1. Sarah J. Dirks, DDS Geriatric Dental Group of South Texas, PA San Antonio, Texas 78229 December 2, 2011 1.0 AGD CEUs Oral Care for Residents in LTC Facilities “Overcoming Common Barriers”

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3. 3 Topics: 1. Two Distinct LTC Goals & the Barriers:  Provision of Medically Necessary Oral Care  Provision of Daily Oral Care 2. Three Momentum Makers for Change Research Momentum Regulatory Momentum Culture Change Momentum

4. Provision of Medically Necessary Oral Care Long Term Care Goal #1

5. Provision of Medically Necessary Oral Care LTCF’s must have a providing dentist. Applied income can be used to pay for oral care. TSBDE Rule 115.5 Oral Health part of MDS Fee Schedule More LTC dental practices.

6. Provision of Daily Oral Care In LTC Long Term Care Goal #2

7. 7 Improving Oral Health for LTC Residents in Texas 1. Two Distinct LTC Goals & the Barriers:  Provision of Medically Necessary Oral Care - Dental Profession = primary tactical team - Primary Champion = _____________  Provision of Daily Oral Care - LTC Profession = primary tactical team. - Primary Champion = ____________

8. Reality Check  Dental Profession: stagnant  LTC Profession: in crisis Goal #1: Medically Necessary Oral Care Goal #2: Routine Daily Oral Care

9. 9 Improving Oral Health for LTC Residents in Texas Overcoming Common Barriers (1) Provision of Medically Necessary Oral Care - Dental Profession = primary tactical team (2) Provision of Daily Oral Care - LTC Profession = primary tactical team. Three Momentum Makers for Change

10. 10  Medically Necessary Oral Care is Priority Driven Care. - Relieve - Manage - Prevent - Increase - Improve - Keep

11. 11 Improving Oral Health for LTC Residents in Texas Overcoming Common Barriers (1) Provision of Medically Necessary Oral Care - Dental Profession = primary tactical team

12. 12 Who Provides Medically Necessary Oral Care to LTC Residents? Geriatrics Practices: Focused on LTC Facilities Mobile Services & In Office Services Metropolitan Areas & Smaller Communities Periodic rotations by contract dentist Services may be Provided Room by Room Services Provided in Multipurpose Treatment Room Partner with Podiatrist? Other Medical Teams? New facility construction? General Practices: Focused on Continuum of Care Mobile hygiene services? & In Office Services Metropolitan Areas & Smaller Communities

13. 13 Report: Building Better Oral Health ADA commissioned independent third-party report on the issue of access to oral health care in Texas Identify the state’s most pressing issues, needs and challenges associated with improving the oral health of all Texans. Special focus on the state’s most vulnerable. www.buildingbetteroralhealth.org Recommendation #5

14. 14 Policy Recommendation (5/5) Building Better Oral Health Expand access to oral health services for older Texans Provide incentives to encourage dentists to practice in LTC facilities: Loan payback programs young dental graduates/retired dentists (experienced foreign trained dentists – expedited path to licensure?) (encourage life cycle continuum of care)

15. 15 Common Barriers: Dental Profession  Mainstream dental office ≠ LTC dental office Complex Coordination of Care Solution: Develop LTC administrative systems Medically Compromised Patients Solution: Implement strict clinical protocols

16. 16 Develop Administrative Systems and Protocols Tailored to LTC Learn LTC lingo/enter the culture of LTC Have SW or DON fax medical info to office prior to exam visit or hygienist visit to NF. Establish 3 rd party protocols Medical & Financial RP Consent Forms Templates for NF premeds, po antibiotics, post-op orders, oral hygiene orders, etc. Written authorization for hygienist template Documentation of phone conversations

17. 17 Solutions Continued: 3 rd Party Contacts: Medical/$ POA Resident’s Spouse Primary Care Physician Resident’s dentist of record Director of Nursing Social Worker Business Manager Production musts: Set minimum # of pts Plan on compressed tx hours at NF due to lunch Have pt room #’s Premeds called in the day before Confirm pt will be there Be flexible Be positive

18. 18 Solutions: Strict Clinical Protocols Preprocedural brushing with Chlorhexidine Cardiac & stress reduction protocols on all residents Use high quality pt monitoring device Blood pressure/O2 saturation HVE /minimal water/ more upright INR monitor, blood glucose monitor Pre and post blood pressures

19. 19 The Exception becomes the Norm Complex coordination of care Administrative systems Compromised patients Clinical protocols

20. 20 GDG Ideal Protocol – “NF Flow” Resident needs medically necessary oral care SW completes IME paperwork & calls our tx coordinator to initiate treatment DDS reviews MARS & provides written authorization for dental hygienist to go to NF: Begin initial charting, take x-rays, FMD DDS reviews x-rays & hygienist notes DDS goes to NF to provide COE

21. 21 STATE BOARD OF DENTAL EXAMINERS Texas Administrative Code TITLE 22 PART 5 CHAPTER 115 TITLE 22CHAPTER 115 EXTENSION OF DUTIES OF AUXILIARY PERSONNEL--DENTAL HYGIENE RULE §115.5 Dental Hygienists Practicing in Certain Facilities

22. 22 Improving Oral Health for LTC Residents in Texas Overcoming Common Barriers (1) Provision of Medically Necessary Oral Care - Dental Profession = primary tactical team (2) Provision of Daily Oral Care - LTC Profession = primary tactical team. Three Momentum Makers for Change

23. 23 Oral Care Provided by Certified Nursing Assistants in Nursing Homes Journal Am Geriatr Soc 54:138-143, 2006 Patricia Coleman, PhD, RN First observational study in U.S. Nursing Homes of oral care actually provided to residents by CNA’s

24. 24 Dentate Nursing Home Residents CNA Self Report Teeth brushed: ? Mouth rinse: ? Teeth flossed: ? Time brushing: ? Clean gloves worn: ? Actual Care Observed Teeth brushed: ? Mouth rinse: ? Teeth flossed: ? Time brushing: ? Clean gloves worn: ? CNA’s were told that observations were to understand morning care.

25. 25 Supplies Available to Provide Oral Care of residents had toothbrush/paste of residents had mouthwash of residents had floss had no visible supplies

26. 26 Three Promising Momentum Makers for Change Research Momentum Regulatory Momentum Culture Change Momentum

27. 27 Momentum Makers for Change (1) Research: Utilize BSS for residents in LTC facilities Basic screening survey for older adults Determine financial burden for LTC facility to provide daily oral care Pilot Project: Oral Care Specialty Trained CNA How many man hours? 1 CNA/100 bed facility/per day?

28. 28 Momentum Makers for Change  (2) Regulatory Pressure/Legal Issues Training of CNAs BBOH Policy Recommendation #5 Surveyor Expectations: BBOH Policy Recommendation #5 Oral Neglect

29. 29 Policy Recommendation (5/5) Building Better Oral Health Expand access to oral health services for older Texans Mandate that all providers who assist in activities of daily living for the physically dependent or elderly be properly trained in providing oral hygiene.

30. 30 Momentum Makers for Change  (2) Regulatory Pressure/Legal Issues Training of CNAs BBOH Policy Recommendation #5 Surveyor Expectations: BBOH Policy Recommendation #5 Oral Neglect

31. 31 Procedures for Review of Dental/Oral Status of Residents (1) Interview resident & family (2) Visual observation of residents’ mouths (3) Record review (4) Observation of the oral care furnished

32. 32 Policy Recommendation (5/5) Building Better Oral Health Expand access to oral health services for older Texans Require that nursing home inspections include a mandatory oral health component.

33. 33 Momentum Makers for Change  (2) Regulatory Pressure/Legal Issues Training of CNAs BBOH Policy Recommendation #5 Surveyor Expectations: BBOH Policy Recommendation #5 Oral Neglect

34. 34 “ Defining Oral Neglect in Institutionalized Elderly” “ “A consensus definition for the protection of vulnerable elderly people” Journal of the American Dental Association Vol. 141 – April 2010 Katz, R., Smith,B., Berkey, D.,Guset,A.,O’Connor,M. Federal payments to nursing facilities require that there be no oral neglect. 34

35. 35 Time to qualify as neglect # of days after which failure to have a dental consultation would constitute oral neglect Acute Condition = 3 days Chronic Condition = 14 days # of days after which failure to initiate or reject treatment would constitute oral neglect Acute Condition = 5 days Chronic Condition = 21 days 35

36. 36 Rapid Oral Decline in Frail Elderly Multiple co morbid medical conditions Medication induced xerostomia Aging restorations Decreased ability and/or inability for self daily oral care Decreased ability to get to dental office Decreased ability to tolerate routine care

37. 37 Momentum Makers for Change (2) Regulatory Pressure/Legal Concerns  Oral Neglect and relevance to the: Initial screening of resident’s oral status Federal mandate Within 14 days of admission Usually screened by nurse Part of Minimum Data Set

38. 38 Minimum Data Sets Comprehensive health assessment Includes oral health Sections K and L Goal is to identify oral health problems and therefore a plan of care and intervention is triggered

39. 39 Minimum Data Set Items Related to Oral Cavity: Chewing Problem Mouth Pain Debris in Mouth Some or all natural teeth missing Broken, loose, carious teeth Inflamed gums Has daily mouth care by resident or staff 39

40. 40 Promising Momentum Makers for Change (1) Research Momentum (2) Regulatory Momentum (3) Culture Change Momentum

41. Culture Change  DON is Key to Geriatric Oral Health

42. 42 Momentum Makers for Change  Culture Change The Promise of Collaboration: Dentistry must enter the world of LTC Redefine and discover new relationships Trust, unity, shared purpose, & understanding

43. 43 Momentum Makers for Change  Culture Change The Promise of Collaboration: New Relationships: Examples DON and contracted dentist? DON and consultant dental hygienist? Dental hygienist and oral care aide? TSBDE & expanded function hygienist?

44. 44 Example: Trust and Collaboration Minimum data set Sections K and L Oral Health Dental professional provides initial oral screening and/or examination after admission to NF.

45. 45 Promising Momentum Makers Culture Change Momentum Future Collaborations? Dentist Director & Facility Administrator? Hygienist Consultant & Facility Administrator? Facility Wide Oral Care Program Hygienist Consultant & DON? Individual Resident Oral Care Plan

46. 46 LTC Facility Oral Health Program Dental Consultant + Administrator  Oversee/implement facility’s daily oral care program  Coordinate facility’s medically necessary oral care plan  Social worker/family/transportation/pt preferred dentist  Develop yearly/periodic screening or exam schedules  Provide education and in-service training  Specialty training of assigned “Oral Care Aide”  Maintain oral care records/documentation  Maintain needed individualized oral care supplies  Help facility meet federal and state regulations  Conduct periodic quality assurance

47. 47 Individual Resident’s Plan Dental Hygienist Consultant + DON  Resident Advocate  Family Liaison  Work with Social Worker - Funding options  Provision of:  Initial Oral Screening?  Daily Oral Hygiene Plan  Documentation of daily care  Coordination of:  Resident’s Medically Necessary Dental Plan

48. 48 LTC Hygienist Consultant (Liaison ) Responsible/reports to: Authorizing dentist Requires written authorization: TSBDE Rule 115.5 Administrator??????? Medical director????? Coordinates with: Resident and resident’s responsible party Resident’s preferred dentist/dentist of record DON and communicate special precautions OT, PT, Speech Pathology

49. 49 The Role of a Liaison? Answer questions Find resources Share information Facilitate processes Support efforts Help connect Solve problems

50. 50 The promise of transdisciplinary Nurse-dental hygienist collaboration In achieving health-related quality of life for elderly nursing home residents www.dentaliq.com Grand Rounds in Oral-Systemic Medicine September 2006, Vol.1. No. 3 Pages 40 - 49

51. 51 Oral health coordinators in long-term care — a pilot study Special Care in Dentistry Volume 30, Issue 2 - pages 59–65 March/April 2010 Pronych, G. J., Brown, E. J., Horsch, K. and Mercer, K.

52. 52 Oral health education for nursing personnel; experiences among specially trained oral care aides: One year follow-up Scand J Caring Sci Volume 17: pages 250-256 2003 Wardh, I. (dentist); Hallberg, L. (RN); Berggren,U.; Andersson,L.

53. Promise of Future Collaboration?

54. 54 Resources www.oralhealthamerica.org www.buildbetteroralhealth.org www.thetrecsinstituge.org www.astdd.org www.txoralhealthcoalition.org www.oralhealthamerica.org Patricia Coleman, RN, PhD Articles

55. 55 Sarah J. Dirks, DDS 210 - 617- 4446 www.geriatricdentalgroup.com