Making Medical-Dental Collaboration Work - Lessons from Across the Country

1. Making Medical-Dental Collaboration Work - Lessons from Across the Country Hugh Silk, MD, MPH Clinical Associate Professor April 13, 2012

2. By the end of this talk participants will be able to discuss: Some of the national efforts creating medical-dental momentum Educational opportunities for collaboration Massachusetts - an example of a comprehensive oral plan in evolution Medical providers and fluoride varnish - a gateway to more oral health and how we are making it work Learning Objectives

3. Acknowledgment: Some materials today are used from Smiles for Life 8 annotated 50 minute PowerPoint modules www.smilesforlifeoralhealth.org 4

4. National Medical-Dental Efforts But first – why is this important

5. The Big Picture • “You are not healthy without good oral health…” David Satcher, Surgeon General 2000 • Dental care: the most common unmet health need • Oral disease can severely affect systemic health • Profound disparities in oral health and access to care exist at all ages • Much oral disease is preventable or at least controllable 5

7. Still Need to Know More! Dental caries is the most common chronic disease of childhood Severe gum disease affects 19% of adults aged 25-44 ~ links to DM, CAD 30,000 oral cancers diagnosed annually; 8000 die 50% of the elderly perceive their dental health as poor/very poor; 33% have untreated cavities 7

8. And you know the Consequences Mounting evidence of aggravating effects on systemic conditions Oral pain Poor school performance in children Work loss in adults Poor chewing and poor nutrition Costly emergency department visits Dental decay and tooth loss Aesthetics and self-image Speech and language development Costly restoration Photos: Donald Greiner DDS MS, ICOHP 8

9. The Disconnect Children are 2.5 times more likely to lack dental coverage than medical coverage > 50% of MDs had little or no oral health training Little communication and cooperation between medical and dental providers 9

10. 62% of OB-Gyn residency programs provide no prenatal oral health education < 50% of pediatric residencies have 2 hours or less of oral health education Only 32% of family medicine residency directors are satisfied with their residents' competency in oral health 1 in 10 medical school have no OH curriculum More recently…

11. 50 million Americans live in rural or poor areas where dentist d o not practice Only 43% of elderly visit the dentist Preventable dental conditions were the primary reason for 830,590 ED visits (2009) Only 34% of pregnant women visit the dentist The Medical Home is the Dental Home! Why is this such a big deal?Because…

12. Prenatal visits - ~13 visits ~4 hours Infants (WCC) – 11 visits before age two Children & Teens – 18 visits, plus sick visits Adults – annually Geriatrics – admission to NH, every 30 days Specialty visits, ED visits, VNA, etc How we practice

13. >90% of physicians think oral health should be addressed at well visits 75% of OB/GYN directors “agreed” that residents should address oral health 95% of peds and FM programs have some oral health training 45% of peds programs teach fluoride varnish 80% of medical schools teach about oral cancer; 70% about oral-systemic relationships However, some good news…

14. American Academy of Pediatrics: Section on Oral Health Society of Teachers in Family Medicine: Smiles for Life 2006 NY DPH: Oral Health During Pregnancy and Early Childhood (2010 CDA Revised OH During Pregnancy Evidence Based Guidelines) American Dental Association: Access to Care Summit Dept. of Health and Human Services: Oral Health Initiative 2010 Physician Assistants Leadership Summit on Oral Health Healthy People 2020: Oral Health = Leading Health Indicators Institute of Medicine and Health Resources & Service Admin HRSA: Advancing Oral Health in America 2011 IOM: Improving Access to Oral Health Care for Vulnerable and Underserved Populations 2011 Assn. of American Medical Colleges: oral health curricula Since 2000

15. Personal physician: ongoing relationship with a personal physician trained to provide continuous and comprehensive care Physician directed medical practice: the personal physician leads a team who collectively take responsibility for the ongoing care of patients. Whole person orientation: provide for all the patient’s health care needs Care is coordinated and/or integratedacross specialists, hospitals, home health agencies, and nursing homes. Quality and safety are assured by a care planning process, evidence-based medicine, clinical decision-support tools, performance measurement, participation of patients in decision-making, information technology, quality improvement activities Enhanced access to care is available (e.g., via "open scheduling, expanded hours and new options for communication"). Payment should reflect the value of "work that falls outside of the face-to-face visit," should "support adoption and use of health information technology for quality improvement," and should "recognize case mix differences” Wikipedia Patient-Centered Medical Home

16. Move beyond dental and medical homes: Set up in same building and conduct meetings together (e.g. a ‘good’ CHC) Have a professional perform “visiting” consults (e.g. hygienist in MD office once a week) Create lists for proper referrals – know who does what, what insurance they take, what patient sets they see, etc “Health Homes”

17. Change is difficult Change leads to creative solutions “Change your thoughts and you change your world” Norman Vincent Peale Culture Change

18. Support cross pollination of ideas: Dental supporting fluoride varnish done by medical providers Medical supporting dental doing oral cancer screens, blood pressure monitoring, nutrition advice More inter-professional health in schools/residencies And more! Work synergistically

19. Medical and dental sitting on Head Start, WIC, school health committees Work together on water fluoridation campaigns State Task Force; State Oral Health Plans Watch Your Mouth – trainings to learn the same media messages, social marketing Moving Beyond “Our Offices”

20. Cavity Free at Three (cavityfreeatthree.org) Training practicing oral health and medical professionals together Meet in CHCs, Health Department offices, Community Centers Giving joint faculty appointments in medical and dental schools Use AHEC (Area Health Education Centers) “Train-the-trainer” model The Colorado Experience

21. Train medical and dental to do oral exams, anticipatory guidance and varnish for all children under three Medical need to learn dental elements; dental need to learn to be comfortable with young children and sometimes about varnish Also combine forces for community social marketing Colorado: Cavity Free at Three

22. started in 2008 54  Cavity Free at Three, Master Trainers throughout Colorado have had 89 training presentations since inception over 1500 multi-discipline individuals trained have requests for presentations at 100+ new sites distributed over 22,434 fluoride varnish kits through the trainings  We estimate the total number of children and families in Colorado exposed to Cavity Free at Three to be 40,000! educational materials have been translated to 8 languages, available at www.cavityfreeatthree.org.  Colorado Results

23. Educational opportunities for collaboration

25. www.niioh.org

26. Third Edition

30. Aphthous Stomatitis 30 Three Clinical Forms • Minor: less than 7mm, most common • Major: greater than 7mm • Herpetiform Symptoms • Recurring, painful, solitary, or multiple ulcers • White/yellow pseudomemembrane, surrounded by an erythematous halo Treatment • Most mild aphthae require no treatment • Orabase, topical or intralesional steroids • Avoid trigger foods and chemicals Photos: Joanna Douglass, BDS, DDS

37. Physician Assistants – On the Move!

38. Association of American Medical Colleges

40. Massachusetts - an example of a comprehensive oral plan in evolution

41. State plan

42. Backed by:

43. Better Oral Health Committees Oral Health Advocacy Taskforce Oral Health Caucus Department of Public Health Massachusetts Medical Society Massachusetts Dental Society – CAPIR Dentaquest Foundation The Players

44. 1) Providing school-based dental services for underserved children screen, educate, fluoride and sealant applications added Head Start centers 2) Increasing the amount of oral health care for underserved Actively recruited Medicaid dentist Expand/promote Community Health Centers, Dental Hygiene School 3) Advocacy for oral health policy Change local legislative, administrative, and regulatory policies 4) Establishing a dental residency program Used local health centers/med school create interest in treating the underserved; pool of future local dentists 5) Educating health professionals on oral health medical students, residents and practitioners using Smiles for Life Educate on common issues; build confidence in referrals CMOHI – a regional example

45. 1) 28 schools; 4,423 children (40%); >20 000 service visits 2) Medicaid dentists 14% -> 55% Doubled CHC capacity 3) Reimbursement, “cap” policy; 3rd party payer 4) 9 or 15 residents in area, underserved 5) increase local residencies education – peds, FM, EM and Grand Rounds OB, IS, IM Results

46. Commonwealth of Massachusetts Legislature *Family Health Center of Worcester *Great Brook Valley Health Center Health Care for All and Health Law Advocates Massachusetts Coalition for Oral Health Massachusetts Delta Dental Foundation Massachusetts Dental Society Massachusetts Department of Public Health Massachusetts Society for the Prevention of Cruelty to Children (MSPCC) *Oral Health Initiative of North Central Massachusetts *Quinsigamond Community College Dental Hygiene School Southbridge Public Schools Southern Worcester Neighborhood Center *The Health Foundation of Central Massachusetts *UMass Medical School's Office of Community Programs *UMass Memorial Health Care United Way of Webster and Dudley Webster Public Schools Worcester City Council Worcester Department of Public Health *Worcester District Dental Society *Worcester District Hygienists' Association Worcester Public Schools South Worcester Neighborhood Center * Denotes member on steering committee Partners

47. MA Medical Society – Oral Health Summit OB, Peds, Fam Med, Int Med, Pub Health, ENT, Emerg Med, Cards, Endo, MDS, othr dental experts – DPH, DH, CHW The resolution – A Taskforce The “hook” Medical Initiatives

48. Medical Schools One by one UMass – “every course – spiral curriculum” Medical Residencies Fluoride varnish = gateway Emergency Medicine (procedures) IM (lesions), OB (safety/referrals) PAs, Pharmacy, Nursing CME – AAFP, AAP, on-line Medical Education

49. Anatomy – saliva, teeth, mouth Genetics – cleft lip/palate Doctoring – physical exam Cancer concepts – ICE case – oral cancer Infections – strep, biofilm, herpes, thrush Host Defense – perio and inflammation UMMS Year 1

50. Cardiology – perio-CAD; SBE prophylaxis Pulmonology – aspiration pneumonia The Brain – oral pain Nutrition – sugar and cavities Population Health Clerkship – 2 weeks in oral public health – Headstart, care mobile, prisons UMMS Year 2