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Innovations in Oral Health and Primary Care Integration

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Innovations in Oral Health and Primary Care Integration Innovations in Oral Health and Primary Care Integration Alignment with the Shared Principles of Primary Care thePCC.org Innovations in Oral Health and Primary Care Integration Acknowledgments ADVISORY GROUP PCC convened an advisory group to help inform this report. The following individuals contributed to developing and evolving the final document over the last year: Chair: Anita Glicken, MSW, National Interprofessional Initiative on Oral Health Lynda Flowers, JD, MSN, RN, AARP Dean Fry, DDS, Humana Ann Greiner, MCP, Primary Care Collaborative Judith Haber, PhD, APRN, FAAN, NYU College of Nursing Lawrence Hill, DDS, MPH, American Association for Community Dental Programs Alan Morgan, MPA, National Rural Health Association Cheryl Parcham, MSW, Families USA Russ Phillips, MD, Center for Primary Care, Harvard Medical School Jason Roush, DDS, Association of State and Territorial Dental Directors Ann Salamone, DDS, New York Hotel Trades Council (formerly) Hugh Silk, MD, MPH, FAAFP, University of Massachusetts Medical School Howard Straker, EdD, PA, MPH, George Washington University Capt. Pamella Vodicka, Health Resources & Services Administration Marko Vujicic, PhD, Health Policy Institute, American Dental Association This report would not have been possible without support from: Lisa Simon, MD, DMD, Fellow in Oral Health and Medicine Integration, Harvard School of Dental Medicine, who adeptly wrote much of the report Anita Glicken, MSW, NIIOH, for her thought leadership as chair and important contributions to the writing of the report Ann Greiner, MCP, Primary Care Collaborative, for her contributions to conceptualizing this project and writing of the report Sarah Greenough, MPP, Primary Care Collaborative, for her work to manage this project CareQuest Institute for Oral Health, for its generous funding and support Sample citation The Primary Care Collaborative. ( January 2021). Innovations in Oral Health and Primary Care Integration: Alignment with the Shared Principles of Primary Care. https://www.pcpcc.org/ resource/innovations-oral-health-and-primary-care-integration-alignment-shared-principles 2 © Produced by the Primary Care Collaborative in January 2021 Primary Care Collaborative Contents 5 Executive Summary 8 Introduction 8 The Importance of Comprehensive Care 11 The Case for Oral Health 17 Integrating Oral Health in Primary Care 21 Methodology for This Compendium 22 Shared Principles for Primary Care: Oral Health Exemplars 22 Principle 1: Patient- and Family-Centered 27 Principle 2: Continuous 32 Principle 3: Comprehensive and Equitable 36 Principle 4: Team-based and Collaborative 41 Principle 5: Coordinated and Integrated 45 Principle 6: Accessible 50 Principle 7: High-Value 54 Lessons Learned from the Patient-Centered Medical Home Initiative 59 Lessons Learned from Behavioral Health Integration 64 A Call to Action 71 Appendix 71 Creating a Shared Understanding 3 Innovations in Oral Health and Primary Care Integration 4 Primary Care Collaborative Executive Summary ral health is health. Yet for far too many Primary care, as the main point of entry and Americans, it is unreachable. One- access to support for patients in the healthcare Othird of Americans do not have dental system, represents a remarkable opportunity to insurance, and low-income Americans and better meet patients’ oral health needs across those with public insurance have substantially the socio-economic spectrum. In particular, lower rates of dental access than their more integration of oral health and primary care is well-off neighbors, friends, and family.1, 2 These increasingly acknowledged as a key strategy to oral health inequities most directly impact achieve health justice. groups that have endured and continue to face racism and injustice. Communities of color have Models of primary care and oral health higher rates of tooth decay and tooth loss and integration epitomize the Seven Shared Principles lower rates of annual dental visits.3, 4, 5 Dental of Primary Care, a consensus-derived framework care utilization is even lower among people of that articulates the ideal values of primary care color who report experiencing more frequent delivery and which has been embraced by more discrimination.6 than 350 diverse organizations.11 The Shared Principles state that primary care should be: The consequences of these inequities are far- reaching. Oral health interacts with and impacts 1) person- and family-centered; multiple chronic health conditions.7, 8, 9 Patients 2) continuous; in pain with untreated oral health needs often 3) comprehensive and equitable; end up in hospital emergency departments, 4) team-based and collaborative; where their dental disease most often cannot 5) coordinated and integrated; be treated, with significant consequences 6) accessible; and for individual patients and substantial costs 7) high-value. to the health system.10 Tragically, such untreated disease can even, in rare cases, lead This compendium demonstrates the dynamic to death. Independent of these unfortunate and innovative ways that healthcare clinicians, outcomes, the shame and pain experienced community members, and public health leaders by too many Americans with poor oral health are working together to reunite oral health represents entirely preventable suffering that and primary care through the lens of these disproportionately affects the most vulnerable, Shared Principles. We highlight the many demonstrating the synergy between oral health diverse mechanisms and the varying scope of and the social determinants of health. integration efforts, ranging from statewide 5 Innovations in Oral Health and Primary Care Integration initiatives to incorporate oral health care into medical, and social needs of individuals, families, value-based primary care payment models to and communities are accounted for by high- initiatives to embed oral health within the fabric functioning teams that put the priorities and of the community, such as food pantries and goals of patients first and elevate community schools. Examples illustrate the potential for voices for continuous improvement. oral health to be delivered in the primary care setting and primary care to be a key component The models highlighted in this compendium of a dental visit. We describe interoperable celebrate what is possible in primary care, yet electronic health records that seamlessly share do so despite being embedded in a system that medical and oral health data and programs continues to keep oral health out of the reach of that send front-line health workers to provide people who are most vulnerable and a payment oral health and medical care to patients in their system that does not readily support integration. homes. We include educational initiatives that In the midst of the COVID-19 pandemic and with will ensure the next generation of primary a new presidential administration at the helm, care clinicians is equipped with oral health the opportunity to help rectify deeply embedded skills as well as programs to empower patients structural racism within health care has arrived. themselves to care for their oral health. These Now is the time to ensure oral health is not left initiatives enhance care for patients across the out of a transformed health system, focused, life spectrum from pregnant women and infants in the words of Dr. Martin Luther King Jr., on to older adults living in skilled nursing facilities, bending (the system) towards justice. a group with some of the most severe unmet oral health needs in the nation. As communities and the nation strive to move forward, we highlight key policy changes The continued success of these oral health needed to truly integrate oral health and integration efforts has important precedent in primary care. First, we call on the primary care other landmarks in primary care innovation. and oral health communities to advocate with The establishment of competencies surrounding policymakers for increased oral health coverage interprofessional collaborative practice and through expanding Medicaid and adult Medicaid the adoption of interprofessional education dental coverage and adding a dental benefit in mandates across health professions has Medicare. Coverage, however, is not access, encouraged adoption of oral health curricula for and we further call for leaders in education to many future primary care clinicians and other support a more diverse, equitably distributed health professionals. The patient-centered oral health workforce to meet the needs of medical home (PCMH) model has made communities across the nation. equitable, comprehensive, whole-person care the centerpiece of primary care, opening the We also call public and private payers and quality door for oral health integration within medical experts to develop oral health-related quality homes. And the behavioral health integration measures to incentivize oral health prevention, movement has demonstrated effective tactics interprofessional collaboration, and reduction to engage stakeholders and disseminate care in inequities as well as for the information models that provide better, more comprehensive technology infrastructure to support related data primary care. Taken together, these efforts and collection. Such measures will support the more the many innovations within the compendium rapid adoption of value-based payment models demonstrate the future of whole-person care: that encourage medical homes to innovate, build an integrated, quality-based delivery system out their teams, and deliver a truly
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