Medical /Dental Collaborations

Dennis Lewis DDS - Director of Dentistry, Dental Aid Inc.

Patricia Braun MD, MPH – Denver Health, Children’s Outcomes Research Program

Educational Objectives

Discuss the use of Caries Risk Assessment by medical providers

Demonstrate the positive effect of perinatal oral health care on the oral health of children

Discuss the use of Fluoride varnish in busy medical practices

Educational Objectives

Demonstrate the utilization and outcomes of dental hygienists working in medical practices

Examine restorative options in the very young child

Demonstrate we CAN affect the caries rates of high risk populations

Cavity Free At Three Program Overview

History of CF3 in Colorado

Multiple Foundation Support

Multidiscplinary Technical Assistant Team

Year One Grants and Presentations

Early focus was on Medical Providers

Problem – Dental Support

What does it look like today

Colorado Statistics

18% of children ages 2-4 have dental caries; 16% have untreated decay

45.7% of children in kindergarten have dental caries; 26.9% have untreated decay

57.2% of third graders have dental caries; 26.1% have untreated decay

By the age of 17 years, 78% of children have had at least one cavity: 7% have lost a permanent tooth to dental decay

Cavity Free at Three Model

Child Oral Health Integrated into well child care and dental visits

Caries risk assessment

Anticipatory guidance

Parent counseling and goal setting

Establishment of a dental home

Fluoride varnish application

Cavity Free at Three Model

Perinatal Oral Health Special emphasis on pregnant women

Assessing oral health of the mother

Patient counseling and education

Referral to a dentist during pregnancy

Education of oral health professions to increase access to care for pregnant women

Prevention of oral disease in the infant begins before birth

Cavity Free at Three

What we teach

The role of fluoride in prevention of early childhood caries

How to apply fluoride vanish as a tool in oral disease prevention

Proper procedures for Medicaid reimbursement for oral evaluation and fluoride varnish application

Role playing and anticipatory guidance

Hands on practice with infants and toddlers for oral exam and varnish application

Contact Information

WWW.CAVITYFREEATTHREE.ORG

Karen Savoie, RDH, BS

Director of Education

Cavity Free at Three Program

University of Colorado, Denver

Area Health Education Center

303-724-4750

karen.savoie@ucdenver.edu

Dr. Patricia Braun

Does this model really work in a busy medical Practice?

Co-locating dental hygienists in medical practices

Cavity Free At Three Program Evaluation

Patty Braun MD, MPH

Associate Professor of Pediatrics Children’s Outcomes

Research Program

Financial Disclosures

The authors do not have any significant financial interest or relationship with either the manufacturer of any commercial products or services or any commercial supporters of any activity.

Surgeon General’s Report

2000-U.S. Surgeon General David Satcher

2003-National Call to Action to Promote Oral Health

1. Change perceptions of oral health

2. Overcome barriers by replicating effective programs and proven efforts

3. Build the science base and accelerate science transfer

4. Increase workforce diversity, capacity and flexibility

5. Increase collaborations

Mouradian WE et al. Progress in Children’s Oral Health Since the Surgeon General’s Report on Oral Health. Academic Pediatrics 9(6), November-December

2009

Background-National

North Carolina-Into the Mouth of Babes

Questionnaire administered 12 months after training

Medical providers at well child care visits

28 family physician offices/49 pediatric offices

70% of participants providing dental services on regular basis

Major barriers integration of dental procedures into practice (42%)

difficulty in applying varnish (29%)

staff resistance (26%)

dental referral difficulties (21%)

Close K, Rozier G, Zeldin LP, Gilbert AR. Barriers to the Adoption and Implementation of Preventive Dental Services in Primary Medical

Care. Pediatrics 125 (3), March 2010

Background-National

Washington-Access to Infant and Childhood Dentistry (ABCD)

Focus group themes

PCPs influenced by their concerns for their patients’ oral health

Being part of decision making process helped adoption

Logistics to identify eligible patients were helpful

Lewis C, Lynch H, Richardson L. Fluoride Varnish Use in Primary Care: What Do Providers Think? Pediatrics 115 (1), January 2005

Background-Colorado

2007-2009: CF3 Technical Assistance Team comes together to build initiative

2008-2009: CF3 awards 10 grantees training, supplies, support

July 2009: Colorado Medicaid allows medical providers to deliver oral preventive care to children birth at well child care visits (up to age five)

States with Medicaid funding for physician oral health screening and fluoride varnish

Background-Colorado

Medicaid mandates that providers must receive oral health training (CF3 or Smiles for Life online)

2009-2010: 100’s requests for CF3 training

CF3 training refined to a

2 hour infant oral health

2 hour perinatal health

Hands-on

Methods

RE-AIM Conceptual Framework (F. Glascoe)

Reach

Effectiveness

Adoption

Implementation

Maintenance

Methods

Subjects-Training:

Grantees-10

Providers- 332 (medical, dental, public health nurses, home health nurses)

Denver Health- Colorado’s largest safety-net health care system (8 FQHCs)

Methods

CF3 Training:

Outcomes (RE-AIM): evaluation of the training

change of behavior after training

Administrative records

Risk Assessment Forms

Survey

Methods

CF3 Training:

Administrative records (Reach) Denver Health

Fluoride Varnish (1206) + Well Child Check (V20.2)

Risk Assessment Forms Survey

Methods

CF3 Training: Administrative records

Risk Assessment Forms (Reach) Collected from sites using them

Survey

Methods

CF3 Training: Administrative records

Risk Assessment Forms

Survey on-line

all trainees

validated questions

Piloted

Results-Reach of Services

Administrative Records: >3000 (as of June 2010)

Children at Denver Health who received oral preventive visit with fluoride varnish at well child care visits: 1510

Risk assessment forms collected= 1538 (year 1)

Reach of Training

Survey - 70% response rate (N = 175/248) Gender - 80% female

Year of profession graduation – 1967-2008

Provider type

24% medical providers 16% dental providers 17% public health nurses 21% RNs/medical assistants 22% administrative/other roles

Workplace 37% public health clinic 20% federally qualified medical health center 8% medical school/university setting 4% private dental 2% federally qualified dental clinic

0 25 50 75 100

I can change the oral health

behaviors of my patients

Fluoride varnish is safe

ECC is a problem for my patients

I have a role in preventing ECCAll

Dental

Non-Dental

Knowledge, Attitudes and Beliefs

p = ns

Strongly/Somewhat Agree

How confident do you feel with

examination of teeth?

0

20

40

60

80

100

% o

f re

sp

on

da

nts

Dental Non-Dental

Already Confident Before Training

Effectiveness of Training

p > 0.0001

0

20

40

60

80

100

Dental Non-Dental

Confident After Training

% o

f re

sp

on

da

nts

p = 0.44

N = 104

How confident do you feel with

demonstration of brushing of child’s teeth?

0

20

40

60

80

100

% o

f re

sp

on

da

nts

Dental Non-Dental

Already Confident Before Training

Effectiveness of Training

p > 0.0001

0

20

40

60

80

100

Dental Non-Dental

Confident After Training

% o

f re

sp

on

da

nts

p = 0.18

N = 104

How confident do you feel with

measuring child’s risk for caries?

0

20

40

60

80

100

% o

f re

sp

on

da

nts

Dental Non-Dental

Already Confident Before Training

Effectiveness of Training

p > 0.0001

0

20

40

60

80

100

Dental Non-Dental

Confident After Training

% o

f re

sp

on

da

nts

p = 0.28

N = 104

How confident do you feel with

application of fluoride varnish?

0

20

40

60

80

100

% o

f re

sp

on

da

nts

Dental Non-Dental

Already Confident Before Training

Effectiveness of Training

p > 0.0001

0

20

40

60

80

100

Dental Non-Dental

Confident After Training

% o

f re

sp

on

da

nts

p = 0.01

N = 104

How confident do you feel with

providing anticipatory guidance?

0

20

40

60

80

100

% o

f re

sp

on

da

nts

Dental Non-Dental

Already Confident Before Training

Effectiveness of Training

p = 0.005

0

20

40

60

80

100

Dental Non-Dental

Confident After Training

% o

f re

sp

on

da

nts

p = 0.32

N = 104

How confident do you feel with

caregiver goal setting?

0

20

40

60

80

100

% o

f re

sp

on

da

nts

Dental Non-Dental

Already Confident Before Training

Effectiveness of Training

p = 0.0003

0

20

40

60

80

100

Dental Non-Dental

Confident After Training

% o

f re

sp

on

da

nts

p = 0.11

N = 104

Have provided oral preventive care in past two work weeks to ≥ 75% of children

Adoption of CF3 care

0 20 40 60 80 100

Goal Setting

Anticipatory Guidance

Fluoride Varnish

Measuring Risk

Exam Teeth

Demonstrate Brushing

All

Dental

Non-Dental

p = 0.02

p = 0.002

p = ns

Have provided oral preventive care in past two work weeks to ≥ 50% of children

Adoption of CF3 care

0 20 40 60 80 100

Goal Setting

Anticipatory Guidance

Fluoride Varnish

Measuring Risk

Exam Teeth

Demonstrate Brushing

All

Dental

Non-Dental

p = 0.001

p = ns

Barriers to Adoption of CF3 care to children

0 25 50 75 100

Time

Obtaining

Fluoride

Lack of

Reimbursement

Forget

Difficulty

obtaining risk

All

Dental

Non-Dental

Definitely/Somewhat of a Barrier

*

*

*

*

* p>0.05

As a result of CF3, has your workplace done any of the following? YES % (N = 104)

Changed medical record/billing 51

Billed Medicaid 60

Planned for future training 58

Made arrangement for getting own fluoride 67

Made arrangement for getting own oral health supplies 75

Established referral system to dental home 79

Implementation/Maintenance of Training

Maintenance of Training

0 20 40 60 80 100

Children 0-36 mo

Pregnant Women

Dental

Non-Dental

In the future….very/somewhat likely to provide oral preventive care to ….

p = 0.03

p = 0.67

CF3 care reached almost 5000 children in first year

The CF3 training model is effective at providing necessary skills

Variety of providers are willing to adopt new behavior

Providers can assess a child’s risk for caries

Lack of time to provide care is most reported barrier to providing care

Oral health kits help with adoption and implementation

Trainees request updates

Conclusions

1. Change perceptions of oral health

2. Overcome barriers by replicating effective programs and proven efforts

3. Build the science base and accelerate science transfer

4. Increase workforce diversity, capacity and flexibility

5. Increase collaborations

Summary

Cavity Free at Three Program Evaluation

Thanks to CF3 Technical Assistance Team

Co-investigators Matt Daley Elaine Morrato Sarah Ling Katina Widmer

Funds Caring for Colorado Foundation The Colorado Health Foundation The Colorado Trust Delta Dental Foundation of Colorado Kaiser Permanente Rose Community Foundation

Thank you for collaborating!

Early Childhood Caries Prevalence Rates and Parent Oral Health

Knowledge, Attitudes, Beliefs and Behaviors

Children’s Outcomes

Research Program

Co-located Dental Hygienist Project

Background: Early Childhood Caries

Most common chronic disease of children 18% of Colorado’s Head Start children have caries

experience Large disparity exists

80% of disease occurs in 25% of children AAP and AAPD recommend first oral health visit by 12

months of age Innovative models of care delivery necessary Colorado Head Start Basic Screening Survey, 2004

The Impact of Oral Disease on the Health of Coloradans, CDPHE, 2005

Background: Co-location

General Considerations

Placing multiple services in same physical space

Premise that proximity will enhance access to necessary services

Continuum of care

co-location > collaboration> integration

S. Ginsburg, The Commonwealth Fund, July 2008

Goal

Overarching goal of project is to test feasibility of co-locating registered dental hygienists into medical practices.

Objectives

Objective 1: Using co-located dental hygienists in medical practices, measure baseline early childhood caries prevalence in young children, 0-36 months of age

Objective 2: Describe the baseline oral health knowledge, attitudes, beliefs and behaviors of primary parents/caregivers of young children

Methods: Study Setting

Five medical offices purposefully selected

All offices serve predominantly low income children

Registered Dental Hygienists (RDH) hired from 10/08 through 4/09

Dual function exam rooms built

RDH care specifically directed to children 0-36 months of age

Dual Function Exam Room

Methods

Recruitment Efforts Letters mailed to parents at practices Open recruitment by hygienists in offices Direct referral of patients by medical staff

Services Oral examination, rubber tip prophy, assessment of

caries, fluoride varnish application and oral health instruction

All children referred to dentist Business Model

RDH practice independently Do own scheduling and billing

Measurement of Cavities

Decayed, missing, filled surfaces (d1d2mfs) RDHs calibrated to caries measurement NIDCR and DRURY criteria (white spot lesions) Visualized on dried teeth, overhead light source, no probing

or x-rays

USDHHS, PHS, NIH, NIDR. NIH Publication No. 91 (1991) Drury TF. et al. J Public Health Dent 59. 1999

Measurement of Parent/Caregiver Variables

Parent/Caregiver knowledge, attitudes, beliefs, behaviors

Hand written paper-based survey

Health Belief Model

Validated questions (e.g. BRFSS)

Piloted

Administrated at first visit, 12 month visit

Results

Total = 2,101

Nov. 2008 to June 2010

0

50

100

150

200

250

300

350

400

450

500

Aurora(0

.1FTE) 11/08

Fort Collin

s(1.0FTE) 02/09

Montrose

(0.3FTE) 0

2/09

Delta(va

riable) 0

2/09

Thornton(0

.2FTE) 04/09

Num

ber

of patie

nts

Target children

<36 months

(N=525)

Non-target

children >36

months (N=805)

Baseline Characteristics of Study Population

N=528

Age (mean)

Range

18 months

(6-36)

Insurance

Medicaid

CHP+

67%

11%

Household Income

<= $29,999

55%

Caries

d1s only

d2mfs

9.6%

3.9%

Baseline Characteristics of Target Population

Yes

‘Has your child ever been received care by a dental provider?’

9%

‘Do you have a dental provider you plan on taking your child to?’

27%

‘Have you (parent) seen a dental provider in the past 2 years?’

51%

Baseline Parent Attitudes about Co-location

How much do you agree or disagree with the following statements?

Strongly

Agree

Somewhat Agree

Convenient to get dental care in same office as child’s medical provider

84% 15%

More likely to take my child to a dental provider located in doctor’s office than one in the community

63% 29%

Getting dental care at the same time as getting medical care makes sense

78% 17%

Perceived Barriers to Taking Children to Dental Provider

How much are the following a problem for you to take your child to a dental provider?

A Big Problem Somewhat a Problem

Cost 14% 25%

Finding a dentist that takes child’s insurance

13% 23%

Finding a dentist close to my house 10% 14%

Child afraid of the dentist 9% 19%

Too busy to take child to dentist 5% 14%

Parent Knowledge Regarding Provision of Dental Care

Has medical provider told you when to take child to see dental provider

Yes- 40%

Has dental provider told you to take child to see dental provider

Yes - 26%

By what age…

By age 1

By age 1 and before age 3

..did medical provider tell you to take child to dental provider (n=210)

65% 32%

…did dental provider tell you to take child to dental provider (n=137)

62% 31%

…do you think you should take child to dental provider (n=525)

51% 42%

Other Important Attitudes and Behaviors

47% brush child’s teeth once a day

22% use toothpaste when brushing child’s teeth

47% agree child won’t let them brush teeth

44% agree that most children eventually get cavities

Other Important Attitudes and Behaviors

47% of children currently use a bottle

23% reported putting child to bed with a bottle (milk, formula, juice) daily

However, 87% described taking child to dental provider as “very important” to preventing cavities

12 Month Parent Attitudes about Co-location

N = 48

How much do you agree or disagree with the following statements?

Strongly

Agree

Somewhat Agree

Convenient to get dental care in same office as child’s medical provider

83% 15%

More likely to take my child to a dental provider located in doctor’s office than one in the community

48% 44%

Getting dental care at the same time as getting medical care makes sense

73% 21%

12 Month Perceived Barriers to Taking Child to Dental Hygienist

How much of a problem? Big/Somewhat of Problem

Not a Problem

Dental hygienist is not in the office at

convenient times

13% 87%

Takes too much time to see both the medical provider and the dental hygienist on the same day

23% 77%

Dental hygienists don’t fill cavities 21% 79%

12 Month Perceived Barriers to Taking Child to Dental Hygienist

How much of a problem? Big/Somewhat of Problem

Not a Problem

Dental hygienist is not in the office at

convenient times

13% 87%

Takes too much time to see both the medical provider and the dental hygienist on the same day

23% 77%

Dental hygienists don’t fill cavities 21% 79%

Too busy to take my child to the dental hygienist

15% 85%

My child is afraid to see the dental hygienist 29% 71%

12 Month Parent Attitudes about Co-location

Really Like Like

What is your opinion about having your child see the dental hygienist in the medical office?

73% 25%

12 Month Parent Attitudes about Co-location

Yes No Not sure

Do you plan on taking your child to the dental hygienist in this office in the future?

87% 0.2% 12%

Would you recommend this doctor’s office to others because a dental hygienist works here?

90% 0.2% 10%

Key Informant Interviews

Positive Theme: Access to services

Medical Director:

“[It was] something we had always tried to do. To co-locate anything we can… It's kind of like this- what is this new term, Medical Home that we've done for a long time. So it just makes sense - the one stop shop being the Medical Home issue.”

RDH:

“I thought it was a great idea to help the kids out and help them find a dental office. Because it is really hard to find an office who will take - like in their case, a lot of our children have Medicaid and some of them don't have any insurance. So helping them find where to go…Finding a resource for them.”

Key Informant Interviews

Challenge Theme: Medical buy-in

Medical Director:

“The biggest thing for my consideration was selling it to my own staff… Trying to get buy-in was probably the one biggest thing.”

RDH:

“At the beginning it was kind of rough. Only because we…had conferences with the pediatricians there and their assistants because of scheduling and getting the patients in and having them know and be aware that we are there to help them out… part of it was educating PA's and pediatricians who worked there to work together.”

Challenges and Limitations

Challenges to Co-location

Medical practices lack space for new providers

Getting medical providers to refer patients slow

Incorporating dental hygienists into scheduling of clinics difficult

Limitations

RDH assessing for caries

Generalizability

Selection Bias

Conclusions

Co-located dental hygienists seeing both targeted and non-targeted children

Young children are receiving preventive oral health services

Few targeted children previously seen by dental provider

and already are developing white spot lesions and cavities

Reported barriers are less common/haven’t been encountered yet

Conclusions

Most parents think child should see dental provider by age 3

Most parents report that dental visits prevent cavities

Co-locating dental hygienists into medical practices is

feasible and expands dental access

Acknowledgements

Delta Dental Foundation

Barbara Springer

Helene Kent

C0-Investigators

Matt Daley

Shelby Kahl

Sarah Ling

Katina Widmer

Dental Hygienists

Maria Matias,

Mike Bennett

Ginnette Trujillo

Mary Vigil

Suzi Shada

Conclusions

Co-located dental hygienists seeing both targeted and non-targeted children

Few targeted children previously seen by dental provider and already are developing white spot lesions and cavities

Parents support receiving dental care in the medical office Reported barriers are less common Parents think child should see dental provider by age 3 Parents report that dental visits prevent cavities Co-locating dental hygienists into medical practices is feasible and

expands dental access

Why Treat Moms?

Improving Children’s Oral Health Through Perinatal treatment and Education

Dental Aid Inc.

What is Dental Aid?

History and Location

Scope of Services

Who comes to Dental Aid

Funding

Current size

# of providers

Patients per year

Visits per year

Bright Smiles Program

Purpose

History

Number of women Participating Per year

Logistics of the Program

Funding For Bright Smiles

What treatments are Provided

ALL Aspects of General Dentistry

New York Guidelines August 2006

California Guidelines February 2010

Priority of treatment

Does treating Mom help?

The children have less decay

They have less SEVERE decay – fewer hospital cases

They have their first dental visit earlier

Their parents are more active in providing home care and good nutrition

Decay rates dmfs

BS kids dmfs ages 2 to 3 = 3.4 all other kids 6.3

BS ages 3 to 4 = 8.4 15.0

Bs kids ages 4 to 5 = 12.6 21.5

Decay Rates dmft

Ages 2 to 3 BS = 1.0 2.7

Ages 3 to 4 2.9 5.1

Ages 4 to 5 3.15 5.4

Hospitalizations

Bright Smiles children under age 5 18%

All other children under age 5 50%

Bright Smiles children are treated with general anesthesia at 1/3 the rate or frequency of our general population of children

Other Outcomes

We see the children earlier in life and the parents are more involved.

14% of Bright Smiles babies are seen by age one. Of 250 audited charts of children in our patient population under age 5, NONE were seen before 30 months.

Parents are more involved in the child’s home care. Parents are brushing the child’s teeth. BS = 66% vs. 19%

What Next?

Xylitol Interventions

Cost Savings Analysis

Talk to Dentists Too many won’t see young children

Apprehension about treating women during pregnancy

THANK YOU

QUESTIONS