1. “Dental Homes for Nursing Home and Geriatric Patients” Patricia Skur, DDS Assistant Professor Baylor College of Dentistry TAMHSC

2. Larger proportion of society that is older More people in need of long-term care After 2020, exceptional slow labor force growth, including people who could provide long-term care Changing Risks for Society

3. How many elderly are there? 35 million now, doubling to 70 million by 2030

4. How many elderly are there? 35 million now, doubling to 70 million by 2030

9. Places Where Long-Term Care is Provided At Home by family At Home by skilled and less skilled personal assistance At day care centers In a variety of senior housing alternatives In assisted living facilities In nursing homes

10. Options for Individuals to Finance Long-Term Care Retirement saving and assets Move into a continuing care retirement Community (CCRC) or life-care community Purchase long-term care insurance

11. Current LTC System Little planning, especially on the part of individuals Health insurance does not integrate social services Medicare does not cover most long-term care needs Medicaid, by default, has become the primary source of financing Medicaid eligibility varies by state Medicaid home and community-based waiver services vary from county to county Availability of services varies dramatically by region Neither private long-term care insurance nor Medicaid cover the full array of long-term care needs Hard to know what to do or where to go for help (including information) Everyone wants to remain at home, but assistance from Medicaid is much more likely from a nursing facility

12. Living Arrangement of the Long Term Care Population Age 65 and Older

13. Of Long Term Care

14. Oral Health and Access Challenges Why is oral health care particularly important? Because oral diseases: Are cumulative and more complex over a lifetime Have an increasing impact on the quality of life Have an increasing impact on general health

15. Oral Health and Access Challenges Why do the elderly need special care? – Many have experienced extensive oral disease – Medical problems complicate their care – Diagnosis and care planning are complex

16. The elderly should receive special consideration in terms of their oral health care needs since they: 1)May have unique problems accessing the health care delivery system 2) Experience different patterns and prevalence rates of oral diseases and 3) May have characteristics that affect the amount and types of dental treatment and the method by which it is performed

17. Older adults are maintaining their natural teeth into their later years and epidemiologic trends suggest the increasing need for dental services by older adults. Yet dental utilization rates are lower for older adults than for younger age groups and barriers to care include the cost of dental care, the lack of perceived need for care, transportation problems, and fear.

18. The Panoply of Oral Structures, Functions, A&P and Environmental Factors Socio-dental Scale: chewing, talking, smiling, laughing, pain, appearance General Oral Health Assessment Index: chewing, eating, social contacts, appearance, self- consciousness Dental Impact Profile: Confidence, happiness, social life, relationships Oral Health Quality of Life Inventory: nutrition, breath odor, self-rated oral health, overall quality of life Oral Impacts in Daily Performance: performance in eating, speaking, oral hygiene, sleep, emotion

19. Oral Health and Access Challenges Characterizing the elderly based on access to dental care: Independent elderly Frail elderly Functionally Dependent elderly

20. Oral Health and Dental Access Barriers Older adults face dental access barriers due to physical limitations and functional dependence

21. Oral Health and Access Challenges What is the split based on access?

22. What are the “Frail Elderly” like? The Majority are Female: By age 65 there are approx 141 females for every 100 males By age 85 there are approx 237 females for every 100 males Many are Homebound: Dependency in physical abilities May be cognitively impaired Often economically disadvantaged

23. What are dependent elderly like? Some live in nursing homes: Tend to be over 75 with the average around 85 Often widowed Mainly white, non-Hispanic Functionally dependent Dependent on Medicaid

24. Barrier ALTC (%) NH(%) 1)Willingness of general dentist to treat 73 50 residents at your facility 2) Willingness of general dentist to treat 25 50 at private office 3) Financial concerns of resident or family 41 60 4) Transporting resident to dentist or hygienist 37 32 5) Availability of suitable dental treatment space 32 37 6) Availability of suitable treatment equipment 33 39 7) Time constraints on facility 20 26 Barriers to Oral Health for Residents of Alternative Long Term Care (ALTC) and Nursing Home (NH) Facilities

28. There is a widespread oral health problems among nursing home residents, including: Poor oral hygiene High levels of dental needs Low rates of dental care utilization

29. Geriatric Patients

36. Root Caries  Soft irregular shaped lesions Confined to the root surface Undermines enamel at CEJ Initiates on the root surface Starts only if root is exposed

37. Class V Restorations

38. Within nursing homes a number of barriers prevent access to professional care or prevent residents from receiving daily oral hygiene While the level of dependence of nursing home residents varies from patient to patient, most residents require some assistance to complete oral hygiene regimes

39. Some of the challenges providing dental services in nursing homes are: 1)Communication with family members or representatives 2)Patients are medically complex 3)Medicaid (regional nurse) has (had) the authority to approve or disapprove dental treatment 4)Lack of facilities at nursing homes 5)lack of adequate equipment 6)lack of training of the nursing homes staff 7)Lack of oral education of the staff and most patients 8)Little or none training of the undergraduate students

40. Additional barriers include –the functional and medical status of the individual –transportation and accessibility difficulties –financial considerations –lack of education –and fear

41. Brown Dental Health Management,INC. Steps for treating Nursing Facility Residents 1)Receive a referral from the Social Worker of Director of the Facility 2)Make dental chart for the resident: a) Face sheet or health information sheet b) Medications list c) Verify resident is either private pay or has Nursing Home Medicaid d) If the residents is Nursing Home Medicaid, they have an applied income that must verified with the bookkeeper or the TDHS case worker

42. 2) Cont. e) “1263 B- Certification of no medical contraindication- dental” form must be completed by the social Worker, signed by the patient or the responsible party, and the patient’s practitioner. “ Routine Dental Treatment” is all that is required on the 1263 B form under dental services. No approval is required. The only treatment that can be performed will be on the “ Routine Dental List” provided by Medicaid. If other dental services are recommended, these procedures would be sent to the Medicaid RN for prior approval.

43. Cont. 3) when the chart is complete, it goes into the dentist box to schedule the exam. Exam is completed and if the resident has teeth, an x-ray is ordered. –x-ray team schedules a visit, if the resident requires sedation, the practitioner is contacted before the treatment plan. –x-rays are placed in the dentist’s box for a treatment plan to be completed –If the resident has teeth, the dentist will order prophy at this time and will be completed before the treatment plan.

44. 3) cont. –Once the treatment plan is written, it is faxed and mailed to the responsible party and/or the Social Worker for the resident to sign off for treatment. –Once treatment consent is signed, the dentist is given the chart with the consent and schedules the visit to begin treatment. –Once treatment is completed, the Medicaid insurance claim is ran and the original 1263B and the signed treatment consent is sent to Medicaid to be funded through the resident Medicaid Applied Income (which is their rent).

45. 3) cont. –Medicaid is to make an adjustment to the applied income and the dental bill is to be paid from the responsible party who pays the resident’s rent. They would lower the amount they pay the nursing facility in rent and pay for their dental services. –If the resident is private pay, we have a private consent instead of the Medicaid 1263B, otherwise we make up the dental chart the same way, the process is the same

46. Other mobile dental companies in the area” Mobil Dental Residential Life cycle Dr. Leddett

47. Why aren’t graduating dental students more willing to treat geriatric patients? Lack of experience and fear when treating geriatric problems Lack of financial incentives Transportation and access problems to the dental office Special problems that exist in providing dentistry to homebound and institutionalized patients Negative attitudes toward the elderly’s need for dental care and their low perception and motivation for oral health care The poor oral status of the elderly, resulting in an edentulous state or teeth compromised by periodontal disease Difficulties dealing with debilitation and life threatening illnesses The problem of informed consent and of family members or residential facility staff member with negative attitudes

48. Education It is of utmost importance for dental professional to be well trained, understanding and compassionate, and to be aware of the special needs of the mature population The dental profession should seed interdisciplinary team training to better address these needs Education in the elderly care, however, must be supplemented with practical experience in the treatment of seniors, in various locations and using appropriate dental equipment

49. Education in geriatric dentistry include not only the practical clinical aspects of treating the elderly, but the social, environmental, psychological, behavioral and financial aspects as well