Redefining Oral Health:

Engaging the Primary Care Provider in Oral

Health

An Oral Health Coordinator

at Traverse Health Clinic

Rene A. Louchart, B.S., R.D.H.

2017 MPCA Annual Conference

HRSA 3 yr Grant 2007

RN managed dental referral

program

RDH expanded program &

created, managed outreach

programs

New Location October 2016

Matinee Dental Days

FEBRUARY

NATIONAL CHILDREN’S

DENTAL HEALTH MONTH

OCTOBER

NATIONAL DENTAL

HYGIENE MONTH

“Path to Prevention”

Traverse Health Clinic Dental Access

Program 2010

DAP Intake Program

Enrolled in CHAP

DAP

DAP Referral

Prevention Program Program

Increasing Oral Health

Dental Hygiene Data

• 1st Day= 1.11.2011 @ 1:00P.M.

• 2 Days a week

• 34 months

• 221 Days of Hygiene

• 310 Unique patients

• 936 Appointments

Value of Hygiene Services

$118,000

Last Day= 10.24.2013

University of Michigan School of Dentistry

• Pilot Clinic Feb 2011

• 26 Clinics total

• 581 Clinic hours

• 101 dental students

• 766 appointments

• 702 restorations

• 1,429 extractions

• 300 unique patients

• 172 completed tx

Value of Services

$433,000

Last Clinic = 4.12.2014

HEAVEN D.E.N.T. Delighting the Edentulous with New Teeth

,; I ,f!'

TraverseHealthClinic

A collaboration with Traverse Health Clinic (TH) began in July 2013 as

Northern Lakes Community Mental Health (NLCMH) was granted a

Mental Health Block Grant.

People receiving primary care at NLCMH by a TH Nurse Practitioner, a

NLCMH Registered Nurse and Medical Assistant.

In 2014 NLCMH obtained a 4 year grant from

Substance Abuse and Mental Health Services Administration

(SAMHSA).

In January 2015 the Oral Health Coordinator from TH was added to

assess, educate and refer patients to dental care.

Traverse Health Clinic/

Northern Lakes Community Mental Health

“Oral health is an integrated, critical

component of person-centered,

comprehensive healthcare and well-

being…”

-Dentaquest

National Oral Health Innovation & Integration Network (NOHIIN)

Why collaborate?

Primary Care with Oral Health

• Reduce burden and costs of oral diseases

• Partnership to assess, reduce risks, screen for

early signs

• Identify patients at risk and need

• Build workforce to support:

Prevention

Early detection

Promote & increase access to dental services

Challenges to Access

Continuing Issues to Access

• Awareness of oral health: Provider & Patient

• Time to Assess

• Electronic data collection & sharing of information

• How & where to treat

• Cost

• Fear

• Transportation

• Other issues

Better Overall Health

Health outcomes in Primary Care

• Improved patient parameters

• Improved overall health

• Patient feels better

• Healthier community

INFLAMMATION is the oral-systemic connection

The Connection

Dental disease is a chronic disease and

deserves treatment.

Periodontal Disease

Stroke

Diabetes

Pregnancy Problems

Child Caries

Sleep Disorder

Cancer

Kidney & Lung

Disease

ED

RA

Alzheimer's

HIV CVD

“Most of what we deal with in the mouth is really a medical problem; it just has a dental solution.” -Dr. Lee Ostler

PERIODONTAL DISEASE AND

POSSIBLE RELATED MEDICAL DISEASES

•Alzheimers: oral spirochetes

•Cardiovascular Disease: P. gingivalis; strokes;

•Stroke: Strep. Mutans

•Diabetes: advanced glycation end products

•Pregnancy Problems: pre-term low birth weight

•Child Caries: bacteria passed from parent

•Sleep Disorder: biofilm

Continued…

•Cancer: bacteria;

• Breast Cancer: microbes in breast tumors

•Kidney & Lung Disease: bacteria

•Erectile Dysfunction: inflammation

•Rheumatoid arthritis: biofilm

•HIV: bacteria byproducts- metabolic small chain fatty acid (SCFA)

can activate HIV in dormant T-cells, causing the virus to replicate

Xerostomia (dry mouth)

can be associated with any of these conditions.

Patients taking certain medications tend to suffer

more from dry mouth (xerostomia)

42 drug categories and 56 subcategories

More than 400 commonly used drugs

antihistamines anorexiants antianxiety agents antidepressants

antihypertensives bronchodilators anticholinergics

antipsychotics skeletal muscle relaxants

And over the counter (OTC) products including:

benadryl, antivert and others

Dry Mouth can have a profound impact

on oral health and daily life

Physical • Ongoing bad breath

• Increased risk of caries

• Mouth infections

• Difficulty

talking/swallowing

• Perceived decrease in

sense of taste

Emotional • Feels self-conscious

• Low confidence level

• Feels different from others

• Anxious

• Stressed

Social • Avoids socializing

• Needs to carry & sip water

• Embarrassed

• Irritable with people

• Avoids eating out

• Difficulties doing usual job

Patient

Oral Health Coordinator (1)

M.D. (1)

Nurses (14)

M.A. (4)

Behavioral

Health (4) Support

Staff (20)

Lab

Pharm

Admin (3)

Traverse

Health

Clinic

TEAM

Refer to:

NWMHSI

DCN

http://www.smilesforlifeoralhealth.org

Modules for staff

Oral Health Coordinator (OHC) / Primary Care Provider (PCP) in integration

Process

• OHC reviews charts for the day

• Select Pts to receive OHHx form

• OHC alerts staff which Pts to be seen

• OHC sees Pts in room or Oral Health Office

• Referral info/assistance given to Pt

• OHHx info entered into eCW

• Notes made regarding findings & Referral to

dental clinic

Update April 2017

Current selection

• Currently over 353 patients living with diabetes

• 41 with diagnosis of Pre-diabetes

• Excel sheet of OHHx’s has 1236 names

• Patients with conditions listed in Problem List in eCW:

pre-diabetes, diabetes (I & II), GERD, COPD, OSA,

murmur, Hep C, Fibromyalgia, Raynaud’s Disease,

CHEW (tobacco), dental decay, RA

ORAL HEALTH HISTORY FOR TRAVERSE HEALTH CLINIC

NAME DATE OF BIRTH TODAY’S DATE

PHONE NUMBER TO CONTACT YOU

Please circle an answer or write your response to each question below

Yes No

Yes No

Yes No

Yes No

other

1. Have you been to a dentist in the last 12 months?

2. When was the last time your teeth were cleaned at a dental office?

3. Are you currently experiencing dental pain or discomfort?

4. Does your mouth often feel dry or somewhat dry?

5. Do your gums bleed when you brush or floss?

6. How often do you clean your teeth or dentures?

Never 1 time/day 2 times/ day more than 2 times per day

7. Circle the amount of sugar in your diet each day (1 serving = 1 tablespoon )

This includes sweet coffee, sweet tea, soda, sports drinks, candy, cookies, etc. None 1 serving 2 servings 3 servings 4 servings more than 5 servings

8. If you would spend the rest of your life with your oral health as it is right now, how would you feel?

Terrible Mostly unsatisfied Undecided Mostly satisfied Delighted

To help us coordinate your healthcare, you will be given information to contact a dental provider.

For Staff:

Appointment need is: Emergent Dental Care No

No

Seen at TH Yes

Info Given: Yes

Referred to: DCN NMHSI Other Status: New Dental Patient Existing Dental

Patient is living with Diabetes Yes No Dental benefits through

COMMENTS _

Unable to contact: Patient Seen on:

FAXED:

E.M.R.

eClinical Works

(eCW)

Dental questions

In Social Hx

&

Entered in HPI

From OHHx form

Social Hx dental hygiene questions:

1. Have you seen the dentist in the last 12 month?

2. Date of your last dental visit?

3. Do you have dentures or partials?

4. Do you have a dental problem now?

5. How often do you brush your teeth?

6. How often do you floss your teeth?

7. Dental Referral Information Given to patient

OHHx now:

1. Have you been to a dentist in the last 12 months?

2. When was the last time your teeth were cleaned at a dental office?

3. Are you currently experiencing dental pain or discomfort?

4. Does your mouth often feel dry or somewhat dry?

5. Do your gums bleed when your brush or floss?

6. How often do you clean your teeth or dentures?

7. Circle the number of times you have sugar in your diet each day. (sweet coffee, tea, soda, sports drinks,

candy, cookies, etc.)

8. If you would spend the rest of your life with your oral health as it is right now, how would you feel?

Delta Dental Foundation Brighter Futures Community Grant

Oral B Electric Toothbrushes

for Patients Living with Diabetes

February – July 2016

60 Oral-B Vitality Electric TB

Baseline and After few months data tracked:

Brushing frequency = 10 improved

A1c or blood glucose = 31 improved

Bleeding gums when brushing = 10 improved

Grand Traverse Region

Oral Health Coalition

Shape Up North

2017

Fruit and Vegetable

Prescription Program

References

Centers for Disease Control and Prevention (2015). Oral and Dental Health. National Center for Health Statistics.

Doyle, K. (2016). Periodontitis tied to risk of erectile dysfunction. International Journal of Impotence Research,Medscape.

Health Resources & Services Administration (2017). Integration of oral health and primary care practice.

Hostetter, M.,& Klein, S.(2015). Integrating oral health into primary care.

Quality Matters- Innovations in Health Care Quality Improvement.

Institute of Medicine.(2011). Advancing Oral Health in America, Washington, D.C. National Academies Press.

Institute of Medicine.(2011). Improving Access to Oral Health Care for Vulnerable and Underserved Populations, Washington,

D.C. National Academies Press.

Qualis Health: Oral Health: An Essential Component of Primary Care: White Paper June 2015

The Journal for Nurse Practitioners; October 2015; Vol 11, Issue 9, p 889-896; Oral Health: An Untapped Resource in Managing

Glycemic Control in Diabetes and Promoting Overall Health; Cynthia S. Darling-Fisher, PhD, FNP-BC, Preetha P. Kanjirath,

BDS, MS, Mathilde C. Peters, DMD, PhD, and Wenche S. Borgnakke, DDS, PhD

Intraoral Photos

66 yr Female

BMI = 38.76

BP = 136/78

A1C = 10.5%

Glucose was 209

Last dental = NEVER

54 yr Female

BMI = 46.10

BP = 124/90

Not diabetic

Not brushed in 6 yrs

Last dental = 34 years

6.8.2015

58 yr Female

BMI = 26.97

BP = 120/84

Newly diagnosed

diabetic

Last dental visit = years

11.16.2016

Sublingual mass

present 3 months

BMI = 27.04

BP = 116/70

Referred – biopsy & CT scan

Diagnosed, Refused Tx

3.8.2017

BMI = 25.11 (lost 18 lbs)

BP = 100/72

Eats mostly root beer floats

Referred for pallative care-

Hospice

4.19.2017 (refused photo)

BMI = 23.4

(lost 31 lbs since December)

BP = 100/72 (3 trys)

(6.8.2015 same patient)

Squamous cell carcinoma

Thank You

REDEFINING ORAL HEALTH: ENGAGING THE PRIMARY CARE PROVIDER IN ORAL

HEALTH

HEALTH SYSTEMS CHANGE IN TREATING TOBACCO

DEPENDENCE IN DENTAL CLINICS

Michigan Primary Care Association

www.mpca.net

CDC

• Prevent Block Grant

• Increase healthy lifestyle

• Decrease tobacco use

• Decrease obesity

• Focus on high-risk, vulnerable populations in one urban (Washtenaw County) and one rural (Northwest Michigan –Antrim, Charlevoix, Emmet, and Otsego Counties) setting

MDHHS

• Getting To The Heart Of The Matter (GTHM)

• GTHM strategies contribute toward the accomplishment of State Innovation Model (SIM)

• Reduce adult obesity by 5%

• Reduce adolescent obesity by 10%

• Increase adequate physical activity for adults by 20%

• Increase reported recent dental visits by 5%

• Reduce proportion of adult tobacco use by 15%

• MDHHS aims to increase the number of health systems and dental clinics that have institutionalized tobacco cessation interventions into routine clinical care

MPCA

• Health Systems Change for Treating Tobacco Dependence in Dental Clinics

• Application process based on focus area of the CDC Prevent Block Grant

• 6 Health Centers

• 2 in South East (Working with Washtenaw County Public Health Department)

• 4 in North West (Working with Health Department of Northwest Michigan)

Health Systems Change for Treating Tobacco

Dependence in Dental Clinics

Advantage Health Centers

Baldwin Family Health

Care

Hackley Community Care

Center

Muskegon Family Care

Northwest Michigan

Health Services

Western Wayne Family

Health Centers

Background

Aligning our efforts

• HEDIS measures • Meaningful Use • HRSA/BPHC goals

Health Center population using tobacco 50% (2015 UDS)

State of Michigan population using tobacco 21.3% (2015 Vital Records)

HRSA Goal is to reduce adult smoking rate to 12%

MPCA

Strategies

Professional Development

Increase Dental Provider

Optimize IT

Align with Meaningful Use

and IDS

Medical & Dental Collaboration

Health Systems Change for Treating

Tobacco Dependence in Dental Clinics

Sustainability

Review and Revise Share successes

Do it

Monitoring Give feedback to staff MPCA Check in and reporting

Workflow

Gather Resources Staff Trainings

Process Workflow Develop plan

Site Assessment

Electronic Dental Record Policies and procedures for

tobacco dependence treatment Workflow Assessment

Professional Development

Clinical Practice Guidelines using the 5 A’s of Behavior Change Model Training and the Michigan

Tobacco Quitline

◦ Provided by MDHHS Staff

from the Tobacco Section Over 90 staff in the 6 Health

Centers have been trained since June 2016.

Professional Development cont.

Motivational Interviewing Training

◦ 4 hour training

◦ Over 130 Medical and Dental staff were

trained since June 2016

Monthly Network TA calls facilitated by

MPCA staff

◦ Peer Learning/Sharing of best practices,

challenges, and opportunities.

Future Opportunities through

MPCA

Limited funding expansion into 1-3 more

Health Centers in FY 17-18

Funding into Year 3 for FY 17-18

Motivational Interviewing 2.0 Training and

continuation of Motivational Interviewing

and Clinical Practice Guideline trainings

for new staff due to turnover

Questions?

For more information, please contact:

Lindsay Sailor

Clinical Program Manager

517-827-0889

lsailor@mpca.net

www.mpca.net

Hackley Community Care Center REDEFINING ORAL HEALTH:

ENGAGING THE PRIMARY CARE PROVIDER IN ORAL HEALTH

Joshua Joshua, DDS, Dental Director Allan Mingus, Quality Manager

HCCC Philosophy

• Our philosophy is to serve the whole person in every aspect of their lives that includes: medical, dental, economic, social, psychological and spiritual. We treat each of these areas for an individual to achieve overall health.

HCCC Guiding Principles

• Is it good for the patient? • Is it good for the staff? • Is it good for the organization? • Is it good for the community?

HCCC Values • Quality - High degree of excellence. Going above and

beyond. Making a difference. • Integrity - Sincerity, honesty and candor. Doing the right

thing. • Respect - High or special regard for patients and each

other. Treating others as you want to be treated. • Compassion - Giving, comforting and bringing hope.

Being there for others.

About Us • Multiple sites serving the Muskegon County community:

• Baker site, Leahy site, Integrated Health Clinic (HealthWest), Muskegon High School Teen Health Center, Oakridge High School Teen Health Center, Nelson Elementary School, Covenant Charter Academy, Marquette Elementary School, Muskegon Heights Academy, Muskegon Middle School

• Services offered: Medical, Dental, Behavioral Health, Pharmacy, OB/Women’s Health, and MIHP

About Us (Continued) • Total staff – 218 • Medical providers – 25 • Dental providers – 9 • RN Care Managers – 7 • Community Health Workers – 4 • Behavioral Health providers – 14 • Pharmacists – 3

Why Participate in the MPCA Grant?

• Work aligns with HCCC Strategic and Quality Work Plans • Goal is to reduce the number of active smokers

• Increase the percentage of patients that receive smoking/tobacco use documentation and cessation intervention (Ages 13-17 and 18+)

• Identify the number of patients that quit smoking in the current year

How to Apply Grant Funding to Impact Patient Care?

• Researched two interfaces: 1)Dentrix to Allscripts 2) Dentrix to i2i Systems

How to Apply Grant Funding to Impact Patient Care? (Continued)

• Implementation of Patterson Dental’s Caesy Cloud Patient Educational Services • Installed monitors in all Dental operatories (3 locations) • Allows dental staff to provide patient educational

materials in video format • Multilingual and easy to understand • Good animations • Entertaining for children • Flexible and customizable

How to Apply Grant Funding to Impact Patient Care? (Continued)

• Created English/Spanish versions of a patient reference that highlights ways the practice can assist in quitting

• Currently researching adding additional digital x-ray equipment: • Provide immediate images without the need for scanners, etc. • Provide better manipulation of images • Provide higher quality images to aid in diagnosing oral cancer

and other diseases

Building the Process to Support the Work

• What data is currently available? • Dentrix allows users to populate patient smoking

history - focused on cigarette smoking only • How do we track specific data points in Dentrix to report

for the grant work? • Need to identify patient’s willingness to quit

• Responses lead to different process paths

Building the Process to Support the Work (Continued)

• Dentrix smoking history options don’t provide enough detail – added questions to Medical Alerts section to track supplemental data • Types of tobacco/smoking usage (ex: cigarette, e-cig,

hookah, marijuana, etc.)

Building the Process to Support the Work (Continued)

• Who’s going to do the work? • Dental Assistant or Hygienist will document smoking status and

discuss willingness to quit • If tobacco user, then will review options for quitting

• If patient requests NRT prescription, then the DDS is advised • HCCC Life Coach is provided weekly reports to identify patients

that identified as a tobacco user and will outreach • Dental Administrative Assistant performs reporting functions

Building the Process to Support the Work (Continued)

• How will we extract the data and report? • Dentrix: Requires a separate module to report the smoking history details - tied to

a MU component ($$$) • MPCA: Working with Dentrix to capture the information for the four practices

utilizing this EDR participating in the grant • Work Around:

• Worked with HCCC IT department to obtain Dentrix data dictionary • Identified two tables needed to acquire needed information • IT pulled raw data from database tables and created Excel spreadsheets • Utilized Access to link data and generate final report that can be modified to

provide counts/details on patient smoking status

Building the Process to Support the Work (Continued)

• How do we best communicate/collaborate with Medical? • Shared pamphlet to be provided to patients in both groups on

quitting resources • HCCC Life Coach has been provided Dentrix training to allow for

documentation of dental only patients (currently proficient in Allscripts)

• HCCC Life Coach is a shared resource and is receiving referrals from both groups

• Any prescription written by a dental provider is reported to the medical group to be included in Allscripts

Building the Process to Support the Work (Continued)

• How do we best communicate/collaborate with Medical? • Dental providers have been provided access and training to Allscripts

(review medical charts) • Developed referral process to direct concerns to the appropriate medical

resource • FYI: email or EHR message to provider • Information request: Referral Supervisor • Findings: Lead Care Manager • Behavioral Health: send patient to medical for potential same day

appointment or provide contact information to schedule appointment • Requires medical attention: follow the process flow

Lessons Learned • Interfacing is great……BUT when researched, it may not provide the efficiencies

that were initially expected • It can be challenging to modify/change vendor systems - end up building work

arounds • We identified a number of process issues that needed to be worked through

when dealing with systems that don’t connect or “talk” to each other (Dentrix/Allscripts)

• Dental providers are identifying a significant number of patients that identified as interested in quitting have been prescribed an NRT from their medical provider

• Dental providers had varying comfort levels with prescribing NRT medications (not traditionally done) - it is becoming more common place as it is good for the patient and within the scope of a DDS/DMD

Questions?

Thank you