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5/3/17Integrating Oral Health andPrimary Care: Where We Are, What’sNextAmerican Association of Community Dental Programs:PreconferenceMarcia K. Brand, Ph.D., Senior Advisor for National PolicyDentaQuest FoundationInitiative activities are made possible as a result of funding from the DentaQuest Foundation,the Washington Dental Service Foundation, and the REACH Healthcare FoundationThis Presentation Reminder: making the “case” for integrating oral health andprimary care Activities that are already underway Tools and resources to support this work Becoming a champion for oral health integration21

5/3/17Think about it Your primary care provider .Listens to your lungs,althoughNot a pulmonologist2

5/3/17Your primary care provider Listens to your heart,althoughNot a cardiologistYour primary care provider Looks in your eyes, althoughNot an ophthalmologist3

5/3/17Your primary care provider Looks in your ears, nose andat your larynx, althoughNot an Otolaryngologist (Ear,Nose and Throat Specialist)BUT Your Primary Care ProviderDOES NOT EXAMINE YOURTEETH AND GUMSBECAUSE HE/SHE IS NOT ADENTIST 4

5/3/17Why We Need a Different Approach to Oral HealthCare Delivery: What We Know A person’s oral health impacts overall health and quality of life Most oral disease is preventable Despite the availability of effective prevention and treatmentmethods, we have seen small improvements in oral healthstatus over the past two decades Among some populations, the oral health status has declined Our current model DOESN’T WORK for large segments of ourpopulation, including low-income and rural populations Lack of access to oral health care contributes to profound andenduring oral health disparities WE NEED A DIFFERENT APPROACH: INTEGRATION (upstream,prevention focused)9What We Know (continued) There aren’t enough dental providers to address unmet oralhealth need and even if we train more dental providers, manypeople can’t pay for their services or dental providers won’t seethem We need an interprofessional approach that integrates themouth back into the body and engages all health care providers In 2000, the Surgeon General’s report on oral health called for all healthproviders to participate in oral health care That call was echoed by the Institute of Medicine in 2010 and 2011 and byHRSA in 2014105

5/3/17And We Are Making Progress! A focus on team based, patient-centered care creates anenvironment for oral health integration Health professions educators, accreditors and licensingorganizations are including oral health in curricula and on exams The scientific evidence demonstrating the connection betweenoral health and overall health continues to grow11Oral Health Integration into Primary Care Progress Across ALL of Health CareRecent Publications in Key Health Care Journals, not just the“dental literature” Health Affairs: The Dental-Medical Divide – Elizabeth Mertz, December2016² Emphasizes the importance of oral health for overall well-being²²Examines challenges resulting from historic separationExplores implications for future oral health policy Modern Healthcare: Moving Dental Health Into Primary Care – ElizabethWhitman, January 7, 2017² Notes growing recognition that improved dental health leads tobetter overall health is leading some providers to look for ways tointegrate dental care into primary care, which tends to be moreaccessible for patients126

5/3/17Oral Health Integration: Progress Across ALL ofHealth Care Other Mainstream Media:NPR – A Good Dentist is Hard to Find in Rural America – Alison Kodjak,September 16, 2017 “What we know is that oral health is closely tied to overall health. At the Marshfield Clinic centers, dental care is treated as another part ofgeneral health care. Dental and medical records are combined. Patientswho come to the dentist get their blood pressure and blood sugarchecked. Patients who are there for a filling may end up being sent to thehospital for a stress test or diabetes followup. Doctors at the health centers routinely look into patients' mouths. Ifthere's a problem, they refer them to the dentist.”13Further Evidence of Support for Oral HealthIntegration Recognition by Key Organizations American Medical Association - AMA Journal of Ethics: OvercomingHistorical Separation Between Oral and General Health Care:Interprofessional Collaboration for Promoting Health Equity Lisa Simon,DMD, September 2016 Resolution Adopted in 2016: AMA: (1) recognizes the importance of (a)managing oral health and (b) access to dental care as a part of optimalpatient care; and (2) will explore opportunities for collaboration withthe American Dental Association on a comprehensive strategy forimproving oral health care and education for clinicians.147

5/3/17Making Patient-Centered Approaches to Oral HealthCare/Primary Care Integration Happen Who has to be involved? Dental providers – need to see themselves as part of a patient-centeredteam Primary care providers – need to see oral health as a part ofcomprehensive patient care Educators, accreditors, licensing boards – need to build oral health intocurriculum and credentialing Administrators – need to envision how this can happen, lead What tools and resources are we going to need? Tools for teaching primary care providers about oral health Models and frameworks for successful oral health and primary careintegration; EHRs that support integration Articles and meetings that “get the word out”15What Tools and Resources Have AlreadyBeen Created? Tools for teaching primary care providers about oral health Models and frameworks for successful oral health and primarycare integration168

5/3/17Tools for Teaching Primary Care Providers AboutOral Health Smiles for Life On line curriculum Nearly a million visits Free CEU – 17 organizations! “There’s an app for that!” - clinical support tool Other resources (posters, pocket cards, risk assessment) Faculty Resources Smiles for Life (can be used in a classroom) NYU Oral Health in Nursing Education and Practice tools Physician Assistant Education Association What’s Next? New modules- community health workers, special needs patients Streamlining and improving interactivity17Nearly a millionvisits!9

5/3/17We Needed Models and Frameworks for SuccessfulOral Health and Primary Care Integration First - White Paper: Oral Health: An Essential Component ofPrimary Care - Available at: www.QualisHealth.org/white-paper(Summer 2015)19Oral Health Delivery Framework5 actions primary care teams can take to protect and promote their patients’oral health. Within the scope of practice for primary care; possible to implementin diverse practice settings.Preventive interventions: Fluoride therapy; dietary counseling to protect teeth and gums; oralhygiene training; therapy for substance use; medication changesto address dry mouth.Citation: Hummel J, Phillips KE, Holt B, Hayes C. Oral Health: An Essential Component of Primary Care.Seattle, WA: Qualis Health; June 201510

5/3/17Then Field-Testing The ConceptualFramework19 diverse healthcare delivery organizations: Private practices, FederallyQualified Health Centers; medical only and on-site dentalAdults with diabetes (9), pediatrics (3), pregnancy (1), adult well visits (1) eCW(5), EPIC (3), NextGen (2), Centricity (2), Success EHS (2)Oregon PCA, Kansas Assoc. Medically Underserved, Massachusetts League CHCsAddl support: Kansas Health Foundation, United Methodist Health Ministry FundResulted in a “How To” Guide“Oral Health Integration Implementation Guide”Toolkit for primary care teams (Oct 2016) Workflow maps Referral agreements Patient engagement strategies Patient/family education resources EHR templates Case examples Impact data and more Qualis Health, 201611

5/3/17Is This Really Possible in Today’s Busy PracticeSetting? YES! Patient-centered medical homes and other advanced primarycare practices have resources in place to implement now;others can take an incremental approach Possible without new members of the team and within aProvider/Medical Assistant “Teamlet” Most activities can be performed by a trained MedicalAssistant or LPN Does not require specialized equipment or space Viability in the long-term will require policy and paymentchanges (e.g., reimbursement for care coordination activities)What about referrals? Modeled on med/surg processGoal to take burden off patientsRequires a referral network able to serve diverse patientsWhat else?üüüüReferral agreements to clarify expectationsConnectivity; ability and commitment to share informationTracking and care coordination processesLogistical support12

5/3/17From a Policy Perspective: How Do We PromoteOral Health Integration? Dentists: Participate in referral networks & accept patients of mixedinsurance statusPayers: Assess adequacy of payment for covered services and considerexpanding reimbursement optionsResearchers and Policymakers: Invest in research to strengthen theevidence-base for preventive oral health careLawmakers: Support patient-centered care demonstrations and newreimbursement models that promote better population outcomesPatient & family advocates: Engage patients and families in championingfor changeEducators: Ensure basic oral health clinical content is taught and learnedPractice Administrators: Serve as champions, provide leadership in servicedelivery settings and systems, support EHR integrationBe An Oral Health Champion – Get Engaged Happening in Every State Oral Health 2020 (OH 2020) National effort, originally funded by the DentaQuest Foundation Creates framework for achieving the goal of “good oral health for all” Does this by connecting “Grasstops, Grass Middles and Grass Roots” in asystems approach2613

5/3/17Oral Health 2020 NetworkIncludes Organizations Such As .WAMEMTNDVTMNORIDWISDNYCTMIWYCA PAIANENVILINOHWVUTCOKSMONHMAVARINJDEMDD.C.KYNC33 statewide networksTNOKSCARAZ37 State PrimaryCareAssociationsNMGAMSAL20 “Grassroots” organizations in 6 statesLAGranteesat national, state TXand communitylevelAKFL1,000 registered users of OH2020 web-based collaboration toolHI272714

5/3/17Oral Health 2020 Network Goal 5: Integrate OralHealth Into Person-Centered Healthcare Make targeted investments to develop alignment around effective caremodels Make targeted investments to support national organizations to developaccreditation and certification standards that include oral health Engage national dental providers and payer associations in the designand regulation of PCMH, ACO, and other payment reform efforts Identify and engage oral health champions within primary care healthprofessions to prioritize the adoption of oral health integration Build and expand interprofessional education resources to include oralhealth for a broad range of clinical professions Support oral health care model implementation tools to be publishedand adopted Support implementation efforts to integrate medical and dental records29What Can You Do to Engage OH 2020? Reach out to your State’s PCA and see if they are participating Connect with your State’s Oral Health Coalition Go to the Oral Health 2020 website and search by your state to seeif there are others who are engaged in the work Support AACDP’s larger effort – share success stories, challenges,opportunities related to improving oral health Be a leader in your State, engage your legislators3015

5/3/17Contact InformationMarcia K. Brand, Ph.D.Senior Advisor For National Policy, Dentaquest FoundationMarcia.brand8@gmail.com304-283-83943116

DentaQuest Foundation Initiative activities are made possible as a result of funding from the DentaQuest Foundation, the Washington Dental Service Foundation,and the REACH Healthcare Foundation This Presentation Reminder: making the “case” for integrating oral healt