Providing Comprehensive Care

Comprehensive care is the optimum goal in providing health services, and oral health care is an important component of this approach. Poor oral health may adversely affect systemic health, nutrition, sleep patterns, psychological status, social interactions, and other activities of daily living.¹ Most oral health disease is preventable; however, by age 5, 60% of American children will have experienced tooth decay.² Low-income populations are at high risk of oral health problems and this has created a public health crisis that will impact quality of life now and in the future.^3–5 One in five low-income adults report their mouth and teeth are in poor condition.⁶ There is a high prevalence of periodontitis among older adults, making the oral-systemic relationship an important factor to address with this population.⁷ High rates of decay in vulnerable populations and a high prevalence of periodontal diseases negatively impact the medical, social, and economic health of society, suggesting a new approach to achieve comprehensive care is needed.²

The 2000, 2010, and 2014 reports of the United States Surgeon General, Institute of Medicine, and Health Resources and Services Administration (HRSA) called for all health care providers to participate in improving the oral health of the nation.^8–10 Integrating oral health care and dental professionals into the medical model of care will improve outcomes. Interprofessional education (IPE) is the first step in expanding interprofessional collaboration in health care. The Centre for the Advancement of Interprofessional Education defines IPE as “occurring when two or more professions learn with, from, and about each other to improve collaboration and the quality of care.”¹¹ The World Health Organization supports IPE, as it encourages effective collaborative practice, resulting in better health services and improved outcomes.¹² IPE benefits clinicians and patients because it leads to the establishment of interprofessional teams in real world practice, working together to improve the provision of comprehensive health care (Figure 1).¹³

INTERPROFESSIONAL EDUCATION

At New York University (NYU) in New York City, leaders in dental and nursing education are committed to changing the traditional health care paradigm of health professions students learning and working in silos.¹⁴ NYU dental, dental hygiene, and nurse practitioner students work collaboratively on assigned cases to determine the best overall approach for each patient. This provides students of different disciplines the opportunity to work together using their professional training and knowledge to determine a more comprehensive approach to patient care.

The Center for Interprofessional Education and Collaborative Care at Virginia Commonwealth University (VCU) in Richmond focuses on developing health professionals’ team-based skills.¹⁵ Students in the Schools of Pharmacy, Allied Health (occupational therapy and physical therapy), Nursing, and Dentistry (dentistry and dental hygiene) are required to take “Foundations of Interprofessional Collaborative Practice.” The course provides instruction on developing team-based skills for interprofessional collaboration; recognizing roles, training, licensure, and typical practice of various health professions; and determining strengths and opportunities for improvement in the health care system. Students are introduced to working together as a team within their own disciplines and with students from other disciplines. The interprofessional teams explore the needs of all involved in health care, helping to improve quality, safety, and access to care. This approach provides a baseline for growth that will support interprofessional collaboration when in practice.

The Virginia Geriatric Education Center (VGEC)—a consortium of VCU, University of Virginia, and Eastern Virginia Medical School—conducts several interprofessional geriatrics training programs, each intended to advance the quality of health care for older adults through team-based learning.¹⁶ The VGEC interprofessional program includes a 200-hour faculty development program, whose goal is to improve the geriatrics training of health professionals who have faculty appointments, so they can pass their own training to colleagues and students. At the start of this academic year, the VGEC added a dental hygienist/gerontologist to the faculty and included oral health in the program’s curriculum to achieve more comprehensive geriatric patient care.

In Portland, the Oregon Health and Science University (OHSU) Interprofessional Initiative focuses on working collaboratively across schools and programs, building an IPE model that makes team-based, patient-centered care the new standard.¹⁷ The Collaborative Life Sciences Building is an interprofessional facility where students of various disciplines—including dental, medical, nursing, pharmacy, and physician assistant—from OHSU, Portland State University, and Oregon State University are brought together under one roof, fostering collaboration in undergraduate and graduate education among students and instructors. Students learn together in seven IPE courses, introducing them to the importance of best practices for professionalism, roles and responsibilities, teamwork, communication, ethics, and collaborative practice as a means to improve the quality and safety of patient care. This educational approach limits miscommunication, improves collaboration, and helps students learn to work with colleagues at the highest scope of their professional capacity to collectively improve patient care.¹⁷

HRSA developed the Integration of Oral Health and Primary Care Practice (IOHPCP) initiative to improve access for early detection and preventive interventions.¹⁸ The initiative recommended the inclusion of oral health in health care professional education, training, and continuing education curricula. In response to this recommendation, various online toolkits and educational programs have been created to improve integrated approaches to dental care in medical primary practice. The Virginia Oral Health Coalition developed an online toolkit that can be used by health care providers to integrate oral and overall health care and to increase and improve collaborative efforts in order to achieve a more comprehensive patient-care approach.¹³ Training provided in the free online toolkit focuses on leadership, education, patient populations, available services, communication, assessment, financing, infrastructure, and community support.¹⁹

The Oral Health Nursing Education and Practice organization developed an online interprofessional toolkit that serves as a starting point for faculty, clinicians, and organizations. It leads the way in establishing interprofessional oral health workforce capacity, while striving to improve access to dental care and decrease oral health disparities.²⁰

Smiles for Life, a national oral health curriculum, was developed by the Society of Teachers of Family Medicine. Eight interprofessional courses are offered free of charge to practicing clinicians and educators. The goal of the courses is to empower primary care physicians to promote oral health among all age groups.^{21, 22} 

PILOT PROJECTS

The IOHPCP initiative recommended implementing pilot projects to identify innovative ways of integrating oral health care into medical settings. The Colorado Dental Hygiene Co-Location Project put dental hygienists into five medical practices serving disadvantaged children. This new dental hygiene practice model was designed to expand access to preventive services and improve outcomes for high-risk populations.²³ Each site has a dual-function room to accommodate a dental hygienist or a medical provider based on patient need and schedule, as well as a chair for either dental or medical exams. The medical and dental professionals learn and work together. Results revealed that co-locating dental hygienists into medical practices is a feasible and innovative method of providing primary preventive dental care to high-risk children. Pilot findings led to the Colorado Medical-Dental Integration Project (see page 44 for more information).^24,25

CONCLUSION

IPE and new initiatives incorporating oral health care into medical care settings are steps in the right direction for modernizing the medical model of care to improve overall patient care and health outcomes. Utilizing interprofessional health care, along with addressing costs to enhance public and private reimbursement for oral health throughout the lifespan, will increase the provision of coordinated patient-centered and value-focused care, leading to improved quality of life and providing a positive economic impact.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. October 2016;3(10):40-43.