From the First Tooth to Cavity Free at Three: Quality Improvement & New Components of Two Successful Integrated Oral Health Programs

Transcription

1 From the First Tooth to Cavity Free at Three: Quality Improvement & New Components of Two Successful Integrated Oral Health Programs NNOHA Conference November 18, 2015 Kneka P. Smith, M.P.H. Director, From the First Tooth

2 LEARNING OBJECTIVES Participants will be able to: 1. Describe two models of integration of pediatric oral health into primary medical care. 2. Describe three pediatric oral health quality improvement metrics tested in the primary care setting. 3. Identify the challenges and opportunities involved in the integration of oral health care into primary care settings. 2

3 Video: WHAT DOES THIS REALLY LOOK LIKE IN A MEDICAL PRACTICE?

4 What is FROM THE FIRST TOOTH? Statewide pediatric oral health prevention initiative started in 2008 and led by Maine s largest health system, MaineHealth. Goal: To improve the oral health of Maine s children by: A. Increasing children s access to preventive oral health services B. Integrating early oral health as the standard of care for children in medical practices through: 1.Oral evaluations 2.Fluoride varnish applications 3.Parent/caregiver education and counseling 4.Referrals to dentists

5 MEDICAL PROVIDERS PARENTS PRACTICE SYSTEMS DENTISTS

6 Children who receive at least 4 applications of fluoride varnish by age 4 years have ~40% less tooth decay. ¹, ² ¹ Pahel, BT, Rozier, RG, Stearns, SC, Quinonez, RB, Effectiveness of Preventive Dental Treatment by Physicians for Young Medicaid Enrollees. Pediatrics, 2011;e682-9 ² Weintraub, JA, Ramos-Gomez F, Jue, B et al. Fluoride varnish efficacy in preventing childhood caries. J Dent Res. 2006;85(2)

7 May 16, 2014

8 AAP Recommendations for Preventive Pediatric Health Care Fluoride Varnish - September 2015

9 7 FTFT CORE COMPONENTS Primary Care Consumers Policy Provider/Practice Recruitment Partnerships & Pilots Clinical Champions Quality Improvement Planning Periodicity Schedule EMR Integration Tech Assistance Training Smiles for Life Messages: Child OH Social Media Media Partners Providers Maine Families MaineCare Birthing Hospitals Employers Other Payment Reform Periodicity FQHC State Health Assess. Other Linkages with other child health efforts Quality Metrics & MOC Meaningful Use Employee Competencies Standing Orders Provider Messaging Workforce Pipeline Recruitment Training Curriculum Integration Transitions of Care (Dental) Dining with the Dentists Partners Referral Tools Evaluation & Research Claims: MaineCare (Muskie) QI: Practice/System Data OH Status: Claims, Practice Leadership Information Exchange Regional FTFT Pilot new initiatives

10 REIMBURSEMENT Primary Care (Maine) 1. D1206 Application of Fluoride Varnish (0-20 Y) - $12 2. D Oral Evaluation (<3 Y) - $20 Medicaid Self-Insured Employers Other Insurance FQHC D $12 D $20 D $12? D $? 99188? Medicaid - $0 Other Insurance - $?

11 POLICY: FQHC Medicaid Policy Initiative (Maine-2015) Direct the Department of Health and Human Services to amend the MaineCare Benefits Manual for Federally Qualified Health Services to assure equity in payment for preventive dental services for pediatric members in the area of preventive dental services provided by medical providers. The payment would be beyond the ambulatory encounter rate utilized for medical providers. Services should include fluoride varnish application and oral evaluation to be consistent with preventive dental services provided for children receiving medical services in settings other than federally qualified health centers. ALIGNED with: Asthma self-management, Diabetes education, Smoking cessation counseling FAILED

12 STEPS TO IMPLEMENTATION: Primary Care Medical Practice 1. Practice Recruitment & Commitment Clinical Champion & Lead Staff 2. EMR Integration Clinical & Billing 3. Workflow 4. Training & Launch Date 5. Technical Assistance 6. Quality Improvement Data Monitoring & Reporting Quality Metrics Maintenance of Certification EMR Integration Guide: Pediatric Oral Health in Primary Care Practices (Documentation, Coding, Charging, Billing & Measurement)

13 CLINICAL CONSIDERATIONS: Primary Care Fluoride Varnish: Applied 2-4 per year 1 6 months through age 5 years 1 Intervals between (~3 months) Not risk-based 1 Standard Periodicity 9m, 15m, 24m, 30m, 3y, 4y, 5y 12m, 18m, 24m, 30m, 3y, 4y, 5y 15m, 18m, 24m, 30m, 3y, 4y, 5y Referrals for Dental Care: Recommendations? Referrals? How Tool Two-Way Communication ¹ AAP, Bright Futures

14 Supply & Demand Supply Of Providers Primary Care Policy Partners Pipeline Dental Demand (Consumers) Providers Marketing Partners

15 Target 246 Practices* Active Practices Trained** 169 Practices 143 Implementing EMR 100+ Integration PRIMARY CARE *Includes Pediatric & Family Medicine; FQHCs **Includes 8 never trained but implementing

16 Federally Qualified Health Center Pilot Project Target: 8 FQHCs and 1 Rural Health Center (28 sites) Purpose: Expand Provider Network FQHCs Statewide: 19 organizations with 65+ sites Pilot: Requirements: Champion, training, Electronic medical record (EMR) Integration, Data Reporting Status: 100% trained 100% implemented 6 of 9 organizations have integrated pediatric oral health into their EMR 16

17 FQHC PILOT PROJECT: Alternative Approach Imbedding RDH in medical Team: Medical Providers, Nurse, MA, RDH Purpose: Increase access to preventive dental services via primary care Increase percent of children establishing a dental home Decrease age at entry to dental care/ establishment of dental home Prevent dental caries in children From the First Tooth! Services: Screening, Parent Education, Fluoride Varnish, Warm Hand-offs to Dental, Coordinated Scheduling for Recall (medical/dental) Target: Minimum of ~15 pediatric patients per day Seek threshold to assure model is self-sustaining

18 TRANSITIONS OF CARE: Dining with the Dentists Target: Medical and Dental Providers/Practices Primary Purpose: Bring dental and medical professionals within a community or region together to better coordinate the physical and oral health care of young children 1. Meal 2. Introductions 3. Build awareness of each provider s practice scope and patient population 4. Build professional relationships to facilitate communication 5. Enhance referral process for routine and emergency care 6. Next steps Sponsorship: From the First Tooth & Northeast Delta Dental 18

19 CONSUMERS Educational Resources: TV Radio Transit Web Waiting Room Display Monitors Newsletter/Newspaper Text Collateral Materials Table Tent/Window Cling Tri-fold Brochure Waiting Room Poster Exam Room Reminder (for physician) 4 by 4 Rack Card

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21 MEASURING PROGRESS: METRICS

22 ORIGINAL METRICS: Fluoride Varnish in Primary Care 1 Fluoride Varnish/ year 2 Fluoride Varnishes/ year 2+ Fluoride Varnish Proportion of CE MaineCare children ages months with 2 or more fluoride varnish applications in a 12 month period Pediatric medical care periodicity schedule differs from pediatric dental care. 80% 70% 60% Need metrics appropriate for pediatric medical care. 50% 40% 30% 20% 10% 0% 6% 8% 7%

23 STANDARD DATA ELEMENTS

24 EMR Integration Guide

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26 3 NEW METRICS: 2014 FTFT Targets 4 by 4 (Under 48 months) : Actual Target 19% 20% 20% 10% 4 by 4 Percent of children who have received at least 4 fluoride applications by 4 yrs. old, by year 8% 12% 16% 19% 2015 Target: 45% 0% Well Child Visits: Actual Target 19.35%* 20% 2015 Target: 50% 20% 10% Well Child Visits Percent of well child visits with an oral evaluation and/or 7% fluoride varnish for children mos. 8% 12% 19.35% 0%

27 3 NEW METRICS: 2014 FTFT Targets Children Reached: Actual Target 35% 45% 2015 Target: 60%

28 100% Sample Pediatrics Group Early Pediatric Oral Health by Practice August Population: All patients with teeth, ages 9 through 47 months Source: Clinical Improvement Registry 90% 80% 70% 71% 60% 50% 40% 30% 20% 10% 0% 31% 40% 38% 25% 21% 35% Dentist Seen within the last year 34% 32% 22% 13% 56% 45% 28% 13% 27% 7% 49% 30% 46% 21% 45% 11% 56% Oral Evaluation Completed Fluoride Varnish Applied Fluoride Varnish without a Dentist 17% 5% 4% 4% 0% 0% 4X4 Total Practice A Practice B Practice C Practice D Practice E

29 MAINTENANCE OF CERTIFICATION: 4 Oral Health Metrics Numerator(s): Denominators: Age(s)/ Visits: Baseline: Considerations: Fluoride Varnish (2) Oral Evaluation Dental Home Well Child Visit (3) Children with: -FV: YES -FV: DECLINED CIR: 9 to <47 mo Alt: 12 to <47 mo CIR: Range 7-49% Alt: No baseline -Age (12 mo) -WCV or OV Children with: -OE: YES OV in measurement period; with teeth CIR: 9 to <47 mo Alt: 12 to <36 mo CIR: Range 13-56% (Mean 34%) Alt: No baseline -Age (<36 mo) -WCV or OV Children with: -Dentist in last year: YES CIR: 9 to <47 mo Alt: 12 to <47 mo CIR: Range 21-40% -Age (12 mo) -Age stratified -WCV or OV WCV with: -FV &/or OE: YES -FV: YES -OE: YES WCVs in measurement period; with teeth Visits: 12, 15, 18, 24, 30, (36), (48), (60) Align visits with periodicity schedule?

30 Kneka Smith: or (207) General: or (207) CONTACT: FROM THE FIRST TOOTH

31 Acknowledgements: