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Improving Dental Care to the Elderly in a Nursing Home
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University of San Francisco
CNL Online Program
Prospectus Summary Brief
Improving Dental Care to the Elderly in a Nursing Home
Cara Mia Licavoli
Specific Aim Statement:
We aim to improve dental care of clients at the San Mateo County nursing home facility by
100% by May, 2015.
Background:
The institution is a non- for profit facility located in a community setting. The institution is
accredited by California Public Department of Health (CPDH), Licensing and Certification
Program (L&C) and the U.S. Department of Health and Human Services’ Centers for Medicare
and Medicaid Services (CMS). The microsystem is a long term facility that has 34 acute
psychiatric, 100 general acute care and 94 skilled nursing beds. The nurse manager identified an
issue with poor dental care assessments. Apple Tree Dental (ATD) has collaborated with
Peninsula Health Care District (PHCD) to address the needs of the community. Based on the
2013 San Mateo County Health Needs Assessment, it was found that the prevalence of
community members without dental coverage had increased significantly since the 1998 survey.
32.4 % (representing more than 185,000 county adults) lack dental insurance.
Supportive Data:
According to the profile of Older Americans: Administration on Aging Administration for
Community Living U.S. Department of Health and Human Services (2013), America’s older
population who are 65 and older grew to 43.1 million in 2012, an increase of 7.6 million ( 21%
since 2002) and is projected to increase to 79.7 million in 2040. The need for accessible dental
services for the elderly is imperative to prevent further deterioration of their health.
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Microsystem Status Relative to the Project:
The Fishbone diagram in Figure 1 in Appendix A indicates four major categories with detailed
issues associated with poor dental or oral health cavity. Currently oral care in the nursing facility
is provided by the nursing assistants and is thought to be inadequate in assessment and a process
in provision of dental care.
The SWOT analysis in Figure 1 in Appendix C, indicates the strengths and weaknesses of the
project. It also identifies both the opportunities. These activities in this project are focus on the
on the development of nursing involvement and special expertise in enhancing the efficiency of
the assessment component of dental care.
Summary of Evidence:
Search Strategies:
The references in this review support the project of improving the dental care of patients in the
skilled facility. The term “oral healthcare”, “ elderly “, “nursing” and “ oral assessments” led to
the following selections ranging from 2002 to 2015 publications.
Database used: MEDSCAPE, MEDLINE, CINHAL , Pub Med,
Summary of Evidence:
Baheker et al in “The prevalence and incidence of coronary heart disease is significantly
increased in periodontitis: A meta-analysis: Spectrum of care treatment planning Application of
the model in older adults” (2007), identifies significant increased prevalence of coronary heart
disease in patients with periodontitis.
Berg et al in “Spectrum of care treatment planning: application of the model in older adults”
(2000), asserts that “If the patient is functionally impaired and unable to carry out brushing and
flossing, then the family and caregivers’ ability to help with daily oral care must be assessed.
Helgeson et al in ”Dental Considerations for the Frail Elderly”(2002) cites the experience
working with frail elderly adults living in nursing homes served by Apple Tree Dental in
Minneapolis/St. Paul and found a 20% increase in the retention of teeth after 10 years of dental
care.
McQuistan et al, in the article “Oral health knowledge among elderly patient” (2015) mentions a
survey on how knowledgeable the elderly are in their oral healthcare, they found that the
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participants were familiar with basic dental disease prevention and treatment; however, many
participants were unfamiliar with concepts pertaining to periodontal disease and oral cancer.
Yao & MacEnte (2009) in the article” Inequity in Oral Health Care for Elderly Canadians:
Reducing Barriers to Oral Care” asserts that the inequity in oral care arises from financial,
behavioral and physical barriers, and remains a challenge for older Canadians.
Theoretical Direction: Orem’s Self Care Deficit Theory
Orem's Self Care Deficit Theory, as explained in to Polit & Henderson (2011), stated that each
individual has the ability to perform self-care, and responsible for their health and the health of
their dependents. Self-care is "the practice of activities that individuals initiate and perform on
their own behalf in maintaining life, health, and well-being. In the event of a self-care deficit
such as an inability to provide dental self- care it is the role of the nursing to assess the needs and
provide interventions. For the institutionalized frail and elderly there is a recognized self-care
deficit in relation to oral and dental care. Not being able to care for themselves due to their
ailments, dexterity or mentation are deficits that will impair their ability to maintain their oral
health care and well- being.
Stakeholders:
The stakeholders are the patients and family at the nursing home facility, staff, Peninsula
Healthcare District, (PHCD), Apple Tree Dental (ATD). The stakeholder analysis, in Figure 1 in
Appendix D, shows the elements of the analysis.
Business Case:
According to the surgeon general ‘s Oral Health in America ( 2000) , Expenditures for dental
services alone made up 4.7 percent of the nation's health expenditures in 1998--$53.8 billion out
of $1.1 trillion. To improve the dental care of the elderly in the community as projected by the
PHCD, during the first three years of the PHCD’s Center for Dental Health, the uncompensated
care totals over $7 Million, while the total value of dental services approaches $15 Million.
Personnel account for 76% of the operating expenses, with dental supplies and lab expenses
accounting for 18% of the budget. Each year, the program generates a very small operating
excess, which is supplemented with grants and gifts income.
Personnel account for 76% of the operating expenses, with dental supplies and lab expenses
accounting for 18% of the budget. Each year, the program generates a very small operating
excess, which is supplemented with grants and gifts income. Qualitative benefits to the family
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and patients include improved oral care for the elderly and less time receiving treatment and
hospitalization for infections.
The project director, for the development of nursing assessment component, is a contribution by
the CNL student and includes 220 hours at a rate of 65 dollars an hour = $14.300.00. The effort
includes research, meetings, data collection, collaborations, teaching sessions, creating a timeline
and professional presentation. As this is a supportive component of the larger effort a cost
benefit analysis specific to this project is not calculable.
Methods:
PHCD and ATD participated in a team approach to address the current issue of improving dental
care of frail and elderly patients in nursing home facilities. The focus of this project was the
adaptation and implementation of existing dental/oral health assessment tools seen in Figure 1
Appendix B, that is nurse driven for patient assessment upon admission to the nursing facility.
The process includes staff education regarding the adapted assessment tool and the identification
of champions to provide for residents self-care deficits
Steps for Implementation:
The ATD PCHD relationship began in January 2013 (Figure 1, in Appendix E). In January 2015
the CNL initiated this project in collaboration with the CEO of PHCD and the Director of ATD.
Once the site was identified in February 2015 the improvement project involving nursing began.
In March 2015, the team identified a specific dental health assessment the Caries Management
by Risk Assessment (CAMBRA), and the Cariscreen caries susceptibility test for the adaption
and use during the patient’s admission. In April 2015, a modified CAMBRA assessment tool
geared towards nursing was approved. Education of the nurses and identification of champions
is anticipated to begin in May.
Evaluation:
Evaluation of data will include a staff survey and direct observation of the assessment process.
Additional need for changes in the process and clarification of dental assessment will follow the
evaluation and support ongoing project improvement.
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Results:
The activities indicated in the timeline may have been delayed as planned in Appendix E, Figure
1. Several meetings were held by the CNL student, ATD director and Registered Dental
Hygienist (RDH) and the CEO PHCD/preceptor. The assessment tool was approved by PHCD
and ATD. It was evaluated by 2 nurse champions and modifications were made. The
implementation of the tool has not been initiated in the nursing home due to the fact that the
nursing facility has not signed the contract with ATD. It takes 1 to 3 months to acquire a
contract and be compliant with CPHD, L& C and CMS regulations. The ATD opened their
center and there were 8 staff members and 2 hygienists who attended the short educational
session about improving dental care for the elderly in nursing home facilities and evaluation of
the assessment tool.
Outcomes:
The PHCD and ATD collaboration to help the dental care needs of the elderly in the San Mateo
County is still in its early stages. They did not anticipate the time and drawbacks of acquiring
nursing home facilities. Therefore the specific aim was not met. As mentioned in the
weaknesses of the SWOT analysis in Figure 1, Appendix C, There were marketing deficiencies
and more time was needed for the project to meet its full potential. Not being able to get into a
nursing home facility because of time constraints is unfortunate. They had a possible nursing
home facility when the CNL started the project but due to regulations it fell through, as
mentioned in the threats in the SWOT analysis. The modified assessment tool that is nurse driven
would have assisted in the oral assessment of new patients in the nursing home facility which
most nursing homes do not have.
Recommendations:
As a CNL, I will encourage the use of the modified CAMBRA tool with every admission for
dental care assessment for the elderly in the nursing home facility. If it was used as planned; the
improvement of dental care in the nursing home would increase at least 75% with compliancy of
the patient and staff members. Continued education, feedback and continued gathering of data
would be necessary to determine the effectiveness of the tool
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Appendices:
Appendix A:
Fishbone Analysis
Patient History
Personnel
MEDICAL HISTORY
Age
Valvular heart disease
NURSING HOME STAFFING
DENTAL HISTORY
Inconsistent clinical staff
Gum Disease
CABG, MVR, AAA
insufficient staff
Root canals
EDUCATION
Medications
inadequate dental skills
inadequate dental knowledge
Limited opportunities
incompetency
Poor dental
and oral
cavity health
Facility’s inadequate to meet
demand
Poor role definition
among staff
Communication among staff
Noncompliance
Poor assessments
skills by staff
Environment
Reporting Structure
Patient education
Poor follow up
Process
Figure 1: Fishbone analysis: The fishbone displays the many potential causes for a specific
problem which is the poor dental and oral cavity health, It is particularly useful in a group setting
and for situations in which little quantitative data is available for analysis.
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Appendix B: Modified CAMBRA Assessment tool
Caries Risks Assessment form for the Elderly ( > 65)
Patient’s Name:_________________________ MR number:_________________DOB:_____________ Assessment date:_______________
(Place circle ) baseline or recall
Disease Indicators (any one “yes” signifies likely “high risk” and to do a
bacteria Test ***)
Visible cavities or radiographic penetration of the dentin
White spots on smooth surfaces
High Risk
YES = Circle
Moderate
YES=Circle
Low Risk
YES= Circle
YES
YES
Restorations last 3 years
YES
Broken teeth
YES
Risk Factors (biological predisposing factors)
Visible heavy plaque on teeth
YES
Frequent snacks (> 3x daily between meals)
YES
Saliva reducing factors (medications/radiation/systemic)
Medications:
YES
Recreational drug use/ alcohol abuse ______
YES
Dry mouth at night
YES
Diet: pureed, liquids
YES
Exposed roots
YES
Dentures or partials
YES
Protective Factors
Drink tap water
YES
Fluoride toothpaste at least once daily
YES
Fluoride toothpaste at least 2x daily
YES
Fluoride mouth rinse daily
YES
Chlorhexidine prescribed/used one week each of last 6 months
YES
Xylitol gum/lozenges 4x daily last 6 months
YES
Adequate saliva flow (> 1 ml/min stimulated)
YES
Did you see the dentist in the last 3 months?
YES
Featherstone JD, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk
assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007;35(10):703
VISUALIZE CARIES BALANCE (Use circled indicators/factors above)
(EXTREME RISK = HIGH RISK + SEVERE SALIVARY GLAND HYPOFUNCTION) CARIES RISK ASSESSMENT (CIRCLE): EXTREME HIGH
MODERATE LOW
RECOMMENDATION:
Doctor/RN signature:____________________________________________ Date:______________________________
Figure1: Modified assessment tool, that indicates the risks factors, ,( indicates the risks of patients base on these factors)
predisposing factors and behavioral factors that may affect the results of the C AMBRA assessment. The colors red= high risk,
orange =moderate risks and green= low risks.
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Appendix C: SWOT Analysis
Figure 1: SWOT Analysis, is a useful technique to understand the strengths and weaknesses (internal
factors), and for identifying both the opportunities open to and the threats (external factors) of the project
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Appendix D:
Figure 1: Indicates the stakeholders , the process, the potential impact, the stakeholder delivery
and perceived attitudes.
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Appendix E
Timeframe
Timeline
Tasks
2013- 2016
Apple Tree Dental Group and the Peninsula Health Care District
Board propose and implement a Center for Dental Health on the
PHCD’s campus that includes a building, staff and the
development of processes to improve the dental care of residents
of nursing home facilities in the San Mateo County.
January 2015
Team meetings to discuss the CNL role in the development of
processes to assist in promoting dental health.
Development of Fishbone diagram indicating factors to address
for project improvement.
February 2015
Determined the microsystem on focus to be the mobile dental
health clinic in a nursing home in San Mateo County
Team meeting to discuss oral in the elderly, explore evidence
March 2015
Team identified specific dental health assessment. The Caries
management by risk assessment (CAMBRA), the Cariscreen
caries susceptibility
April 2015
Developed and presented a modified dental assessment tool
geared toward nursing to the team.
Additional modification
May , 2015
Education of nurses using the dental assessment tool, the nurses
at the nursing home facility approximately, 3 champion nurses.
Implementation of the assessment tool at the microsystem
Obtain information regarding staff use of tool via survey
Present evaluation outcome to team for further consideration
Figure 1: Timeline indicates the initiation of the project and the planned intervention will be completed by.
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References:
Administration on Aging. Profile of Older Americans, (2013). Retrieved from:
www.aoa.gov/aoa/stats/profile/default.htm
Bahekar,A.A., Berg, R, Berkey, D.B.,Garcia, L., Janos, M., Rohit, A., Sandeep, S. and Sarabjeet,
S. (2002). The prevalence and incidence of coronary heart disease is significantly
increased in periodontitis: A meta-analysis: . Spectrum of care treatment planning:
Application of the model in older adults. General Dentistry;5:534-43. Retrieved from:
http://dx.doi.org/10.1016/j.ahj.2007.06.037.
Berg R., Garcia, L.T., and Berkey, D.B.(2002). Spectrum of care treatment planning: application
of the model in older adults. General Dentistry Sep-Oct;48(5):534-43. Retrieved from:
http://www.ncbi.nlm.nih.gov/pubmed/11199633
Cariscreen , Retrieved from : http://carifree.com/dentist/cariscreen-caries-susceptibility-testingmeter.html
Cardinal and Stritch University Library. (2011). Dorothea Orem 1914- Self-care Framework.
Retrieved from: http://library.stritch.edu/research/subjects/health/nursingTheorists/orem.html
Featherstone, JD, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk
assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007;35(10):703
Helgeson,M.J. ,Ebert, C.D, Johnsen,M and Smith, B.J.(2002). Dental Considerations for the
Frail Elderly. Retrieved from: http://www.mohc.org/files/SCDFrailElderly/Helgeson.pdf
McQuistan,M.S., Macek, M.D.,Qasim, A., Shao, C. and Straub. C.L.(2015). Oral health
Knowledge among elderly patients. Journal of American Dental Association,146(1).
17:26. Retrieved from: http://jada.ada.org/article/S0002-817728(14)2900003-8/pdf
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O'Connor L.(2012). Oral health care. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s).
Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY):
Springer Publishing Company; 2012. p. 409-18.
Yao, C.S., MacEntee,M.I. (2009). Inequity in Oral Health Care for Elderly Canadians:
Reducing Barriers to Oral Care. Journal of Canadian Dental Association 2014;80:e11