Transcript The Medical Home in Pediatric Practice

Serving Special Populations
Medical and Dental Homes
Children with Special Health
Care Needs
Washington Oral Health Regional Forum
August 1, 2008
Washington State Medical Home Project
Katherine TeKolste, MD - Co-Director
Washington State
Medical Home Project
University of Washington - CHDD
Partners:
– DOH, CSCHN Program
– Dept. Pediatric Dentistry
– MHLN Teams – 21
Community-based teams
– WC AAP
– CCSN
– CHDD
– Division of Genetics and
Developmental Medicine,
UW
– ITEIP
– Family Voices of
Washington
– Fathers’ Network
– OSPI
– LEND Program
– Parent to Parent Program
– Washington Family to
Family Network
– Medical Assistance
Administration
Medical Home:
High-quality health care partnership
Families, physicians and office staff working
together to:
• Provide acute and preventive primary health
care and a central location for health records
• Set priorities and plan a child’s care
• Identify medical and non-medical services
needed to optimize outcomes
• Coordinate specialty care & community
services
• Connect with information resources
In a context of:
• Respect, mutual trust and collaborative
decision-making in health care
encounters
• Respect for cultural and religious beliefs
and personal preferences
Originated in context of CSHCN. Evolved
to include all children and adults…
Endorsed by the AAP, AAFP, ACP, AOA
Oral Health Issues:
Prevalence in General Population
Oral disease is the single most common
chronic childhood disease
• Five times more common than asthma
• 2% of 1-2 year olds have at least one
tooth with decay
• 18% of 2-5 year olds in Head
Start/ECEAP programs (WA) have ECC
•Citizen’s Watch for Oral Health
•Washington State Smile Survey, 2005
Dental High-Risk Groups:
• Young children – ECC
– Washington’s 1 yo are 5x and 2 yo twice as likely as
children nationwide to have dental decay
(Citizen’s Watch for Oral Health)
• Children from families with active dental
disease (AAPD Caries Risk Assessment Tool)
• CHSCN
•Across all income levels, 2x as
likely to have unmet oral health
needs as non-SHCN peers (Nat’l
Maternal Child Oral Health Resource Center)
•With severe dental decay,
often need treatment in
hospital operating room (Citizen’s
Watch for Oral Health)
PCP Steps:
• Prevention emphasis:
– Reinforce importance of daily oral care
– Provide information on oral hygiene
– ‘Innoculate’ against cavities – review fluoride
exposure, supplement as needed
– Review diet and feeding practices that increase risk
for caries and gingivitis
– Review medications and dosage regimens to
minimize oral health side effects
• Monitor interactions of oral and systemic health
• Recognize and teach implications of poor oral
health on overall health across the lifespan
Bright Futures in Practice:
Oral Health Pocket Guide
http://www.mchoralhealth.org/pocket.html
• To help health professionals implement
specific oral health guidelines during
pregnancy, postpartum, infancy, early
childhood, middle childhood and
adolescence
• Addresses risk assessment for caries,
periodontal disease, malocclusion and
injury.
http://www.mchoralhealth.org/PediatricOH/index.htm
Cost Savings of Early Oral Health
Care for Preschool Children
• Over the course of 5year study of N Carolina
Medicaid children
enrolled at birth:
– Average cost per child
who had a dental visit
before 1 yo - $262
– If child’s first visit not until
4-5 yo, cost doubles to
$546
– Older age of first dental
visit associated with
increased restorative and
emergency visits for oral
health
Age at First Dental Visit
1000
900
800
700
600
500
400
300
200
100
0
$492*
$546*
$449*
$339*
$262*
0-1 yo
N=23
1-2 yo
249
2-3 yo
465
3-4 yo
4-5 yo
915
823
*Average cumulative dental expenditure per
child according to age at first dental visit
Savage MF et al. Pediatrics. 2004.
Children/Youth with Special
Health Care Needs
• Children who have or are at increased risk for a chronic
physical, developmental, behavioral, or emotional
condition and require health and related services of a
type or amount beyond that required by children
generally
• 14% of population; 5-6% severe
• E.g. children and youth with:
–
–
–
–
–
–
–
Down syndrome
Seizure disorder
Cleft lip or palate; other craniofacial defects
Cerebral palsy
Intellectual or developmental disability
Vision and/or hearing impairment
Genetic and hereditary disorders
The Problem:
In surveys of the special needs population,
parents and families identify dental care as
the most common unmet health care
need for their children.
CYSHCN - Higher risk for oral health problems
– Routine self-care may be difficult or impossible for a child
• Motor disability such as seen in spastic quadriplegia
• Cognitive or behavioral impairment.
– The underlying disease may impact oral health
• Cleft lip and palate
• Leukemia.
– The treatment of a chronic disorder may lead to secondary oral
health problems,
• Gingival hyperplasia with anticonvulsants, methotrexate,
immunosuppressants and calciuim channel blockers.
CYSHCN:
• Need for dental care exceeds need for either
preventive or specialty medical care
• Individuals with a personal doctor/nurse
(medical home) are significantly less likely to
have unmet dental needs
‘Dental care should be an integral and explicitly
stated part of the comprehensive coordinated
services that the medical home aims to provide
for CSHCN.’
Lewis C et al. Pediatrics. 2005.
Medical Home:
Oral Health Strategies
• Develop referral, tracking and follow-up
protocols, including oral health
• Establish collaborative relationships with oral
health professionals to ensure coordinated care
• Include oral health as part of routine health
supervision
– Oral health assessment
– Anticipatory guidance
– Preventive services
Nat’l Maternal and Child Oral Health Resource Center
The Dental Home
“The dental home is the ongoing relationship
between the dentist and the patient, inclusive
of all aspects of oral health care delivered in
a comprehensive, continuously accessible,
coordinated, and family-centered way.
Establishment of a dental home begins no
later than 12 months of age and includes
referral to dental specialists when
appropriate.”
American Academy of Pediatric Dentistry
Endorsed by:
•American Dental Association
•Academy of General Dentistry
•American Academy of Pediatrics
Dental Home
Concept:
Oral health professionals helping families:
• Understand what care is needed
• Find necessary care
• Coordinate care with specialists and other
health professionals
Dental Home Provides:
• Acute and preventive services
• Assessment for oral diseases/conditions
• Preventive dental health program based on risk
assessment for caries and periodontal disease
• Anticipatory guidance
• Plan for acute dental trauma
• Information about care of teeth and gingivae
• Dietary counseling
• Referral to dental specialists as needed
• Transition to adult dentist
(AAPD schedules)
AAPD
Dental Home for CSHCN:
AAPD Guideline on Management of Dental Patients with SHCN
http://www.aapd.org/media/policies.asp
• Provide appropriate preventive and routine dental care
• Document informed consent as appropriate to patient’s special
needs
• Determine optimal communication methods for patient
• Appointment scheduling should include determination of the
special needs, primary medical care provider, and need for
additional time or dental personnel to accommodate needs
• Know the patient’s medical history and updates to prevent
aggravating a medical condition
• Consult with medical providers to coordinate care
• Provide summary of findings and recommendations
• Understand behavior guidance* – most patients with physical and
mental disabilities can be managed in the dental office
• Know and use community-based resources to assist with issues
from cultural and language preferences to transportation and
financial support.
• Work with insurers on financial coverage, especially in genetic and
*http://www.mchoralhealth.org/Special/mod5_0.htm
congenital conditions with oro-facial
malformations
CSHCN Stories in the last 48 hours:
• Access
– Family of child with ID – 2 pediatric dentists (unsuccessful) and then
Seattle Children’s community dentist referral. But graduates from
pediatric dentist at 21 yo.
– HMC used to have dental clinics for SHCN patients, but no longer
– Need dental care from someone who speaks the same language as
the child/family
– Physician with 18 yo former preemie with CP, shunted HC, ID and
significant orthodontic needs (small jaw, crowded teeth, very high
arched palate) cannot access care at UW, CHRMC or private
orthodontist to date – trying almost 2 years to get care for this member
of a Spanish-speaking family on Medicaid
• Transitions:
– Children’s Village patients aging out at 18 years and no adult program
to serve the population (DECOD consultation in progress)
– Very difficult to find dentists who accept adults on Medicaid
CSHCN Stories in the last 48 hours:
• Extra care needs
– ‘Long-term consequences of oral health were not at the top of the list:
feeding issues, drooling, teeth grinding, biting, pica, oral sensitivity,
inadequate oral hygiene (difficult to brush, impossible to floss) and
dentist ‘just doing the best (s/he) could’ on q 6 mos cleaning; ended up
with severe gum disease
– Physical access issues – e.g. wheelchair
– ‘There is a great need for the dentist or hygienist to take adequate
time to address oral sensitivity and sensory integration
issues’…private room, quiet music, calm and pleasant voice,
explaining before doing - understand, ask and accommodate
– Privacy for individual who must wear a diaper and may need to be
changed while at the office
• Expenses and insurance coverage
– Medical vs dental coverage for maxillofacial problems; high out-ofpocket expenses ($3,000-6,000 not uncommon), esp. in genetic and
congenital disorders with oro-facial manifestations
– Loss of family dental insurance with retirement – move onto Medicaid
which few providers take
These themes are echoed in key informant interview (WA) and survey (UT)
Access to a Dental Home:
• Fewer than half of US dental schools offer
meaningful clinical experiences in care of very
young children/CSHCN
• Fewer than 1 in 10 general dentists regularly
provide care for children and youth with CP, ID
or who are medically fragile
(Nat’l Maternal and Child Oral Health Fact Sheet)
• In King County: (Smith RG, Lewis CW. Pediatr Dent. 2005.)
– 99% of dental offices seeing children would see a new 5 yo
patient, but only 15% would if on Medicaid
– 9% would see new under 1 yo, but only 3% would accept if on
Medicaid
Access?
• 136 Pediatric Dentists in WA (AAPD)
• At best: 4337 dentists licensed in WA
(How many are general dentists, active?)
– If 10% see CSHCN  434
– Dentists billing Medicaid 2008 (All seeing
children?) – 693
• WA 0-5 population – 434,000 (DOH, 4/1/2008)
• WA CSHCN population – 214,600 (CSHCN survey
2005-6)
How to provide care?
• 4,520 children per pediatric dentist
– Of which 1,578 have SHCN
OR
• 1,078 children per general and pediatric dentist
who see CSHCN
– 702 0-5yo + 376 with SHCN
OR
• 936 children per Medicaid billing dentist
– 626 0-5yo + 309 with SHCN
OR
• 97 children 0-5 per general dentist
(assuming all are general dentists)
Other Providers:
• Dental Hygienists – 4443 (2007)
– Oral Health Assessments
– Cleaning
– Sealants and some restorative
• Dental Assistants
• Dental Students
– Some prevention and education at WIC
• Primary Health Care Offices
– Anticipatory guidance, fluoride varnish
• Other?
Washington Resources:
• UW Dental Education in the Care of
Persons with Disabilities (DECOD)
• Seattle Children’s
• Odessa Brown
• Community Health Clinics (KGC)
• Yakima – Children’s Village, Farm
Worker’s Clinic
• Access to Baby & Child Dentistry-ABCD
• Smile Mobile
Practice Tools for Dental Offices Caring for Special
Needs Children:
From The Maternal and Child Oral Health Resource
Center
Special Care: Dental Office Considerations Checklist
Special Care: Getting to Know Me
Special Care: Family Satisfaction Questionnaire
http://www.scdonline.org/
• American Academy of
Developmental Medicine
and Dentistry
•AAPD Dental Home
resource center
•International Assoc.
for Disability and Oral
Health
•And others….
What will work
for our future?
Issues:
• Workforce - numbers, distribution,
capability/training
• Knowledge gap – child development,
family and social context, behavior
management, what families want from
medical/dental homes
• ‘Willingness’ gap – Ethics, social
responsibility, reimbursement
enhancements, carrots?
Examine New Workforce
Paradigms
• Medical Office Prevention Efforts
– ICHOP
– Learning Collaboratives
– (discussion of overlapping roles of medical
and dental homes)
• Oral Health Practitioners (MN)
• Dental Therapists (NZ)
• Nursing/Dental (NYU) – synergistic
relationship to improve overall health
New paradigms:
• Special clinics – Premier Health
Program, NYC
• ABCD program for CSHCN
• Centers of Oral Health Excellence
• Head Start – AAPD linkage
• Dental Internship requirements (NY 2007)
– Increased experience with complex problems
– Opportunity for hospitals to establish dental
training programs
Align With Referral Capacity:
As a community, move for change – improving
dental outcomes for young children and
CSHCN is a priority; effective prevention will
leverage significant cost savings and alleviate
unneeded suffering…
1. Dental professionals
•
Capacity – esp. for subpopulations by age, ESL
2. Establish referral criteria with local dental
resources
3. Other community resources
•
•
WIC nutritional education
PHD/LHD oral health specialists
Connecting Your
Medical and Dental
Community:
– Personal links – your own doctor/dentist
– Local Medical and Dental Societies
– Organizational –
• Washington State Dental Association, Medical Association,
WC AAP
• Public Health Department
– DOH-CSHCN Program,
– Oral health liaison, CSHCN Coordinator in LHJ
• Community Health Clinics, FQHCs
• Medical and Dental Schools, Faculty Contacts
• ABCD Program
Medical-Dental Linkage - Models
• West Treasure Valley, ID
– 1:1::MD:DDS relationships for direct
patient referral
• Boise, ID
– Toll-free 211 referral hotline “Idaho
CareLine” with rotating list of dentists
accepting patient on MD referral
• Yakima, WA –
–
–
–
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Smile Mobile; ABCD Program
Referral system for adults w/HIV
Pilot for access for pregnant women
Initiation of Children’s Village/ DECOD
Transition collaboration
Take Home Messages:
• Prevent EARLY
• Break down silos for prevention
• Rejoice in children being embedded in families
who work to make it happen (may not be as
true for other populations you will discuss
today). Leverage family power.
• Start to organize services at your community
level
• Be open to examining new models.
‘Considerable work remains to define the health team composition
(including dental professionals) and technology requirements,
develop the optimal medical home [and dental home] curricula and
performance measures, and evaluate the effectiveness and cost of
coordinated services as well as their financing and methods of
provider compensation.’
Kenney MK et al. Parental perceptions of dental/oral
health among children with and without special health
care needs. Ambulatory Pediatrics. In press.