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Whole-person care: Practical ways to improve your patients' oral health

By Jeff Hummel, MD, Qualis Health's Medical Director for Health Informatics.

It’s widely recognized that lack of access to basic dental services contributes to health inequity, but separating dental care from medical care has been a historical norm within the U.S.   That is changing. It’s becoming clear that periodontal disease has a significant impact on inflammation elsewhere in the body. We see this most dramatically in cardiovascular disease and diabetes, but it also appears to impact pregnancy outcomes.   Likewise with tooth decay in children, the impact of poorly treated caries can last a lifetime.  Both caries and periodontal disease are examples of how providers simply cannot separate the mouth from the body as we become accountable for the whole person.  

The Affordable Care Act (ACA) brought coverage to millions of people who had never had health insurance before.  But even with the ACA in place, many millions of Americans still don't have dental insurance.  Medicare has never covered preventive teeth cleanings, restorative fillings, screeing dental X-rays, or routine exams.   Despite these very real barriers to care, there are many effective things primary care providers can do to help close the gap on this huge unmet need.   We recently completed The Oral Health Integration in Primary Care Project, and have published an accompanying implementation guide, which contains helpful information primary care practices can use to integrate oral health prevention into the care they provide.  

Take the most important first step 
The most important thing your practice can start doing right now is to ask patients one or two questions about their oral health and start looking closely at their teeth and gums.  On the basis of what you find there are several simple but effective actions any one of which can make a big difference for patients.  If you can do just this, you’ve taken a big step forward.  

Identify your target population
Once you’ve made the teeth and gums part of a routine health assessment, you can move quickly into a population approach to oral health.  In Qualis Health’s oral health integration work, we helped providers in 19 clinics across the U.S. define their target population.  Many focused on kids because there are Medicaid reimbursement and revenue streams, and many insurance companies pay for fluoride varnish and preventive health care.  So that’s a perfectly reasonable place to start. But if a clinic has made diabetes a strategic priority it also makes perfect sense to focus on diabetes.  

Define your standard of care
After identifying your target population, ask yourselves:  “What’s our standard of care going to be?”  A very reasonable standard of care is to include concise and clear prevention messages at every well child visit. Make sure every child gets fluoride varnish if it is due, and look into the mouth to see if there are any signs of tooth decay.  If you find signs of decay, or someone in the family has had decay or lost a tooth from decay in the past year, the child needs to see a dentist.  Every child should have a dental exam at age one and an established relationship with a dentist.  If you don’t have a dental service in-house, develop a referral relationship with one or more dental partners in the community who will accept referrals.  Once you’ve established your standard of care, you need to measure it so you can track on a population level how well you’re meeting it.

The standard of care has to be translated into workflow tasks, so we make a list of tasks to carefully insert into the office visit workflow.  For instance, you could establish a workflow to assure that all kids in your practice get fluoride varnish three times a year.  You might also set up reminders to talk with parents about the risk factors for caries, including oral hygiene and sugary snacks.  Most of these tasks take very little additional effort or time.  

Get creative to make this sustainable
There are creative ways to make oral health integration pay for itself, or at least be cost-neutral.  For children, it depends on the Medicaid arrangements in your state. Here in Washington, as in many other Medicaid expansion states, the reimbursement is relatively generous:  you can get reimbursed not only for a fluoride varnish application, but also for the primary care oral health assessment and counselling.  In this way, oral health preventive care for children can generate an important revenue stream.  For adult populations there may be no direct revenue stream, but an oral health population program can help meet requirements for value-based reimbursement like MACRA, and it positions a clinic well for controlling total costs as we move deeper in to new payment models. 

It’s all connected—and it’s the right thing to do
As we move out of fee-for-service medicine and into value-based reimbursement, we’re becoming increasingly accountable for whole-person care.   We can’t exclude parts of the body.  It’s all connected. Caring for the mouth and gums is not just the right thing to do:  It’s a key component of assuring high-quality patient care, improved population health, and controlling overall cost.  

Jeff Hummel, MD, is a general internist with more than 30 years of medical experience, including extensive work in primary care and health informatics. He is currently Medical Director for Clinical Informatics at Qualis Health. Before joining Qualis Health, Dr. Hummel held clinical, research, and medical informatics positions at the University of Washington Physicians Network.  He has also played important roles in the Regional Extension Center community with the Washington & Idaho Regional Extension Center and as a member of the Office of the National Coordinator's Meaningful Use Advisory Group.

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