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Family Medicine and Community Health Making Medical-Dental Collaboration Work - Lessons from Across the Country Hugh Silk, MD, MPH Clinical Associate Professor.

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Presentation on theme: "Family Medicine and Community Health Making Medical-Dental Collaboration Work - Lessons from Across the Country Hugh Silk, MD, MPH Clinical Associate Professor."— Presentation transcript:

1 Family Medicine and Community Health Making Medical-Dental Collaboration Work - Lessons from Across the Country Hugh Silk, MD, MPH Clinical Associate Professor April 13, 2012

2 Family Medicine and Community Health Learning Objectives 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

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

4 Family Medicine and Community Health National Medical-Dental Efforts But first – why is this important

5 Family Medicine and Community Health 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

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7 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

8 Family Medicine and Community Health Photos: Donald Greiner DDS MS, ICOHP 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

9 Family Medicine and Community Health 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

10 Family Medicine and Community Health More recently… 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

11 Family Medicine and Community Health Why is this such a big deal? Because… 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!

12 Family Medicine and Community Health How we practice 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

13 Family Medicine and Community Health However, some good news… >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

14 Family Medicine and Community Health Since 2000 2001 American Academy of Pediatrics: Section on Oral Health 2003 Society of Teachers in Family Medicine: Smiles for Life 2006NY DPH: Oral Health During Pregnancy and Early Childhood (2010 CDA Revised OH During Pregnancy Evidence Based Guidelines) 2009 American Dental Association: Access to Care Summit 2010 Dept. of Health and Human Services: Oral Health Initiative 2010Physician Assistants Leadership Summit on Oral Health 2011 Healthy People 2020: Oral Health = Leading Health Indicators 2011 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

15 Family Medicine and Community Health Patient-Centered Medical Home 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 integrated across 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

16 Family Medicine and Community Health “Health Homes” 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

17 Family Medicine and Community Health Culture Change Change is difficult Change leads to creative solutions “Change your thoughts and you change your world” –Norman Vincent Peale

18 Family Medicine and Community Health Work synergistically 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!

19 Family Medicine and Community Health Moving Beyond “Our Offices” 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

20 Family Medicine and Community Health The Colorado Experience 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

21 Family Medicine and Community Health Colorado: Cavity Free at Three 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

22 Family Medicine and Community Health Colorado Results 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.

23 Family Medicine and Community Health Educational opportunities for collaboration

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25 www.niioh.org

26 Family Medicine and Community Health Third Edition

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30 Aphthous Stomatitis 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 30

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37 Physician Assistants – On the Move!

38 Family Medicine and Community Health Association of American Medical Colleges

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

41 Family Medicine and Community Health State plan

42 Family Medicine and Community Health Backed by:

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

44 Family Medicine and Community Health CMOHI – a regional example 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

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

46 Family Medicine and Community Health Partners 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

47 Family Medicine and Community Health Medical Initiatives 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”

48 Family Medicine and Community Health Medical Education 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

49 Family Medicine and Community Health UMMS Year 1 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

50 Family Medicine and Community Health UMMS Year 2 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

51 Family Medicine and Community Health UMMS Year 3 Oral Health Clerkship –Geriatric –Prenatal –Pediatric –Urgent care –Systemic –Fluoride varnish Disabilities Clerkship –Special Needs Oral Health

52 Family Medicine and Community Health UMMS Year 4 Clinical Emergent Problem Solver –Sepsis from oral infection Elective – oral public health Oral Health Interest Group – –2 talks per year –1 community service event

53 Family Medicine and Community Health Medical Providers and Fluoride Varnish A gateway to more oral health and how we are making it work

54 Family Medicine and Community Health Building Upon the Work Done by Others The Gurus –North Carolina –Washington –Maryland

55 Family Medicine and Community Health AAP 2008 – Preventive Oral Health Interventions for Pediatricians –9 recs including risk history and FV 2011 National Quality Forum – includes FV during WCC as 1 of 43 measures In 2007 only 7.5 % of 2-4 year olds in the US had any fluoride treatment In 2009 only 5% of physicians self reported providing fluoride varnish in MA

56 Family Medicine and Community Health Comprehensive program: tri-state (CT 3.5, MA 6.5, RI 1.0 ) Preparation - Project Coordinator prior to site training to allow our trainer to enter a practice ready to implement change Commitment – ensure the office starts varnish use “same day” Practice work flow – identify eligible patients; work it into visits Clinical record – incorporate oral health prompts into the record Billing –Add codes to encounter forms or EHR billing system Train ALL staff – establish buy-in; use web-based training for those who are absent Hands on practice - hands-on patient experiences with hygienist Supply provisions - comprehensive informational packet, patient posters, laminated fact cards, carrying cases with 50 free varnish packets, patient handouts, gauze, gloves, billing stickers/information Follow-up – “adopt a practice”

57 Family Medicine and Community Health Promotion Each state AAP, AAFP meeting – booths, talks, handouts Newsletters List serves Medicaid lists of biggest practices Local success stories Personal connections

58 Family Medicine and Community Health Building Bridges Medicaid – promotion, data, “fixes”, lists State DPH – trainings state Dental Society – train age 1 visits Head Start – coordinate; messaging Dentaquest – hands on AAP – promotion, forum AAFP – presentation, forum

59 Family Medicine and Community Health The next generation Training all pediatric and family medicine residents Leaving in place a plan for future training Converting offices – continuous education >50% of graduates stay in the state

60 Family Medicine and Community Health Year One 16 residencies 100 offices Skilled trainers Residencies with future plan

61 Family Medicine and Community Health Conclusions Medical providers have to be part of the oral health solution Education is a key area to focus on Learn from our success and mistakes in Massachusetts Takes a Village! Fluoride Varnish may be the entry way for many medical providers

62 Family Medicine and Community Health Questions www.smilesforlifeoralhealth.org hugh.silk@umassmemorial.org


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