1. Oral Health Integration in the Patient Centered Medical Home Presentation to the Practice Transformation Committee of CSI-RI June 19, 2014

2. Presentation Outline I.Goals for dental-medical integration in RI – RI Oral Health Plan II.Does oral health matter? – RI Oral Health Surveillance Report III.What is already happening in RI – Integration survey – Possible best practices

3. “Oral health is critical to an individual’s overall health” Dental caries is the most common preventable chronic childhood disease Nationally, oral cancer is the sixth most common cancer for black men and the eighth most common cancer for white men Periodontal disease is associated with diabetes, heart disease and stroke, respiratory disease, adverse pregnancy outcomes – Pregnant women who have periodontal disease may be 7 times more likely to have a baby that is born too early and too small Evidence of many systemic diseases and conditions can be found in the mouth – Nutritional status, tobacco exposure, microbial infections, immune disorders, and some cancers can be assessed through oral exams

4. R.I. Oral Health Plan 2011 – 2016 Goals 1.Improve access to oral healthcare 2.Implement evidence-based oral healthcare 3.Prevent oral disease, promote oral health 4.Maintain the dental safety net 5.Sustain the oral health workforce 6.Inform oral health policy decisions

5. Specific Goals for Integration R.I. Oral Health Plan Recommendation 3.4 – Expand the patient-centered medical home model to include oral health Recommendation 3.5 – Increase knowledge of the dental/medical home model among dental practices in Rhode Island – Strategy: dental home model

6. 6 Chronic Disease Prevention & Control: Does Oral Health Matter? Oral Health Surveillance Data Report

7. Adults’ Oral Health, U.S. Dental decay experience* – 92% of adults 20-64 years Periodontal disease † – 47% (65 million) of adults ≥30 years – 70% of older adults ≥65 years Edentulism † – 15% of older adults 65-74 years – 22% of older adults ≥75 years * NHANES 1999-2004 † NHANES 2009-2010

8. Periodontitis Measurement  Clinical Self-reported - Tx history - loose teeth - bleeding

9. Per-Capita Dental Expenditure, US Source: Centers for Medicare and Medicaid Services; U.S. Bureau of Economic Analysis; U.S. Census Bureau. Note: Expenditure adjusted for inflation using GDP implicit price deflator. Per-capita dental expenditure in 2012 dollars.

10. Healthcare Expenditure by Source of Financing, 2012 Source: Centers for Medicare and Medicaid Services

11. 11 RI Adults’ Access to Dental Care

12. Annual Dental Checkup/Cleaning among RI Adults ≥45 Years 12 Data sources: 2006, 2008, 2010 RI BRFSS

13. Diabetes Management Recommendations CDC 1 and American Diabetes Association 2 HbA1c test twice/year at minimum A complete foot exam each year A complete dilated eye exam each year At least twice/year dental exams 1.http://www.cdc.gov/diabetes/pubs/tcyd/dental.htm 2.http://www.diabetes.org/living-with-diabetes/treatment-and-care/oral-health-and-hygiene/

14. Diabetes Care, RI Adults ≥ 45 yrs Data sources: 2006, 2008, 2010 RI BRFSS

15. Diabetes Care by Diabetes Education Have ever taken a diabetes course/class? YesNo Dental cleaning 74.4% (70.0-78.8) 71.5% (66.9-76.0) Foot check 83.5% (79.9-87.0) 74.3% (69.7-78.9) Eye exam 85.0 (81.0-88.9) 79.4 (75.0-83.8) Significant at p value <.05 Data sources: 2006, 2008, 2010 RI BRFSS

16. Adjusted Odds of Dental Cleaning (Logistic regression model) PercentAOR (95% CI) Age 45-6472.8%0.86 (0.57-1.30) ≥65 (reference)72.7%— GenderMale72.6%0.91 (0.62-1.33) Female (reference)72.9%— Race/ Ethnicity Non-Hispanic White75.2%1.87 (1.11-3.16) Other (reference)59.5%— Education≤12 yrs (reference)67.7%— >12 years76.6%1.80 (1.23-2.63) Dental coverage Yes74.9%1.64 (1.07-2.51) No (reference)66.5%— Significant at p value <.05 Significant at p value <.01

17. Disparities in diabetes care/management across race/ethnicity, income status, and educational attainment are most pronounced for dental care. Affecting factors might be … - Lack of dental insurance -Lower priority on dental care in competing demand of diabetes care/management -Lack of coordination between medical & dental care -Patient’s attitudes about oral health -Knowledge of the link between diabetes & oral diseases Implication

18. What is Already Happening in RI

19. Survey of Strategies to Coordinate Care in RI July 2011 survey was conducted of all dental centers affiliated with medical centers in RI by Oral Health Commission Safety Net Workgroup Traditionally, medical and dental have been two separate practices Current patient-centered medical home movement presents opportunity for integration American Academy of Pediatric Dentistry first issued support of dental home concept in 2001 – Follows many of the same principles of patient-centered medical home model Clinical evidence for efficacy of dental home for early childhood oral health – Children who have a dental home are more likely to receive preventive and routine oral health care

20. Approaches to Medical-Dental Integration “Oral Health Commission Safety Net Workgroup Patient Centered Medical-Dental Home Initiatives: A Survey of Current and Future Strategies to Coordinate Care in Rhode Island” September 2011 10 medical-dental centers in RI have implemented systems to encourage coordination between dental and primary care

21. Emerging Best Practices in R.I. Shared Medical and Dental Records Patient Orientation to Health Services Routine Screenings on Both Ends Closing the Loop (follow-up communication between dental and medical providers) Joint Staff Meetings Incorporating the dental home into the patient-centered medical home can ensure better coordination and integration of health care services and benefit patients’ overall health and well-being

22. Resources for National Best Practices National Network for Oral Health Access http://www.nnoha.org/ “Promising Practices” programs and initiatives: Integrated pediatric health home projects – Internal referral – Providing preventive services in pediatric waiting rooms – Varnish program by dental hygienists in pediatric clinics Collaborative training between state oral health programs and primary care associations Oral HIV testing in the dental chair Dental-WIC collaboration (at Providence Community Health Centers!) DentaQuest Dental Benefit Solutions http://www.dentaquest.com/ Best practices for member access and higher HEDIS scores: Programs like Dental Homes to help promote regular dental care from an early age Educational materials for members and their families to understand the importance of preventive services

23. Contact Information Junhie Oh, BDS, MPH RI Department of Health Junhie.Oh@health.ri.gov Rebecca Kislak, JD RI Health Center Association RI Oral Health Commission rkislak@RIHCA.org RI Oral Health Commission http://www.oralhealth.ri.gov/