September 14, 2017

Closing the Dental Disparity for Rural Health

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According to former Surgeon General David Satcher, “you cannot be healthy without oral health.”

“Oral health and general health should not be interpreted as separate entities,” Satcher said. “Oral health is a critical component of health and must be included in the provision of healthcare and the design of community programs.”

Even though there have been many advancements in oral health knowledge and its practice, immense disparities still exist in many rural communities across the nation. These disparities encompass utilization to access and healthy outcomes across rural America.

To close the gap, many rural communities are developing oral health programs that are responsive to the specific needs of their respective populations. Specifically, the aim of these programs are to:

  1. Increase access and provision of oral healthcare services.
  2. Increase utilization of dental health services.
  3. Improve oral health outcomes.
  4. Build a healthy dental network.
  5. Work on retention, recruitment, and innovation of dental health services.
  6. Provide education and oral patient literacy.
  7. Provide evidence-based approaches to care.

It is no surprise that one such model being considered is the Interprofessional Practice (IPP), an approach to care that integrates, coordinates, and implements dental medical care with primary care and behavioral health to support individual and community population health. The IPP model, while early in its review and implementation, is showing encouraging promise with a focus on quality, access, positive patient outcomes, and lowering costs of care. Note that even dental can meet the qualifiers of the Triple Aim! It also should be noted that the Health Resources and Services Administration (HRSA) has provided guidance and recommendations regarding the approach of the integration of oral health into the primary care delivery model, acknowledging its importance in overall health and healthy patient outcomes.

Using the IPP collaborative design, the DentaQuest Institute recently partnered with the Medical University of South Carolina (MUSC) and the South Carolina Office of Rural Health to test the oral health care delivery model. Here is an update:

Phase 1: The focused integration of oral health into primary care and building dental care referral networks. 

Phase 2: A focus on implementation with collaborative partners at the Pennsylvania Office of Rural Health and the Colorado Rural Health Center. Currently there is a total of 15 dental care partners and 21 primary care team sites participating in three sites. 

The MORE Model Means More Care

The model known as the Medical Oral Expanded Care (MORE) initiative advances oral health promotion in primary care by way of  assisting teams on strategies. These strategies include innovation in the training of teams by providing them with new skills, including very specific motivational interviewing (questions), plus a focus on quality improvement practices and the means by which to measure impact. This new model focuses on collaborations and relationships, as well as developing referral networks to meet needs of patients, the rural health system, and primary care delivery teams. 

Additionally, dental teams adopt risk-based disease management practices for periodontal disease management. 

Three Focus Areas of Services

Medical:

Oral health evaluation (utilizing HEENOT, a head, ears, eyes, nose throat, and oral cavity focus) and a risk factor identification

  1. Self-management goals (such as patient- centered care)
  2. Pediatric fluoride application
  3. Referral dental care
     

Cooperative Tasks

  1. Implementation of a bi-directional referral systems utilizing medical referral coordination.
  2. Identification of areas of operational and clinical overlap to optimize resources, time, and delivery of care.
  3. Development and improvement of inter-professional communication processes and protocols.

Operational Integration Of Primary Care Referral Characteristics:

  1. A referral acceptance is verified.
  2. All clinical summaries are completed for referral communication.
  3. Referral dental care completion is verified. It should be noted that dental care teams are highly encouraged to incorporate a person-centered, risk-based approach to manage oral disease.

Additionally, what is remarkable with this model is the focus on inter-professional oral health networks (known as IPOHNS). Again, much like the patient-centered care model (think of the circle of care), the patient is at the center. And the support teams are centered around the patient and include the following: 

  1. Hospital systems
  2. Dental care teams
  3. Community health support systems such as school systems and religious organizations, state offices of rural health and rural health organizations, telehealth and information technology and social support organizations
  4. Medical care teams

Innovation Equals Opportunities, Complexities, and Challenges

Some key areas include:

  1. Continued focus on expanding knowledge within the integration of oral health in primary care and the coordination of care among medical and dental partners.
  2. Continued focus on creating an improved environment of care – refining and implementing quality improvement, policies, and protocols.
  3. Establishing a sense of stewardship coordinating and integrating care to improve community-based oral health.
  4. Facilitating healthcare model transitions and opportunities to keep building leadership and guidance to address complex challenges of the ever-changing healthcare environment and the rural, minority, and underserved population health needs.
  5. Implementation of a solid IT infrastructure for electronic health record (EHR) platforms.
  6. Development of dental referral networks to address oral health disparities – improved care coordination, education, and extended provider opportunities, from urban to rural.

Immense challenges for sustainability exist across the spectrum of rural and minority healthcare. These challenges include workforce retention, financial resources, transportation, policy, grants and reimbursements, and the overlap and coordination of public health. These factors must be aligned so that models of care that focus on the 360 degrees of care can be developed and implemented. In fact, this very model is one of the first that enables patients to realize the connection that oral health has to their own overall well-being, thus encouraging healthy behavioral change while promoting prevention strategies. This approach also brings into focus opportunities for a better understanding of the connection of oral health to diabetes and other chronic diseases. This approach could also advance tobacco cessation, nutrition coaching, and immunization practices. 

This model is definitely bringing a focused system of care – dentistry-- into the mainstream of care. This allows payer groups, patient advocacy, rural health, and other healthcare organizations as well as the federal government to see that the innovation of care can include oral healthcare.

Janelle Ali-Dinar, PhD

Janelle Ali-Dinar, PhD is a rural healthcare expert and advocate with more than 15 years of healthcare executive experience in many key areas addressing critical access hospitals (CAHs), rural health clinics (RHCs), physicians, and patients. Dr. Ali-Dinar is a sought-after speaker on Capitol Hill. A former hospital CEO and regional rural strategy executive, Janelle is also a past National Rural Health Association rural fellow, Rural Congress member, and Nebraska Rural Health Association president. She is currently the Nebraska DHHS chair of The Office of Minority Health Statewide Council, addressing needs of rural, public, minority, tribal, and refugee health, and she serves on the Regional Health Equity Region VII council as co-chair of Rural Health and Partnerships. Janelle holds a master’s degree and doctorate in communications and is a recent graduate in public health leadership. Janelle is currently the vice president of rural health for MyGenetx and is a member of the RACmonitor editorial board.  

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