Oral Health Integration in the Patient Centered Medical Home

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 • Goals for dental-medical integration in RI • RI Oral Health Plan • Does oral health matter? • RI Oral Health Surveillance Report • 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 • Improve access to oral healthcare • Implement evidence-based oral healthcare • Prevent oral disease, promote oral health • Maintain the dental safety net • Sustain the oral health workforce • Inform oral health policy decisions

5. Specific Goals for IntegrationR.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. Chronic Disease Prevention & Control: Does Oral Health Matter?Oral Health Surveillance Data Report 6

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. RI Adults’ Access to Dental Care 11

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

13. Diabetes Management Recommendations CDC1 and American Diabetes Association2 • 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 Significant at p value <.05 Data sources: 2006, 2008, 2010 RI BRFSS

16. Adjusted Odds of Dental Cleaning (Logistic regression model) 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 • 10 medical-dental centers in RI have implemented systems to encourage coordination between dental and primary care “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

21. Emerging Best Practices in R.I. • 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 RebeccaKislak, JD RI Health Center Association RI Oral Health Commission rkislak@RIHCA.org RI Oral Health Commission http://www.oralhealth.ri.gov/