CO MDI The Colorado MedicalDental Integration Project Colorado

CO MDI The Colorado Medical-Dental Integration Project © Colorado Medical-Dental Integration Project

Oral Health Across the Lifespan © Colorado Medical-Dental Integration Project

Early Childhood Caries § Early childhood caries (ECC) describes a disease process that results in cavities of primary dentition. § Most chronic condition of childhood. Source: Cavity Free at Three Clinic at Children ’s Hospital Colorado © Colorado Medical-Dental Integration Project § 5 times more common than asthma. § 7 times more common than obesity. § 14 times more common than allergies.

Disparities The prevalence of caries among poor and near-poor five-year olds (50%) is twice that of their non-poor peers. 70% 60% 50% 40% 30% 20% 10% 0% Source: Tinanoff N, Reisine S. Update on early childhood caries since the Surgeon General ’s Report. Academy Pediatric. 2009; 9: 369 -403. © Colorado Medical-Dental Integration Project

Chronic Infectious Disease Source: Cavity Free at Three Clinic at Children ’s Hospital Colorado 1. Cariogenic bacteria (S. Mutans, et al. ) live in mouth of caregiver (usually mom). 2. Caregiver vertically transmits bacteria to infant. 3. Bacteria feast on carbohydrate-rich diet of child. 4. Feast by-product = acid. 5. Acid quickly erodes thin enamel surface of child. © Colorado Medical-Dental Integration Project

Older Children and Adults § Independent oral hygiene. § Added risk for disease. § § § Source: Cavity Free at Three Clinic at Children’s Hospital Colorado © Colorado Medical-Dental Integration Project Gingivitis + periodontitis Piercings Tobacco HPV Comorbidities (e. g. hypertension, diabetes, pregnancy, etc. )

PERIODONTAL INFECTION A reservoir of gram negative anaerobes HOST RESPONSE Elevated levels of chemical mediators (PG, IL, TNF) PREMATURE LABOR Mediators of parturation (PG, IL, TNF) that consequently may induce low birth weight preterm babies Source: New York State Department of Health. Oral Health Care During Pregnancy and Early Childhood: Practice Guidelines. Kumar J and Samelson R. Albany, NY. 2006. P. 23. Pregnant Women § Low birth-weight. § Preterm births. § Caries. © Colorado Medical-Dental Integration Project Effect of toxins

Elderly § Lack of dental insurance. § Medicare: no dental benefit. § Medicaid: new adult dental benefit ($1000/year). § Lack of advocates. § New problems (e. g. edentulism). § Long overlooked. © Colorado Medical-Dental Integration Project

Disease Consequences § Pain/progressive infection. § Worse oral-health quality of life. $111 B § Impaired chewing and nutrition. § School/work absenteeism. § Poor self-esteem. US expenditures (2013) © Colorado Medical-Dental Integration Project § Increased risk for lifetime of disease. § Hospital care: $859 million (20002008) on hospitalizations.

Dental Prevention Gap % 40 Americans lack dental insurance § ACA: 10 essential health benefits. § Medicaid: limited benefit. § Medicare: no dental benefit. § Dentist shortage areas. § Americans much more likely to see a medical provider than a dental provider. © Colorado Medical-Dental Integration Project

er. Being iated c o s s or is a with vid o r p l a dent a o t ing not go po rs. This ed g n a h c hasn’t yea 5 1 t e pas h t n i ch mu Source: American Dental Association Health Policy Institute Percent of children aged 2 -18 years with a dental visit within the year by income group 2000 -2012 © Colorado Medical-Dental Integration Project

Source: American Dental Association Health Policy Institute Publicly insured children per Medicaid dentist within a 15 -minute travel time © Colorado Medical-Dental Integration Project

Source: American Dental Association Health Policy Institute Dental office locations and % of children with public insurance © Colorado Medical-Dental Integration Project

I wish we lived in a world where everyone had access to dentists and dental care, but we don’t. © Colorado Medical-Dental Integration Project

Leverage the Medical Visit © Colorado Medical-Dental Integration Project

Promoting Oral Health in Medical § Oral health is essential for overall health. § Ultimate goal in all models is to facilitate establishment of dental home with dentist. § Prevent disease. § Get treatment for existing disease. § No one size fits all. © Colorado Medical-Dental Integration Project

Common Approach § § Risk assessment. Oral health evaluation. Preventive intervention. Oral health education and anticipatory guidance. § Interprofessional collaborative practice. § Building trusting, collaborative relationships with dental colleagues to improve health of patients. § Medical providers are great for your business model. © Colorado Medical-Dental Integration Project

Continuum of Oral Health in the Medical Home Coordinated Co-Located © Colorado Medical-Dental Integration Project Integrated

Coordinated Care, e. g. referrals Co-Located Care, e. g. FQHC Integrated Care § Separate systems, e. g. scheduling, billing. § Usually in separate facilities. § Communicate about cases on occasion. § May never see each other. § Separate treatment plans. § Some collaboration of efforts. § And more…. § Separate systems although may have some sharing, e. g. billing. § May communicate via phone/email. § May know who each other. § Some shared knowledge of each other’s activities. § EMR may talk with EDR. § And more…. § Same space/same facility. § Common systems, e. g. scheduling, billing. § Communicate frequently. § Agreed-upon screening processes. § Shared treatment plan for patient. Source: Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D. C. SAMHSA-HRSA Center for Integrated Health Solutions. March 2013 © Colorado Medical-Dental Integration Project

Coordinated Care, e. g. referrals Co-Located Care, e. g. FQHC § Autonomous decisions. § Better communication between providers. § Traditional — what we all are used to. § More successful referrals. § Don’t need to change. § Care teams becoming more aware of oralsystemic health relationships. § Providers get to know each other. § Systems gain efficiency. § Others. Integrated Care § Treating whole patients. § Barriers to care removed. § Patient-coordinated care plans. § Completed treatment plans. § Better patient outcomes. § Improved patient satisfaction. § Improved provider satisfaction. § Others. Source: Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D. C. SAMHSA-HRSA Center for Integrated Health Solutions. March 2013 © Colorado Medical-Dental Integration Project

Coordinated Care Drive Walk Bus § Core team of medical providers and support staff. § Oral health instruction +/- fluoride varnish. § Coordinated referral to outside dental provider. § Coordinated Referral (informal to formal). © Colorado Medical-Dental Integration Project

Co-Located Care § Core medical team. § Co-located core dental team. § Oral health instruction +/- fluoride varnish. § Coordinated referral to co-located dentist. § Coordinated referral to outside dentist. © Colorado Medical-Dental Integration Project

Denver Health/Cavity Free at Three Setting Program Approach § Coaching § Metrics § Tools © Colorado Medical-Dental Integration Project

Source: Braun PA, Widmer-Racich K, Sevick C, Starzyk EJ, Mauritson K, Hambidge SJ. Effectiveness on Early Childhood Caries of an Oral Health Promotion Program for Medical Providers. Am J Public Health. 2017; 107: S 97 -S 103. % of children who received fluoride varnish application at medical visits © Colorado Medical-Dental Integration Project

Measured dental disease Trained medical providers Source: Braun PA, Widmer-Racich K, Sevick C, Starzyk EJ, Mauritson K, Hambidge SJ. Effectiveness on Early Childhood Caries of an Oral Health Promotion Program for Medical Providers. Am J Public Health. 2017; 107: S 97 -S 103. % of children who received fluoride varnish application at a Denver Health well child visit or attended a Denver Health dental visit: Denver, CO, 2009– 2015 © Colorado Medical-Dental Integration Project

Source: Braun PA, Widmer-Racich K, Sevick C, Starzyk EJ, Mauritson K, Hambidge SJ. Effectiveness on Early Childhood Caries of an Oral Health Promotion Program for Medical Providers. Am J Public Health. 2017; 107: S 97 -S 103. Comparison Across 3 Unique Cohorts of Children Receiving Dental Care at a Safety Net Health Care System: Denver, CO 2009 -2015 © Colorado Medical-Dental Integration Project

Medical-Dental Integration § Core medical team. § Extended team includes dental hygienist. § One-stop shop. § Integrated systems. § Scheduling, billing, treatment planning. § Case-coordination for restorative services. © Colorado Medical-Dental Integration Project

Stepped Care Framework © Colorado Medical-Dental Integration Project

Medical Dental Integration § Medical providers are busy. § Difficulty finding dentists to see kids with Medicaid. § Fitting one more thing into a visit. § Team-Based Care. § Patient-Centered Medical Home. © Colorado Medical-Dental Integration Project

Could innovative dental hygiene practice models increase access to care and improve outcomes for high-risk populations? © Colorado Medical-Dental Integration Project

Co-located 5 Dental Hygienists © Colorado Medical-Dental Integration Project

Dental Hygienist Co-Location 1. 0 § 2008– 2011. § Demonstrated feasibility in a medical setting. § Sustained in 4 out of 5 practices. © Colorado Medical-Dental Integration Project

Findings § Medical providers liked the idea. § Higher investment in model if dental hygienists employed by practice vs. independent business. § Full-time dental hygiene better. § Families liked the idea. § Dental hygienists liked the work. © Colorado Medical-Dental Integration Project

Colorado Medical-Dental Integration Testing Sustainability Expanding Access Improving Oral Health © Colorado Medical-Dental Integration Project § CO MDI. § Five-Year Initiative. § Launched in 2014. § Integrates dental hygienists in medical practices to provide preventive services.

What makes CO MDI different? § Full-scope dental hygiene care. § Integrated, team-based care. § Extension of medical team and dental home. © Colorado Medical-Dental Integration Project

Colorado © Colorado Medical-Dental Integration Project

Hospital Systems Federally Qualified Health Centers Private, non-profit medical clinics Private, for-profit medical clinics Practice Type © Colorado Medical-Dental Integration Project Independent Practicing Dental Hygienists

Start Up — Lots of Technical Assistance § Development of built space with dental hygiene equipment. § Hiring of “right” dental hygienist. § Credentialing of dental hygienist. § Relationship with dentist. § IT and Billing support. © Colorado Medical-Dental Integration Project

Integrated Care Workflows Team-based care * Extension of core team * Huddles and team times Dental hygiene visits in the medical space * Scrubbing medical schedule and identifying patients * Warm hand offs from medical * Scheduled dental hygiene new visits and recall visits. Follow-Up * Treatment planning with medical team * Risk-based follow up/recall * Coordinated referral to dentist © Colorado Medical-Dental Integration Project

Practice Coaching for Success § § © Colorado Medical-Dental Integration Project Support clinics in reaching goals. Coach to build integrated models. Clinic-level metrics used in coaching. Financial metrics used to achieve sustainability.

Stepped Care Framework © Colorado Medical-Dental Integration Project

Questions? © Colorado Medical-Dental Integration Project