Download Oral Health & Primary Care Cooperative Education Model

Oral Health & Primary Care
Cooperative Education Model
Maria C. Dolce, PhD, RN, CNE
Associate Professor
School of Nursing
Jessica L. Holloman, MS, RDH
Program Director
Innovations in Oral Health
2015 National Network for Oral Health Access
Indianapolis, IN
November 16, 2015
Learning Outcomes
•  Describe a cooperative education model for
integrating oral health and primary care.
•  Apply innovative interprofessional practice and
education strategies to promote oral health
integration.
Health Professions
Nursing
Applied Psychology
Audiology
Health Informatics
Health Sciences
Physical Therapy
Speech-language Pathology
Physician Assistant Studies
Public Health
Pharmacy
Innovations in Oral Health:
Technology, Instruction, Practice, Service
Improve Workforce Training and
Capacity Building
•  Primary care
•  Rural and medically
underserved areas
•  Preventive medicine
•  Public health
•  Behavioral health
•  Oral health
•  Team management of
chronic disease
Co-operative Education
http://www.northeastern.edu/coop/
Patient-Centered Medical Home
Federally Qualified Health Center with a level-3 Patient Centered Medical Home
BHCHP Mission
Access to the highest quality
health care for Boston’s homeless
men, women & children
Photos courtesy of J O’Connell
Care Model
Collabora#on
Quality
Pa#ent
Cultural
Competence
Comprehensive
Acute &
chronic
health
conditions
Morbidity
&
mortality
Trust &
hope
Delayed
treatment
& reliance
on ED
Homeless
Health
Access to
care
Premature
aging
Oral Health in the Homeless Population
•  Homeless people have poorer oral health than the general
population. (IOM, 2011)
•  Dental care is the most commonly reported unmet need.
(Baggett et al., 2010)
•  Conditions are more often severe when diagnosed
•  More likely to engage in behaviors detrimental to oral health
such as:
–  Smoking and using other types of tobacco products (Conte et al., 2006;
Gibson et al., 2003),
–  Heavy alcohol use (Gibson et al., 2003), and substance abuse (Chi and
Milgrom, 2008).
•  12,500 patients/year
•  104-bed medical respite
unit
•  2 Teaching Hospitals
•  50
–  Shelters
–  Treatment programs
–  Soup kitchens
Dental sees less than 25%
of the overall patient
population.
“How do we provide oral health care
to the rest of our patients?”
- Dr. Colleen Anderson,
Dentist at BHCHP
Medical and Dental Integration
Multidisciplinary Integration Team
Goal: Increase access to oral health care for primary care patients
and family teams
•  Oral exams
•  Oral health education
•  Identify acute conditions for
immediate referral
•  Connect patients with
dental providers
Initial Integration Steps
Changes to EMR medical notes
Integration Efforts
•  Oral health fairs at family team sites
•  Resources for staff and patients
•  Events to raise staff awareness and encourage oral exams
•  Risk assessments, patient education, and care coordination
within our medical clinic and family team clinics
Frameworks
Smiles for Life Oral Health
Curriculum
www.smilesforlifeoralhealth.org
Job Description
Risk
Assessment
Oral Exam
Patient
Education
Survey Tools
Collaborate
with Medical
Providers
Fluoride
Varnish
Outreach
Referral
Resources
Schedule
Appointments
Workshops
1. 
2. 
3. 
4. 
5. 
Teamwork & Communication
Risk Assessment
The Oral Exam
Acute Dental Problems
Fluoride Varnish
Workshop 1:
Teamwork & Communication
Communication
Team Structure
TeamSTEPPS®: Strategies and Tools to Enhance Performance and Patient Safety. September 2015. Agency for Healthcare Research and Quality,
Rockville, MD.
http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/index.html
TeamSTEPPS® Dental Module
TeamSTEPPS®
Primary Care Module
Workshop 2: Risk Assessment
Smiles for Life Course 6: Caries Risk Assessment
•  Discuss the etiology of early childhood caries (ECC).
•  Assess a child's risk of developing ECC.
•  Recognize the various stages of ECC.
Workshop 2: Risk Assessment
Smiles for Life Course 3: Adult Oral Health & Disease
•  Recognize adult caries and periodontal disease and refer
patients for appropriate treatment.
•  Learn how aging and chronic medical conditions affect
oral health.
Case-based learning
Pedo
Adult
Geriatric
Risk Assessment Tools
Oral Health Risk Assessment Tool
The American Academy of Pediatrics (AAP) has developed this tool to aid in the implementation of oral health risk
assessment during health supervision visits. This tool has been subsequently reviewed and endorsed by the National
Interprofessional Initiative on Oral Health.
Instructions for Use
This tool is intended for documenting caries risk of the child, however, two risk factors are based on the mother or primary
caregiver’s oral health. All other factors and findings should be documented based on the child.
Caries Risk Assessment Form (Age >6)
Patient Name:
Birth Date:
The child is at an absolute high risk for caries if any risk factors or clinical findings, marked with a a sign, are documented
yes. In the absence of a risk factors or clinical findings, the clinician may determine the child is at high risk of caries
based on one or more positive responses to other risk factors or clinical findings. Answering yes to protective factors
should be taken into account with risk factors/clinical findings in determining low versus high risk.
Date:
Age:
Initials:
Low Risk
Contributing Conditions
I.
Fluoride Exposure (through drinking water, supplements,
professional applications, toothpaste)
II.
Sugary Foods or Drinks (including juice, carbonated or
non-carbonated soft drinks, energy drinks, medicinal syrups)
III.
Caries Experience of Mother, Caregiver and/or
other Siblings (for patients ages 6-14)
IV.
Dental Home: established patient of record, receiving
regular dental care in a dental office
General Health Conditions
Moderate Risk
Yes
No
Frequent or
prolonged between
meal exposures/day
Primarily
at mealtimes
No carious lesions in
last 24 months
Yes
Carious lesions in
last 7-23 months
No
II.
Chemo/Radiation Therapy
No
III.
Eating Disorders
No
Yes
IV.
Medications that Reduce Salivary Flow
No
Yes
V.
Drug/Alcohol Abuse
No
Yes
Cavitated or Non-Cavitated (incipient)
Carious Lesions or Restorations (visually or
radiographically evident)
Yes (over age 14)
No new carious lesions
1 or 2 new carious
3 or more carious
or restorations in
lesions or restorations lesions or restorations
last 36 months
in last 36 months
in last 36 months
Teeth Missing Due to Caries in past 36 months
No
Visible Plaque
No
Yes
IV.
Unusual Tooth Morphology that compromises
oral hygiene
No
Yes
V.
Interproximal Restorations - 1 or more
No
Yes
VI.
Exposed Root Surfaces Present
No
Yes
VII.
Restorations with Overhangs and/or Open Margins; Open
Contacts with Food Impaction
No
Yes
No
Yes
IX.
Severe Dry Mouth (Xerostomia)
Yes (ages 6-14)
Check or Circle the conditions that apply
II.
Overall assessment of dental caries risk:
•
Yes
III.
VIII. Dental/Orthodontic Appliances (fixed or removable)
RISK FACTORS
a
Check or Circle the conditions that apply
Special Health Care Needs (developmental, physical, medical or mental disabilities that prevent or limit performance of
adequate oral health care by themselves or caregivers)
I.
Patient Name:____________________________________ Date of Birth:___________________ Date:___________________
Visit: ■ 6 month ■ 9 month ■ 12 month ■ 15 month ■ 18 month ■ 24 month ■ 30 month ■ 3 years
■ 4 years ■ 5 years ■ 6 years ■ Other___________________
Carious lesions in
last 6 months
No
I.
Clinical Conditions
High Risk
Check or Circle the conditions that apply
•
•
•
Mother or primary caregiver does
not have a dentist
■ Yes ■ No
Continual bottle/sippy cup use
with fluid other than water
■ Yes ■ No
High
Patient Instructions:
Existing dental home
■ Yes ■ No
•
Fluoride varnish in the last
6 months
■ Yes ■ No
•
Drinks fluoridated water or takes
fluoride supplements
■ Yes ■ No
Has teeth brushed twice daily
■ Yes ■ No
Special health care needs
■ Yes ■ No
Medicaid eligible
■ Yes ■ No
CLINICAL FINDINGS
a
White spots or visible
decalcifications in the past 12
months
■ Yes ■ No
a
Obvious decay
■ Yes ■ No
a
Restorations (fillings) present
■ Yes ■ No
•
•
Visible plaque accumulation
■ Yes ■ No
•
•
Teeth present
■ Yes ■ No
Gingivitis (swollen/bleeding
gums)
■ Yes ■ No
Healthy teeth
■ Yes ■ No
ASSESSMENT/PLAN
Caries Risk:
■ Low ■ High
Completed:
■ Anticipatory Guidance
■ Fluoride Varnish
■ Dental Referral
Yes
Moderate
•
•
Frequent snacking
■ Yes ■ No
Yes
No
Low
•
PROTECTIVE FACTORS
Mother or primary caregiver had
active decay in the past 12
months
■ Yes ■ No
Self Management Goals:
■ Regular dental visits
■ Dental treatment for parents
■ Brush twice daily
■ Use fluoride toothpaste
■ Wean off bottle
■ Less/No juice
■ Only water in sippy cup
■ Drink tap water
■ Healthy snacks
■ Less/No junk food or candy
■ No soda
■ Xylitol
Treatment of High Risk Children
If appropriate, high-risk children should receive professionally applied fluoride varnish and have their teeth brushed twice
daily with an age-appropriate amount of fluoridated toothpaste. Referral to a pediatric dentist or a dentist comfortable
caring for children should be made with follow-up to ensure that the child is being cared for in the dental home.
Adapted from Ramos-Gomez FJ, Crystal YO, Ng MW, Crall JJ, Featherstone JD. Pediatric dental care: prevention and management protocols based on caries risk assessment. J Calif Dent Assoc.
2010;38(10):746–761; American Academy of Pediatrics Section on Pediatric Dentistry and Oral Health. Preventive oral health intervention for pediatricians. Pediatrics. 2003; 122(6):1387–1394; and
American Academy of Pediatrics Section of Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics. 2003;111(5):1113–1116.
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Copyright © 2011 American
Academy of Pediatrics. All Rights Reserved. The American Academy of Pediatrics does not review or endorse any modifications made to this document and in no event shall the AAP be liable for any such changes.
© American Dental Association, 2009, 2011. All rights reserved.
Workshop 3: The Oral Exam
Smiles for Life Course 7: The Oral Examination
•  Review basic oral anatomy and characteristics of healthy
teeth.
•  Use proper equipment to perform an oral exam.
•  Perform a consistent, thorough oral, face, and neck
examination of children and adults. •  Understand some of the differences between normal
and abnormal findings.
Peer-to-Peer Learning
Workshop 4: Acute Dental Problems
Smiles for Life Course 4: Acute Dental Problems
•  Review common acute dental problems.
•  Diagnose, initially manage, and appropriately refer:
–  Oral pain, oral infections, dental trauma
Case-based Learning
Trauma
• Tooth avulsion
Infection
• Abscess
Pain
• Dry Socket
Workshop 4: Fluoride Varnish &
Counseling
Smiles for Life Course 6: Caries Risk Assessment,
Fluoride Varnish & Counseling
•  Discuss the effects, sources, benefits, and safe use of
fluoride.
•  Describe the benefits and indications for fluoride varnish.
•  Demonstrate the application of fluoride varnish.
Peer-to-Peer Learning
Evaluation Methods
• 
• 
• 
• 
• 
TeamSTEPPS® Teamwork Attitudes Questionnaire
Oral Health Survey
Workshop Evaluation
BHCHP Outcome Data
Student Reflections
Knowledge - How would you rate the extent of your professional
knowledge about the following oral health topics?
(1=little to no knowledge, 2= some knowledge, 3= extensive knowledge)
Question
Impactoforalhealthon
nutrition.
Pre-Assessment
Post-Assessment
Caries(toothdecay)
Pre-Assessment
Post-Assessment
Oral/dentaltraumafrominjuries
Pre-Assessment
Post-Assessment
Relationshipbetweenoral
andsystemichealth.
Pre-Assessment
Post-Assessment
LittletoNo
Knowledge
Percentage
(Frequency)
60.0%(3)
O%(0)
O%(0)
O%(0)
40.0% (2)
O%(0)
60.0%(3)
O%(0)
SomeKnowledge
Percentage
(Frequency)
20.0%(1)
20.0%(1)
100% (5)
40.0% (2)
60.0%(3)
40.0% (2)
40.0% (2)
60.0%(3)
Extensive
Knowledge
Percentage
(Frequency)
20.0%(1)
80.0%(4)
Mean(STD)
O%(0)
60.0%(3)
O%(0)
60.0%(3)
O%(0)
40.0% (2)
2.00(0.00)
2.60(0.55)
1.60(0.55)
2.60(0.55)
1.6(0.89)
2.80(0.45)
1.40(0.55)
2.40(0.55)
Attitudes- To what extent do you agree or disagree with the following
statements about integrating oral health and primary care practice?
(Likert scale: 1-Strongly disagree; 5-Strongly agree)
Question
Strongly
disagree
Disagree
NeitherAgree orDisagree
Agree
Strongly
Agree
Mean
(STD)
(Frequency)
(Frequency)
(Frequency)
(Frequency)
(Frequency)
Primarycarecliniciansshould
incorporateoralhealthclinical
competenciesinpatientcare.
Pre-Assessment
Post-Assessment
O%(0)
O%(0)
O%(0)
O%(0)
O%(0)
O%(0)
40.0%(2)
O%(0)
60.0%(3)
100%(5)
4.6(0.55)
5.0(0.55)
Healthcaresystemsshouldengage
andeducateconsumersaboutoral
healthinprimarycareasanexpected
standardofinterprofessionalpractice.
Pre-Assessment
Post-Assessment
O%(0)
O%(0)
O%(0)
O%(0)
O%(0)
O%(0)
60.0%(3)
20.0%(1)
40.0%(2)
80.0%(4)
4.4(0.55)
4.8(0.45)
AccreditationandcertiMicationbodies
shouldintegrateoralhealthclinical
competenciesintoprimarycare
practitionerstandards.
Pre-Assessment
Post-Assessment
O%(0)
O%(0)
20.0%(1)
O%(0)
O%(0)
0%(0)
60.0%(3)
40.0%(2)
20.0%(1)
60.0%(3)
3.8(1.10)
4.6(0.55)
Skills - How well do you think your education and practice have prepared
you in the following oral health clinical skills?
(1=not at all prepared, 2= somewhat prepared, 3= very prepared)
Question
Providetargetedpatienteducationaboutthe
importanceoforalhealthandhowtomaintaingood
oralhealth,whichconsidersoralhealthliteracy,
nutrition,andpatient’sperceivedoralhealthbarriers.
Pre-Assessment
Post-Assessment
Identifypatient-speciMic,oralconditionsanddiseases
thatimpactoverallhealth.
Pre-Assessment
Post-Assessment
Provideappropriatereferralstodentalprofessionals.
Pre-Assessment
Post-Assessment
Relationshipbetweenoralandsystemic
health.
Pre-Assessment
Post-Assessment
Notatall
prepared
(Frequency)
40.0% (2)
O%(0)
Somewhat
prepared
(Frequency)
40.0% (2)
40.0% (2)
Veryprepared
(Frequency)
Mean(STD)
20.0% (1)
60.0%(3)
1.80(0.84)
2.60(0.55)
40.0% (2)
O%(0)
40.0%(2)
O%(0)
60.0%(3)
40.0% (2)
60.0%(3)
40.0%(2)
O%(0)
60.0%(3)
1.60(0.55)
2.60(0.55)
O%(0)
60.0%(3)
1.60(0.55)
2.60(0.55)
60.0%(3)
O%(0)
40.0% (2)
60.0%(3)
O%(0)
40.0% (2)
1.40(0.55)
2.40(0.55)
BHCHP Outcome Data
94Pa#ent
Encounters
110Dental
Appointments
24Pa#ent
Referrals
2HealthFairs
Outcomes
Outcomes
• 
• 
• 
• 
Limited resources
Skill gap
Competing priorities
Referrals
Challenges
41
Conclusion
•  Safety net settings should partner with academic
institutions to incorporate students as change
agents in your environment to meet the needs of
vulnerable and underserved populations.
Acknowledgements
•  Pooja Bhalla, MSN, RN, Chief Operating Officer,
BHCHP
•  Colleen Anderson, DDS, BHCHP
•  Melinda Thomas, PA, BHCHP
•  Dierdre Jordan, MS, Associate Coop Director,
Northeastern University
•  Jacki Diani, MEd, Senior Coop Officer,
Northeastern University
The DentaQuest Foundation is committed to optimal oral
health for all Americans through its support of prevention and
access to affordable care, and through its partnerships with
funders, policymakers and community leaders. For more
information, please visit dentaquestfoundation.org
References
• 
• 
• 
• 
• 
Baggett, T. P., J. J. O’Connell, D. E. Singer, and N. A. Rigotti. 2010. The unmet health care
needs of homeless adults: A national study. American Journal of Public Health 100(7):1326-1333.
Chi, D., and P. Milgrom. 2008. The oral health of homeless adolescents and young adults and
determinants of oral health: Preliminary findings. Special Care in Dentistry 28(6):237-242.
Conte, M., H. L. Broder, G. Jenkins, R. Reed, and M. N. Janal. 2006. Oral health, related behaviors
and oral health impacts among homeless adults. Journal of Public Health Dentistry 66(4):276-278.
Gibson, G., R. Rosenheck, J. Tullner, R. Grimes, C. Seibyl, A. Rivera-Torres, H. Goodman, and
M. Nunn. 2003. A national survey of the oral health status of homeless veterans. Journal of Public
Health Dentistry 63(1):30-37.
IOM (Institute of Medicine) and NRC (National Research Council). 2011. Improving access to oral
health care for vulnerable and underserved populations. Washington, DC: The National Academies Press.
http://www.hrsa.gov/publichealth/clinical/oralhealth/improvingaccess.pdf
Thank you
QUESTIONS ?
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