Integrating Medical and Dental Care

As dental professionals well know, oral health is directly connected to overall health. Dental hygienists take thorough health histories to be aware of systemic conditions, inquire about various medications and dosages to evaluate for oral health implications, and take blood pressure readings. They also discuss diet and the effect of overall nutrition on health. When making self-care recommendations, dental hygienists must consider patients’ physical disabilities and how devices and techniques may help them achieve optimal oral hygiene. When patients present with various mental health conditions—including anxiety, depression, and eating disorders—they understand their effect on the oral cavity, as well. While many patients may visit their primary care provider just once per year or not at all, they often visit their oral health professional twice per year. This presents a unique opportunity for dental hygienists to refer patients to other specialties based on assessments and screenings conducted during the dental appointment.

Despite this opportunity, how often do dental hygienists make a referral only to hear at the patient’s next dental visit that an appointment was never scheduled? There are many barriers to both medical and dental care, especially for low-income and uninsured patients. From the inability to take time off work to a lack of available providers, myriad obstacles may interfere with patients’ abilities to seek medical or dental care.

INTEGRATED HEALTH SETTING

Imagine a setting where dental hygienists are among several health professionals working together to serve patients using a team-based approach. Patients would have better access to care and many barriers would be eliminated through the integration of dental and medical services provided in one setting. If further questions about the systemic health of a patient arise, his or her primary care provider is present, working to provide comprehensive care alongside the dental hygienist. Through the support of the Delta Dental of Colorado Foundation, this has become a reality for 16 clinics across the state of Colorado involved in the Colorado Medical-Dental Integration Project (CO-MDI).

Northwest Colorado Health—a federally qualified health center with two locations in Moffatt and Routt counties—began oral health integration efforts in June 2015, at which point the first dental hygienist was hired. The primary care team at Northwest Colorado Health is composed of three physicians, four physician assistants, one nurse practitioner, and several licensed mental health professionals. Although Colorado Medicaid offers a dental benefit for both children and adults, in rural areas there is often a lack of providers accepting this insurance. Oral health services are greatly needed in Moffatt and Routt counties, as there is only one provider accepting new adult patients covered by Medicaid in either county. Transportation is another barrier, as the one dental safety-net clinic is located 44 miles from the largest town in these two counties. Instead of needing to drive 1 hour for preventive dental services, missing time away from work or school, what if a patient could receive dental hygiene services following an appointment with his or her primary care provider? This is the case at the Community Health Center at Northwest Colorado Health. Due to the high volume of patients served at the center, a category of priority was developed for initial oral health screenings: patients with diabetes, patients who use tobacco products, patients who are pregnant, and children age 12 and younger. Each morning, the dental hygienist joined the medical and behavioral health providers for a daily huddle to discuss the needs of each patient and the priorities for the day. This team-based approach allows for patients to have their whole health care team communicate about their needs and to better understand how different aspects of their health and care are affecting overall well-being.

COMMUNICATION IS KEY

During the patient´s medical appointment, overall communication between team members is of the utmost importance. In Northwest Colorado Health’s Community Health Center, the medical assistant screens the patient for his or her oral health needs, inquiring about the presence of a dental home, last dental visit, and existence of any oral pain. Based on the answers to these questions and the risk level of the patient, a referral to the dental hygienist is initiated.

At the initial screening appointment with the dental hygienist, an oral cancer screening, evaluation for obvious decay, risk assessment, oral hygiene instruction, and fluoride varnish application are provided. Following the dental hygiene screening, a referral is sent for the patient to visit a dentist for a comprehensive examination, in addition to any restorative needs.

After equipment purchases were made and the required credentialing processes were completed, full dental hygiene services began at both clinics, allowing the dental hygienist to work at the top scope of licensure in Colorado. A portable radiography machine shared between the two clinic locations allows the dental hygienist to perform a full-mouth series of radiographs at an initial assessment appointment, in addition to a full periodontal examination. Following this appointment, the patient is scheduled for a prophylaxis or periodontal scaling and root planing with the dental hygienist. These visits can often be scheduled in concurrence with a follow-up medical appointment. Due to a shared electronic health records system between medical, dental, and behavioral health staff, documentation notes are sent from the dental hygienist to the primary care provider to keep him or her up to date on the patient’s dental needs.

CONCLUSION

This new alternative model of care allows dental hygienists to actively participate with other health disciplines. It is absolutely essential that access to care expand and improve as new health care delivery models are developed to treat patients in the most comprehensive and holistic way possible. The Delta Dental of Colorado Foundation´s CO-MDI project has created a feasible way for dental hygienists to work at the top of their license and treat patients alongside other allied health providers, with the goal of improving overall health outcomes for all patients.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. October 2016;3(10):44-45.