Learning from Health System Initiatives: What Can Be Done to Scale Up Integration?

Dushanka V. Kleinman, DDS, MscD, Prof. and Principal Assoc. Dean, School of Public Health. U. Maryland, College Park.
Kathryn A. Atchison, DDS, MPH, Prof. of Public health and Community Dentistry, UCLA.

Patricia Braun, MD, MPH, FAPP, Prof. of Pediatrics and Public Health, U. of Colorado School of Medicine/Colorado School of Public Health/ Denver Health.
Greg Nycz, Executive Director, Family Health Center of Marshfield, Inc., Marshfield, WI.
Michael J. Hegelson, DDS, Co-founder and CEO, Apple Tree Dental. Rochester, MN.

Andrew Snyder, MPA Public Policy. Health Insurance Specialist, CMS.
Hannah L. Maxey, PhD, MPH, RDH. Indiana U. School of Medicine.

Initiatives to include oral health within primary care medical settings preceded the current groundswell to advance the integration of dentistry and medicine in research, policy, education, and practice. To explore how they have fared, the Santa Fe group invited representatives of three programs to describe their origins and evolution. While the systems described share certain features, each is unique in design, crafted to meet the needs of the specific patient populations, utilizing the workforce available, and to secure the funding necessary to operate in a fiscally sound manner. Co- moderator Dr. Kathryn Atchison introduced the speakers.

Leveraging the Medical Visit. First was Dr. Patricia Braun, a Colorado-based pediatrician whose initial foray into dental/medical integration was motivated by the realization that dental caries remains the most prevalent disease of children, yet is largely preventable. So, in 2009 an oral health initiative was launched in association with Denver Health, a major “safety net” health plan with medical and dental clinics across the state. The goal was to improve the oral health of very young children. Dental problems were rampant, yet, the number of physicians on Denver Health staff far exceeded the number of dentists, limiting parents’ access to dental care for their children. Planners decided to teach the MDs the rudiments of dental exams, and how to apply fluoride varnish as a decay-preventive measure. When mothers brought their toddlers in for medical check-ups the visit would now include an oral component. The plan worked. Three -year-olds who had had at least 4 varnish treatments over time had 20 percent fewer signs of decay than toddlers who had no preventive treatments. The approach was widely endorsed by pediatric professional associations and other provider groups.

But there was a problem. Even though the profession saw the value of adding oral care surveys of pediatricians more broadly indicated that only 18 percent said they had incorporated oral exams and fluoride varnish in their practice. Apparently, the additional time and/or insufficient reimbursement for the vanish treatment were deterrents.

A change was needed. As Dr. Braun explained, instead of training physicians to be rudimentary dentists for young children why not turn to existing, highly qualified practitioners of preventive measures in dentistry: dental hygienists. Colorado is one of 42 states in America where dental hygienists can practice without the presence of a supervising dentist. Furthermore, the Delta Dental of Colorado Foundation was already experimenting with adding a dental hygienist to medical teams. Dr. Braun’s group worked with the Foundation on an initial test using 5 dental hygienists, found it feasible, and between 2014 and 2019 started Wave I of a program to add dental hygienists to medical teams.

Key to the success of the model was the establishment of “Learning Collaboratives” at the outset where team members would meet regularly to share experiences and develop best practices, guided by “practice coaches.” A system of evaluations was in place and included interviews of the medical team members, the hygienists, and patients. Specific metrics were developed to assess health outcomes and costs, providing feedback that allowed the program to evolve to improve efficiency, sustainability, and patient satisfaction.

In 2019 Wave II was created to run through 2024, expanding the model beyond Colorado with funding from a cooperative grant from the Health Services and Resources Administration. The four states of the Rocky Mountain Network of Oral Health (Montana, Wyoming, Colorado, and Arizona) currently support 42 dental hygienists working on medical teams at Federally Qualified Health Centers, small rural not-for-profit hospitals. and large urban not-for-profit hospitals serving over 75,000 patients from toddlers to adults. Seventy percent of the patients are Medicaid recipients, so the program is particularly valuable in addressing oral health disparities prominent in low-income patients.

Dr. Braun’s concluding remarks emphasized the importance of engaging leaders and team members in the model, finding the “right” dental hygienists, and using coaches. In the expanded network they are exploring expanded dental workforce models, patient management through an oral health registry, value-based care with incentivized payments, and enhanced patient engagement. Most important, she emphasized, in words of advice to anyone wanting to start a comparable program, is to plan your program to suit the patient population you want to serve because “no one size fits all.”

Echoing Dr Braun’s admonition, the next presenter, Greg Nycz, Executive Director of the Family Health Center of Marshfield, Inc. in Marshfield, Wisconsin, knew exactly the patient population he wanted to serve: the rural low-income residents of northern Wisconsin with limited dental services available in their areas and hence limited access to oral care. Because they were largely poor, uninsured, or publicly insured, they are also among the groups experiencing oral health disparities. He approached the physicians leading the Marshfield Clinic Health System , which at that time was a large 85-year- old state health system with 50 medical clinics throughout the state but no dental components. He proposed partnering with Federally Qualified Health Centers that could provide dental services as an initial step to meet the needs of what he saw as “a public health emergency.” The physicians were persuaded of the importance and built a new facility in the small rural town of Ladysmith, staffed by 5 dentists, 5 dental hygienists and support staff. Mr. Nycz described it as an initial concrete symbol of the intent to solve a major health problem, not just take the edge off it

“Impressive success.” Still there needed to be a way to generate and sustain investment and growth. “Failure was not an option,” Mr. Nycz said—nor was complete success, either—lest the legislature consider the job done and stop funding it. What was needed was “impressive success.” Impressive success meant the plan needed to further incentivize state funders, as additional patient populations were added. Initial steps includedaddressing the problem of people with dental emergencies, offering services provided at the Marshfield dental center, to prevent patients from showing up at high-cost emergency rooms. A second center was built with wheelchair access and arrangements were made with local hospitals to treat patients with disabilities from around the state. Dental care was also the number one health need voiced by low-income veterans, so their needs were addressed as well. State-trained workers were a liability if they were unable to get jobs after training because of severe oral conditions. So Marshfield prioritized treatments for them, too, so they could then be gainfully employed. And finally, legislators formerly besieged by constituents who complained they could not get dental care said their phones went silent once the Marshfield dental clinics materialized.

Today the 10 Marshfield dental centers treat between 55,000 and 60,000 patients a year, over 90 percent of whom have incomes at or below 200 percent of the federal poverty level. The centers have devised an interoperable medical-dental electronic health record to facilitate integrating medical and dental services for patients. They encourage physicians to improve their own and patients’ oral health literacy and to recommend regular dental check-ups, as well as enlist dentists to advise patients on immunizations and other general health issues. But barriers to integration remain. Among them are the limited number of hours devoted to oral health topics medical students receive. (One survey reported that only 1.3 percent of physicians said they were “very well” trained on oral health topics in medical school.) Mr. Nycz’s final slide pressed that point home with a slide of a dog and a cat. “Vets get it,” he said. Our pets get holistic treatment because their docs understand the connection between oral and systemic health. It’s time we all did, too.

Apple Tree Mobile Services. The third presenter, Michael Helgeson, DDS, is the CEO of Apple Tree Dental in Minnesota , who described his model as a Community Collaborative Practice designed to bring dental care to people “where they live, go to school or get other health or social services.” This is a variation on the one-stop shopping principle that is especially beneficial for populations with limited access to dental services, including patients in long-term care facilities or living in rural communities. Apple Tree has a fleet of trucks equipped with dental units that go out to designated sites each morning, such as a nursing home, and set up a dental service unit for scheduled appointments with patients. A diversified workforce team including dental hygienists, dentists, dental therapists, nurse practitioners and others, sees the patients, maintains electronic health records, and can use telehealth contacts for consultation and advice as needed. Apple Tree has leveraged resources from private, government and non-profit sectors.

Currently, the company supports 8 Centers for Dental Health delivering care at 145 community sites in 85 out of Minnesota’s 87 counties. Populations served are largely low-income children and families, individuals with disabilities, and seniors in long-term care facilities. Three-fourth of patients are Medicaid eligible. The success Apple tree has sustained with its model has led to its work with other states interested in replicating the model.

More recently Apple Tree has built a facility in Rochester, Minnesota across the street from the celebrated Mayo Clinic, the oldest and largest non-profit multi-specialty group practice in the world. Apple Tree has also established a facility within the Mayo Clinic itself. The Fairmont Center provides urgent care and receives emergency room referrals. The co-location affords opportunities for health information exchange and research collaboration. Dr. Hegelson was excited to report that Apple Tree is adding oral health records to enrich a major Mayo Clinic study, the “Rochester Epidemiological Project”, in which a million residents of Rochester’s Omsted County (95 percent of the population) have agreed to provide their medical records to constitute a rich database for analysis.

Dr. Hegelson’s concluding remarks reflected on the challenges to be overcome to achieve dental-medical integration in practice. In particular, he mentioned the need to eliminate “age discrimination in Medicaid and mouth discrimination in Medicare.”

Co-Moderator Dr. Dushanka Kleinman next introduced the two reactors to the presentations. First was Andrew Snyder, MPA, a health policy expert from the Medicaid side of the Centers for Medicare and Medicaid Services (CMS). He also leads an Oral Health initiative aimed at increasing oral health services for Medicaid-served children.

Mr. Snyder emphasized that even though Medicaid is a jointly funded federal-state health plan, the states are largely in control of how the funds are spent—determining what services are covered, for whom, by whom, for what reason, and at what cost. He said that as models involving medical/dental integration are being tested he believes that states are ready to engage. As confirmation, he cited Medicaid’s decision to launch a Learning Collaborative along the lines described by Dr. Braun. It has been robustly received by Medicaid staff, he said, with 14 states agreeing to participate in a year-long program to explore the implications of fluoride varnish treatment, examining issues of workforce utilization, workflow, reimbursement, and other considerations, with coaches to guide discussion and policy development. Telehealth is another example of a growing health care resource, prompted by the pandemic, in which each state will have to set policy and reimbursements.

Overall, Mr. Snyder urged all those involved in the clinical/operational side of health care to engage with Medicaid representatives—and not just at the leadership level—but with those involved in day-to-day operations. Finally, he reminded the audience that in all policy-making activities involving federal/state interactions, there is a mandatory period for public comment. Again, it is important to engage with the public and ensure that the patient issues are clearly understood and expressed since all comments are reviewed in the course of decision-making.

The second reactor was Dr. Hannah Maxey, an Associate Professor of Family Medicine at Indiana University School of Medicine, and a licensed dental hygienist with expertise in health services and workforce policy and research. She spoke forcefully saying that medical/dental integration would not succeed without major systems reforms in three key areas: Reimbursement, Occupational Regulation, and Education.

“Show me the money” inevitably is the issue when it comes to expanding or defining new roles for health professionals, such as applying fluoride varnish as a preventive treatment. It is the crux of the matter in starting any new program of care delivery and figures even more in any scaling up of activities.

But workforce issues are critical. The idea of using dental hygienists as independent oral care providers in primary settings is attractive, but only if state practice laws allow it. She noted that even though her home state of Indiana is considered a direct access state, allowing hygienists to see patients without the supervision of a dentist, access is limited to the first encounter with the patient. A second appointment, according to the “access practice agreement” requires intervention by a dentist in an associated practice. That impediment plus little in the way of implementation or guidelines of the law has resulted in little uptake by the hygiene profession. As for the more advanced skills of a dental therapist, she reminded the audience that there was much weeping and gnashing of teeth by the medical profession when nurse practitioners appeared on the scene decades ago. There was fear, not in terms of danger to patients (which is the focus of scope of practice laws), but to the monopoly the medical profession enjoyed. Today nurse practitioners are esteemed as a welcome addition to health care delivery systems allowing MDs to concentrate on more complex and challenging patients.

Education is the third issue demanding systems change. It is simply not tenable to maintain a system in which medical students learn little about the oral cavity during their years of medical school, Dr Maxey said. This is in spite of pronouncements and acknowledgment that oral health is essential to general health, “What gets measured matters,” she said, and physicians emerge with their license to practice with little testing of their oral /dental knowledge. The only way to fix this is for the medical schools and licensing organizations to work together for change.

In summing up, Dr. Maxey acknowledged her systems reforms agenda was admittedly idealistic, ambitious and time-consuming. Aiding the effort would be continued research on oral/systemic connections, on the impact of new models of care delivery and on workforce diversification. Until reforms are in place, the siloes separating medicine and dentistry will stand and dentistry will remain outside health care systems looking in.

In the limited time remaining Dr. Kleiman posed three questions to the panel. The first concerned what they would most like to do to expand their programs. Dr. Braun acknowledged the importance of establishing the kinds of contacts described by Mr. Snyder and following developments within the dental hygiene community. Dr. Hegelson said he would like to target a “value-based” purchasing concept in which the actual delivery of care to Medicaid-eligible patients taps into new resources, including doctors, nurses, mental health providers, schoolteachers, and Head Start teachers, to break down barriers to information and advice and help to create true “health homes”. He also urged reforms that eliminate state barriers. It makes no sense, especially with new resources like telehealth, to set policies and practices in each state that stop at the state line. CEO Nycz said his concern was along policy lines. He would like to see the Affordable Care Act fixed to include dental care for adults, a statement which provoked a reference to the earlier comment that there should be no age discrimination in Medicaid, nor mouth discrimination in Medicare.

Dr. Kleinman’s second question concerned the impact of the models and whether they had formed any networks with other programs. All agreed that measuring health outcomes was an important impact, although costly and time-consuming to measure. All were involved in a variety of networks. Dr. Hegelson was particularly pleased that Apple Tree was contributing 10,000 dental health records with diagnostic data to the ongoing Rochester Epidemiological Project.

Dr. Kleinman’s last question asked each of the panelists to describe in a word or two what they would advise anyone who wanted to start a program like those described. Dr. Braun said. “Learn from our failures. No one size fts all.” Mr. Nycz said, “Call us.” Dr. Maxey said, “Understand the policy environment; what’s feasible and what response is needed to implement a program.” Mr. Snyder said, “Talk to your state folks.” And lastly, Dr. Hegelson said. “Collaborate. And think actively about public, private and not-for-profit resources. No one can do it alone.”

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