Improving the Quality of Oral Healthcare through Case Management

1. Improving the Quality of Oral Healthcare through Case Management Introduction & Module 1

2. Acknowledgements Improving the Quality of Oral Healthcare through Case Management is a professional education and training program designed to advance the knowledge, skill, and competency of the dental workforce. The curricula is made up of 6 training modules which have been made available through the generous support of the following organizations and agencies: • Rhode Island Department of Health • Rhode Island Executive Office of Health and Human Services • Rhode Island Dental Association • Medicaid|Medicare|CHIPServices Dental Association • Health Resources and Services Administration

3. Goals of the Course To provide professional education and training to dental personnel in an effort to: • Improve the quality oral healthcare services; • Improve the oral health outcomes of all; • Lower the costs of oral healthcare across the healthcare delivery system.

4. Overview of the Course • Introduction • Learning Modules: • Principles of Quality Improvement • Principles of Medicaid Dental Practice Management-Part 1 • Goal Setting • Process and Outcome Measurement • Principles of Medicaid Dental Practice Management- Part 2 • Principles of Case Management • Module Post-tests • 1.5 Continuing Education Units (CEU) will be granted upon completion of each module and submission of the respective post-test. • RI EOHHS Certification will be granted upon completion of all modules and post-testsand submission of all post-tests.

5. Advisory Team and Faculty • Robert Bartro, DDS • Paul Calitri, DMD • Marty Dellapenna, RDH, MEd • Jeff Dodge, DMD • Mary Foley, RDH, MPH • Deborah Fuller, DMD • Mary Ann Heran, RDH, BS • Marie Jones-Bridges, RDH, BS • Laurie Leonard, MS • Beth Marootian • Timothy Martinez, DMD • Lynn Douglas Mouden, DDS, MPH • Joan Pillsbury • Renee Rulin, MD • John Verbeyst, DMD

6. Faculty Marty Dellapenna, RDH, MEd Ms. Martha Dellapenna is the MSDA Center Director. In this role, Ms. Dellapenna provides oversight to the projects and activities of each the five divisions within the Center. She is the former Project Manager for the Rhode Island Oral Health Access Project. Ms. Dellapenna joined the RI Department of Human Services in the Center for Child and Family Health in 2003 through its project management contractor, Xerox. Ms. Dellapenna’s primary role at that time was to manage the development of RIte Smiles, the state’s first managed care dental program for young children. Ms. Dellapenna is also the current Chair of the Center for Medicare and Medicaid Services (CMS) Oral Health Technical Advisory Group.

7. FacultyMary E. Foley, RDH, MPH Ms. Mary E. Foley is the Executive Director of the Medicaid|Medicare|CHIP Services Dental Association (MSDA). Ms. Foley is a dental hygienist and holds a Masters Degree in Public Health with a concentration in Epidemiology and Biostatistics from the University of Massachusetts School of Public Health and Health Policy. Earlier in her career, she served as the Director of the Massachusetts Department of Public Health, Office of Oral Health. In this role she had oversight of state dental public health programs addressing surveillance; access; prevention; and education. Just prior to her current position, Ms. Foley served as the Dean of the Forsyth School of Dental Hygiene at the Massachusetts College of Pharmacy and Health Sciences in Boston, Massachusetts. Since joining the Medicaid|Medicare|CHIP Services Dental Association, Ms. Foley has been instrumental in broadening national stakeholder collaboration, and advancing state program policy and protocols to improve the health, health care and costs for all Medicaid programs and their beneficiaries.

8. Faculty Timothy S. Martinez, D.M.D. Timothy S. Martinez, DMD, is the Associate Dean of Community Partnerships and Access to Care at the UNE College of Dental Medicine. Dr. Martinez recently relocated to the New England area after spending six and a half years developing the community-based dental programs for Western University of Health Sciences College of Dental Medicine in Pomona, California.  He served as program evaluator at the Forsyth Institute from 2010 to 2011; state dental Medicaid director at the Commonwealth of Massachusetts, Executive Office of Health and Human Services from 2006 to 2009; and dental consultant at the Office of Public Protection, Board of Registration in Dentistry, Massachusetts Department of Public Health from 2005 to 2009. Dr. Martinez also served as dental director for Harbor Health Services Inc. from 1999 to 2003 and dental director at Boston Healthcare for the Homeless from 1994 to 2003. He earned a Doctor of Dental Medicine degree from the Harvard School of Dental Medicine.

9. Improving the Quality of Oral Healthcare through Case Management Module 1 Principles of Quality Improvement

10. Module 1 Learning Objectives: Upon completion of this learning module, learners will: • Gain knowledge of the Dental Quality Alliance (DQA) • Understand what is meant by quality improvement (QI) and why it is important in dentistry • Understand the difference between quality assurance and quality improvement • Understand how to use data to assess quality improvement goals. • Learn how to establish an office plan for setting improvement goals; collecting data and assessing progress and achievement of QI goals

11. Background

12. 1967 John Wennberg Unwarranted Variation in Healthcare • In 1967, Wennberg worked with the Regional Medical Program created with a $350,000 grant from President Lyndon B. Johnson. • He began analyzing Medicare data to determine how well hospitals and doctors were performing. • Utilization data from Vermont, Maine & Iowa: • Hysterectomy by age 70 20% vs. 70% • Prostatectomy by age 85 15% vs. 60% • Tonsillectomy 8% vs. 70% • Significant variability • Could find no scientific research on outcomes of care to demonstrate that one population was better off than the other Wennberg J, Gittelsohn A. Small area variations in health care delivery. Science 1973 Dec 14;182(117):1102-8. PMID 4750608 Slide courtesy of Dr. Rob Compton

13. Readers Digest Article How Honest are Dentists? February 1997 • Same patient – 50 different dentists • Direct reimbursement plan • $460 $700 $1,220 • $3,110 $8,665 $11,282 • $13,774 $19,402 $29,850 • Significant variability • All cannot represent the most effective and beneficial treatment Goal of EBC is to identify the most effective and beneficialtreatments for each individual diagnosis based on the best available scientific evidenceand to reduce treatment variabilityby creating clinical guidelines to ensure consistent quality of care Slide courtesy of Dr. Rob Compton

14. Quality of Care Institute of Medicine 1990 • Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomesand are consistent with current professional knowledge • This prescript contains just two concepts: measurement and knowledge. Medicare: A Strategy for Quality Assurance. IOM, 1990, p.21 Slide courtesy of Dr. Rob Compton

15. Quality in Healthcare Institute of Medicine Health Care Quality Initiative http://nationalacademies.org/HMD/Reports/2011/Advancing-Oral-Health-in-America.aspx

16. IOM Recommendations- 2001 • Evidence-based decision making: Patients should receive care based on the best available scientific knowledge. • Care should not vary illogically from clinician to clinician or from place to place. Crossing the Quality Chasm. Institute of Medicine 2001 Slide courtesy of Dr. Rob Compton

17. Age of AccountabilityTriple Aim Health Reform Institute for Healthcare Improvement http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx

18. Six Aims for Improvement • Safe: avoiding injuries to patients them. • Effective: providing services based on scientific knowledge • Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values • Timely: reducing waits and sometimes harmful delays • Efficient: avoiding waste • Equitable: providing care that does not vary in quality

19. Congress Mandates Quality Assessment & Improvement • The Children’s Health Insurance Plan Reauthorization Act of 2009 (CHIPRA), mandates that quality assessment programs be implemented to assess and improve the quality of care for children that receive oral health care under the Medicaid and CHIPRA programs. • In 2009 the CMS proposed to the American Dental Association (ADA) that a Dental Quality Alliance be established to develop performance measures for oral health care and that the ADA take a leadership role in its formation.

20. Healthcare Quality Improvement Institute for Healthcare Improvement

21. Dental Quality Alliance • 2009 ADA convened stakeholder group • Charge: • To develop quality measures for dentistry • To assess quality of dental programs/dental offices • Commercial plans • Medicaid and CHIP programs • Community dental programs • Dental managed care plans • Private dental offices

22. Metric vs. Measure vs. Measurement • Metric is an attribute or a property of something that you’re interested in measuring. For example, height, weight, IQ, quality. • Measure is an operation for assigning a number to something. For example calculate the percentage of higher risk 6 year olds who received a dental sealant on a first molar. • Measurement is the number obtained from measuring. For example, 25% of higher risk 6 year olds had dental sealants placed in 2011.

23. Quality and Performance Measures • A quality measure is a mechanism that enables the user to quantify the quality of a selected aspect of care by comparing it to a criterion. • A subtype of a quality measure is a clinical performance measure. • A clinical performance measure is a mechanism for assessing the degree to which a provider competently and safely delivers clinical services that are appropriate for the patient in the optimal time period. Agency for Health Research and Quality https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/index.html

24. How Are Quality Measures Used? • Quality measures are used for three general purposes: • Quality improvement, • Accountability, and • Research. http://www.qualitymeasures.ahrq.gov/selecting-and-using/using.aspx

25. Business Intelligence

26. Quality Improvement Initiative Improve the structures of care, access to care and/or processes of care as needed in order to improve the health state of individuals or populations as well as their experience with the healthcare system

27. Clinical Quality Measures Measures used to assess the performance of individual clinicians, clinical delivery teams, delivery organizations, or health insurance plans in the provision of care to their patients or enrollees, which are supported by evidence demonstrating that they indicate better or worse care. http://www.qualitymeasures.ahrq.gov/about/domain-definitions.aspx

28. Interpreting Quality Measures • Quality measures often require summing data about the health care given to many patients and expressing the results as a rate, ratio, frequency distribution, or score for average performance. • The measure result is often composed of a number and unit of measure. • The number provides the magnitude, and the unit provides a context for interpreting the number. • It is difficult to interpret the result of a quality measure as good or poor unless there is a standard of comparison by which it can be compared. http://www.qualitymeasures.ahrq.gov/selecting-and-using/selecting.aspx

29. Comparison to a Standard Value 99.7% 95.4% 68.2% 2.2% 16% 50% 84% 97.8%

32. Institute for Healthcare ImprovementThe Model for Improvement

33. Difference Quality Assurance Quality Improvement

34. par·a·digm shift noun noun: paradigm shift; plural noun: paradigm shifts a fundamental change in approach or underlying assumptions.

36. Does your office have room for improvement?

37. Could your office improve in any of these areas? • Improve dentist capacity? • Improve hygienist capacity? • Improve daily, weekly, monthly, and annualvisit goals? • Is your productivity at sustainable or profitable levels? • Improve patient procedure goals? • Improve patient/client mix (children; adults; special populations? • Modify payer mix (including adult Medicaid) to reach sustainable and profitable levels?

38. Is there room for improvement? • Is the patient demand in your office • Too low? • Too high? • Do you know your no-show rate? Is it above 15%? • Do your emergencies visits cause havoc in your office? What could you do to improve upon this?

39. Practice Goals

40. Business Intelligence

41. It Takes Team Work

42. Principles of Quality Improvement STOP Take Module 1 Post-Test Now