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Improving Dental Care to the Elderly in a Nursing Home 1 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. Improving Dental Care to the Elderly in a Nursing Home 2 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 Improving Dental Care to the Elderly in a Nursing Home 3 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 Improving Dental Care to the Elderly in a Nursing Home 4 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. Improving Dental Care to the Elderly in a Nursing Home 5 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 Improving Dental Care to the Elderly in a Nursing Home 6 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. Improving Dental Care to the Elderly in a Nursing Home 7 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. Improving Dental Care to the Elderly in a Nursing Home 8 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 Improving Dental Care to the Elderly in a Nursing Home 9 Appendix D: Figure 1: Indicates the stakeholders , the process, the potential impact, the stakeholder delivery and perceived attitudes. Improving Dental Care to the Elderly in a Nursing Home 10 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. Improving Dental Care to the Elderly in a Nursing Home 11 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 Improving Dental Care to the Elderly in a Nursing Home 12 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