1. .
SPNS IHIP Oral Health Webinar Series: Healthy Mouth, Healthy Body ………………. Presented by CDR Mahyar Mofidi, DMD, PhD and Jane Fox, MPH December 13, 2013

2. Agenda
Introduction to SPNS Integrating HIV Innovative Practices (IHIP) project
Sarah Cook-Raymond, Managing Director of
Impact Marketing + Communications
Presentations from:
Dr. Mahyar Mofidi; Branch Chief of the Division of Community HIV/AIDS Programs and Chief Dental Officer, HRSA HIV/AIDS Bureau
Jane Fox, MPH; Project Director of SPNS Oral Health Initiative Evaluation Center for HIV and Oral Health (ECHO), Boston University School of Public Health
Q & A *

3. IHIP Resources on TARGET Center Website www.careacttarget.org/ihip

4. IHIP Oral Health Resources
Training Manual
Curriculum
Pocket Guide
Webinar Series
Healthy Mouth, Healthy Body
Dental Case Management
Clinical Aspects of Oral Health Care for PLWHA
Recording and slides for all Webinars will be uploaded to TARGET Center Web site following the live event:

5. Other IHIP Resources Buprenorphine Therapy
Training Manual, Curriculum, Monograph, and Webinars on implementing buprenorphine in primary care settings
Engaging Hard-to-Reach Populations
Training Manual, Curriculum, and Webinars on engaging hard- to-reach populations
Jail Linkages
Training Manual, Curriculum, Pocket Guide, and Webinars on enhancing linkages to HIV care in jails settings
UPCOMING: Hepatitis C Treatment Expansion
In Spring/Summer 2014, look for training materials on increasing access to and completion of Hepatitis C treatment for PLWHA on the TARGET Center Web site.

6. CDR Mahyar Mofidi, DMD, PhD
Healthy Mouth, Healthy Body: Oral Health Care's Vital Role in Overall Well Being for People Living with HIV/AIDS
CDR Mahyar Mofidi, DMD, PhD
Branch Chief
Chief Dental Officer
HRSA, HIV/AIDS Bureau
December 13, 2013

7. 12+ years ago You cannot be healthy without oral health.
Oral health is essential to overall health and quality of life, and all families need access to high-quality dental care.

8. Oral Health for PLWHA
“While good oral health is important to the well being of all population groups, it is especially critical for people living with HIV/AIDS (PLWHA). Inadequate oral health care can undermine HIV treatment and diminish quality of life, yet many individuals living with HIV are not receiving the necessary oral health care that would optimize their treatment.” -U.S. Public Health Service Surgeon General Regina M. Benjamin, MD, MBA

9. Why does good oral health matter in HIV care?

10. Oral Disease in HIV Infection
Oral infections and neoplasms occur with immunosuppression
(bacterial, fungal, viral, neoplastic, lymphoma, ulcers)
High prevalence of dental caries and periodontal disease
32-46% of PLWHA have at least one oral disease condition related to HIV
Some HIV medications have side effects (xerostomia or dry mouth) which can lead to tooth decay and periodontal disease

11. Dental caries were present in 66% of patients
Prevalence of Dental Caries and Periodontal Disease in a Ryan White HIV/AIDS Program-Funded Dental Clinic
Dental caries were present in 66% of patients
54% had gingivitis and 28% had periodontal disease
Infectious Disease Society of America (IDSA) 47th Annual Meeting – November 2009 – Poster #1063

12. Oral Manifestations of HIV/AIDS
For those with unknown HIV status, oral manifestations may suggest HIV infection, although they are not diagnostic.
Reznik DA. Perspective - Oral Manifestations of HIV Disease.
International AIDS Society–USA Topics in HIV Medicine.
Volume 13 Issue 5 December 2005/January 2006

13. Oral Manifestations of HIV/AIDS
For persons living with HIV disease not yet on therapy, the presence of certain oral manifestations may signal progression of disease.
Reznik DA. Perspective - Oral Manifestations of HIV Disease.
International AIDS Society–USA Topics in HIV Medicine.
Volume 13 Issue 5 December 2005/January 2006

14. Oral Manifestations of HIV/AIDS
For persons living with HIV disease on antiretroviral therapy, the presence of certain oral manifestations may signal a failure in therapy.
Hodgson TA, Greenspan D, Greenspan JS. Oral lesions of HIV disease and HAART in industrialized countries. Adv Dent Res Apr 1;19(1):57-62

15. Oral Disease is Rarely Self-Limiting
Oral health diseases are linked to systemic diseases: diabetes, heart disease, pregnancy issues
Untreated oral disease may lead to systemic infections, weight loss, malnutrition
Oral diseases impact quality of life: psycho-social problems, limited career opportunities

16. How can dental providers make a difference?

17. Role of Dental Providers
Eliminate infection, pain, and discomfort
Restore oral health functions
Early detection of HIV and referral: Oral lesions can be the first overt clinical feature of HIV infection. Early detection can improve prognosis and reduce transmission/
A visit to the dentist may be a health care milestone for PLWHA. The dental professional can address oral health concerns and play a role in helping engage or re-introduce patients into the health care system and coordinate their care with other primary care providers.

18. What are the Benefits of Early Linkage to Oral Health Care After HIV Diagnosis?
196 HIV-positive individuals:
63 newly diagnosed cases (out of oral care and within 12 months of their HIV diagnoses)
Previously diagnosed controls (66 out of oral care and diagnosed with HIV between )
Historical controls (67 receiving regular oral care and diagnosed with HIV between )
IADR – March Jennifer Webster-Cyriaque DDS, PhD – UNC School of Dentistry.

19. Findings
Persons who were newly diagnosed had significantly more teeth at baseline compared to the previously diagnosed and historical groups.
Newly diagnosed individuals had less periodontal disease (attachment loss and less bleeding on probing).
Previously diagnosed individuals had poorer gingival health and more broken teeth.
The previously diagnosed group had the most dental decay.
Service usage varied considerably:
Newly diagnosed: more preventive and maintenance services
Previously diagnosed: more costly prosthodontic services
IADR – March Jennifer Webster-Cyriaque DDS, PhD – UNC School of Dentistry.

20. Findings
The higher levels of dental disease in the previously diagnosed group resulted in higher treatment costs.
“Early dental intervention in the newly diagnosed HIV-positive individuals results in significant functional maintenance, more optimal oral health, and considerable financial savings.”
IADR – March Jennifer Webster-Cyriaque DDS, PhD – UNC School of Dentistry.

21. What oral health needs/barriers do PLWHA face?

22. Unmet Oral Health Needs
Oral health is one of the top unmet needs for PLWHA who obtain services through the Ryan White HIV/AIDS Program nationwide.
PLWHA have more unmet oral health care needs than the general population and have more unmet oral health care needs than medical needs.
PLWHA most likely to report unmet need for dental care are African American, uninsured, Medicaid recipients, and within 100% of federal poverty limits.

23. Barriers to Oral Health Care
Lack of dental insurance
Limited financial resources
Shortage of dentists
Too many appointments, other aspects of illness seen as being more important
Fear, no positive role models, stigma, shame
Negative patient-provider experiences
Shrinking adult dental Medicaid benefits

24. State Adult Dental Coverage in Medicaid, 2013
Number of states 18 14 10 9
Source: ADULT DENTAL BENEFITS IN MEDICAID, ADA

25. Oral Health Care is Expensive
Service
National average fees charged by private practitioner
Sample reimbursed fees by Medicaid
Comprehensive oral evaluation/ examination
$66.29
$ $44.61
Limited oral evaluation
$57.60
$ $36.76
Intraoral radiograph (first film)
$23.41
$ $14.91
Adult cleaning
$77.64
$ $58.00
Filling (amalgam, one surface)
$110.35
$ $64.56
Filling (clear, one surface)
$131.30
$ $65.90
Extraction (simple)
$138.21
$ $63.54
Extraction (surgical)
$224.11
$ $109.23
Endodontic (molar root canal)
$868.00
$ $409.90
Crown (porcelain)
$908.00
$580.00
Complete denture (upper)
$1,333.57
$584 - $600

26. What are we doing about oral health?

27. Oral Health: HRSA Strategic Priority
Expand oral health and integrate it in primary care settings

28. Ryan White HIV/AIDS Program and Oral Health Services
Safety net

29. SPNS OHI
Special Projects of National Significance Innovations in Oral Health Care Initiative
15 sites across country
Grantees implemented innovative models of comprehensive oral health care services to expand dental access

30. Other HIV/AIDS Bureau Oral Health Investments
Oral health capacity assessment during site visits
All Grantee Meeting
Oral health performance measures
Oral health a funding priority under Part C Capacity Development Funding Opportunities
Program evaluations
Publications

31. Impact of Ryan White HIV/AIDS Programs on Oral Health Care
FY 2011: 135,004 clients received dental services
FY 2011: 8,480 dental providers (mostly dental students and residents) provided direct oral health care as part of CBDPP and DRP
FY 2011: 8,461 health care professionals (3,451 dental, 5,010 non dental) received oral health care education through AETCs

32. Impact on Our Clients
“People treat you as if they have known you their whole life.”
“They take care of my fear.”
“They are like a big family…they gave me my smile back.”
“I feel free, secure and welcomed by the staff.”
“I feel comfortable…not treated as a HIV patient but a person who needs dental care.”
“We’re all so fortunate to get what we need.”
“It’s affordable. It’s a one stop shop.”
“This is the only game in town.”
“Quality of care here is 110%.”

33. Acknowledgment
Dr. David Reznik

34. Contact Info
CDR Mahyar Mofidi, DMD, PhD HRSA/HAB Chief Dental Officer

35. Evaluating the HRSA SPNS Oral Health Initiative
Jane Fox, MPH Boston University

36. HRSA Oral Health SPNS Initiative
September 2006 HRSA funded 15 sites and one evaluation & TA center
Five year funding cycle
Sites were charged with increasing access to oral health care for PLWHA
Eval center at BU
Site could design any program to meet this goal.
Evaluation center: Study design includes a quantitative survey with patients – baseline, 6 and 12 months (with an optional 18 and 24), collection of all dental utilization data, and a qualitative study with in-depth interviews with 60 patients from 6 sites.

37. SPNS Sites 15 sites = 7 urban and 8 rural
2 in NYC, 2 in CA and one in USVI. The remainder are scattered.

38. SPNS Models - Typology Three types of host agencies
ASO/CBO (5), CHC (4), and hospital/University-based programs (6)
Three basic models:
Fixed site
Expansion of prior dental program/services
Implementation of new dental program
Mobile dental units
Since sites were not required to follow a set format in creating their programs, we designed a typology to categorize the programs for descriptive purposes. All of the sites fall into one of these 3 types of host agencies and have adopted one of these 3 basic models. Fixed sites either expanded the kind of services they provided or expanded their service area by opening satellite clinics.
Other commonalities we looked at across the sites were the use of a case manager – either dental specific or the HIV case manager and collaboration between the sites and a dental/hygiene school.

39. Evaluation Study Questions
Do the demonstration programs increase access to oral health care for the target population?
What are the main similarities and differences in strategies and program models to increase access to oral health care across programs?
Are the oral health services performed in accordance with professional practice guidelines?
Do clients experience improvements in health outcomes over time?
Working with the sites and HRSA we came up with 8 study questions we proposed to answer by the end of the project.

40. Evaluation Study Questions
Are clients’ oral health care needs met?
Do clients experience improvements in oral health related quality of life after enrollment in oral health care?
What strategies are most effective in furthering successful program implementation: barriers, facilitators, key lessons learned?
What strategies to address the structural, policy and financing issues can be replicated in other settings?

41. Evaluation Study Design
Study criteria
HIV+, 18+ years of age, and no oral health care* for the past 12 months or more
Quantitative survey at baseline and follow-up
Demographics, past access, insurance, HIV status, past oral health symptoms, SF-8, OH QOL, and presenting problem
Utilization and ancillary data
CDT codes of EVERY procedure done, evidence of tx plan completion and recall
Quantitative survey at baseline, 6, 12 and optional 18 and 24
Challenges of collecting utilization data – Every procedure by code vs billing codes and formal vs informal recall systems
Ancillary data – optional and good consistent data from 5 sites

42. Evaluation Study Design
Qualitative interviews
In-depth interviews of 60 patients at 6 sites
OH experiences and values, OH self care knowledge and behaviors, patient education, and impact of HIV on OH
Dental case manager focus group
June 2008 with 12 participants
Two sets of qualitative interviews have been conducted with this subset of patients months apart.
Sites included HIV Alliance, Montefiore, Native American Health Center, Special Health Resources in Texas, St Luke’s Hospital and the University of Miami
DCM is a new concept so we hosted a focus group to gather more information about the tasks, training and needs of this type of professional

43. Patient Demographics 75% male 40.6% Black, 21.2% Latino
33.4 % high school education, 43.0% beyond high school
30.6% working, 55.7% monthly income < $850
Age = 43.6 (18 – 81),
Yrs positive = 10.07
N=2469
11.7% patients were diagnosed in the past year
More than half the patients reports their last dental visit 2 or more years ago.

44. Baseline Dental Access
Usual place for dental care: 38.6% none; 31.0% private dentist
48.2% reported needing dental care but were not able to get it since testing positive
Of those who did not get dental care, 53.8% stated affordability as the reason.
Usual place for dental care
None 37.6
Private dentist 30.4
Community health center 17.9
Dental school 5.4
Other 6.7

45. Baseline HIV Status
97.5% had a regular place for HIV care and 95.0% had seen their HIV provider in the past 6 months
85.2% had an HIV case manager and 77.9% were taking ARTs
57.35 had a CD4 count over 350 and 52.8% had an undectable viral load

46. Significant Changes in Outcomes at 12 Months, N=1391
Baseline
12 Mos.
Report unmet need for oral health care
48%
17%
Report good/excellent health of teeth and gums
38%
67%
Oral health symptoms: mean (SD)
3.35 (2.34)
1.78 (1.93)
We found significant changes at 12 months related to a reduction in unmet need for oral health, improvement in the overall health of peoples’ teeth or gums and the total reduction in symptoms.

47. Significant Changes in Oral Health Symptoms at 12 Months, N=1391
We also found significant reductions in oral health symptoms over 12 months, as we would hope to find. All of these were significant at p<.001

48. Significant Changes in Habits at 12 Months, N=1391
Baseline
12 mos
P value
Daily brushing
83%
82%
.407
Daily flossing
19%
25%
<.001
Flossing at all in past 6 months
53%
62%
Current smoker
50%
45%
Eating candy or chewing gum with sugar
61%
52%
Drinking soda with sugar
64%
31%
Jane
In bivariate analysis we saw some significant changes in habits related to oral health over 12 months.
No significant change in brushing habits, but flossing habits changed a lot. Still not great, but an improvement.
A small but significant change in smoking.
Larger changes in sugar consumption – via candy, gum or soda, and a significant change in teeth grinding.

49. Patient Perspectives - Habits
Improvements in oral health care practices
Better brushing & flossing techniques & frequency
“ Now I buy lots of toothbrushes and use them for a short time and replace them.”
“I brush everyday instead of 3 times/week...I floss a lot more”
“I brush longer”
Reduce or stop smoking/tobacco use
“ I still use snuff but I cut back a little and don’t leave it in my mouth as long...”
“I cut down from 3 cigarettes/day from 1 pack...”
Dietary changes
“I still drink soda but only once in awhile...I try not to buy it”
We also conducted a qualitative study with 60 patients and conducted a second in-depth interviews with 39 of the patients: at the baseline period of receiving oral health care; At the initial interview we asked about their experience with dental care as a child, prior to being diagnosed with HIV, and post diagnosis; We asked about their values attitudes and practices about dental care and taking care of their teeth; At follow up interviews approximately 12 months of being in the program we asked about:
New information learn
Changes in the oral health & hygiene behaviors
The role of the staff and specifically the dental case manager, care coordinator patient navigator in the dental care
What made the biggest differences with oral health care

50. Standards of Care We established a set for the multi-site evaluation:
The presence of a comprehensive exam
The presence of any xrays
The presence of any cleaning or periodontal work
Completion of Phase I treatment plan
Patient placed on recall
In the absence of professionally accepted standards of care, we established a set for the multi-site evaluation – at the time HAB did not have their standards out and there are no standards of care from the ADA.
There is just one HIV Qual measure and for the sites that are collecting this information, they ask patients if they have had at least one dental visit in the past year. The type of visit is not defined.
Phase 1 Treatment: Prevention, maintenance and/or elimination of oral pathology that results from dental caries or periodontal disease.

51. Service Utilization: N=2178, 14 sites
Over the course of the study:
Patients made over 15,000 clinic visits
They received over 37,000 services
917 (42%) completed a Phase 1 treatment plan
Services provided in first 12 months of care
# provided
Pts who received any service
n /%
Clinic Visits
11,315
2178
100%
Phase 1 Treatment Plans Completed*
717
33%
Comprehensive Exams
2077
1944
89%
Although there were 15 sites in the study we were only able to use the treatment data from 14 of the 15 sites.
*Phase 1 Treatment Plan = Prevent and treat active disease

52. Access to & Retention in Care
43% of patients came in for preventive care
64% of patients were retained in care
Those retained in care were:
More likely to complete their treatment plan
More likely to have a recall visit
Reported less pain, fewer symptoms at follow up
Factors significantly associated with retention
Older age, better physical health, on HIV medications, more recent dental visit
Receipt of patient education – 6 times as likely to be retained in care
This 43% reported having no other problem, they just wanted a cleaning or checkup
Looking at participants who were in the study 18 months or more (N=1466) we looked at the rate of retention (defined as 2 or more dental visits at least 12 months apart during an 18 month or greater observation period)
In multivariate analysis controlling for clustering by site and other factors significantly associated with retention in bivariate analysis, a number of factors were significantly associated with retention in care, but one really stood out – the receipt of patient education.

53. “…I very rarely go. I was not a regular client at the dentist because my parents only took me to the dentist once in my life and so I didn’t know the need for follow-up dental—you know keeping a good hygiene program until I got older.”
As we found in the longitudinal quantitative study, some patients did not get oral health care because they could not afford it. We also found that many patients just did not know or value the importance of oral health care. A little less than half of the patients interviewed in the qualitative study indicated an unstable history of oral health care.

54. Our study and past studies such as the HCSUS study have documented a need for dental care for HIV patients. So it should be as easy as just opening up new clinics, expanding what is already in place or designing and implementing a mobile unit. Taking the cost factor out of the way patients will flock to oral health care right?

55. Engagement in Care
“Outreach and retention were two things we did not anticipate to be problematic when planning for this grant. As we began to open our clinic and serve patients, we realized that this is one of the most important aspects of operating a dental clinic for this population.”
Not true. Most of the sites found that although they built it, the masses of patients did come. This is at least not with out a little or in some cases a lot effort on their part.

56. Getting Patients in the Door
Marketing
Paid & unpaid media
Community materials
Literacy level
Outreach to providers
Clinicians
Case managers
Other CBOs
Ancillary services
Transportation
Other social or medical services
Special events
SPNS days
Word of mouth
Peers
Marketing – Almost all sites did some sort of mass marketing – PSAs, newspaper ads, announcements in CBO/clinic newsletters
Targeted marketing was much more successful than wide spread efforts
Patient targeted community materials – CHC story
Outreach to providers for referrals – HIV case managers overloaded
Ancillary services – helping patients to get there – ACG and SHRT
SPNS days – contrary to what many consider as a positive method of providing OH care to HIV patients, integrating HIV patients into an existing care system. Dedicated SPNS days and expanded clinic hours were very successful in getting patients in the door.

57. Keeping Patients in Care
Follow-up appointments
Timely and efficient
Reminder calls
Dedicated staffing
Patient navigators/dental case managers
Staff skills and relationships with patients
Patient education and empowerment
“When both the dentist and the dental case manager reviewed the treatment plan with the patients, the patients gained a better understanding of why the proposed treatment was needed.”
Incentives
“thank you gifts”
transportation
Patient retention has proved challenging for a number of reasons. Here are some of the barriers we have identified.
Patient population – this is not always a priority for patients especially after they realize how much work they need to have
The dental clinic system – multiple follow-up appts and scheduling
Relief of pain versus completing a treatment plan
Patient experience – getting there, staff interaction, dentist/hygienist interaction
Strategies:
Scheduling appts and reminders – two strategies to reduce no show rates that have been identified include scheduling follow-up appts quickly and providing reminder calls the day before and/or of the appt.
Dedicated staffing such as a dental case manager or patient navigator who has frequent contact with patients to help patients stay in care. This person also works closely with the HIV case manager.
Patient education – unified messages from dental staff and motivation interviewing techniques to build patient relationships and teach self-care techniques.
Incentives – provide a thank you gift for the patient’s time and effort getting into care once the treatment plan is completed. This is not advertised but patient word of mouth is a powerful tool. And reimbursing for or providing transportation to follow-up appts.

58. Dental Case Management
8 programs included dental case management
5 in non-urban settings and 3 in urban settings
DCMs were either
Dental assistants who were given training on case management; or
HIV case managers who were given training on oral health topics
758 patients were enrolled into the study from the 8 DCM sites.
They had a total of 2715 encounters with a DCM over the course of a year of treatment.
Appointment reminders/rescheduling
Arranging or providing transportation
Provision of food or nutritional information
Provision of oral health information and support
Outcomes
Participants with more DCM encounters were significantly more likely to complete their Phase 1 treatment plan at 12 months, be retained in oral care and experience improvements in overall oral health and mental health status.
Participants with 5+ DCM encounters (23%) were 2.73 times more likely to complete their treatment plan compared to those with just one DCM encounter. (Lemay, et.al)
IHIP webinar scheduled for January 9th.
Of the 2715 encounters
29% had one encounter
21% had 2 encounters
27% had 3 -4 encounters
23% had 5+ encounters
Most frequent encounters were

59. “ ” Patient Perspectives DCMs
She has helped me very much. First and foremost, she has helped me just with the comfort level of dealing with a place like this. I am kind of intimidated by a dentist. I mean, who is not? But she has been very comforting and she has been very good at explaining procedures. If it wasn’t for what she has done for me as far as helping, scheduling, talking, sitting with me during the dentist and everything, I may not have followed through. So it has made a really big difference. It makes me feel like there is somebody committed to my dental care, so my commitment can’t be any less than that. ”

60. Patient Perspectives- The role of the DCM
Access to oral health care
“I would not have dental care if it wasn’t for (name of dental case manager)”
“He (dental case manager) got me into the program and it has been good to me”
Retention in dental care
“ I feel comfortable with her and it makes me want to come to appointments”
Helps with patient/provider communication
Provides oral health education
This quote from a X patient “she has helped be very much…” hanging on wall —exemplifies several of the themes from patients about the role of Dental case managers—
Overall we found roles that DCM’s play include (these are listed on the posters):
Helping with accessing dental services
Better retained in care
Reducing fear about dental procedures
Explaining and demonstrating how to take care of mouth and teeth & sharing information
Helping patients communicate and coordinate care with dental and medical providers; between dental providers

61. Policy Implications
Successful strategies for outreach, engagement and retention in dental care
Increasing access is feasible
Standards of care
Patient and community education
Workforce innovations
Future financing and sustainability
The HRSA standards of care are important, even if somewhat controversial in the field. This is the first time extensive data have been collected to look at things like treatment plan completion rates and recall visits.
Increasing access is feasible – especially if cost barriers are removed. Even though they had been out of care for over a year, and for the majority over 2 years, people came into care through referrals from medical providers, case managers and through publicity and outreach. And many of these were people who were not experiencing active pain – just wanted a cleaning.
If care is provided and funded, then patient and community education are critical to ensure that people enter care and stay in care. Patient education had a six-fold effect on retention in care, highlighting the importance of this activities. In all the discussion over the training and competencies of mid-level dental clinicians, we need to remember this essential public health function that should be part of any job description.
Finally, finding secure financing is essential to sustainability and we now have information about the range of costs and range of care to fit every budget – information that we help will be useful in discussions around reauthorization.

62. Evaluation Center for HIV and Oral Health
Contact Information
Jane Fox, MPH
Evaluation Center for HIV and Oral Health
Boston University

63. Upcoming Oral Health Webinars
Dental Case Management
January 9, 2014 at 1 PM EST
Presenters:
Dr. Howell Strauss and Mr. Nelson Diaz, AIDS Care Group of Chester, PA
Dr. Carolyn Brown and Ms. Lucy Wright, Native American Health Center of San Francisco, CA
Clinical Aspects of Oral Health Care for PLWHA
January 22, 2014 at 3 PM EST
Dr. David Reznik, HIVDent and Grady Health System of Atlanta, GA
Ms. Helene Bednarsh, RDH, MPH, HIVDent and Boston Public Health Commission of Boston, MA

64. IHIP Web site: www.careacttarget.org/ihip
Q & A
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