Quality Initiatives in Oral Health

1. Quality Initiatives in Oral Health A topic you can sink your teeth into!! Suzanne Boulter, MD South Carolina Chapter Meeting July 23, 2011

2. Bright Futures Recommendations • Oral health risk assessment performed • Anticipatory guidance given • Fluoride modalities addressed • Referral to dental home make

3. Measures for SC Project • Was an oral health risk assessment done and documented between 12 and 36 months? • Did you refer the patient to a dental home? • Did you apply fluoride varnish to a high risk patient between 12 and 36 months of age? • Have you documented a discussion about fluoride in the family’s water source?

4. Opportunities for Microsystems Improvement THE PDSA CYCLE

5. Defining an Aim: Examples in Oral Health for SC • By December 1st 2011, using an oral health risk assessment tool, screen 100% of 12 to 36 month old patients at health supervision visits to identify those at high risk. • By December 1st 2011, refer 100% of high risk patients to a dental home with tracking of compliance

6. More Examples • By December 1st 2011, perform fluoride varnish application on 75% of high risk children as identified by the oral health risk assessment. • By December 1st 2011, test and document all well water fluoride levels in households without public water supply

7. Pick a Measurement then Brainstorm and Map Process • Oral Health Risk Assessment screening done • Fluoride varnish applied • Referral to dental home • Order and track well water fluoride test results

8. Example of Mapping Process MA puts materials in room Patient calls For appt. Patient arrives MA rooms patient MA gives patient information about OHRA Provider visit with patient Fluoride varnish applied if OHRA positive Patient leaves Provider does screening List of Dentists given

9. Using Tools to Address Your Questions

10. 1) Was Oral Health Risk Assessment Done? • Caries Risk Assessment Tools: - Bright Futures CAT tool • AAPD CAT www.aapd.org • American Dental Association CAT (not finalized yet) www.ada.org • AAP Policy Statements on Oral Health • Pediatrics May 2003 • Pediatrics December, 2008 On line trainings: • www.aap.org/oralhealth/smilesforlife • Free on line training • Endorsed by AAP • Six chapters; 3 of importance for pediatricians • www.aap.org/oralhealth/pact/index

13. Oral Health Flipchart

14. eQIPP Module on Bright Futures Released August 2010 QI areas recommended Elicit and Address Patient/Family Concerns and Needs Perform Risk Assessment and Medical Screening Perform Developmental Surveillance and Screening Address maternal depression (birth -36) Promote Oral Health (birth -36)

15. eQIPP Module on Bright Futures Screen for Chlamydia Implement a strength based approach Provide Anticipatory Guidance Utilize a Recall Reminder System Promote Community Relationships and Resource Case Studies: Oral Health, Teen Driving, Foster Care

16. Data Collection Tools – Some Examples • Paper chart tools • Electronic Medical Record tools

22. 2) Was the Patient Referred to a Dental Home? • First dental visit should take place at 1 year; earlier if patient is at high risk • Develop list of dentists who will accept patients this age • Include office phone numbers and addresses • Refer Medicaid patients to state web site or phone line if no access

23. 3) Was Fluoride Varnish Applied? • Offer to patients at high risk • Evidence for up to 35% decreased caries • Apply and bill per your state Medicaid guidelines • Give information sheet about what to do after application

24. Office Tools for OHRA and Varnish Application

25. Medicaid Codes and Reimbursement • Fluoride varnish D 1206 $12 - $53 • Oral evaluation new pt D 0145 $29 - $56 • Oral evaluation estpt D 0120 $20 - $27 • Age limit – varies; ages 6 months to 5 years • Number of varnish applications reimbursed annually – 2- 4 • Training required – varies; state specific • Delegation of procedure (NP, RN, LPN, CMA) about 2/3 of states allow

26. 4) Did You Document a Discussion About Fluoride in the Patient’s Water Source?

27. Identify Potential Systems Solutions • Train everyone in practice on OHRA • Choose coordinator • Determine staff roles for screening, counseling, referral and varnish • Have supplies in kit • Store kit in central location • Screen for needed services at every visit • Close K, Rozier G, Zeldin L, Gilbert A.Barriers to the adoption and implementation of preventive dental services in primary medical care. Pediatrics 2010;125:509-517

28. Pilot Study Results • Brightening Oral Health Bright Futures Implementation Project 2010 • Funded by Proctor & Gamble

29. Project Details • Initial QUINN practice pilot done • 10 sites chosen to test OHRA tool as part of QI Brightening Oral Health project • Pre test survey of practices • Post project survey of data completed

30. Clinician Agreement on Oral Health

31. Practice Has a System to Document OHRA • Our practice has a system in place to document oral health risk assessment.

32. Practice Has a System and Can Identify High Risk Patients • My practice has a system to identify high risk patients for an oral health referral

33. System to Apply Fluoride Varnish

34. Easily Accessible Dental Referral List in my Office

35. Responsible for Regularly Updating Someone responsible for regularly updating practice’s oral health list

36. Brightening Oral Health Study Conclusions • Practice teams employing a system to document oral health risk assessments increased significantly • Practice teams utilizing a system to identify high risk patients for an oral health referral increased significantly

37. Summary • Bright Futures and AAP Policy Statements recommend: • OHRA • Anticipatory guidance • Assessment of fluoride modalities • Referral to dental home South Carolina data will help determine feasibility of including oral health recommendations in a busy practice setting!!!