolicy Location Level Addressing

Policy of Gov't of Australia Australia Federal Coverage

Securite sociale & couverture maladie universelle

France Federal Coverage

Social Security Germany Federal Coverage

Irish Legislation Ireland Federal Coverage

Medicare and Medicaid: State operations manual

US Federal Care/Access

North Carolina Senior Tar Heel Legislature

US State Advocacy

Policy of American Public Health Association

US Federal Advocacy

United States Medicaid and Medicare US Federal Care/Access

Key Findings

• Policies can be classified as governing care/access, coverage or advocacy

• There are relatively few policies directly mandating the Oral Health of Seniors

• There is also a lack of research or assessments of the few existing policies

Program ScanProgram Scan

What is a Program?

• Division of programs (better and promising)

Profile of Programs (total = 58)Canada: 32

US: 18

International: 8

How did we select ‘Better Programs’

Based upon:

1. Theoretical and best practices literature findings from:– health prevention/promotion literature

– community development and capacity building literature

2. Discussions with senior oral health program directors (e.g. Apple Tree, Baycrest Geriatric Dental Program and Golden Care)

Key Indicators

Sustainability

Public/Private Partnerships

Duration

FundingOH initiatives

Geriatric EducationExpansionAwareness

On-going evaluationAwareness

DeliveryLocation

TransportationOpen to seniors

Accessibility

Literature and Program findings used to help determine ‘better seniors’ oral health programs’ using accessibility and sustainability as the assessment markers

Key findings

• Halton Dental Program (Ontario)

• Golden Care Dental Services (Ontario)

• Baycrest Centre for Geriatric Care (Ontario)

• Apple Tree Dental (US)

• Geriatric Dental Clinic, Yad Sarah (Isreal)

Insurance ScanInsurance Scan

What is a Dental Insurance Plan?

• An agreement that guarantees the financial coverage of costs (partial or full) incurred as a result of receiving dental treatment

• Two kinds: – Private– Public

Private Insurance

Company

Dental Packages for Seniors Evaluation

Individual Group Program Needs Assess.

Liberty N/A

Green Shield Canada

(none offered in NS) No

Standard Life N/A

Imperial N/A

Sun Life N/A

Maritime Life No No No

Great West Life (retiree packages) No No

Manulife No No

Canada Life Not willing to participate

Atlantic Blue Cross No

Public InsurancePlan Coverage Population

NWT Extended Benefits Dental Plan Comprehensive

$1000 max

All seniors 60 and over

Yukon Comprehensive

$1400 2 years max

All seniors 65+

Veteran Affairs Dental Plan Comprehensive

$600 max

All veterans 60 and older

NIHB Dental Plan Comprehensive All Status First Nations & Metis

Denmark Public Health Dental Plan Comprehensive All residents

Finland Public Health Dental Plan Comprehensive

70% Coverage

All residents

Norway Public Health Dental Plan Comprehensive Seniors (homebound and LTC) and children

Sweden National Dental Plan Comprehensive Seniors (homebound and LTC), partial for others

Germany National Dental Plan Partial coverage All residents

Key Findings

• Private: If seniors come forward and ask for private insurance – the insurance companies will develop a dental plan

• Public: Not good enough just to have a system in place (e.g. NFLD children’s)

• Explore why not working: attitude and beliefs of seniors, caregivers perception of need, dental community not raising awareness about the system

Prevention & Promotion Scan

Prevention & Promotion Scan

Prevention and Promotion Scan:

• This scan is ongoing

• The three components of this scan are:• Basic Informational Resources

• Educational Tools – Workshops

– Tool Kits

– Other educational aids

• Assessment tools developed

Professional Training Scan

(DDS and DH)

Professional Training Scan

(DDS and DH)

DDS and DH Programs in North America

DH Programs (US)

Diploma = 115

Degree = 60

DH Programs (Cdn)

Diploma = 20 (1 private)

Degree = 4 (2 pending)

DDS Programs (US)

Undergraduate = 53

DDS Programs (Cdn)

Undergraduate = 10

Key Findings DDS Programs

Geriatric dental education is not universal in Canadian and US schools

Need to develop universal geriatric educational standards Curriculums not changing to meet the needs of the

population; no major changes over the last decade Major barrier to inclusion/expansion of geriatric didactic

and clinical components in curriculum, over crowded curriculum

Lack of faculty members with an interest in or training in geriatrics

Geriatric Component in DDS Undergraduate Programs

Canada N=10

US N=53

Didactic 1. Requires some geriatric component in curriculum 10 53 2. Specific course or series of courses in geriatric dentistry

2 44

Clinical 1. Integrated as part of clinical training 8 25 2. Specified/defined component of clinical training

2 28

Comprehensive Geriatric Training Geriatric training/residency program 2 9

Key Lessons: Iowa University Geriatric Dental Program

Geriatrics: multidisciplinary should be integrated into clinical departments

Seniors require specific OH treatment Senior faculty member as director of geriatric courses Students should only provide care when equipped with the

knowledge and skills Students need to gain clinical experience working with

seniors Faculty need CE in geriatric dental care

Key Findings DH Programs

Lack of standardized geriatric accreditation standards

Differences between geriatric components offered in Diploma and Degree programs

Lack of faculty trained in geriatric dentistry

Overcrowded curriculum cited as the key barrier to the growth of geriatric curriculum within programs

No major changes in geriatric components in curriculum over last decade

Geriatric component in DH curriculum

Curriculum requires: Canada and USA

N = 210

Geriatric Component 187

Clinical Component 113

Specific Course 40

Average time allotted for geriatric didactic and clinical components

in dental hygiene programs

DiplomaPrograms

Degree Programs

Time devoted to geriatric didacticcomponents:

Average:Range:

10 hrs1 to 45 hrs

Time devoted to geriatric clinicalComponents:

Average:Range:

22 hrs0 to 130 hrs

Comparison: Geriatric didactic components 9 hrs 13 hrsComparison: Geriatric clinical components 26 hrs 11 hrs

Time Allotted to Geriatric Clinical Components: Dental

Hygiene Programs

DiplomaPrograms

DegreePrograms

1. Long-term care 16 hrs 6 hrs2. Acute care 3 hrs 1 hr3. Oral Examinations 5 hrs 5 hrs4. Education for care givers 4 hrs 4 hrs5. Average amount of time spent providing geriatricoral health care 29 hrs 17 hrs

Key Findings DDS and DH Programs

Similar barriers identified to lack of enhancement of geriatric dentistry components in curriculum

Overcrowded curriculum

Lack of faculty trained in geriatric

Financial considerations

Lack of standardized accreditation standards

No major changes in geriatric components offered over last ten years

                           

   

Lack of standardized accreditation assessment

tool

Lack of a continuum of oral health care from one setting to another (independent living, homecare, long-term care, hospital)

Lack of care providers

Lack of insurance coverage

Lack geriatric education/awa

reness

Lack of standardized

geriatric accreditation

standards

Lack of seniors’ oral

health delivery

programs

Lack of policies/standards

Lack of availability of

services (transportation,

facilities, equipment)

Lack of communication between health

sectors

Lack of training for

care providers

Building a Model

Education

Services

Policy

Funding

TrainingResearch

?

Public Private

Discussion Questions

1) How can these findings be used in the development of a model?

2) What is necessary to build the model:a) During the Forum

b) After the Forum

3) Do we need new team members to help with strategic planning and model development?

Closing Remarks - Workplan

Synthesize, design and prepare a final report and executive summary for the Focus Group findings

Synthesize, design and prepare a final report and executive summary for the Best Practices Scan

Design Forum process, recruitment strategy, funding, develop materials/presentations

Host Forum Assist with the development of proposals for future

projects/initiatives Develop a oral health services model for Nova Scotia Disseminate project findings

Research

Best Practi

ces

Forum Planning

Team