Guest Editorial: The Colorado Medical-Dental Integration Project

The traditional model of providing clinical dental hygiene services in a private practice setting involves a daily patient schedule. Dental hygienists provide a full scope of dental hygiene services to patients who have made appointments, and dentists provide restorative dental care. Medical-dental integration differs from this model. It’s an emerging and evolving concept that seeks to reach populations with high, unmet oral health care needs who are not currently receiving regular dental care.

Varying levels of medical-dental integration have been tested in settings—such as basic oral health promotion by medical providers with a referral to a dental provider and fluoride varnish applications—throughout the country.¹ Some medical organizations have co-located a dentist and/or dental hygienist inside or next to their buildings to provide care for patients who are referred for preventive or restorative dental care. Telehealth dental hygiene projects are also used to connect rural dental hygienists and patients with dentists in urban areas.

Referring to these tested and emerging models and building on previous experience of its own, Delta Dental of Colorado Foundation launched the Colorado Medical-Dental Integration (CO MDI) Project in 2014. It takes the concept of medical-dental integration a step further with 16 Colorado medical practices receiving funding to integrate dental hygienists into their medical care teams. The dental hygienists working at the CO MDI medical practices provide the full scope of dental hygiene services for patients during medical visits that are within the confines of the Colorado Practice Act.

Sixteen health care systems received funding (five nonprofit, two for-profit, one federally designated rural health clinic, and eight federally qualified health centers). One practice withdrew from the project. Among the remaining 15 organizations, 21 dental hygienists have been integrated into 21 individual clinics, which include eight school-based health centers.

MEETING THE NEED 

Low-income children have double the caries rate of more economically advantaged children, and they are less likely to receive dental care.² These children face many barriers to accessing care. Scheduling time off work for multiple medical and dental appointments can be difficult for parents/caregivers. In many areas of the country, there are not enough dental providers to meet the need for oral health care. For example, in Colorado, eight counties are classified as dental deserts, meaning they do not have a dentist providing oral health care services.³ 

Limited or no dental insurance can also prevent individuals from accessing care. According to the 2015 Colorado Health Access Survey, 11.8% of children enrolled in Colorado’s Medicaid and Child Health Plan Plus (CHP+) programs had a dental checkup by age 1. In comparison, the same survey reported that 90% of children enrolled in those insurance programs had at least one medical checkup by age 1.

Delta Dental of Colorado Foundation decided to test different levels of medical-dental integration through the CO MDI Project. The goal of the project is to reach those in greatest need of dental care—particularly children—in convenient settings to improve their oral health.

THE MODEL IN ACTION 

The medical practices provide opportunities to connect with patients who may otherwise not receive dental care. In the CO MDI Project, the dental hygienists serve as an extension of the dental home. They provide evidence-based, comprehensive dental hygiene care in the medical practice 4 days to 5 days per week. Each medical practice works to establish a target patient population, such as low-income children, children in the foster care system, refugees, pregnant women, or low-income adults, prior to implementation of the project.

When CO MDI patients attend a medical visit, they are screened for oral health care needs. The screening includes a discussion about the patient’s last dental visit and whether the patient has a current dental home. Limited services delivered by the dental hygienist or the medical provider are offered during the medical visit, such as a screening, fluoride varnish, and education. Additional dental hygiene services are then provided in the dental hygiene exam room within the medical practice, as needed. These visits often serve as an opportunity for dental hygienists to communicate proper oral health habits to patients with low oral health literacy. The need is great, as CO MDI patients frequently present with untreated dental caries. The dental hygienists then help navigate patients to restorative care with a dental referral.

In the CO MDI Project, medical providers are also involved in promoting oral health by conducting dental screenings, applying fluoride varnish, and referring patients to the integrated dental hygienist or outside dentist. This approach emphasizes the connection between oral health and physical health to patients and providers. As frequently as possible, medical and dental care are provided at the same visit. If a question about a patient’s overall health arises during a hygiene visit, a medical provider is available for immediate consultation and vice versa.

Many of the CO MDI practices have established daily huddles in which the comprehensive team, including dental hygienists, medical providers, and behavioral health staff, meet to review the day’s schedules and activities. This team-based approach improves communication among the comprehensive care team and builds a holistic understanding of patient needs.

Integrating medical and dental care is a culture shift that requires collaboration and patience from all staff members involved in the project. Ideally, front desk staff assist dental hygienists in scheduling future dental hygiene appointments and ensuring restorative care referrals are kept. The most successful CO MDI practices also have support from key leadership, including their chief executive officers or medical directors.

The CO MDI model can be implemented in the 40 states that permit direct patient access to dental hygienists. The American Dental Hygienists’ Association defines direct access as “the ability of dental hygienists to initiate treatment based on their assessment of a patient’s needs without the specific authorization of a dentist, treat the patient without the presence of a dentist, and maintain a provider-patient relationship.”⁴ Each state’s practice act will determine which services can be provided by dental hygienists.

ESTABLISHING RELATIONSHIPS WITH DENTISTS 

Patients seen in the CO MDI Project do not typically visit the dentist on a regular basis. Each CO MDI medical practice has established relationships with dentists to connect patients to restorative care. Several practices provide co-located dental care in addition to the integrated model of care delivered in the medical side of the practice. Others have established referral relationships with outside dentists.

Inner City Health Center, one CO MDI grantee, is a faith-based, nonprofit medical and dental practice located in Denver. In its CO MDI model, the dental hygienist has a referral relationship for restorative care with the practice’s co-located dentist. Through a shared electronic and dental medical record, the dental hygienist is able to see if her patients complete the restorative care referral and the treatment plan.

Establishing referral relationships with outside dentists has required flexibility on the part of CO MDI grantees, especially those located in more rural areas. These relationships require initial, direct communication about the goals of the CO MDI Project and ongoing communication regarding patients’ treatment needs.

EVALUATION 

The multilevel CO MDI evaluation uses the Reach, Effectiveness, Adoption, Implementation and Maintenance (REAIM) framework to measure the impact of the project on practices, providers, and patients.⁵ This comprehensive approach includes qualitative methods to understand the in-depth insights of practice leadership and participating dental hygienists. It also includes quantitative methods to measure change in provider oral health characteristics and patient/caregiver satisfaction with the model. Additionally, calibrated practices submit monthly disease metrics and quarterly financial metrics.

As of December 2017, dental hygienists at the CO MDI medical practices provided more than 40,000 visits: 25% to those age 0 to 5; 33% to those age 6 to 18; and 43% to those age 19 and older. The insurance status of this patient population was mixed: 72% covered by Medicaid; 3% covered by CHP+; and 25% had other forms of payment.

A total of 39% of the CO MDI patients seen had untreated caries; more than 19,000 referrals were made for dental restorations, and more than 58% of those restorative appointments were kept. The majority (62%) of patients had not seen a dental provider in the previous 12 months. Five practices’ revenue exceeded expenditures by 18 months.

NEXT STEPS

The Delta Dental of Colorado Foundation will provide a second wave of funding for the CO MDI Project to support the integration of dental hygienists into the medical care teams of up to 10 new nonprofit medical practices. Medical-dental integration is not a “one size fits all” approach. Every practice is different; therefore, integration looks different in each practice.

Many lessons have been learned over the course of the CO MDI Project. Based on the initial evaluation data, CO MDI grantees are reaching patients who have lacked consistent access to dental care and establishing collaborative referral relationships with dentists to ensure patients are part of a dental home.

REFERENCES

1. Braun P, Cusick A. Collaboration Between Medical Providers and Dental Hygienists in Pediatric Care. J Evid Based Dent Pract. 2016;16:59–67.
2. Dye BA, Thornton-Evans G. Trends in oral healthy by poverty status as measured by Healthy People 2010 objectives. Public Health Rep. 2010;125:817–830.
3. Daley J. Study Finds ‘Dental Deserts’ In Rural Colorado. Available at: cpr.org/news/story/study-finds-dental-deserts-rural-colorado. Accessed February 15, 20
4. American Dental Hygienists’ Association. Direct Access. Available at: adha.org/direct-access. Accessed February 15, 2018.
5. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89:1322–1327.

From Dimensions of Dental Hygiene. March 2018;16(3):12.