When Two Becomes One:

Mark DohertyOctober 24, 2011

An Effective Model for Medical-Dental Integration

What do you think of when you hear:

Medical-Dental Integration

????

?

?

?

?

Communication

Coordination

Sharing of Information

Co-located or Separate?

Medical Home-Dental Home-Patient Centered Home?

Treatment at the Point of Contact

Collaborative Care

Reverse Co-location

Referrals

Collaboration or IntegrationCollaboration = primary care and oral health working with one

another

Integration = oral health working within and as part of primary care or vice versa…..Provision of dental services within primary care

Why Consider Collaboration/Integration?

• Dental disease and medical health problems are inter-related

• Safety net population has a higher level of dental disease

• Service gap for dental disease in the safety net is huge and getting bigger!

• OH access is enhanced when provided in primary care settings. (Extra point of contact )

Collaboration/Integration cont.

• OH prevention and disease management is cost effective when provided in primary care settings

• Outcomes for children receiving preventive and disease management protocols in PC settings are good

• One stop shopping model of care is a proven +• Children and pregnant women are focus

groups with documented needs and are a good source of revenue.

Predicted, dentally related, cumulative costs according to age at the first preventive visit.

Savage M F et al. Pediatrics 2004;114:e418-e423

©2004 by American Academy of Pediatrics

FQHC OH Vision• The creation of an oral health

program which provides affordable, quality managed care which documents the improved oral health status of the patients we serve which is carried out in a financially responsible manner targeted toward sustainability.

Barriers to Integration/CollaborationMedical and Dental Professionals :

• Educated separately • Licensed separately• Regulated separately • Practice independently• Non-integrated benefits/insurance programs• PCPs see the mouth as the property of dentists• Sharing of information rarely occurs• Seen by the public as separate• Oral Health Training for health professionals has been sparse to

non-existent

• Time– No time built into physician visit for the oral health component

• Comfort– Many PCPs uncomfortable with the mouth, due to lack of oral

education and training– Lack of comfort with caries risk assessment, anticipatory

guidance, screening • Reimbursement

– Lack of incentive to provide dental services because PCPs do not get reimbursed for all procedures they can perform

• Referrals– If there is no place to refer patients when a dental problem is

found…. why find the problem?

Barriers to Integration/Collaboration

• Coordinated care service delivery models connecting oral health primary care and medical primary care lead to promising approaches of collaboration and integration

• The comprehensive health care system supports dental collaborations/integration that treats the patient at the point of care where the patient is most comfortable and applies a patient-centered approach to treatment

• Integrated with the healthcare system• Emphasizes health promotion/disease

prevention• Monitors population OH status and needs• Offers QA, CQI and cultural competency

“Attributes of an Ideal Oral Health System” JPHD Volume 70 Issue S1

• Effective

• Efficient

• Sustainable

• Equitable

• Universal

• Comprehensive

• Ethical

• Patient Centered

“Attributes of an Ideal Oral Health System”

Stepped Care• Causes the least disruption in patient’s life

• Least extensive care for positive results

• Least intensive care for positive results

• Least expensive care for positive results

FQHC with an OH Mandate for Care

• FQHC does not have dental• Separate locations • Referral: minimal to good communication• FQHC has Dental=co-located PC and OH• In-House:

– Minimal to good communication– Minimal to good collaboration– Partial Integration

Spectrum of Integration/Collaboration

of OH & PC

Care Model

Business Model

Implementation Issues

Examples

Evidence Base

Outcomes

MODELS OF MEDICAL/DENTAL COLLABORATION / INTEGRATION

Separate locations Co-Located

Min Collaboration

More Collaboration

MinCollaboration

PartIntegrated

Dental more Integrated into

PC

Continuum

Separate locationsOutside referrals

only

CHC Pvt

Little to no communication Good communication

ContinuumCo-Located

No formal collaboration

Continuum

Co-LocatedFormal collaboration

ReferDiscussWarm handoffsCommunicateCoordinate Formal relationship

With a policy

Continuum

Co-LocatedPartial Integration

ScreeningGuidanceCRAFl VarnishReferral

Non-dental providersproviding OH services

Dental suite inPrimary care

More fully Integrated Model Features…

• Patient experiences oral health as a key component of a routine medical visit

• Primary care team incorporates oral health into disease management processes of delivery system; entire patient population is the target

• Primary care team treats ordinary oral health conditions in their practice, consult with dentist if patient does not improve, refers patients with treatment needs to dentists; retains responsibility for routine care

• For those at risk, primary care team delivers brief, focused interventions

• Primary care team has comfort level with oral health

Challenges• Education and training for PCPs • Training for general dentists to treat small children• Patient communication – low literacy, culturally

competent education materials• Policy defining the process• Case Management system• Training for application of FL varnish by non-dental

personnel• Reimbursement mechanism• Designated access appointments• Time allotment• CRA tool

Cavity Risk Assessment (CRA)

Smiles for Life

Populations of Focus

• Children 0-5

• All Children

• Pregnant women

• Medically compromised patients with high risk for dental problems – Diabetics– Cardiovascular patients

Considerations for choosing a model:

• In-house alternative to care• Referring to oral health providers that medical

providers know• Quick access for acute oral health situations• Better coordination• Warm hand-offs and curbside consults• Better hands-on chronic disease management• More reimbursement options now (e.g. 40

states reimburse non-dental professionals for fluoride varnish applications)

Outcomes• Early Intervention

• Prevention Invention

• Portal to the family

• One stop shopping

• > OH Literacy

• < OH disparities

• >OH Promotion

• Innovative finance and service delivery

• Drives accountability

• Healthy People 2020

• Non dental professionals providing care

• Increased access

• Win-Win…Finance/OH

• Improved Health

• Reimbursement for children’s dental services

Partnering to Strengthen and Preserve the Oral Health Safety Net

2400 Computer Drive, Westborough, MA 01581 Tel: 508-329-2280 Fax: 508-329-2285 www.dentaquestinstitute.org

A PROGRAM OF THE