dentaquest partnership for oral health advancement dental... · 19/03/2011 · 4 • recognize the...

DENTAQUEST PARTNERSHIPFOR ORAL HEALTH ADVANCEMENTChief Dental Officer Value-Based Care

Training Workshop

DoubleTree by Hilton Hotel Orlando at

SeaWorld Sunday, November 3, 2019

2

Pre and post evaluation survey must be completed to receive 6

CE credits

Pre evaluation: https://www.surveymonkey.com/r/7GTG2PF

Post evaluation survey will be done at the end of the training

https://www.surveymonkey.com/r/7GTG2PF

33

2018 FACHC Training Recap

Session One: Laying the Groundwork – Fundamentals

of Operating an FQHC Dental Program

Session Two: Measuring Dental Program Productivity

in Access and Finance

Session Three: Managing Chaos – Best Practices to

Reduce Broken Appointments and Manage

Emergencies

.

4

• Recognize the top ten areas for defining dental program success and identify essential

components to developing a business plan for FQHC dental programs

• Establish key dental policies and procedures for managing an efficient and effective dental

program

• Measure dental program capacity & understand its impact on access to care

• Develop a strategic scheduling template to maximize access, improve oral health outcomes

and dental program financial viability

• Develop effective policies & procedures for managing broken appointments & emergencies

• Use data for improvement strategies

• Prepare for a Shift to Value-Based Care

Today’s Learning Objectives

5

Our Mission

IMPROVE THE ORAL HEALTH OF ALLDentaQuest is driven by our mission to improve the oral health of all, to achieve a nation free of dental disease.

6

Our Approach

Preventistry is our all-in approach to

revolutionizing oral health in fundamental ways

PREVENTISTRY®

CARE VALUE INNOVATION TRANSFORMATION

PERSON-CENTERED CARE AND A CHANGING HEALTHCARE LANDSCAPE

Sean Boynes, DMD, MS

Executive Director, Person-Centered Care

DentaQuest Partnership for Oral Health Advancement

8

A Status Quo

Schneider EC and Squires D. N Engl J Med 2017; 377:901-904.

Schneider et al. Commonwealth Fund, 2017

9

FIRST ERA - 1.0Medical care &public health services

SECOND ERA - 2.0 Health care system

THIRD ERA - 3.0Health system

Goals of health system Improve life expectancy Reduce disability Optimize health

Primary focusof services

Diagnose and treat

acute conditions

Prevent and manage

chronic diseases

Promote and optimize

health of individuals

and populations

Role of health andhealth care provider/organization

To protect from harm,

cure the sick, and heal the ill

To prevent and control risk,

manage chronic disease and

improve quality of care

To optimize health

and well being

Role of individualand community Inexperienced patient Activated partners in care Co-designers of health

Changing Priorities: The 1.0 to 3.0

10

The Economic Burden of Oral Disease

World Health Organization. http://www.who.int/oral_health/disease_burden/global/en/.FDI World

Dental Federation. http://www.worldoralhealthday.com/wp-

content/uploads/2014/03/FDIWhitePaper_OralHealthWorldwide.pdf.

11

Oral Health and a Healthy Life

12

Oral Health’s Shared Systemic Impact

• Inflammation

• Chronic oral infection contributes to systemic inflammation and increases in the

plasma concentration of acute-phase proteins, inflammatory cytokines and coagulation

factors.

• Symbiosis / Dysbiosis [Bacteremia]

• Growth of bacteria implicated in various systemic disorders and diseases

– Bacterial end products enter the blood stream and result in transient bacteremia

– Tissue damaging bacteria proliferate

• Diet and Nutrition

• Based on the dysfunctional masticatory system and on the ability to obtain proper

nutrition from the diet

13www.dentaquest.com

http://www.dentaquest.com/

15

CHANGING CONSUMERS AND EMPOWERING CONSUMERISM

https://www.pinterest.com/bfdentistry/dental-cartoons-funny-stuff/

16

What Do Patients Want?

They want convenience

http://www.dds1800.com/whitepapers/What_Dental_Patients_Want/

17


To read and evaluate reviews

http://www.dds1800.com/whitepapers/What_Dental_Patients_Want/

18


VALUE

• The offer of preventive dental care and advice was an amazing revelation for

this group of patients as they realized that dentists could practice dentistry

without having to “drill and fill” their teeth.

• All patients, regardless of the practice they came from or their level of clinical

risk of developing dental caries, valued having a caring dentist who respected

them and listened to their concerns without “blaming” them for their oral

health status.

• These patients complied with and supported the preventive care options

because they were being “treated as a person not as a patient” by their

dentists.

Sbaraini et al. BMC Oral Health. 2012; 12:177

20

“Ch-ch-ch-ch-changes. Turn and face the strange.”

- DAVID BOWIE

Song writer, musician, entertainer and actor.

21

Signs of change in landscape…

• Focus on prevention and early intervention with increased focus from industry

on prevention agents and devices

• Continued efforts for MDI and Interprofessional practice

• Efforts to increase diagnostic codes utilization in dentistry

• Increased use of electronic records and practice management

• Continued consolidation of care delivery systems

• Changing dental workforce environment

• Care being delivered outside of the traditional brick and mortar dental office

www.oralhealthworkforce.org

22https://hcp-lan.org/apm-refresh-white-paper/

23

Providers paid to care for a

population; incentives for

preventing dental disease

Prevention-focused, minimally

invasive care that includes

innovative new solutions for better

health outcomes

Incentives for medical-dental

integration between primary care

and dental providers

Electronic health records focused

on linking quality to care

Patients receive risk-based care

that corresponds to their needs; the

appropriate distribution of

resources

TRADITIONAL DENTAL CARE VALUE-BASED ORAL HEALTH CAREFee-for-service model incentivizes

high cost, complex procedures and

focuses on volume

Treating dental disease after it

occurs

Dentistry is siloed; limited

interaction with other health care

disciplines

Electronic dental records store

information and meet billing needs

All patients receive the same care,

regardless of need, which can

waste resources

What Does it Look Like?

24

Average Per Patient Spending on Dental in Medicaid, by Age

and Plan Type, 2017

$0.00

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70

FFS - National Medicaid Average APM - National Medicaid Average

Dental Service Utilization Rate, by Age and Plan Type, 2017

0%

10%

20%

30%

40%

50%

60%

70%

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72 74 76 78 80 82 84 86 88

% o

f En

rolle

d A

cces

sin

g D

enta

l Ser

vice

s

FFS - National Medicaid Average APM - National Medicaid Average

25

“Healthcare is an exercise in interdependency- not personal

heroism... a need for greater teamwork and to ask, what am I

part of?”

- DON BERWICK

President Emeritus and Senior Fellow, IHI

26

A Person-Centered Pathway

27

How Can It Be Accomplished?

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiw_qP5l7bKAhWKPiYKHU92D1MQjRwIBw&url=http://medcitynews.com/2015/02/start-skills-medical-technology-keys-enterprise-success/&bvm=bv.112064104,d.eWE&psig=AFQjCNGaqRJ8kIMgUbViHWmlTCHw_r0xOA&ust=1453303559435037

28

PLANNING

Levels of integration and role identification

The implementation

process of oral health

and medical systems

integrating using IPP

as a tool requires input

and participation from

both medical and

dental personnel.

https://www.dentaquestpartnership.org/sites/default/files/Finding-meaning-with-interprofessional-practice-part-1_Dental_Economics.pdfoynes SG.

Quality of team leadership/

level of engagement

Ability of personneland community

to consolidate and arrange efforts

Capacity, technology and design of the

care model

Willingness to change

MODERATE

HIGH

BASIC

CREATIVE

Dep

th o

f Inte

gra

tion

29

Medical Team Tasks Cooperative Tasks Dental Team Tasks

CREATIVE

HIGH

MODERATE

BASIC

PL

AN

NIN

G

Complete a readiness assessment

Alter practice policies and procedures to address changes in care

Develop and implement necessary documentation systems, electronic management systems, and ancillary changes to operations

Develop training plan and attain agreement with dissemination process

Create and finalize business and memorandum agreements that include documentation of capacity limitations, HIPAA, target population agreement, etc.

Formalize leadership or point-of-contact teams

Complete a readiness assessment

Alter practice policies and procedures to address changes in care

Identify and implement necessary documentation, electronic management systems, and ancillary changes to operations

30


CREATIVE

HIGH

MODERATE

BA

SIC

Complete oral health screenings and

prevention opportunity on target

population(s)

Query patients about their "dental

homes" and most recent dental visits

Evaluate prescription list and provide

dry mouth coaching and intervention

Initiate an interprofessional referral

process

Use cross-promotional documents

and marketing materials

Develop appropriate post-care

communication

Evaluate interoperability and HIT

standards, compatibility, and

capabilities

Query patients about their "medical

homes“ and most recent medical

visits, including immunization status

Record body mass index, blood

pressure, heart rate, and respiratory

rate for all patients with the ability to

refer for urgent or emergent findings

and needed systemic intervention

Develop and implement oral health

risk assessment processes

PLANNING

31


CREATIVE

HIGH

MO

DE

RA

TE

Administer primary and secondary preventive oral health procedures to target population(s)

Understand oral health disease processes and how they can impact well-being

Provide complete pediatric oral health integration (patients receive an oral health risk assessment, anticipatory guidance, fluoride application; patients are referred to dental team)

Evaluate individual social determinants during chronic care visits

Provide care to priority populations, and complete a strategic plan to determine the process for adding priority populations

Achieve Bi-directional consultative and referral management

Establish and engage partnerships or affiliations with community entities

Utilize a certified EHR system, with foundational interoperability

Understand primary-care disease management and applied intervention methodology (understanding treatment goals)

Screen for systemic disorders or diseases for target populations or areas

Establish business operations and financial tracking for risk stratified care management

Use auxiliary personnel to the highest level of their licenses and scope of practice

Evaluate individual social determinants during comprehensive evaluations

BASIC

PLANNING

32


CREATIVE

HIG

H

Adopt all characteristics of basic and moderate levels

Implement and document oral health quality assurance/quality improvement plans and outcomes

Analyze and share oral health benchmarks in real time

Reduce the need for oral health surgical or restorative intervention

Involve a behaviorist (A professional with experience and training in evidence-based behavior change methods) to assist with high-risk, low-compliance patients in need of behavioral chronic disease management

Complete high-level medical and dental screenings that result in accurately finding undiagnosed disease

Utilize a certified EHR system, with structural interoperability

Meet regularly with all partners; meetings should include updates on care administration and review of performance/ quality measurements

Work with community leadership and interprofessional team to positively impact social determinants of health and local health policy

Adopt all relevant characteristics of basic and moderate levels

Implement and document primary-care-specific quality assurance/quality improvement plans and outcomes

Analyze and share systemic disease treatment benchmarks in real time

Use the international statistical classification of diseases and related health problems (ICD) coding system

MODERATE

BASIC

PLANNING

33

Medical Team Tasks Cooperative Tasks Dental Team TasksC

RE

AT

IVE

Encourage innovation, allow creativity, and facilitate professional and patient development

Design population-based health planning aimed to achieve a geographic distribution of integrated

health infrastructure

Weave social determinants of health into risk stratified care management

Utilize a certified EHR system, with semantic interoperability

Deliver patient care holistically using data-driven insights that establish population and

individualized medical and dental outcomes from oral health interventions

Implement quality assessment that leads to practice translation and meets identification

parameters of the Quadruple aim approach to health care

HIGH

MODERATE

BASIC

PLANNING

34

CREATING AND MAINTAINING INTERPROFESSIONAL CARE NETWORKS

https://www.dentaquestpartnership.org/rural-ipp

35

Cooperative Tasks

• Coordinate care with bi-directional referral and consultative system

• Create shared outcomes through collaborative interprofessional practice

• Develop joint care planning and health data exchange

• Create regular interprofessional and cross-professional meetings or huddles

• Work with community leadership and interprofessional team to positively impact social determinants of health and local health policy

Driving interprofessional practice

DENTAL

Dental Care Appointment

• Accept and close loop on referral &/or consultation from medical care team

• Review medical/dental histories

• Complete Oral Health Risk Assessment of soft tissue and teeth and assign appropriate risk status

• Conduct Preventive Dental Care Appointment and full head and neck examination

• Create treatment plan focused on disease management

Disease Management

• Complete counseling aimed at prevention and/or stabilization of disease (self management goals)

• Screen for systemic disease indicators of systemic diseases correlated or related to oral health such as: diabetes, hypertension, depression, obesity, etc.

• Establish re-care appointments according to a patient’s health needs and goals

• Utilization of data-driven insights to improve care delivery, health behaviors, and oral health outcomes

MEDICAL

Oral Health Opportunity

• Review medical/dental histories

• Perform Oral Health Evaluation (HEENOT);

– Identifiers for odontogenic, soft tissue disease, oral cancer

• Review current prescriptions for opportunities to; optimize oral health and decrease dry mouth,as needed

• Determine opportunity for oral health prevention and self-management

• Document findings and management plan, including referrals and consultations

Oral Health – Risk stratified care

• Conduct counseling to decrease or maintain low oral health risk (healthy behavior and patient retention & engagement)

• Set oral health self management goals that align with systemic treatment or prevention

• Follow up and develop referral and consultative plan with dental care team and verify risk and confirm diagnoses

36

“The best creative solutions don’t come from finding good answers to

the questions that are presented… They come from inventing new

questions.”

- SETH GODINAMERICAN AUTHOR AND FORMER DOTCOM EXECUTIVE

37

The Dependability of Coordination

Business Model

Satisfaction and Ease of Electronic Health Record use

No-Show Rate (15% or more)

https://www.ncbi.nlm.nih.gov/pubmed/28913876

38

The Dependability of Integration (Medical)

Health Information Technology / Electronic Health Record

• Respondents who reported EHR ease were 2.4 times more likely to administer fluoride varnish and conduct risk assessments

– Embedded risk assessment

– Ease of reporting and monitoring

https://www.ingentaconnect.com/content/cscript/fmch/2018/00000006/00000002/art00004?crawler=

true&mimetype=application/pdf

39

The Dependability of Integration (Medical)

Medical to dental referral capability

• Respondents signifying a dependable medical to dental referral system were 4.5

times more likely to administer FL/RA/SM

https://www.ingentaconnect.com/content/cscript/fmch/2018/00000006/00000002/art00004?crawler=

true&mimetype=application/pdf

40

IP and Care/Operation/Business Models

IP Practice can serve as an adaptor to allow multiple care-business models to

converge and bridge care pathway gaps

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwihzLmQruXQAhWE7iYKHTiOC9EQjRwIBw&url=https://www.rei.com/learn/expert-advice/world-electricity-guide.html&bvm=bv.140915558,d.eWE&psig=AFQjCNHplXmv0MHSYjJMdO_VnORf4Czb3g&ust=1481312709501511http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiBk8eiruXQAhVDySYKHcUBDXgQjRwIBw&url=http://www.traveloasis.com/world-power-adapter-kit.html&bvm=bv.140915558,d.eWE&psig=AFQjCNHplXmv0MHSYjJMdO_VnORf4Czb3g&ust=1481312709501511

QUESTIONS?

LAYING THE GROUNDWORK FOR MAXIMUM EFFICIENCYChief Dental Officer Value-Based Care Training

Workshop

Bob Russell, DDS, MPH, MPA, FACD, FICD,

November 3, 2019

44

Agenda / Table of Contents

• Administrative Differences between Medical and Dental

• Essential Policies and Procedures

• Defining Success

• Benchmarks for Operations Comparison

• Scope of Service and Capacity

• Staffing

• Financial Success

• Summary: Issues Common to FQHC Dental Operations

45

MEDICAL DENTAL

DIFFERENT CARE PLAN DIFFERENT BUSINESS

PLAN

46

Medical Dental

80% of clinic volume 20% of clinic volume

80% of visits = similar 80% of visits = varied

80% of visits = shorter 80% of visits = longer

80% of billing similar 80% of billing varied

80% of visits diagnostic 80% of visits treatment

80% of RVUs similar 80 % of RVU different

100% of governance is designed

around medical

0% of governance is designed around

dental

EMR silo EDR silo

Familiar with medical model Not familiar with dental model

Confident leadership Lack of confidence

47

The organization..

• Inspects, tests, and maintains

medical equipment

• Conducts performance tests on

Sterilizers (general performance

testing)

• Verifies staff qualifications

• Grants initial, renewed, or revised

clinical privileges

• Implements infection prevention

and control activities

• Reduces the risk of infections

associated with medical equipment,

devices, and supplies

• Has policies and procedures that guide

and support patient care, treatment, or

services

• Safely stores medications

• Assesses and manages the patient’s

pain

• Honors the patient’s rights to give or

withhold informed consent

Essential Policies & Procedures: Environment of Care

48

The Essentials

Resources:

https:// www.dentalclinicmanual.com

https://bphc.hrsa.gov/programrequirements/svprotocol.html

https://www.jointcommission.org/standards_applicability_grid_for_dental_care_s

ettings/

https://www.jointcommission.org/dental_service_standard_tip/

https:///http://www.dentalclinicmanual.com/https://bphc.hrsa.gov/programrequirements/svprotocol.htmlhttps://www.jointcommission.org/standards_applicability_grid_for_dental_care_settings/https://www.jointcommission.org/dental_service_standard_tip/

49

Essential Policies & Procedures

Environment of Care

• The organization inspects, tests, and maintains medical equipment

• Conducts Performance Tests on Sterilizers (general performance testing

• The organization verifies staff qualifications

• The organization grants initial, renewed, or revised clinical privileges

• The organization implements infection prevention and control activities

• The organization reduces the risk of infections associated with medical

equipment, devices, and supplies

50

Environment of Care…Cont..• Requirements for sterilizing dental equipment, devices, and supplies

• Storing dental equipment, devices, and supplies

• The organization has policies and procedures that guide and support patient care,

treatment, or services

• The organization safely stores medications

• Expired, damaged, and/or contaminated medications storage

• The organization assesses and manages the patient’s pain

• The organization honors the patient’s rights to give or withhold informed consent

• The procedure site is marked

• A time-out is performed before the invasive procedure

51

Sample Policies & Tools

• Dental Policy & Procedure Manual Template

• Sample Clinical Protocols

• Sample Dental Job Descriptions

• Sample Broken Appointment Policies

• Scripting for CHC Dental Staff

• Profit & Loss Budget Variance Tool

• Sample Scheduling Policy

• Sample Emergency Policy

• Sample Quality Assurance Policy

• Dental Clinic Performance Monitoring/Tracking Tool

• And much, much more!

https://www.dentaquestinstitute.org/learn/safety-net-solutions/sns-sample-

policies-and-tools

https://www.dentaquestinstitute.org/learn/safety-net-solutions/sns-sample-policies-and-tools

5252

The First Major Challenge

Not Defining what Success is and Having a Plan That is Clear,Documented and Shared including:

Goals, Roles, Responsibilities, Timelines

Challenges and Barriers

52

5353

Clarity…

Our Program Goals are

My Goals are

My Role is

My Responsibilities are

Your Goals, Roles, and Responsibilities are

We need to get this done by

And… by the way:

THIS IS HOW WE ARE

EVALUATED

53

54

Defining Success

Service & treatment options at impact productivity should be based on the

following priorities:

• Availability of resources

• Space and design of the clinic

• Service prioritization

• Size of the target population

• Dental disease prevalence and types

• Demand of the population

55

Defining Success, Cont.

All providers calibrated on a reasonable concept and path towards creating

dental health verses highest cost = ideal restorations.

56

Data is Essential for Success

• What is measured can be controlled

• What is controlled produces predictability

• Predictability improves success!

57

• Number of visits• Number of unduplicated

patients

• Number of new patients• Procedures by ADA

code

• Procedures per visit

• Broken Appointment rate

• Emergency rate

• Gross charges

• Total expenses

• Net revenue

57

• Collection Rate

• Expense per visit

• Revenue per visit

• Aging report past 90 days

• Payer and patient mix

• % of completed treatments

• % of children needingsealants who receivedsealants

• HRSA Sealant metric

Data to Evaluate Program Performance

58

Need a Benchmark for Comparison to

Measure Performance

• Using National Standards

• UDS Averages

• Successful Programs

59

Dental Capacity is a

little over 1/4th of

medical capacity

Average cost per dental

visit

Average admin cost

allocation to dental

28.3 million unduplicated

FQHC patients

What is Everybody Else Doing?2018 UDS National Data Averages

Visits per Year per Provider

2,630 Visits/Year/FTE

Dentist83.9%Accessed

Medical

services 23.8

million patients

22.6%Accessed

dental services

(6.4 million

patients

1,151 Visits/Year/FTE Hygienist

784Visits/Year/Dental

Therapist

$209

12%

Benchmarks

1300-1600 encounters/year/FTE hygienist

2500-3200 encounters/year/FTE dentist

2700 encounters

/year with 1100 patient base

8-10 patients/day for hygienists

1.7 patients/houror 13.6 patients/day/dentist

Gross Charges =

>$400K-$500K

per dentist per year

60

Benchmarks

$209 average cost

per encounter (UDS 2018)

230 work days/year (or 1600 work hours/year after

holidays and vacations)

330 = 12%Allocation Average

1.5 Assistants/dentist (1 DA per chair is ideal)

2 Chairs/dentist (3:1 is ideal)

2.6 ADA coded services

/treatment visit 2 ADA coded servicesas the diagnostic part of a recall or comprehensive visit (exam,

FMX)

61

Benchmarks

All sealants needed(1,2,3 or 4) at sealant visit

or as part of recall or comp exam visit

2 ADA coded services as preventive part of a recall/comp exam visit

(Prophy, FL, SDF)

Blood Pressure on all new patients, rechecked annually, at every visit with anesthesia, on hypertensive patients, and at all extraction/surgical

visits

Services should not be unbundled.

The community standard of care needs to be upheld.

62

Scope of ServiceBenchmarks

Diagnostic 35%

Preventive 33%

Restorative 20%

Oral Surgery 5-10%

Specialty (endo/perio) 2-6%

Prosthetics 0-2%

Emergencies

64

Capacity=Quality

64

65

Defining Capacity

• We are limited by our structure

• Chairs-Rooms-Operatories, Dentists,

RDHs, DAs, Staff, Hours of Operation

• Our structure determines our capacity, not our hearts

• We cannot be all things to all patients

• We only have 20% of the capacity of Medicine

• Understanding and defining capacity is essential to the creation of

the dental business plan

• We need to decide WHO gets the care by creating priority

populations

Equitable, quality care mandates that

we work within our capacity65

66

Benchmark Guide

66

67

Example

67

Staff and Operatories:

• 2 FTE General Dentists

• 3.0 FTE DentalAssistants

• 1 FTE Hygienist

• 5 Operatories

• Each Dentists works out of 2 Ops

Hours:

• Monday through Friday 8:00-5:00 (1 hour lunch)

• 8 clinical hours per day

68

Determining Capacity Goals Based

on Our Structure

68

69

# of

Providers

# of total

clinical hours

worked

x recommended

# of visits/

clinical hour

Potential

Daily Visit

Capacity

Mon. 2 16 1.7 27

Tues. 2 16 1.7 27

Wed. 2 16 1.7 27

Thurs 2 16 1.7 27

Fri 2 16 1.7 27

69

Potential Weekly Capacity = 135 Dentist Visits

Actual

Visits

% of

Capacity

Achieved

20 74%

26 96%

19 70%

18 66%

10 37%

*At least two operatories and 1.5 dental assistants

Setting Productivity/Access Goals: Visits

Potential vs. Actual – FTE Dentists

70

# of

Providers

# of total

clinical hours

worked

x recommended

# of visits/

clinical hour

Potential

Daily Visit

Capacity

Mon. 1 8 1.2 9

Tues. 1 8 1.2 9

Wed. 1 8 1.2 9

Thurs 1 8 1.2 9

Fri 1 8 1.2 9

70

Potential Weekly Capacity = 45 Hygiene Visits

Actual

Visits

% of

Capacity

Achieved

7 77%

8 89%

6 66%

7 77%

6 66%

*Benchmark of 1.2 is ideal for a practice with a patient mix of both adults and children

Setting Productivity/Access Goals: Visits

Potential vs. Actual – FTE Hygienists

WHY?

71

Visits/Week 135 Dental Visits + 45 Hygiene visits = 180

visits per week

180

Visits/Year 180 weekly visits x 46 weeks = 8,280 Visits 8,280

Dental Visits Based on Capacity

GOAL CALCULATION TARGET

Visits/Day 27 Dental Visits + 9 Hygiene Visits = 36 visits

per day *same for each day

36

71

72

# of

Providers

# of total

clinical

hours

worked

x recommended

# of visits/

clinical hour

Potential Daily Visit

Capacity

Mon. 2 16 1.4 22

Tues. 2 16 1.4 22

Wed. 2 16 1.4 22

Thurs 2 16 1.4 22

Fri 2 16 1.4 22

2 Dentists each working out of 2 Operatories with 1 dental assistant

72


Model 1

73

2 Dentists each working out of 2 Operatories with 1.5 dental

Model 2

# of

Providers

# of total

clinical

hours

worked

x recommended

# of visits/

clinical hour

Potential Daily Visit

Capacity

Mon. 2 16 1.7 27

Tues. 2 16 1.7 27

Wed. 2 16 1.7 27

Thurs 2 16 1.7 27

Fri 2 16 1.7 27

73


74

Cost of Adding Dental Assistant

74

$16/hour x 40 hrs = $640/week

Fringe benefits @ 25% = $160

Total cost = $800/week

75

Additional 25 Visits per week

• 20% Self pay visits = 5 @ $40 = $200

• 65% Medicaid visits = 17@ $135 = $2,295

• 10% Commercial Insurance = 3 @ $165 = $495

• 5% Homeless (Free Care) = $0

• Total Revenue = $2,990 - $900 (cost of adding a DentalAssistant)

Weekly profit = $2,090

Yearly profit = $108,680

Increases access by providing nearly 1,150 additional visits for the year!

75

Cost vs. Benefit of Adding Dental Assistant

76

Effectively Utilizing Hygienists

• Requires two operatories and dedicated hygiene assistant

• Hygienist can see 1.5 patients/hour or 12-13 patients in an 8- hour day

• Assistant facilitates visit

• Eliminates RDH waiting for dentist to do exam

• Must rigorously manage broken appointments

• Must have demand for hygiene

77

COMPARISON:

Unassisted Vs. Assisted Hygienists

Unassisted

Hygienist

Assisted

Hygienist

Visits/hour 1 1.5

Visits/day 8 12-13

Visits/week (factors in

25% BArate)

30 45

Revenue ($140/visit) $4,200 $6,300

Salary costs (includes

22% fringe)

$1,464 $2,149

Net revenue after salary $2,736 $4,151

Annual net revenue $125,856 $190,946

78

Effectively Utilizing EFDA’s

• General dentist, 1-2 operatories, 1 assistant = 1 visit/hour

• General dentist, 3+ operatories, 1 EFDA and 1-2 assistants = 2.5

visits/hour

• An EFDA must be allowed to complete treatment cases within their

scope freeing up time for the dentist to move to another case

• EFDA’s can set up a standard restorative treatment and complete the

restoration after a dentist has prepared to tooth(teeth) to be filled

79

New Staffing Models: Impact on Productivity

CDHC’s -Community Dental Health Coordinator (ADA)

EFDAs – Enhanced Function Dental Assistants

Advanced Public Health Hygienists

Dental Therapists

81

Provider Incentives to Meet Goals

Performance Incentive for providers as a percentage of net collections

over target

Share incentive across all staff for exceeding targets

Special award or recognition within organization for achieving targets

Incentives must be directed toward those activities directly impacted by

the provider or care team

82

Scope of Service Benchmarks

82

Service Type Procedure Codes % of

Total

Diagnostic D0100-D0999 (excluding D0140)

30-40%

Preventive D1000-D1999 25-35%

Restorative D2000-D2999 18-25%

Endodontics D3000-D3999 1-2%

Periodontics D4000-D4999 2-5%

Removable Prostho D5000-D5899 1-3%

Fixed

Prosthodontics

D6200-D6999

83

Define what Financial Success Looks Like:

83

• Create a profit?

• Break even or zero variance?

• With grants or without grants?

• Willing to accept a loss? If so how much?

84

Determining The Daily Revenue Goal

84

Total direct and indirect expenses ÷ Number of clinic days per year = daily net revenue goal to break even

For example:

Total expenses = $950,000

5 days per week x 46 weeks = 230 clinic days per year

$950,000 ÷ 230 = daily net revenue goal of $4,131

85

Predictability is Key

85

Ability to predict expected reimbursement based

on:

• Payer Mix

• 3rd Party insurance reimbursement

• Sliding fee discounts and nominal fees

• Visits

• Staffing structure

86

Impact of Payer Mix on Sustainability

7,500 visits 7,500 visits

35% Medicaid =2,625 visits x 40% Medicaid =3,000 visits x 100 =$100 = $262,500 $300,000

55% Self-Pay/SFS =4,125 visits 50% Self-Pay/SFS =3,750 visits xx $30 = $123,750 $30 = $112,500

10% Commercial =750 visits x 10% Commercial=750 visits x $125$125 = $93,750 = $93,750

Total revenue = $480,000 Total revenue = $506,250

Total expenses = $500,000 Total expenses = $500,000

Operating loss = ($20,000) Operating surplus = $6,250

86

87

Payer Mix ToolFinancial Projections Projected Visits

Actual Visits

Difference -6500

Patient/Insurance mix: Yearly visits

Percent Medicaid -

Percent Self Pay -

Percent Commercial Insurance -

Percent Other -

Total 0% -

Reimbursement Rate (per visit): Yearly Revenue

Medicaid $ -

Self Pay $ -

Commercial Insurance $ -

Other $ -

Total Projected Revenue $ -

Total Expenses

Projected Bottom Line $ -

87

88

Setting Fees

• Strive to know your community insurance Usual and Customary Fee Rate

(UCR)

• Set your rates to meet 85% or higher the average UCR

• Awareness that your Sliding Fee Scale provides a discount, so no additional

discount is needed

89

Sliding Fee Discount Schedule

The unique aspect of Health Centers; must have 3 levels of discounts or more

Required to offer a sliding fee scale to patients between 100-200% of Federal

Poverty Level (FPL)

Base “nominal fee” that should not impede access to care and below the SFS

lowest fee

Over 200% of FPL can pay full fee

In 2018, 22.6% of HC patients were uninsured

90

Sliding Fee Discount Schedule (SFDS)

Lab cost for dentures, partials, crowns, bridges and other appliances may be

charged before the SFDS is applied to determine what the final charge to the

patient will be.

For instance, your lab bill for a denture is $100.00 per denture. Your Full Fee for

the denture is $800.00. You may charge $100.00 to your lowest SFDS and the

full $800. for the full fee SFDS.

At each level of your SFDS the difference between the lab charge and Full Fee

is discounted based on your SFDS policy

91

Common Problem Areas:

91

• Unfavorable Payer Mix• Working under or over capacity• Lack of goals and accountability• High broken appointment rate

• Scheduling issues (types of patients)

• Insufficient support staff (dental assistants)

• Staff turnover

• Equipment issues (chairs, outdated, missing, broken)• Lack of EDR/PMS (or not being fully utilized)• Billing and collections• Fees are set too low• Other

QUESTIONS?

Practice Redesign to Thrive Today and Survive in the Future

Chief Dental Officer Value-Based Care Training

Workshop

Danielle Apostolon, Value-Based Care Trainer

Sunday, November 3, 2019

95

• Discuss practice systems and operations to support care delivery redesign.

• Demonstrate policies and protocols proven effective to manage broken appointments.

• Provide examples of how to set up a strategic schedule to increase access.

Agenda

97

Why is Practice Redesign Important?

• Practice systems and operations provide the infrastructure to support care

delivery redesign

• Practices that have good control over critical systems and operations will

have an easier time transitioning to value-based care

98

VALUE BASED CARE

102

• $3.7 trillion

• $10,739 per

person

• 17.9% of GDP

2017 National Health Expenditures

103

Mortality Rates Decreasing

https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/#item-overall-years-

life-lost-1990-2017

104

Disease Burden is Higher

105

The Global Burden of

Disease Study 2016

estimated that oral

diseases affected half of

the world’s population

(3.58 billion people) with

dental caries (tooth

decay) in permanent

teeth being the most

prevalent condition

assessed.

Oral diseases are the

most common

noncommunicable

diseases (NCDs) and

affect people throughout

their lifetime, causing

pain, discomfort,

disfigurement and even

death.

“WHO” Knew Key Facts

https://www.who.int/news-room/fact-sheets/detail/oral-health https://www.who.int/news-room/fact-sheets/detail/oral-health

Severe periodontal

(gum) disease, which

may result in tooth loss,

was estimated to be the

11th most prevalent

disease globally.

https://www.who.int/news-room/fact-sheets/detail/oral-health

106

Dental treatment is

costly, averaging 5% of

total health expenditure

and 20% of out-of-

pocket health

expenditure in most

high-income countries.

Oral health inequalities

exist among and

between different

population groups

around the world and

through the entire life

course. Social

determinants have a

strong impact on oral

health.

“WHO” Knew Key Facts

https://www.who.int/news-r https://www.who.int/news-room/fact-sheets/detail/oral-healthoom/fact-sheets/detail/oral-health

Behavioural risk factors

for oral diseases are

shared with other major

NCDs, such as an

unhealthy diet high in

free sugars, tobacco

use and harmful use of

alcohol.

https://www.who.int/news-r

107

Most oral diseases and conditions

share modifiable risk factors (such as

tobacco use, alcohol consumption and

unhealthy diets high in free sugars)

common to the four leading

NCDs (cardiovascular diseases,

cancer, chronic respiratory diseases

and diabetes).

Break Down the Silos

108

Stories In Motion

“I think at our organization, dental services are a key piece of overall care.

We've seen that some people they're unable to get jobs because they can't

smile and go to an interview and have a good self esteem. The physician might

also recognize that patients might be depressed because they can't smile. So

everything's really interrelated. A lot of patients we see are diabetic and if they

have poorly controlled periodontal disease, then we can help them get that

under control to really treat the whole person.”

Dentist, Pennsylvania

109

To Address Health Inequalities You Must Address Social &

Economic Inequities

110

Stories in Motion

“Why that is so important is, as a community health center, you have to go

beyond your walls and you have to look at what are the social determinants of

health in our community? What are the issues of health equity that are affecting

our patients? And how can we help them not only stay healthy and prevent

disease, but help our patients with cavities, diabetes, chronic conditions, have

the food and nutrition they need to stay healthy.”

We ask them, "In the last month, have you gone hungry in the last month, or not

had enough food to eat?" If they answer yes, then at the end of that

appointment we take them into our food pantry and they're able to select items.

And then, from then on, since they screened for that, they can come into our

food pantry once a month and get up to 20 items of food.”

-Chief Dental Officer, FQHC in Kansas

111

What is the Potential Win-Win for All?

112

Get Better at Measuring

Measurement Type Measure Description

Process (Measure the

action that took place)

Risk Status Assessment % of enrolled patients

whose risk status was

formally assessed and

recorded within the

reporting year

Outcome (Measure

results of services

provided to patients)

Reduction in Caries % of patients that show

reduction in caries on

recall (ie, no new caries)

Structural (Measures

conditions of a practice)

HIT Adoption of an

electronic health record

Patient Satisfaction

(Measures patients

experience of care)

Wait Time Patient reports on how

quickly they could get

an appointment

113

How health centers define quality varies

Sealants Tx plan completion

No-show rate

Fluoride

application

Caries risk

assessments

Cost per visit

oral health

instruction/education

Visits

Recall rates

Caries at recall

Emergency visitsAnnual dental visit

(HEDIS)

Comp exam/new

patients

Procedures

Emergencies treated

same day

Tobacco use

Hypertension

115

What is Value?

“We learned in a value-based model, we really had control over the dentistry

that was appropriate for the patient.

So rather than being dictated treatment by a dental insurance company, for

example, saying, "Your patients can only have two cleanings a year," and

truthfully, that's what the patients are going to agree to because that's what's

covered, we were able to tell the patient, "You need three cleanings or you need

four cleanings a year in order to help you maintain the health that you've

achieved," and they were compliant with that.

We were able to do preventative services that aren't covered by typical dental

insurance plans for adults.”

Dental Director, Texas

116

How Can FQHC Dental Programs Prepare for Value-based

Transformation in Oral Health?

• Begin or continue focusing on prevention, disease management and risk-based care

• Hygienists will be key to success – We need primary dental care, not just surgical

interventions

• Start measuring outcomes instead of just process/utilization metrics • % of initially high-risk patients with new caries lesions

• % of initially high-risk patients with decreased risk status

• % of initially low-risk patients with risk status maintained

• Address patient engagement in a more meaningful way and invest in case

management

• Invest in interprofessional practice, including HIT interoperability

• Evaluate how services are being delivered and determine if its reaching the patients

who need care the most

117

Practice Redesign Components

Patient-centered care

Operational workflows

Staff buy-in, teamwork and new roles

Data

Schedule redesign

Emergency management

Control of broken appointments

118

FQHC Measures for Operational Efficiency

AccessTotal

number of visits

Number of unduplicated

patients

Number of new patients

Provider Productivity

Visits/dayProcedures/

visit

Expected net revenue/day

Quality Outcomes

Percentage of completed Phase 1 treatment plans

Percentage of high and moderate risk children ages 6-

9 who received at least one sealant

Financial Outcomes

Gross charges

Net revenue & expenses

Bottom line

119

Financial Data & Predictability

Financial Projections Projected Visits * See the worksheet labeled "Calculating Project Visits"

Actual Visits

Difference 0

Patient/Insurance mix: Yearly visits

Percent Medicaid - * See the worksheet labeled "Payer Mix Projections"

Percent Self Pay -

Percent Commercial Insurance -

Percent Other -

Total 0% -

Reimbursement Rate (per visit): Yearly Revenue

Medicaid -$

Self Pay -$

Commercial Insurance -$

Other -$ -$

Total Projected Revenue -$

Projections Actual Variance

Gross Charges: $ - * See the worksheet labeled "Calculating Gross Ch." for Cell B21

Revenue:

Section 330 Revenue/Grants $ -

Medicaid - $ -

Self Pay - $ -

Commercial Insurance - $ -

Other - $ -

Total Revenue -$ -$ $ -

Direct Expenses:

Salaries $ - *See the worksheet labeled "Staffing and Salaries"

Benefits $ -

Total Salaries -$ -$ $ -

Support Costs:

Rent $ -

Lab Fees $ -

Education, Training, Conferences $ -

Maintenance and repair $ -

Dues $ -

Bad Debt $ -

Office Supplies $ -

Depreciation $ -

Printing, Postage $ -

Laundry $ -

Cleaning $ -

$ -

Total Support Costs - -$ $ -

Total Direct Expenses - -$ $ -

Indirect Expenses:

Administrative costs $ -

Total Direct and Indirect Expenses: -$ -$ $ -

Net Income or (Loss) -$ -$ $ -

Budget Variance Tool Fiscal Year __

Budget Variance Tool Fiscal Year __

120

Benchmark Dental Budget Breakdown

Total Budget: 100%• Dental Practice Overhead: 70-85%

• See breakdown below*

• Allocation for Administrative Costs: 5-10%• Costs for CEO, CFO, COO, etc.

• Health Center Support Allocation: 10-20%• Costs for Human Resources, Security, Medical Records, IT, etc.

Breakdown of the 70-85% Dental Practice Overhead:• Payroll (salary, taxes, & fringe benefits): 68%• Building, Utilities, telephone: 9%• Dental Supplies: 7%• Lab fees: 5%• Depreciation: 4%

• Office Supplies: 2%• Repairs: 2%• Marketing/Promotion: 1%• Recruitment: 1%• Continuing Education: 1%

121

Patient-Centered Care

• Providers share information readily, openly and honestly so patients can

make informed decisions about their care

• The patient/parent is considered a valuable member of the care team

• A good outcome is defined as what is valuable and important to the patient

• The ultimate goal is to promote the health and well-being of patients and

ensure they have both dignity and control over their care

• Goal is to develop long-term, therapeutic relationships with patients rather

than merely providing episodic care

122

Operational Workflow

Define the critical work that needs to get done

• Maximizing exams and preventive services to assigned patients

• Assessing each assigned patient’s risk status

• Providing risk-based care protocols to patients

• Educating, engaging and empowering patients

• Using the schedule strategically

• Minimizing failed appointments

• Providing appropriate emergency care

123

Operational Workflow (Cont.)

• Making and managing referrals appropriately

• Coordinating care for patients at elevated risk

• Documenting care accurately and completely

• Generating reports to evaluate practice performance

• Making informed decisions about practice operations based on data

• Submitting claims and reports effectively; reconciling payments and managing

denials

124

Speaking of Sports…

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530359/

125

Staffing for Success

• A team-based approach to care is essential for successful implementation of

an OHVBC model

• As the practice leader, you are the most crucial member of the OHVBC

team; you are the change agent and the one to lead the way

• Staff buy-in is critical: engage them in why you’re doing this work; find out

what they like (and dislike) about it and get their input on how best to make

this all work; be willing to try new ideas and new ways of doing things

126

Staffing for Success

• Have a strategy for how to use each member of the dental staff to accomplish

OHVBC success

• Everyone should work to the top of his/her license

• Every member of the staff can play an important role even if it’s not their typical

role

• In the beginning, you may not need additional staff to be successful with

OHVBC, but you may need to redesign roles and responsibilities

• Provide training for staff to ensure they are confident and competent in their

roles

127

Best Practice

“I reached out to Rhode Island College because they do have a bachelorette

program for the community health worker, and we already had community

health workers working on the medical side as well as behavioral health side,

and we're always talking about integration. Sometimes, dental gets left out in

that mix, so I thought it was really important for us to have that that bridge that

we needed.”

128

Early Detection & Prevention Matters

One of our providers was able to diagnose a lesion, a dural lesion, the biopsy

had some cancer cells. We were trying to get that patient into an oral surgeon.

He needed care. We contacted several of the private practice oral surgeons in

the area. It was anywhere from $300 to $400 to walk into their office for an

evaluation and a diagnosis. That doesn't mean even treatment.

We were able to get him to The University of Maryland. It's about a two-hour trip

for this patient to get there. His first appointment, his car broke down and he

couldn't get there. The next appointment we were able to get him, he traveled

the two hours and waited for four and a half hours and then wasn't seen. They

had a backlog, and he was sent home and told they would give him another

appointment and come back. He then left our area and came back three years

later in 2017, and our dentist that does pediatrics is actually the only one in the

office.

129

Early Detection & Prevention Matters

When he came as an emergency, she saw him. He had just came out of the

hospital. His ENT just diagnosed him with stage four head and neck cancer. And

if we had been able to see him, got him into care with that initial diagnosis,

which was a very small lesion at the time, we might have been able to prevent

that.

130

Broken Appointments:

#1 cited problem for all safety net dental clinics

5 Key Areas Negatively Impacted:

Access to Care

Oral Health Outcomes

Staff Satisfaction

Patient Satisfaction

Financial Sustainability

131

BROKEN APPOINTMENTS DEFINED

No-Show:A patient is scheduled for an appointment and they do not show up for that appointment.

Late Cancellation:

A patient cancels an appointment less than 24 hours prior to the start of the appointment.

Late Arrival:A patient does not arrive by 10 minutes after the start of their appointment.

132132

MANAGING MOST LIKELY TO “NO-SHOW”

New Patients

Recare Visits

• Require new (non-emergent) patient registration prior to scheduling 1st appt.

• Limit the number of new patients/day

• Book new patient visits within 2 weeks

Emergency Follow-up

• Teach patients to value the hygiene visit

• Consider moving to a “designated access” 2-5 week schedule for hygiene patients

• Require emergency patients who need follow-up care to call to schedule their next visit

133

Factors Likely to Increase Broken Appointment Rates

• No policy

• Policy weak or not enforced

• No understanding of why keeping appointments matters

• Misinterpretation of governance related to no-shows

• No culture of accountability (staff or patients)

• No consequences for broken appointments

134

Underlying Factors

135

Punishment Vs. Consequences

EVERY time the policy is breached:

• Call, letter, document/flag account

STRIKE ONE• Reminder and (only) warning

STRIKE TWO• Consequence occurs; requires a

proactive response from patient

STRIKE THREE• Strongest consequence

implemented by dental staff

136

Consequences:

Broken Appointment

Retraining Session

Same-Day-Only Scheduling Status

• Quick call lists

• Patient required to call

137

Less Favorable Consequences

Charging for No-Shows

• Rarely works

• Can’t charge Medicaid

patients

Double-Booking

• Feast or famine

https://www.medicaid.gov/medicaid/benefits/downloads/policy-issues-in-the-delivery-of-dental-services.pdf (see question 11a)

138138

Strategies For Success

▪ Provide reminder messages for upcoming

appointments

✓ Text/e-mail plus phone

✓ 48 hours in advance

✓ What if: Non-working numbers

✓ What if: Voice mail

139

Strategies For Success

• 30-45 days out

• One appointment at a time

• New (nonemergent) patients

register in advance

• Limit appointments for multiple

family members

• Limit new hygiene patients

• Ask emergency patients to call for

follow-up appointment

• Use alerts to warn schedulers

140140

The Big Five Best Practices For Every Program

• Strong policy with clearly communicated consequences

• Consistent enforcement

• Patient education

• Culture of accountability for patients and staff

• Track and evaluate BA rate

141

CDT TRACKING CODES FOR BROKENAPPOINTMENTS D9986:

Missed Appointment

D9987: Cancelled

appointment

D9991: Dental Case Management – addressing appointment compliance

barriers

142142

NO-SHOW RATE CALCULATION

• Formula is: Number of broken appointments (numerator) divided by the Number of scheduled appointments (denominator)

• The number of scheduled appointments (denominator) is defined as the number of broken appointments + the number of visits.

• For example, if 20 patients broke, and 80 patients came, the percentage of broken appointments = 20/100 = 20% broken appointments

• Target is 15%

143

Barriers

144

Patient Centered Approach

• Educate patients about why keeping appointments is important; scripting

can help

• Patients who feel engaged and empowered may be more likely to show for

appointments

• Important for all patients to keep appointments, but especially patients at

elevated risk of disease

• Care coordination for patients at elevated risk may be effective in removing

barriers and improving show rates

• Patients with high levels of anxiety related to dental care are at increased

risk for failed appointments

145

Patient Centered Approach

Consider other options to address underlying causes:

• Transportation vouchers

• Ease fear, build trust

• Case Managers

• Community Health Workers

“I didn't realize how much fear

was a barrier in these patients,

and not growing up with a

dental home, not growing up

seeing a dentist, and really only

seeing a dentist when they're in

pain, it affects them. It affects

their ability to tolerate dental

care, to seek out preventative

services, so I didn't realize how

strong that fear was as a

motivator for avoiding the

dentist.”

146

Stories in Motion

“Once we reached out to those patients that we have what is called the Over

365 Report where I had her reaching out to patients that hadn't been seen and

hadn't had a dental visit in over 365 days, and that way calling them, seeing,

okay, do they still want to be patients? What was the reason? There was

different variety reasons why they didn't come in, but she was able to get those

patients back in. We were able to reduce our no-show rate by I think it was

about 4% just in 10 weeks.”

Dental Hygienist & Dental Manager, Rhode Island

147

SCHEDULING

148

Designated Access

• The daily schedule ensures

access for all patients

• But a certain number of

appointments are reserved for

patients belonging to priority

populations• These reserved appointments can’t be filled with other

patient types until the day before

• Color coding can help staff identify and manage the

reserved slots

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwjdqtOdjdvdAhWCVt8KHSeUAF0QjRx6BAgBEAU&url=https://www.dentistryiq.com/articles/2014/07/who-is-in-charge-of-the-schedule-in-your-dental-office.html&psig=AOvVaw2P0cjtnY8FjjR1uO21PFZU&ust=1538134866220377

149

Scheduling for Success

• Each staff member works to the top of his/her license

• Non-licensed staff have a role to play in each visit as well

• Relative value units or time studies can help determine the right amount of

time for each appointment type

• Define the workflow for each appointment type, who the right staff person will

be for each step in the visit and the best place for each element to be carried

out (i.e., not all work may need to be done in the operatory)

150

SAMPLE CARE PROTOCOL 1: New Patient Child 0-3

Procedure Codes Staff Member Time

Exam (charting, Treatment

Plan)

D0145 Dentist 5

Caries Risk Assessment D0601 or D0602

or D0603

Certified Dental

Assistant or RDH

with Dentist

validation

5

Talking with Parent/Caregiver

(risk factor reduction

strategies, selection of 1-2

SMGs)

D9993*, D9994*,

D1310, D1320,

D1330

Dental Assistant 5

X-ray *PRN D0210-D0330 Dental Assistant Varies

Prophy/Cleaning D1120 Hygienist/CDA 5-10

Fluoride D1206, D1208 Hygienist/CDA 5

Treatment Plan discussion,

next visit

D9991,D9992,D9

993

Office

Manager/Care

Coordinator

10

(outside

of

operator

y)

Estimated 20-30 minutes of chair time * Check the Medicaid rules regarding when and how to use Code D9993 or

D9994 (eg, may not be able to use without a D1310 or D1330)

151

Scheduling Best Practices

• Implement strategies for reducing broken appointments

• Be strategic with double-booking

• Develop a strategy for managing emergencies/walk-ins

• Consider limiting number of new patients (e.g., one to

two per day in each hygienist’s schedule, priority given

to focus populations)

152


• Recalculate your maximum visit capacity each day and compare against

number of actual appointments being scheduled (are you overscheduling?)

• Logjams at check-in/out

➢ Flow-chart these processes

➢ Root cause analysis—why is this happening?

➢ Develop and test strategies to improve patient flow (re-engineer tasks,

redesign physical space, address staffing issues, etc.)

153


• Providers running late/practice falling behind

➢ Root cause analysis-why is this happening?

➢ Develop and test strategies to stay on time (reconfigure operatory

assignments, availability of support staff, scheduling tweaks, seating and

preparing patients, workflow around x-rays, etc.)

154


• Scheduling Errors

➢ Root cause analysis-why is this happening?

➢ Review scheduling process with current staff

➢ Provide additional training if necessary

➢ Review frequently to enhance accountability

155

Address Root Causes

• Lack of instruments/staff to keep up with sterilization

➢ Root cause analysis--is the issue that we need more instruments or more

staff? In either case, financial investment is generally more than offset by

smoother operations and improved provider productivity

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwj_n42X-7XeAhVL_4MKHUp8DL4QjRx6BAgBEAU&url=https://www.amazon.com/Basic-Dental-Instruments-Mirror-Explorer/dp/B008R5XO1C&psig=AOvVaw2WSXeaiCSfvdJvnE-IS2AM&ust=1541256799471072

156

Emergencies and Walk-ins

• Emergency care is an important component of every dental practice

• Access to emergency care needs to be ensured for patients of record of the

practice

• For a variety of reasons, many patients only seek episodic care (eg, limited

resources, fear/anxiety)

• Emergency care can be the portal to the patient’s overall oral health IF you

can remove the barriers to comprehensive care

157

Emergencies and Walk-ins (Cont.)

• The emergency visit is your opportunity to meet the patient where they are

and find out what matters to them

• Your chance to begin a dialogue and start to build a relationship of trust

• The goal is NOT to force them into comprehensive care

• The goal is to introduce them to the POSSIBILITY of better oral health and

explore their feelings about that

• Recognize that anxiety is a common problem for people with poor oral health

and be ready with strategies

158

To Summarize

• Practice redesign ensures operations and systems will support success

• The cornerstone of OHVBC is patient-centered care

• Operational workflows need to be reviewed and perhaps tweaked to better

support the mission

• Staffing is a key component of success

• Care coordination helps ensure crucial contract performance measures are

attained

159

To Summarize

• Scheduling also lays the groundwork for success by ensuring access to care

• Broken appointments need to be effectively managed

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwiKvJL3-rXeAhUD6oMKHalUAusQjRx6BAgBEAU&url=https://dentallabs.org/4-questions-to-ask-before-your-childs-next-dentist-visit/&psig=AOvVaw0-l9PIuY2WIJYRv8XAOZ9k&ust=1541256711944618

QUESTIONS?

PROMISING PRACTICE PANEL• Tamara-Kay Tibby, DMD, MPH

• Dr. John Curcuras, Dental Director, CL Brumback Primary Care Clinics

• Dr. Greg Stewart, Chief Dental Officer, Community Health Centers

Procedure Mentoring

November 3rd, 2019

John Cucuras, DDS

Tamara-Kay Tibby, DMD, MPH

C.L. Brumback Primary Care Clinics

Educational Background

Kent State - BS, Biology

Ohio State University - DDS

International Congress of Oral Implantologists - Fellow

Dr. John Cucuras

Dental Director


[email protected]

Educational Background

Duke University - BA, Spanish

University of Florida College of Dentistry - DMD

Harvard University - Certificate in Pediatric Dentistry

University of South Florida - MPH

Dr. Tamara-Kay Tibby

Previous Dental Director


[email protected]

Presentation Overview

This presentation will review C.L. Brumback Primary Care Dental Clinic's Promising Practice of Procedure Mentoring.

Objectives

Participants will learn about a health center’s strategic plan.

Participants will learn about procedure mentoring for specialty dental services

like stainless steel crown and pulpotomies.

C.L. Brumback Primary Care Clinics are a network of Federally Qualified Health Centers (FQHCs) managed by

the Health Care District of Palm Beach County, a government, non-profit organization funded, in part, by

local property taxes.

The District was established in 1988 to serve as a safety net healthcare system with the mission of ensuring that all

Palm Beach County residents have access to quality comprehensive healthcare.

The Health Care District began operating the C.L. Brumback Primary Care Clinics as FQHCs in June 2013 beginning with

a medical program which primarily served the uninsured. The four primary care clinics are co-located in the Florida Department of Health Palm Beach County health centers.

In July 2015, dental services were incorporated into the scope of services of the C.L. Brumback Primary Care Clinics

and transitioned away from the Florida Department of Health.

Four Dental Clinic Locations

• Belle Glade (6)

• West Palm Beach (9)

• Lantana (6)

• Delray Beach (6)

Our Dental Team

✓ 7 General Dentists (6.8 FTE)

✓ 2 Pediatric Dentists (1.6 FTE)

✓ 6 Registered Dental Hygienists (5.2 FTE)

✓ 18 Dental Assistants

✓ 8 Dental Registration Specialists

✓ 1 Patient Financial Counselor

✓ 1 Dental Biller

✓ 2 DAs per Dentist

✓ 2 Chairs per Dentist (except Belle Glade)

✓ 1 Chair dedicated to hygiene

✓ Targets: Dentist: 16 Dental Hygienist: 8

Dental Services:

✓ Acute Emergency Dental Services

✓ Preventive and Diagnostic Services

✓Comprehensive Pediatric Dental Care

✓Adult Extractions and Restorations

✓Preventative Maintenance

Monday – Friday

8 am – 5pm

Saturday

9 am – 1pm

Why Procedure Mentoring?

FY 2015-2017 patient base was primarily adults 65-80%

FY 2018 The health center strategic plan centered on increasing to preventative dental services for patients ages 0-20. Goal was to be at 50% pediatric.

Strategies : Adopted the HEENOT for medical which increased referrals of patients 0-20

Created pediatric hubs

Hired part time pediatric dentist

Started the MDI program.

As a result shift in the overall dental population July 2018 (30% peds) to July 2019 (50%)

DENTAL PEDIATRIC TRENDS2019 Strategic Plan Goal50% peds or 1000 peds visits per month

DENTAL PEDIATRIC TRENDS

Tactic : Help People Succeed

Procedure mentoring

Mentors: Pediatric Dentists

Mentees: General Dentists

Focus: Stainless Steel Crowns

Start: December 2018 – present

Stainless Steel Crowns Privileging

Direct observation of a pediatric dentists placing stainless steel crown(SSC) on eight or more patients.

Placement of at least 8 SSCs under the supervision of a pediatric dentist.

Written request for privileging.

Chart review by dental director.

Input from supervising pediatric dentists.

Presentation of Request For Privileges at the Dental Workgroup.

Board approval of privileges

CQI – 6 month reassessment of SSCs

Of the 8 returning patients, one failure due to pulpal status noted.

7 crowns noted to be clinically successful by reviewing provider. Of these 7, one crown had poorly adapted distal margin on radiograph.

30 crowns

102 crowns

Stainless Steel Crowns

In 2019, all general dentists with

SSC privileges have provided 11 or

more visits for crowns. One

provider is still in doing procedure

mentoring.

Procedure Mentoring

96 work hours of direct observation

3 dental providers

General dentists placed 30 crowns in 2018 (7 percent of all crowns)

General dentists placed 102 crowns YTD 2019 ( 20 percent of all crowns)

GROUP BREAK OUT:PEER NETWORKING

MEASUREMENT MATTERS:ORAL HEALTHCarolyn Brown, DDS, Acting Director, Value-Based Care

November 3rd, 2019

190

INTRODUCTION

191

Today’s Agenda

• Dive deep into the emerging field of value-based care, measurement and

data in oral health from national and statewide perspectives.

• Present oral health and clinical measurement approaches and relate to

oversight.

• Discuss value-based health and pay-for-performance approaches to health

systems, and the integral building block of data.

192

• Consultant working with DQP, FQHCs, Primary Care Associations and Foundations advancing oral health programs

• DQP/SNS Expert Advisor

• IHI Improvement Coach

• Former Dental Director

• Research, Marketing, Finance

Carolyn Brown, DDS

Consultant, Acting Director of Value-Based Care

DentaQuest Partnership for Oral Health Advancement

• DDS, University of Maryland School of Dentistry

• MAEd, University of the Pacific

• BS, University of Maryland

• Speaker, researcher, expert advisor, review panel

196

MEASUREMENT IN ORAL HEALTH

197

“True Measures of Success”

1. Define your governing objective.

2. Develop a theory of cause and effect to assess presumed drivers of the

objective.

3. Identify the specific activities that employees can do to help achieve the

governing objective.

4. Evaluate your statistics.

5. Communicate the story of your measurement.

Adapted from HBR “The True Measures of Success”, https://hbr.org/2012/10/the-true-measures-of-success

https://hbr.org/2012/10/the-true-measures-of-success

198

1. Governing objective.

2. Theory of cause and effect.

3. Activities of team.

4. Evaluate your statistics.

5. Storycraft.

Sustainability

Clinic revenue> expenses= sustainability

Patient compliance, Assets, Clinic Mngt

Care team Operations, Pt Support, Billing

% Of Prod on # and type,% Patients on time

Daily, weekly, monthly quarterly

“True Measures of Success”

Adapted from HBR “The True Measures of Success”, https://hbr.org/2012/10/the-true-measures-of-success

https://hbr.org/2012/10/the-true-measures-of-success

199

Measuring Risk and Health

November is Diabetes Awareness Month- 2019Communication Plans are as

important as cold, hard numbers

Patients

Care Team

Other Health Teams

Executive Team

Funders

201

Develop Diabetic Patient

Protocols

Review evidence and rationale with dental team

Partner with primary care team

• Protocols, Care mngt, Tests and Recording,

Quality Goals

Protocols for newly screened and existing patients

Educate and train dental team in reading AND

charting test results, and PILOT

202

External Measurement in Oral Health Programs

https://www.ada.org/~/media/ADA/DQA/2019_DiabetesOralEvaluation.pdf?la=en

https://www.oregon.gov/oha/HPA/ANALYTICS/CCOMetrics/2019-Oral-Evaluation-Adults-Diabetes.pdf

https://www.ada.org/~/media/ADA/DQA/2019_DiabetesOralEvaluation.pdf?la=enhttps://www.oregon.gov/oha/HPA/ANALYTICS/CCOMetrics/2019-Oral-Evaluation-Adults-Diabetes.pdf

203

Baseline for 2019: 27.1%



204

VALUE-BASED CAREPushing the impact, quality and quantity of measurement

205

OHVBC Readiness

Leadership

Value of oral health and oral health transformation

Structure, Systems and Operations

Efficiencies, innovative care delivery

Care Pathways and Provider Buy-In

Risk-based care, Training, patient engagement

Data and Analytic Technology and Personnel

Data/Reports, Interoperability

Financial Viability and Strength

Payer/patient mix, billing infrastructure

https://www.dentaquestpartnership.org/learn/safety-net-solutions/oral-health-value-based-care/ohvbc-readiness-

assessment

https://www.dentaquestpartnership.org/learn/safety-net-solutions/oral-health-value-based-care/ohvbc-readiness-assessment

206

DentaQuest Partnership OHVBC Survey

Barriers to Value-based Transformation in Oral Health –

Most Common Responses

• Patient engagement

• EHR/EDR

• Tracking outcomes; lack of nationally-recognized and standardized quality

metrics in dental

207

How Can FQHC Dental Programs Prepare for Value-based

Transformation in Oral Health?

• Begin or continue focusing on prevention, disease management and risk-based care

• Hygienists will be key to success – We need primary dental care, not just surgical

interventions

• Start measuring outcomes instead of just process/utilization metrics • % of initially high-risk patients with new caries lesions

• % of initially high-risk patients with decreased risk status

• % of initially low-risk patients with risk status maintained

• Address patient engagement in a more meaningful way and invest in case

management

• Invest in interprofessional practice, including HIT interoperability

• Evaluate how services are being delivered and determine if its reaching the patients

who need care the most

208

Value-Based Care

Care Coordination

“Closing out” referrals

Diagnostic coding

Risk Screenings

Care plans based on risk

Patient Engagement

Incentive payments

Quality metrics

Clinic Response

Case Management, IT

Active, timely records mngt.

Mapping Dx codes to CDT

Time, bill CPT codes, Tx plan

IPP, data to/from PC, MH

Recall window important

Attention to $ related metrics

Attention to assigned metrics

Direct and Indirect Effects of VBC on Dental Systems of Care

Utilization Impact

New workforce, CDT codes

New or + workforce, IT

ICD-CM-10 codes

+CDT codes

Modifiers (CPT, ICD10)

+ recall adherence

in incentivized procedures

in sealant, POC A1C,

Counseling codes, SD

209

MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways

210

Risk Assessment and Care Pathways

Triage framework

Conditions and clinical factors

Gaps in care and quality

Likelihood of disease progression

Identify medications

Referral points

Receptivity to behavior change or modification

Lifestyle influences- diet, tobacco

211

The Disease Management DifferenceDisease Management Difference

Traditional Dental Care Disease Management

Approach

All patients return in 6 months,

regardless of risk status

Recare interval is based on the

child’s caries risk

Caries Risk

Level

Recommended

Recare Interval

High Risk 1 – 3 months

Moderate Risk 3 – 6 months

Low Risk 6 – 12 months

Caries

Stabilizing

agents

Health Ed,

Nutritional

Counseling

Anti-bacterial

and Fluoride

interventions

212

Disease Management Care Pathways

DentaQuest Partnership for Oral Health Advancement Disease Management Model

Caries

Stabilizing

agents

Whole

Person,

Inter-

professional

Approaches

Anti-bacterial

and Fluoride

interventions

213

Disease Management and Risk Screening Training

DentaQuest Partnership for Oral Health Advancement’s

Online Learning Center

Disease Management Series

8 modules, 4.0 CDE available

https://www.dentaquestpartnership.org/learn/online-learning-center/online-

courseware/dentaquest-disease-management-series

https://www.dentaquestpartnership.org/learn/online-learning-center/online-courseware/dentaquest-disease-management-series

214

”Dental Home” = Health Home where WE can meet the patient

Oralhealthworkforce.org

216

Clinical Measures – Dental Practice Perspective

Private Practice Office

# New patients seen

Assigned vs seen if capitated

# Treatment plans incomplete

$ produced & per provider

$ collected & monthly per provider

CDT 6000 codes completed

Recall/Hygiene maintenance

Based on this consultant's experienced

FQHC

# Unduplicated patients

# patients seen per day

# Treatment plans complete

$ gained/lost via accounting

Broken appointment rate

# procedures

Sealant rate (annual)

217

• HRSA Sealant Measure Compliance for FQHCs

• Completion of phase 1 treatment plans

• Children seen 0-5 years old

• Children seen getting a preventive service

• # Fluoride Varnish applications

• Pregnant women seen and treated

• Diabetic patients with HbA1C > 7 seen

• Patients seen who have not been seen for 12 months

• Patients seen getting a Risk Assessment

• Patients with moderate or high risk who lower risk at recare

• # Sealants provided http://www.nnoha.org/nnoha-content/uploads/2015/12/Demystifying-HRSA-SEALANT-PRESENTATION_FINAL.pdf

Program Measures

218

HRSA Performance Measurement and Data Collection

• FQHCs and look-alikes submit CY data to HRSA since 2008

• UDS Uniform Data System

• Require FTE for clinical staff, patient demographics

• Dental utilization #s (UDC/TPV)

• Dental Clinical Measure: dental sealants placed on 1st molars, ages 6-9 y.o.

• Health Center Quartile rankings (Clinical measure performance influences

HC rankings as does EHR adoption and other HC characteristics)

219

Low birth weight

Access to prenatal care

Childhood Immunization

Children (Ages 3-17) Receiving

Weight Assessment &

Counseling

Children (Age 6-9) Receiving

Dental Sealant to First Molars

Diabetes Control

Hypertension Control

Pap Test

Depression Screening and

Follow-up (Age 12+)

Asthma Patients (Age 5-40)

Receiving Pharmacologic

Therapy

Colorectal Cancer

Screening (Ages 51-74)

HRSA UDS Clinical Measures

Adults (Age 18+) Receiving

Weight Screening & Follow-up

Adults (Age 18+) Receiving

Tobacco Use Assessment and

Ces

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