Primary care: Dr. Marcia Brand supports efforts to integrate oral care with medical care

By Christine Nathe,RDH, MS

This month, Dr. Marcia Brand, who has been spotlighted in this column before, has answered some questions about her latest initiative. Throughout her career, she has promoted oral health in a variety of endeavors. As you can see, she continues to do so with the vision of truly integrating oral health into our health systems!

You have had a variety of roles in health care since you began your career as a dental hygienist. Can you please tell us about your most recent role?

Since April of last year, I have served as the executive director of the National Interprofessional Initiative on Oral Health (NIIOH). NIIOH, in simplest terms, is an informal collaboration of individuals seeking to improve oral health outcomes by incorporating basic oral health assessment and services into primary medical care. NIIOH is funded by the Dentaquest Foundation and Washington Dental Service Foundation.

Oral health care continues to be beyond the reach of many Americans. Cost, geography, and oral health literacy contribute to oral health disparities. While there is mounting evidence that a person's oral health impacts overall health, that most oral disease is preventable, and despite the availability of effective prevention and treatment methods, we have seen little improvement in the nation's oral health status over the past two decades. Among some populations, oral health status has declined; our current model of oral health care delivery does not work for large segments of the population, including low-income, minority, and rural populations. Lack of access to oral health care contributes to profound and enduring oral health disparities.1,2 We need a different approach to providing oral health care, one that is "upstream," prevention focused, engages primary care providers, and is patient-centered. This is what NIIOH is seeking to create and support.

Oral health care has historically been separated from primary medical care by tradition. Training programs, payment structures, and delivery systems and sites create medical and dental silos. There are not enough dental providers to meet unmet oral health needs, and even if we were to train more dental providers, many people still could not afford to pay for services and many dental providers do not see some types of patients (e.g., seniors, disabled, young children). In primary care settings, physicians and other providers generally look in patients' mouths to examine the throat as part of a routine head and neck exam, but generally there is no expectation that they will examine the teeth and gums for caries and periodontal disease. A recent article in the American Journal of Public Health examines this practice and proposes to change the "head, eyes, ears, nose, and throat exam" to the "head, eyes, ears, nose, oral cavity, and throat exam."³

Marcia Brand, PhD

We need an interprofessional approach that integrates the mouth back into the body and engages all health-care providers. This is not a new idea; in 2000, the Surgeon General's report on oral health called for all health providers to participate in oral health care.⁴ That call was echoed again by the Institute of Medicine in 2011 and by the Health Resources and Services Administration (HRSA) in 2014.^5,6,7

How do the changes occurring in the past decade impact oral health?

Fortunately, the health-care sector is undergoing a transformation that impacts payment, sites, services, and creates an openness to new models. In addition, the Affordable Care Act created accountable care organizations and other patient-centered approaches to care. The Centers for Medicare and Medicaid Services and HRSA have created grant programs that support interprofessional practice and patient-centeredness. There is tremendous interest across multiple disciplines and sectors in patient-centered care and interprofessional team practice, with the goal of improving quality and health outcomes, while containing costs.⁸

How can we integrate oral health into the current health systems?

Integration of oral health into primary care will be accomplished through three ways: 1. Professional training programs for primary care providers 2. Health-care delivery setting process revision 3. Policy and payment reform.

To integrate oral health care into primary care, dental providers need to see themselves as key members of patient-centered teams. Primary care providers need to see oral health as a part of comprehensive patient care. Educators, accreditors, and licensing boards will need to build oral health into program curricula and accreditation. Finally, practice administrators need to envision how this can happen and facilitate the integration.

There are ongoing and very successful efforts to integrate oral health into primary care that we can build on. NIIOH has facilitated cross-sector dialog and created opportunities for collaboration. NIIOH has supported the development of the Smiles for Life curriculum, a national oral health curriculum that teaches basic oral health competencies in modules (e.g., oral exam, pregnant patients, oral and systemic health). Smiles for Life has been broadly endorsed by a number of professional groups and provides free online training and continuing education units; the modules have been viewed by more than a half-million visitors.

Other ongoing efforts to foster the integration of oral health into primary care are taking place in physician assistant and advanced practice nursing education, through faculty workshops, training, and revisions in accreditation and certification standards.

Can you describe the white paper published recently about oral health and primary care?

In June 2015, Qualis Health published "Oral Health: An Essential Component of Primary Care," funded by the Dentaquest Foundation, Washington Dental Service Foundation, and Reach Healthcare Foundation www.QualisHealth.org./white-paper).⁹ This white paper outlined strategies that would prepare primary care teams to deliver preventive oral health care and structure referrals to dentistry.

The work was informed by a technical expert panel of primary care and dental providers; leaders from medical, dental, and nursing associations; payers and policy makers; patient and family engagement experts; and public and oral health advocates. The white paper has been endorsed by 20 organizations, including the American Academy of Pediatrics, the American Public Health Association - Oral Health Section, the American Association of Public Health Dentistry, and the Association of State and Territorial Dental Directors. The paper's framework has been supported by the American Academy of Family Physicians and the National Association of Community Health Centers.

Can you explain the paradigm developed to help integrate oral health into primary health care?

In the Oral Health Delivery Framework outlined in the paper, there are five actions for patient-centered teams related to oral health care:

• Ask about oral health risk factors and symptoms of oral disease.
• Look for signs that indicate oral health risk or active oral disease
• Decide on the most appropriate response
• Act offer preventive interventions
• Document as structured data for decision support and population management

Preventive interventions in the primary care setting may include: fluoride therapy, dietary counseling to protect teeth and gums, oral hygiene training, therapy for substance use, medication changes to address dry mouth, and chlorhexidine rinse.

Primary care providers are encouraged to establish a referral network that includes oral health providers and create tracking and care coordination processes. The framework included case examples from early leaders, including Confluence Health, the Child and Adolescent Clinic, and Marshfield Clinic. Field testing is ongoing, but lessons learned to date include:

• Patient-centered medical homes and other advanced primary care practices have the necessary resources in place to implement oral health assessment and basic services now.
• This is possible without new members of the team and within the provider/medical assistant "teamlet" arrangement.
• Many of the activities can be performed by a medical assistant or LPN.
• There is no need for specialized equipment or space.
• In the long term, policy and payment changes will be necessary to make this approach sustainable (e.g., reimbursement for care coordination).
• Dental providers (DDS, RDH) need to have skills necessary to be key players within this interprofessional team, with the patient at the center.

What does this mean for practicing dental hygienists?

The integration of oral health into primary care settings creates opportunities for dental providers to become members of patient-centered care teams. This could provide dental hygienists with additional roles in both the dental practice and primary care settings.

For example, in a large pediatric practice, it is possible that dental hygienists might be employed to provide oral hygiene instruction and apply fluoride varnish to pediatric patients seen as high risk for dental caries. This arrangement might be more likely where dental services and primary care are co-located, such as in a community health center clinic.

However, as noted above, most primary care settings have the personnel who could be capable of completing the “ask,” and “look” actions in the Oral Health Framework as they “room” patients. Perhaps a more practical use of the dental hygienists’ training and skills would be to provide training for primary care providers and staff about how to perform and record an oral screening; promote the use of the Smiles for Life Curriculum and respond to questions about it; train primary care providers and their staff about oral disease prevention; and suggest strategies for improving the oral health of more challenging patients. Hygienists could play a lead role in care coordination between the dental and primary care practices and ensure that information about a patient’s oral health and its impact on overall health is clearly communicated to primary care providers.

The work in the area of oral health and primary care integration can be strengthened by dental hygienists and dentists, seeking to improve patients’ oral health outcomes by engaging in interprofessional, patient-centered care that focuses on upstream prevention of oral disease.

As always, it is important to describe the issue before developing solutions. Understanding the fundamental issues within dental care delivery is paramount to developing effective solutions. The integration of oral health into health systems is an excellent method to promote oral health and prevent disease. Dental hygienists should strive to work within interprofessional arenas, continuing to improve health in all aspects of society! RDH

References

1. Dye BA, Li X, Thornton-Evans G. Oral health disparities as determined by selected Healthy People 2020 oral health objectives for the United States, 2009-2010. 2012. NCHS Data Brief, U.S. Department of Health and Human Services; No.104.
2. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Oral Health at a Glance: 2011. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention Pub. No. C5217229-AK.201.
3. Haber J, Hartnett E, Allen K, et al. Putting the mouth back in the body: HEENT to HEENOT. Am J Pub Health. 2015; 105(3):437-441. 4. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services; 2000.
5. Institute of Medicine (IOM). 2011. Advancing Oral Health in America. Washington, DC: The National Academies Press.
6. Institute of Medicine (IOM) and National Research Council (NRC). 2011. Improving access to oral health care for vulnerable and underserved populations. Washington, DC: The National Academies Press.
7. Health Resources and Services Administration. Integration of Oral Health and Primary Care Practices. Rockville, MD; U.S. Department of Health and Human Services: February 2014.
8. Patient-Centered Primary Care Collaborative. Joint Principles of the Patient-Centered Medical Home. Issued by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association. Available at:
http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf . 2015.

9. Hummel J, Phillips KE, Holt B, Hayes C. Oral Health: An Essential Component of Primary Care. Seattle, WA: Qualis Health; June 2015.

CHRISTINE NATHE, RDH, MS, is director at the University of New Mexico, Division of Dental Hygiene, in Albuquerque, N.M. She is also the author of "Dental Public Health Research" (www.pearsonhighered.com/educator), which is in its third edition with Pearson. She can be reached at [email protected] or (505) 272-8147.