Improving Oral Health through an Integrated Model of Oral Health Care ( Project ENGAGE)
Amid I. Ismail BDS, MPH, DrPH, MBA Dean and Laura H. Carnell Professor 215-707-2799 ismailai@temple.edu http://www.temple.edu/dentistry/ 3223 N. Broad Street, Philadelphia, Pennsylvania, 19140 2
The dogmas of the quite past are inadequate to the stormy present. The occasion is piled high with difficulty and we must rise with the occasion. As our case is new, so we must think anew, and act anew. We must disenthrall ourselves, and then we should save our country. Abraham Lincoln, 1862 3 LOGO
Instruments Made by Paul Revere at KSOD First Dental Chair (US) Dr. Josiah Flagg, 1790 4
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Dental Caries? Dietary sugar Microbiome and carbohydrates Tooth structure and saliva 9
Trends in Dental Caries in the Primary Dentition (dft). United States, from 1970s to 1980s There has been no change since Mean dft mid 1980s 10
Mean dfs scores in US Children 2-5 Years of Age 11 Centers for Disease Control and Prevention, 2007
Untreated Decay in New Zealand, 2009 Prevalence of Untreated Caries 30 25 20 15 Prevalence of Untreated Caries 10 5 0 Most Deprived 1 2 3 4 5 12 New Zealand Ministry of Health, December 2010
Mean Number of Non-cavitated, Cavitated, and Filled Primary Tooth Surfaces in Children 6-7 Years Old Who were Covered by a Universal Dental Care Program, Nova Scotia, Canada 13 Ismail AI, Sohn W. JADA 2001;132:295-303.
Community family, babysitters, child Housing Peer Group care, neighbors, pastors Main Caregivers (quality and safety, (reinforce good (positive and negative role- hazards, lead…) (positive parenting values, introduce modeling…) practices, stress, destructive employment, child behaviors…) abuse, depression, nutrition…) Neighborhood (safety, violence, play spaces..) Prenatal Exposures Health (stress, fetal growth, Transportation nutrition, substance abuse…) (quality and safety, seat belts, car seats…) Policy Schools Decisions Commercial (buildings, (Medicaid, SCHIP, (product safety, Access to violence, Head Start, WIC…) advertisements…) quality of Health and instruction…) Social Services Environment (medical care, Yellow- prenatal (clean air, water, soil, Silver- People dental care, food availability, power Green - Local Structural immunizations, Blue - National Structural plants, industrial nutrition…) waste…) 14
• We pay for procedures, not OUTCOMES • We focus on dental care by professional providers rather than on a system for promoting health 17
The dogmas of the quite past are inadequate to the stormy present. The occasion is piled high with difficulty and we must rise with the occasion. As our case is new, so we must think anew, and act anew. We must disenthrall ourselves , and then we should save our country. Abraham Lincoln, 1862 18 LOGO
The Current Model of Dental Care for Children What are the Payment per outcomes? procedure The current MA system for dental care of children pays for Higher rewards procedures without any for care under emphasis on health sedation outcomes and with no Social and psychosocial consideration of the Children 0-3 determinants are not years are not a social and psychosocial addressed priority determinants of oral health Current science in caries management Care for is not utilized caregivers is not a priority
Rationale for Project ENGAGE
Health Home
E xchanging health information in real-time through the Project ENGAGE Registry, an innovative online tool designed to store patient data and educational materials. N etworking among dentists, physicians, community health workers, and Managed Care Organizations/Medicaid Funders using the online registry. G uiding the implementation of educational and social support interventions at the child/family level using motivational and self-efficacy models, And G uiding the implementation of evidence-based management protocols of existing disease (dental caries) and control of the caries process via coordinated access to dental providers and preventive/educational interventions assisted by novel workforce models (community health workers, public health dental hygienists, and expanded function dental assistants).
E ducation of the dental team members which includes dentists, allied dental professionals, and community health workers to prevent caries and arrest early carious lesions .
Innovation in Temple University’s Project ENGAGE A dental Evidence- home that based care emphasizes prevention Improved Overall Protocol to Health and Focus on oral diagnose and Social health manage Wellbeing outcomes dental caries for each Child Registry to A aid in community creating a based team HEALTH HOME
What Outcomes We Want to Achieve for Children 0-5 Years of Age? Oral Health Dental Access Higher number of children Lower prevalence of aged 0-5 years with dental children with dental caries homes Outcomes Quality of Life High-caries Children Improve quality of life of Decrease the number of children and their families children who undergo treatment under IV sedation and general 25 anaesthesia
Final and Process Oral Health Outcomes (similar to NDQA) Increase access to dental services Increase in number of children receiving Provide appropriate dental care prevention based on risk status and treatment of carious Dental lesions Health Assist patients to establish and maintain a Reduction in “dental home” restorative care and increased emphasis Reduce cost of care on prevention by reducing the amount of treatment provided under GA/IV sedation
Project ENGAGE Design • Registry o Medical and dental record of children with no dental home and covered by Medical Assistance • Dental team o Community health workers (CHWs) o Public health dental hygienists (PHDH) o Dentists o Specialists • Home and community engagement (education, barriers, fatalism, literacy, coordination) • Clinical care
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Project ENGAGE • Vaccination record will be displayed in the Registry for the CHWs to advice and recommend follow-up care • Major medical conditions o Asthma o Diabetes o Hypertension (pregnant women)
Process to Maintain Healthy Teeth in Children Diagnose initial, moderate and extensive decay Prevent caries from developing in sound teeth Arrest/re-mineralize initial carious lesions Restore minimal cavities Restore extensive cavities ENGAGE Review and monitor oral health Motivational approaches to promote appropriate access to sugary drinks and oral hygiene practices
Project ENGAGE After Care • Home dental visits will be offered to children with high-caries risk or experience • A dental hygienist will visit families of children who are at high risk of developing dental caries o Fluoride varnish o Dietary and oral hygiene plans
Sustainability of Project ENGAGE Savings on treatment of tooth decay, especially of children being treated under GA or IV sedation Savings on cost of repeat dental care provided under GA or IV sedation Income from increased access to dental care by expanding the population served
FUNNEL SYSTEM of DENTAL CARE for CHILDREN Using a Dental Team A Practice Model under Medicaid Level I Lower cost of care with Large patient/population high return on base managed using a team investment of time. that includes dentists and Major contributor to clinical and community staff revenues Level II Medium cost and Patients in need for limited return on simple restorative and investment of time surgical care (at a clinic) Level III Highest cost and Hospital-based or highest return on surgi-center care investment of time 33
OUTCOMES Sound Teeth Protected (preserved) dental tissues (Arrested or non-restored non-cavitated lesions) Preservative treatment of caviated lesions (Minimal/micro cavity preparations, step-wise caries excavation)
Health Can Only by Achieved if We Focus on the Final Desired Outcomes in the Design and Operations of a Health System --------------------------------------- Sound Strategy Starts with having the Right Goal. -Michael Porter
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