Fundamentals of Leading a Health Center Oral Health Program Meet the team!
Ethan Kerns, DDS Scott Wolpin, DMD Tena Springer, RDH, MA An Nguyen, DDS, MPH Bob Russell, DDS, MPH Tina Sopiwnik, DMD Clifton Bush, MS Lisa Kearney, DDS Kecia Leary, DDS, MS Beverly Foster, DDS, MHA Nick Pfannenstiel, DDS Debby Myers, RDH Domenic Caluori, DDS, FIOCI David Kadar, DDS Ryan Tuscher, DDS Sybil Fortner, DDS Leah Schulz, DDS Duane Mata, DDS Donna Bridge, DMD Jeffery Moeller, DDS Janine Burkhardt, DMD, Randi Wingate, DDS FAGD Stacey Robben, DDS Welcome to the NNOHA conference! Who Are We?
National Network for Oral Health Access (NNOHA) envisions a future in which individuals and communities are aware of the importance of oral health to overall health, engage in recommended oral health practices, and receive affordable, high quality oral health services. Achieving this vision requires everyone to have access to care, regardless of income or geography. History of NNOHA • Founded in 1991 • Identified need for peer-to- peer networking and collaboration among health center dental providers • Membership includes over 3,000 dental team members and supporters NNOHA’s Mission
To improve the oral health of underserved populations and contribute to overall health through leadership, advocacy, and support to oral health providers in safety-net systems. NNOHA Resources • Webinars • Listserv • Promising Practices • Learning Collaboratives • Individual consultation/referral • Dashboard Quality Measures • Annual Conference www.nnoha.org or email [email protected] Operations Manuals
Chapters: 1. Fundamentals 2. Leadership 3. Financials 4. Risk Management 5. Workforce and Staffing 6. Quality
http://www.nnoha.org/resources/operations- manual/ National Oral Health Learning Institute (NOHLI) • Clinical leaders in a safety net dental programs with <5 years of experience • Online modules, webinars, and in-person trainings • Curriculum based on NNOHA’s Operations Manual and Patient Centered Health Home Action Guide NOHLI Cohort 7 • Next call for applications: NOHLI Cohort 9 (Summer of 2020)
http://www.nnoha.org/programs-initatives/nohli/ About Today
12:30pm – 4:50pm Fundamentals • Review fundamentals needed for effective management of an excellent health center dental program • Two concurrent tracks for four critical program areas (Track A: Workforce and Staffing/Leadership; Track B: Risk Management/Quality) Pick your track!
4:50 – 5:20pm Breakouts – Palace 1 and 2 • Networking opportunity • Discover available resources • Share promising practices Today’s Schedule Track A – Palace 1/2 Track B – Palace 3 12:30-12:35pm Welcome (Ethan Kerns and Tena Springer) 12:35-1:35pm Fundamentals (Bob Russell) 1:35-2:35pm Financials (Kecia Leary, Clifton Bush) 2:35-2:50pm Break (Split into two groups in separate rooms) 2:50-3:50pm Workforce and Staffing Risk Management (Nick Pfannenstiel/Domenic (Ethan Kerns/Donna Bridge) Caluori) 3:50-4:50pm Leadership Quality (Tena Springer/Leah Schulz) (Ryan Tuscher/Janine Burkhardt) 4:50-5:20pm Breakouts* Breakouts* (All) (All) Breakout Sessions 4:50pm – Palace 1 and 2
Topics Leads 1. Fee Schedule/Sliding Fee Domenic Caluori and Donna Bridge 2. Peer Review Lisa Kearney and Sybil Fortner 3. No Shows/Scheduling Nick Pfannenstiel and Jeffery Moeller 4. Medical/Dental Integration An Nguyen and Randi Wingate 5. Infection Control Beverly Foster and Debby Myers 6. Managing Pts Experiencing Substance Scott Wolpin and Janine Burkhardt Abuse 7. School-Based Ethan Kerns and Duane Mata 8. Advocacy In and Out Tina Sopiwnik and Leah Schulz 9. Referral Follow Up Ryan Tuscher and Stacey Robben 10. Emerging Trends: Teledentistry and Bob Russell and David Kadar Dental Therapists Stop by the Coffee House!
Date Time Topic Facilitator
Monday, October 14 10:00-10:30am The Art of Mark Doherty and Venice Room Leadership Clifton Bush
3:00-3:30pm Dental Dashboard Colleen Lampron, Matt Horan, Carsten Frey Tuesday, October 15 10:00-10:30am Dental Team Janine Burkhardt Venice Room Recruitment and Domenic Strategies Caluori 3:00-3:30pm Scheduling Dori Bingham and Strategies Yogita Thakur Join us by the pool!
• Opening reception is TONIGHT! 6pm – 8pm • Open bar and food • Caesar’s Palace pools Can’t lose focus of the Fundamentals Health Center Fundamentals
Bob Russell, DDS, MPH 2019 Fundamentals NNOHA Annual Conference Learning Objectives
• Discuss the characteristics of Health Center patient populations • Recognize common terms used to reference Health Center oral health programs • Describe how Health Centers are financed • List of partners Health Centers collaborate with • Learn where are Health Centers heading in the future Health Centers
Public or private not-for-profit organizations that provide primary health services to populations with limited access to health care.
Health Centers were created to increase access to care among underserved and medically disenfranchised populations. United States Department of Health & Human Services Examples of Health Centers HRSA 330 grant-supported programs can be: • Federally Qualified Health Centers (FQHCs) • Outpatient health programs/facilities operated by tribal organizations • Hospital-based • Dental schools • County public health departments
Sources: U.S. Department of Health and Human Services Health Resources and Services Administration, bphc.hrsa.gov and CDA May 2009 Federally Qualified Health Centers (FQHCs) • Health care delivery organization must apply to be designated an FQHC by HRSA • Can be reimbursed for Medicaid visits in a different manner than private practice i.e. by encounter/visit • Can apply for Federal Torts Claim Act malpractice protection • Participate in federal student loan repayment programs Health Center vs. FQHC
• Health Centers that also receive 330-HRSA grants are FQHCs
• FQHC “look-alikes” do NOT receive 330- HRSA grant funding, for example, a county health department or a non-profit clinic, but can apply and also receive alternative Medicaid reimbursement such as the encounter based method Jordan Valley Community Health Center Springfield, MO Health Center Facts – 2018 UDS
• Number Health Center programs receiving 330- grant funding: 1,362 • Number HC programs with dental programs: 1,088 or 80% • Total users: 28,379,680 • Number medical users: 23,827,122 • Number dental users: 6,406,667 • Dental Users: 22.6% all FQHC patients • Dental Users: 26.9% of all medical patients
2018 Age Demographics 70
60.05 60
50
40
30.78 30
20
11.13 10
0 0-17 18-64 65 and over Patients by % 2018 Demographics: Ethnicity
• 63% identify as racial and/or ethnic minorities
• Hispanic/Latino 37.27% • African-American 18.86% Percent of Poverty Level – HC users
Over 200% 8%
101-200% 22%
100% and below 70% Common Chronic Conditions
• 23.8 million medical users (2018) • 4.7 million: Hypertension • 2.5 million: Diabetes • 1.3 million: Asthma Scope of Service
• Each HC has a defined scope of service • should be based on assessment of the health care needs of the Health Center service population • When a new service or a new site is added, a change in scope must be approved Primary Care Focus
• Health Centers strive to provide community oriented primary care • Focus on family medicine, pediatrics, general dentistry, pediatric dentistry Public Health Focus
• Develop policies and plans that support health on individual and community level
• Emphasis is on health care that improves and maintains health
• Focus on prevention, screening, patient self- management of chronic conditions Health Care Services Integration
• Strength of HC is multiple services available in one location • Some only provide medical services • Most provide medical, dental, behavioral and ancillary services (social workers, enabling services, community outreach etc.) at the same site • Additional services: • optometry, pharmacy, lab, imaging, podiatry, WIC Leadership Launch
Imagine your Health Center mirrors national data, and has capacity for only 1 in 4 medical patients to receive dental care.
• How would you feel about this? • How would you determine who should access dental care? • Who else would need to be involved in this decision process? Ezra Medical Center Brooklyn, NY Dental Program Scope of Service
• Phase I/Basic/Routine • Level I- Emergency care • Level II- Diagnostic & preventive care • Level III- Expected care: Routine periodontal, restorative (including endodontics) and surgical care
• If not available on site, Level I & II care must be available through contractual arrangement (1998 & later programs) Dental Program Scope of Service
• Phase II/Rehabilitative/Complex • Level IV- Recommended/Rehabilitative care: Complex periodontal, restorative (including endodontics) surgical care and prosthodontics. Other-than-routine specialty care. Scope of Service
• Scope of service should be determined by the oral health needs of the HC population • Most HC dental programs provide a majority of Phase I care services • Many Phase II services have up-front fixed costs (i.e. prosthetic lab fees), which must be factored in the costs of delivering services 2018 Productivity
• 5,099 DDS FTEs across HCs • 2,682 RDH FTEs across HCs • 37 Dental Therapists FTEs across HCs
• 2,682 encounters/FTE DDS • 1,150 encounters/FTE RDH • 783 encounters/FTE DT 2018 Dental Productivity
• 16,529,600 visits • 6,406,667 users • 2.58 visits/user annually
Reasons for dental visits to CHC • 191,151 had an emergency visit • 475,139 had sealants • 1,023,903 had extractions or other surgery Health Center Financing
• Source of mystery & myth • “government pays” • “free care” • “unfair competition”
• The majority of HC revenues are derived from fees generated from patient care • In 2018, Federal grants were on average, 28.5% of revenues Health Center Revenue – 2018
Other revenue State/local/private grants 4% 10%
Federal grants 18%
Medicaid 44%
Self-pay 4%
Private pay 11%
Other public insurance Medicare 1% 8% Prospective Payment System (PPS)
• As FQHCs, Health Centers may be reimbursed for Medicaid visits on an encounter or capitation basis (instead of fee-for-service) • The process for calculating the PPS rate is determined at the state level and can differ by state • Rates differ based on scope of HC services, local cost of living, urban vs. rural, etc. More PPS
• PPS base rate is readjusted yearly based on cost-of-living and whenever a new service is added to the Health Center’s scope of services • Cost-based reimbursement system • For encounter based- rate is the actual cost of delivering services divided by the number of encounters. • For capitation, along with monthly rate, at the end of the budget year the difference between the cap rate and the actual cost is determined and reimbursed. This is called the “wrap around.” Churning
• Churning- systematic, institutionalized practice of maximizing revenues by maximizing visits/encounters • Each payer method has inherent flaws • Encounter based • FFS • Capitation Examples of Churning
• Separation of exam & imaging procedures • Separation of exam, imaging & P&F for children • Lack of quadrant dentistry • Separation of sealants • Lack of definitive treatment of emergencies Adverse “Churning” Outcomes
• Never finish treatment plans • Return emergency visits • Patient dissatisfaction • Increased clinical risk • Increased time burden for patients & caregivers • Below standard of care • Fraud Churning I.D. via Quality System
• Chart audit • Separation of procedures
• Tracked service use measures • Low rates of treatment plan completion
• Patient satisfaction • Low because multiple visits Sliding Scale
• The unique aspect of Health Centers • Required to offer a sliding fee scale to patients between 100-200% of Federal Poverty Level (FPL) • Base “nominal fee” that should not impede access to care • Over 200% of FPL can pay full fee • In 2018, 22.6% of HC patients were uninsured Fiscal Sustainability
• Cost per encounter is fixed regardless of reimbursement source • Sliding scale charges must be subsidized from other sources to balance budget • 330 grant • Other grants • Donations • What in private practice is considered “profit,” in FQHCs is used to subsidize the sliding scale 2018 Cost Per Dental Visit**
• $209.08/dental encounter nationally • Medical visits cost $201.50 each • Each program should know its costs • Most basic financial data point needed to develop budget, allocate resources • Needed to revise PPS rate Leadership Launch
Do you have regular access to your dental program financial data (encounters, cost, payer mix)?
If so, how do you use the information? If not, how would you get this information? Erie Family Health Center Chicago, IL Licensure
• Mandatory process by which a governmental agency grants time-limited permission to an individual to engage in a given occupation • Health Centers must comply with state license requirements for dental staff Credentialing & Privileging
• Credentialing: assess and confirm qualifications • Privileging: authorization to provide specific services • Health Centers must perform both • Usually Human Resources coordinates Oversight
• Health Centers experience a level of oversight not always found in the private sector • HRSA/BPHC site visits- usually every five years • State inspections and Medicaid audits • Joint Commission (JC) accreditation visits IOM Definition Quality- 2001
• “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”
• Measurement • Knowledge Why Assess Quality?
• Section 330 of Public Health Service Act requires every Health Center to have a QI/QA program • Federal Tort Claim Act deeming application process requires submission of Health Center QI/QA plan and QI/QA committee minutes • Assures and improves the quality of health care delivery • UDS Sealant Measure: in 2018, 52.80% of patients 6-9 years old with sealants on 1st molars Leadership Launch
As part of your Dental Director duties, you have to direct your department efforts during Joint Commission (JC) accreditation and state Medicaid audits, as well as develop and implement quality improvement measures.
How do you get the rest of the dental team to buy into these efforts? Academic Collaboration
• Dental assisting programs • Dental hygiene programs • Emerging new provider programs (dental therapy) • Pre-doctoral rotations • Post-graduate residencies • GPR • AEGD • Pediatric dentistry Community Collaboration • As a part of the community, HCs partner with other agencies to facilitate access to health care and/or focus on specific conditions or populations • WIC • Head Start • Title V (maternal & child health programs) • County or state health departments • School districts • Other community based organizations More Collaboration
• Most Health Centers are members of state Primary Care Associations (PCAs) • PCAs provide training, specialized support, advocacy • Some have Dental Director peer networks and/or dedicated staff for oral health • Organized dentistry can be a long-term local partner The Future
• ??? • Health care reform- newly insured populations • Double Health Center capacity • Meaningful Use/Technology adoption • Health Home concept • Integration of health care disciplines Workforce Innovation in Health Centers
• Unique characteristics of HC practice provide broad depth of training experience • HCs train community members for employment • Opportunities for dental programs to expand capacity • Ideal locations to pilot innovations Dental Teaching/Training Centers
• Dental assisting programs/EFDA • Dental hygiene programs • Advanced Practice Hygienist/Dental Therapy • New/emerging dental workforce models • Pre-doctoral rotations • Post-graduate residencies • GPR • AEGD • Pediatric dentistry Practice Scope Innovations
• Expanded scope of practice for public health/Health Center dental hygienists • Employment for dentist licensure by credential requirements • Employer of an ADA Community Dental Health Practitioner • One allowable practice site for the Minnesota Dental Therapist model • Emerging DT State models i.e. Arizona, Maine, Vermont, Oregon
Leadership Launch
Who are the external partners you currently work with to expand your Health Center dental workforce or scope of service? OR Who are the partners you could potentially work with to expand your Health Center dental workforce or scope of service? Conclusion
Source: HRSA BPHC Thank you!
Bob Russell, DDS, MPH State of Iowa Public Health Dental Director 515-281-4916 [email protected]
National Network for Oral Health Access 181 E 56th Avenue, Suite 401 Denver, CO 80216 Phone: (303) 957-0635 Fax: (866) 316-4995 [email protected] Health Center Financials Kecia Leary, DDS, MS Clifton Bush, MHA 2019 Fundamentals NNOHA Annual Conference The Dentist
Kecia Leary, DDS, MS University of Iowa, College of Dentistry The Chief Operating Officer
Clifton Bush, MHA Albany Area Primary Health Care, Inc. Learning Objectives
• Become familiar with common HC financial terms • Understand basic HC financial tools • Develop a financial strategy • Locate and utilize helpful resources
4
Relevant Laws, Regulations and Guidance
• HRSA’s message
• Nominal fees and sliding fees
• Financial management and control policies
• Billing and collections Types of Care
• Mandated • Prevention, Emergency, Risk Assessment
• Expected • Eliminate disease, Phase I
• Optional • Rehabilitative care
• Execution through policies and procedures
Section 330 Grant Funding
• Understanding the 330 grant • Setting our HC fee schedule • Nominal fees • Sliding fees as an art and science • Fees for patients above 200% FPL • Income verification Understanding Health Care Reimbursement Systems
• Fee For Service [FFS] • Private Dental Insurance • Capitation Reimbursement • Managed Care • Pay for Performance!!! Accountable Care Organizations • Prospective Payment System [PPS] • Alternative Payment Methodologies FFS
• Patient centric services • Elimination of Disease or Completion of Phase One Treatment • Productivity goals - Factors to consider related to affordability, access, quality and finance Nominal Fees and Sliding Fees
• Nominal Fees • <100% FPL • Sliding Fees • 101%-200% FPL 13
Medicaid and the PPS
• The PPS system- BIPA 2000 -Why and what does it mean? • “A floor not a ceiling” • The truth about PPS • What to watch out for in the PPS world 14
The PPS as a System
• The PPS formula • The Dental vs. the Medical PPS • How to talk about the PPS • internally • externally • External misconceptions about the PPS • Understanding “wraparound” • How Alternative Payment Methodologies [APMs] fit 15
PPS
• Assuring value for the visit • Quadrant Dentistry: • “Not all quadrants are created equal”. • Think: “Patient First” • The Community Standard of Care • The “Dark Side” 16
“Churning”
• Let’s not make believe it is not out there - Don`t let it be your program. • What can be done about it? -Policy and Protocol to the rescue • Document-Document-Document • Don`t assume anything • Lead through example What Does Success Look Like?
Ask Yourself “What will success look like?” Back-map to a financial plan Use financial tools to achieve the success.
Evaluation Measure by looking at financial reports See what the data accomplishes. 18
Understanding Capacity
• Understand the concept of capacity
• Establish clarity and strategy around productivity guidelines
Health Center dental programs cannot be everything for every patient. 19
Determining Scope of Service
COMBINE:
• Knowledge of patient need,
• Capacity of the organization
This determines the scope of service 20
The Approach
• Keep it simple • Standardized tools and planning • Standardization leads to predictability • Recognize and eliminate variables • Make it a shared journey • Communicate with clarity and regularity • Accurate, meaningful and timely data Evaluating Dental Program Financial Performance Tools that provide you with the meaningful, accurate and timely data with which to evaluate your success • Budget- • estimate or prediction • Profit and Loss Statement- • actual report of finances as they are today • Variance Report- • difference between budget and actual • Reforecast- • new budget prediction based upon evaluation of the variance report 22
Key Data to Evaluate Program Performance • Number of visits • Payer and patient mix • Gross charges • No-show rate • Total expenses (direct and indirect) • Emergency rate • Net revenue (including all sources of revenue) • Number of unduplicated patients • Expense/visit • Number of new patients • Revenue/visit • Percentage of completed treatments • Transactions (procedures by ADA • Percentage of children needing code) sealants who received sealants • Transactions/visit • Number of FTE providers (dentists • Aging report past 90 days and dental hygienists) 23
Also have and use:
• Business plan pro forma
• Capacity report
• Aging report
• Program productivity report
• Individual provider productivity reports 24
The Business Plan
What the dental practice needs to accomplish:
-To be financially sustainable -Maximize patient access -Provide meaningful quality outcomes 25
The Business Plan (cont.)
• Numbers and types of patients to be seen • Numbers, types and lengths of appointments • Scope of service for the practice • Staffing model • Service delivery model • Hours of operation • Financial, productivity and quality goals to be met • Optimal payer mix • Evaluation plan 26
A three page budget or dental business plan pro forma
Financial Projections Projected Visits Actual Visits Difference 0 Patient/Insurance mix: Yearly visits Percent Medicaid - Percent Self Pay - Percent Commercial Insurance - Percent Other - Total 0% -
Yearly Reimbursement Rate (per visit): Revenue Medicaid $ - Self Pay $ - Commercial Insurance $ - Other $ - Total revenue $ - 27
Year One Projections Actual Variance Gross Charges Section 330 Revenue/Grants $ - Commercial $ - Self Pay $ - Medicaid - - $ - Other - $ -
Total Gross Charges $ - $ - $ - Contractual Allowances
Commercial $ -
Self Pay $ -
Medicaid $ -
Other $ -
Total Contractual Adjustments $ -
Total Net Revenue $ - 28
EXPENSES
Direct Expenses: Salaries $ - $ - Fringe Benefits $ - $ - Total Salaries $ - $ - $ - Support Costs: Rent/Building Lease $ - Dental Supples $ - Malpractice Insurance $ - Lab Fees $ - $ - Education, Training, Conferences $ - Maintenance and repair $ - $ - Dues $ - $ - Bad Debt $ - $ - Office Supplies $ - Depreciation $ - Printing, Postage $ - Software License and Fees $ - Utililities $ - Telephone $ - Laundry $ - Total Support Costs - $ - $ - Total Direct Expenses - $ - $ - Indirect Expenses: Administrative Allocation $ - Total Direct and Indirect Expenses: $ - $ - $ - Total Expenses Year Two $ - Net Income (Loss) $ - $ - $ - 29 BUDGET
REVENUE: Jan-18 Feb-18 Mar-18 GROSS CHARGES 451,392 404,048 626,948 INSURANCE ADJUSTMENTS (170,175) (152,326) (236,359) GRANT REVENUE 22,917 22,917 22,916 CAPITATION PAYMENTS 5,366 5,186 5,224 INTEREST/OTHER INCOME - - - TOTAL REVENUE 309,500 279,825 418,729
EXPENSES: SALARIES & BENEFITS 235,182 221,523 247,372 COMMISSIONS - - - RENT, BUILDING EXPENSE, OFF 13,542 13,542 13,542 PRINTING & ADVERTISING 250 250 250 POSTAGE & SUPPLIES 35,808 35,808 35,808 TELEPHONE 1,715 1,708 1,708 OPERATIONAL EXPENSE 1,542 1,542 1,542 PROFESSIONAL SERVICES & CO 18,417 18,417 18,417 INITIATIVES - - - COMPANY INSURANCE - - 2,900 TRAVEL 67 67 67 MISCELLANEOUS 993 993 3,193 DEPRECIATION 32,223 32,223 32,223 Total Expenses 339,738 326,071 357,021
NET INCOME (30,238) (46,247) 61,708 30 Actual P&L Statement
Jan-18 Feb-18 Mar-18 REVENUE: ACTUAL ACTUAL ACTUAL GROSS CHARGES 496,121 455,188 481,936 INSURANCE ADJUSTMENTS (159,450) (191,456) (173,739) GRANT REVENUE 22,917 22,917 22,916 CAPITATION PAYMENTS 4,330 4,524 4,783 INTEREST/OTHER REVENUE - - - TOTAL REVENUE 363,918 291,173 335,896
EXPENSES: SALARIES & BENEFITS 254,205 249,129 256,607 COMMISSIONS - - - RENT, BUILDING EXPENSE, OFF 13,593 14,025 15,989 PRINTING & ADVERTISING - 1,548 - POSTAGE & SUPPLIES 43,958 26,000 27,871 TELEPHONE 1,111 533 29 OPERATIONAL EXPENSE (389) (150) 3,184 PROFESSIONAL SERVICES & CO 17,566 23,301 16,203 INITIATIVES - - - COMPANY INSURANCE 397 508 - TRAVEL 10 - 131 MISCELLANEOUS 919 4,098 - DEPRECIATION 30,507 32,890 30,722 Total Expenses 361,875 351,882 350,736
NET INCOME 2,043 (60,709) (14,840) 31 Variance Report
Month - To - Date Year - To - Date JUNE JUNE Actual Budget Variance Actual Budget Variance Revenues: Gross Charges 410,093 487,190 (77,097) 2,767,732 2,965,725 (197,993) Insurance adjustments (145,552) (183,671) 38,119 (1,001,406) (1,118,078) 116,672 Grant Revenue 22,917 22,917 - 137,500 137,500 - Capitation payments 4,446 5,198 (752) 27,113 32,034 (4,921) Interest/Other Income - - - - Total Revenues 291,904 331,634 (39,730) - 1,930,939 2,017,181 (86,242)
Expenses: SALARIES & BENEFITS 232,954 238,549 5,595 1,464,196 1,413,315 (50,881) COMMISSIONS ------RENT, BUILDING EXPENSE, OFFICE EQUIPMENT 15,636 13,542 (2,094) 88,037 81,250 (6,787) PRINTING & ADVERTISING - 250 250 1,548 1,500 (48) POSTAGE & SUPPLIES 14,378 35,808 21,431 191,953 214,850 22,897 TELEPHONE 2,574 1,708 (865) 6,620 10,257 3,637 OPERATIONAL EXPENSE 2,855 1,542 (1,313) 19,907 9,250 (10,657) PROFESSIONAL SERVICES & CONSULTING 17,224 18,417 1,193 114,384 110,500 (3,884) INITIATIVES ------COMPANY INSURANCE - 2,900 2,900 7,776 5,800 (1,976) TRAVEL - 67 67 262 400 138 MISCELLANEOUS 2,721 3,193 471 10,561 10,357 (205) DEPRECIATION 30,722 32,223 1,500 186,287 193,336 7,049 Total Expenses 319,064 348,198 29,134 2,091,533 2,050,815 (40,718)
Change in Net Assets (27,160) (16,563) (10,597) (160,594) (33,634) (126,960) Reforecast
ORAL HEALTH CENTER 2018 JUNE P&L REFORECAST BY MONTH Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 TOTAL REVENUE: ACTUAL ACTUAL ACTUAL ACTUAL ACTUAL ACTUAL ACTUAL REFO REFO REFO REFO REFO DHC REVENUE 22,917 22,917 22,916 22,917 22,916 22,917 22,917 22,917 22,917 22,917 22,916 22,917 275,001 PRODUCTION REVENUE 496,121 455,188 481,936 444,460 479,934 410,093 408,824 487,500 444,199 487,500 464,534 444,199 5,504,488 INSURANCE ADJUSTMENTS (159,450) (191,456) (173,739) (159,014) (172,195) (145,552) (136,477) (177,583) (155,012) (177,583) (162,536) (155,012) (1,965,609) CAPITATION PAYMENTS 4,330 4,524 4,783 4,561 4,469 4,446 3,863 4,533 4,533 4,533 4,533 4,533 53,641 DIVIDENDS & INTEREST ------TOTAL REVENUE 363,918 291,173 335,896 312,924 335,124 291,904 299,127 337,367 316,637 337,367 329,447 316,637 3,867,521
EXPENSES: SALARIES & BENEFITS 254,205 249,129 256,607 220,420 250,882 232,954 168,858 240,241 214,903 205,400 214,110 186,665 2,694,373 COMMISSIONS ------RENT, BUILDING EXPENSE, OFF 13,593 14,025 15,989 14,971 13,822 15,636 6,139 13,844 13,844 13,844 13,844 13,844 163,394 PRINTING & ADVERTISING - 1,548 ------500 - - 2,048 POSTAGE & SUPPLIES 43,958 26,000 27,871 26,862 52,885 14,378 34,771 34,967 34,967 34,967 34,967 34,967 401,559 TELEPHONE 1,111 533 29 1,314 1,061 2,574 524 1,997 1,997 1,997 1,997 1,997 17,128 OPERATIONAL EXPENSE (389) (150) 3,184 3,363 11,044 2,855 5,770 3,933 3,933 3,933 3,933 3,933 45,342 PROFESSIONAL SERVICES & CO 17,566 23,301 16,203 18,039 22,051 17,224 12,012 15,000 18,750 18,750 18,750 18,750 216,396 INITIATIVES ------COMPANY INSURANCE 397 508 - - 6,872 - 100 3,967 100 100 3,967 16,010 TRAVEL 10 - 131 66 56 - 74 74 74 74 74 633 MISCELLANEOUS 919 4,098 - 2,823 - 2,721 281 3,700 4,500 3,700 1,500 3,700 27,942 DEPRECIATION 30,507 32,890 30,722 30,722 30,722 30,722 18,321 15,593 15,593 15,593 15,593 15,593 282,573 Total Expenses 361,875 351,882 350,736 318,581 389,395 319,064 246,676 329,448 312,527 298,858 304,867 283,489 3,867,399
NET INCOME 2,043 (60,709) (14,840) (5,657) (54,271) (27,160) 52,451 7,919 4,110 38,509 24,580 33,148 122 Dental Quality Dashboard Dental Huddle Form
• Who is in attendance? • Review Previous Day • Schedule details at a glance • Provider Specific • Number and type of appointments • Specific goal details • Labs • Other • Notes • Discussion Section for Goals • Reminders Dental Productivity
FYE No Clinic Monthl 2020 1 Clinic Actual Show Clinic Goal Goal YTD YTD Current Req Sch Goal FYE y Session Sessio Schedul & Patient Based Avg Averag s ns ed No Cancel Add s Total on per Avg Sch Seen Month for goal for 2020 e June thru Availab Worke Deliveri Encount Ses per per per per Specialt August YTD le d Appts. Shows Cancel % Ins Seen Hosp N/H es ers worked Session session session session session y Budget Budget 0 Dental - Hygenist 0 Meshanko Jun-Aug 115 88 134 19 49 51% 6 72 72 704 8 1.52 0.82 1.24 12.06 700 58 Scott Jun-Aug 115 90 190 23 44 35% 0 123 123 720 8 2.11 1.37 2.04 10.82 700 58 Stotler Jun-Aug 115 79 143 21 43 45% 3 82 82 632 8 1.81 1.04 0.76 11.58 700 58 Brown Jun-Aug 115 106 328 79 80 48% 0 169 169 848 8 3.09 1.59 1.34 11.88 700 58 Total Hygenist 4 Jun-Aug 460 363 795 142 216 45% 9 446 446 2,904 8 2.19 1.23 11.60 2,800 233
5/31/19 0 2.57 1.56 Dental - DDS 0 Brown er Jun-Aug 115 95 1,584 349 410 48% 54 879 879 950 10 16.67 9.25 9.33 14.79 3,800 2,800 233 Chapman Jun-Aug 115 83 1,246 405 305 57% 30 566 566 830 10 15.01 6.82 7.64 15.70 3,800 2,800 233 Edwar ds Jun-Aug 115 93 1,595 299 466 48% 91 921 921 930 10 17.15 9.90 9.39 14.80 3,800 2,800 233 Shootes-Miller Jun-Aug 115 85 1,296 189 390 45% 65 782 782 850 10 15.25 9.20 10.63 14.47 3,800 2,800 233 Total DDS 4 Jun-Aug 460 356 5,721 1,242 1,571 49% 240 3,148 3,148 3,560 10 16.07 8.84 14.92 15,200 11,200 933
5/31/19 0 12.25 6.84 0 Total Dental Jun-Aug 920 719 6,516 1,384 1,787 49% 249 3,594 3,594 6,464 9.06 5.00 13.37 14,000 1,167
5/31/19 0 7.66 4.34
Grand Totals 05/31/20 8,308 6,700 59,990 10,818 8,146 32% 1,808 43,577 1,095 786 226 45,458 63,674 8.95 6.50 12.51 208,452 17,371 Total other 2,457 8.12 6.08 1,200 Total Req. 209,652
22,025,3 46 Determining Potential Visit Capacity
• Basis • Number of FTE providers • Hours of operation • Number of chairs • Standard productivity benchmarks • Benchmarks • Different for dentists vs. dental hygienists • Type of patients being seen by the providers • The visit determines your quality and your quantity • No margin, no mission Common Factors Impacting Provider Productivity • No-shows and last-minute cancellations • Scheduling issues--types of patients • Insufficient support staff--dental assistants • Lack of goals and accountability • Individual provider issues • unmotivated, inexperienced, health problems, life issues, etc. • Insufficient instruments, supplies • Equipment issues--outdated, missing, broken • Lack of EDR/EHR--not fully utilized Determining Potential Visit Capacity (Dentists) # of FTE X 1.7 X # of Potential Visit Providers Visits/FTE/Clinical Clinical Capacity Hour Hours Mon. 3 5 8 40
Tues. 4 6.8 8 54
Wed. 3 5 8 40
Thurs. 3 5 8 40
Fri. 3 5 4 20 Determining Potential Visit Capacity (Dentists) # of FTE X 2 X # of Potential Visit Providers Visits/FTE/Clinical Clinical Capacity Hour Hours Mon. 3 6 8 48
Tues. 4 8 8 64
Wed. 3 6 8 48
Thurs. 3 6 8 48
Fri. 3 6 4 24 Financial Production
• Production measured by gross charges or revenue. • If measured by gross charges, must know your collection rate.
• Each provider in the dental department should have individual production goals • They tie in with the dental department`s overall goals.
• Each member of the staff should know what it costs to see a patient (visits/expenses). Setting Goals: Provider Productivity
• Use benchmarks • 1.7 visits/hour for dentists, 1.25 visits/hour for DH • 1 visit/hour for externs and new residents • Benchmark x number of daily clinical time = • total number of visits/day/provider • Example: 1.7 x 8 hours = 14 visits • Goal for procedures per visit: 2-5 • for basic dental program serving a mix of adults and children • Revenue goals need to be based on overall costs of running program. Setting Goals: Provider Productivity
Example: Total operating costs (Breakeven costs to cover from patient care) = $1,000,000 Total expected visits for the year = 7,820 Cost per visit = $1,000,000 ÷ 7,820 visits = $128 (this is also the revenue per visit goal to break even) • Per Month: $1,000,000 ÷ 12 months = $83,333 • Per Day: $1,000,000 ÷ 230 days = $4,348 • Per Hour: $1,000,000 ÷ 1,840 hours = $543 • Per Minute: $1,000,000 ÷ 110,400 minutes = $9 • Per Visit: $128 Individual Production Goals Provider FTE Gross Net Annual Charges/Day Revenue/Day Charges Revenue Days (60%) Worked
Dr. D 1.0 $541,667 $325,000 230 $2,355 $1,413
Dr. G 1.0 $541,667 $325,000 230 $2,355 $1,413
Total 2.0 $1,083,333 $650,000 460 $4,710 $2,826 Dentist
RDH 1.O $291,667 $175,000 230 $1,268 $761
RDH 1.0 $291,667 $175,000 230 $1,268 $761
Total 2.0 $583,333 $350,000 460 $2,536 $1,522 RDH TOTAL $1,666,666 $1,000,000 Payer Mix
• Huge impact on financial sustainability • Big challenge to manage • Determine the average revenue per visit • Per payer type • Use the information to create a payer mix • Ensures financial sustainability • Preserves access for all patients. Tweaking Payer Mix
• Limited capacity • Designate public health and/or medically indicated priority populations • Work to get them into the practice
• Populations likely to have insurance coverage • Pregnant women • Children
• Goal • Preserve as much access for uninsured patients as possible • Maintain financial sustainability
• Financial sustainability • Lays the groundwork for expansion • Increases access for all payer types . • Use data and knowledge of the practice • Informs decisions around patient and payer mix! Impact of Payer Mix on Sustainability
Now (7,500 visits) Better (7,500 visits) 35% Medicaid (avg. revenue/visit = 40% Medicaid (avg. revenue/visit = $100) $100) 55% Self-Pay/SFS (avg. 50% Self-Pay/SFS (avg. revenue/visit = $30) revenue/visit = $30) 10% Commercial (avg. 10% Commercial (avg. revenue/visit = $125) revenue/visit = $125) 2,625 visits x $100 = $262,500 3,000 visits x $100 = $300,000 4,125 visits x $30 = $123,750 3,750 visits x $30 = $112,500 750 visits x $120 = $90,000 750 visits x $120 = $90,000 Total revenue = $476,250 Total revenue = $502,500 Total expenses = $500,000 Total expenses = $500,000 Operating loss = ($23,750) Operating surplus = $2,500 Our Major Strategic Tool: The Daily Schedule
• Scheduling is an art
• Supports maximum access • quality outcomes and financial sustainability
• Done improperly, all of these areas suffer Steps to the Daily Schedule
• First step: Create a formal policy
• Second step: • Create a scheduling template with goals and designated access for priority populations
• Third step: • Make sure staff who schedule know how it needs to be done
• Final step: • Monitor how well things are working • Provide regular feedback to schedulers 49
Conclusion
Becoming knowledgeable about the financial aspects of your Health Center will help your program become more efficient, productive, and ultimately able to provide more care to the patients in the community.
Questions?
Kecia Leary, DDS, MS Associate Professor Director of Pediatric Dental Outreach Clinics [email protected]
Clifton Bush, MHA Chief Operating Officer Albany Area Primary Health Care [email protected] Workforce and Staffing: Utilizing Your Resources to Fulfill Your Mission Nick Pfannenstiel, DDS Domenic Caluori, DMD, FICOI 2019 NNOHA Annual Conference Learning Objectives
• Understand statistics and issues around the current HC workforce to inform recruitment methods and strategies • Develop an effective hiring process • Foster a positive work environment to maximize retention • Develop ideal staffing and equipment ratios for your program • Understand how students, dental hygienists and new dental team members might be effectively utilized Workforce: A Challenge for Health Center Oral Health Programs • 44.4% of Health Centers have at least 1 dentist vacancy • An Analysis of the 2018 NNOHA Health Center Workforce Survey Results
• Nationwide there is a growing shortage of dentists, with more dentists retiring or leaving the profession than graduate each year. • 5,793 Dental Health Professional Shortage Areas (HPSAs) as of December 2018. • https://data.hrsa.gov/topics/health-workforce/shortage-areas
Analysis of the 2018 NNOHA Health Center Workforce Survey Results 2018 NNOHA Workforce Survey – Dentist Vacancies • 2018: 44.4% reported having at least one dentist vacancy • 2018: 19.8% reported having at least 1 dental hygienist vacancy Top 3 Reasons for Choosing a Health Center Career • Dentists: • Felt a mission to serve the dentally underserved population (51.6%) • Loan repayment was available in Community Health Center practice (12.1% ) • Attracted by work schedule/leave policies/fringe benefits (9.3%)
• Dental Hygienists: • Felt a mission to the dentally underserved population (53.3%) • Attracted by work schedule/leave policies/fringe benefits of Community Health Center practice (18.3%) • Wished to practice dentistry/dental hygiene in a community- based setting (13.3%) 2018 NNOHA Workforce Survey
70.6% of dentists and 87.0% of dental hygienists indicated intent to remain in Health Center practices. Putting It All Together…
• Characteristics of satisfied oral health providers • More experienced providers • Providers who had been employed by the Health Center longer • Providers who felt they had full autonomy • Sufficient clinical, administrative, clerical support and adequate facilities and equipment • Sense of mission Reasons for Choosing Health Centers
Reason Dentist (N=182) Dental Hygienist (N=60) Felt a mission to the dentally underserved population 51.6% 53.3%
Wished to offer oral health care within an interdisciplinary 4.4% 0% environment Wished to practice dentistry/dental hygiene in a 7.7% 13.3% community based setting Did not want to invest capital in a private practice or 3.8% 0% borrow money for a private practice Attracted by work schedule/leave policies/fringe benefits 9.3% 18.3% of Community Health Center practice
Loan repayment was available in Community Health 12.1% 5.0% Center practice Sold private practice, or retired from government service 4.9% 0%
Unsatisfied with associate/employee dentist or dental 5.5% 1.7% hygienist arrangements currently available
Was unsure about next career steps 0.5% 8.3% Recruiting, Hiring and Retaining Providers Factors to Consider When Beginning the Recruitment Process
• Mission Alignment • Scope of Services and Patient Population • Cultural Competency and Sensitivity • Language Considerations • Productivity Expectations • Economic Landscape
“If you’ve seen one health center…” Recruitment Strategies
• National Health Service Corps • NNOHA Job Bank • 3RNet/ Glassdoor • Academic Institutions • Primary Care Associations • State and Local Dental Associations • LinkedIn • Recruiters • Word of Mouth Develop new providers through own dental residency program… Recruitment Strategies • Recruit for Your Needs (FT/PT/Saturdays) • Include the Team (Dental Staff and C-suite) • Be Attractive (Salary, Housing, Bonus, Family Members, Daycare)
Never stop looking for new providers… Work Environment / Corporate Culture
• Model the Way • Inspire a Shared Vision • Challenge the Process • Enable Others to Act • Encourage the Heart
Overcoming the Five Dysfunctions of a Team - Patrick Lencioni Work Environment • Clarity of Mission • Open Communication • Build Value in All • Creating a Positive Work Environment • Focus on the Team The best ideas always come from staff members who work in the trenches… Retaining Good Providers • Create OWNERSHIP • Positive Work Environment • Salaries and Benefits • Incentive Programs • Continuing Education
Insist on designing career development plans… Work Environment
• Adequate Number and Quality of Auxiliaries • Adequate Administrative Support & Time for all Leaders • Up to Date Equipment, Instruments and Supplies Salaries and Benefits • Look at the Total Compensation • Salary, Insurance, Retirement, PTO, Loan Repayment Programs LRP, etc.
• Review Compensation Reports and Adjust to Local Conditions. • NNOHA, NACHC, Primary Care Associations
• Fixed, Variable or Both? Incentive Programs
• Simple, Easy to Understand and Manage • Based on a Target Goal that Directly Influences the Organization’s Income • Achievable and Attractive • Frequent (e.g. monthly or quarterly rather than annually) • Commission, Base plus Commission, Bonus • NNOHA Operations Manual Chapter 5 (Workforce and Staffing) 2018 Dentist Compensation
25% 23.70% 23.70%
20% 16.90% 16.90%
15% 11.90%
10%
5.10% 5% 1.70% 0% 0% 0% 2018 Dental Hygienist Salaries
30.00% 27.30% 25.50% 25.00% 21.80%
20.00%
15.00% 12.70% 10.90% 10.00%
5.00% 1.80%
0.00% <$30,000 $40,001-$50,000 $50,001-$60,000 $60,001-$70,000 $70,001-$80,000 >$80,000 Salaries and Benefits
• Average CE Benefits • Dentists - $1916/yr. • RDH - $1208/yr. • HRSA Quality Incentive Grants can help pay for CE. • Median Vacation Days – 20 Days • >95% Health Centers offer a Retirement Plan • >84% Health Centers offer a Retirement Match
(Wave picture permission by johnbaranphoto.com) “Take care of your employees, and they will take care of your business” - Richard Branson Maximizing Efficiency: Staffing, Equipment and Productivity The “HUMAN Resource”…
• Your Team is Your Greatest Asset • There is Always a Demand for Good Team Mates Staffing Recommendations
One size does NOT fit all. HRSA guidelines are just that – guidelines, but they are good ones. • Consider: • Mission of the Program • Scope of Services • Patient Demographics and Patient Mix • Expectations for Growth • Efficient Productivity and Maximal Use of Facilities • State Practice Regulations and Flexibility of Dental Workforce Staffing Recommendations
• For Health Centers, NNOHA recommends 2.0 or more FT Dental Assistants per 1 FT Dentist for Optimum Service • 1 DA per Operatory • Dedicated Dental Front Desk Staff (PAN) • Cross Train in Integrated Practices. PAN➟DA➟RDA Equipment Ratios
• 2 – 3 Dental Chairs per FTE Dentist EXCLUDING Chairs used for Hygienist • Preferably, Dental Hygienists should have a Separate and Dedicated Operatory • SBNC AEGD Residency Program. 1 Resident and 1 Faculty with 2-3 Chairs and 3 DA Encounter Rates & Productivity Standards
Factors to Consider: • Patient Mix • Procedure Mix and Scope of Service • Experience Level of Providers • Emergency Patient Load • Practice Act Allowances for Auxiliaries • Scheduling Efficiency Productivity
• 2017 UDS Data • 2,599 visit/FTE/Year/Dentist • 1,179 visit/FTE/Year/RDH • 901 visit/FTE/Year/Dental Therapist • 2.4 pts per Clinical Hour (Dentist) • $430K in Gross Charges/Year/1FTE Dentist • Relative Value Units (RVUs)? • More on Productivity Standards: https://www.dentalclinicmanual.com • Avg. Cost per Dental Visit = $200.31 • 2.56 Visits/Year/Patient Exploring Scope of Practice Changing Roles of Dental Hygienists
• Direct reimbursement from Medicaid • https://www.adha.org/reimbursement • Direct access to dental hygienists • https://www.adha.org/direct-access • Facts about the Dental Hygiene Workforce: http://www.adha.org/resourcesdocs/75118_Facts_About_the_D ental_Hygiene_Workforce.pdf • Current UDS ratio of .5 RDH/1DDS/DMD Other Emerging Dental Team Members
• Expanded Function Dental Assistant (EFDA) • Advanced Dental Hygiene Practitioner • Community Dental Health Coordinators (CDHC) • Dental Therapists/Advanced Dental Therapists • Patient Navigators/Community Health Workers Other Providers: Students and Residents, Volunteers and Contractors Students and Residents • Potential recruitment • Positive retention tool • Clinical productivity • NNOHA Academic Partnership Paper • http://www.nnoha.org/nnoha- content/uploads/2014/06/Academic- Partnerships-Paper-final_2014-06-03.pdf Students and Residents • Operatory space • Auxiliary support • Sufficient patient/procedure pool • Engaged Providers/Educators • Organizational commitment to hosting student/resident • Good working relationship with School or Residency Program What Should You Expect from the School or Residency Program? • Effective and frequent communication before and during rotations through a specific program contact for all administrative and clinical issues • Clear requests for site and provider information • Send prepared, competent and educated students • Professional liability coverage for the students What Should You Expect from the School or Residency Program? • Communicate specific clinical procedure requirements • Adequate length of rotations • Housing expectations • Revenue sharing expectation Other Benefits to the Site
• The dental staff has the opportunity to share their expertise and experience. • The experience that the student receives at the site can be a very effective recruiting tool. • In most cases, all revenue produced by the student is retained by the site. • The organization has the opportunity to be a partner in educating future dental professionals about cultural, societal and health issues unique to the communities they serve. Benefits to Students . Real World Clinical Practice . Exposure to Alternative practice models . Mentorship Non-Traditional Staffing
• Contract Dentists • http://www.nnoha.org/nnoha- content/uploads/2017/07/Contracting-Checklist-FINAL-July- 2017.pdf • http://www.nnoha.org/nnoha- content/uploads/2017/07/Contracting-Implementing- Strategies-FINAL-July-2017.pdf • Internal Development • Volunteers Thank You!
• For additional support related to workforce: • Read Chapter 5 of the Operations Manual • Explore: http://www.nnoha.org/resources/access-to- care/workforce/ • COMING SOON: VERSION 2! Questions?
Nick Pfannenstiel, DDS Jordan Valley Community Health Center Springfield, MO [email protected]
Domenic M. Caluori DMD, FICOI Santa Barbara Neighborhood Clinics Santa Barbara, CA [email protected] Risk Management: Protecting Your Patients, Your Providers and Your Health Center Ethan Kerns, DDS Donna Bridge, DMD 2019 NNOHA Conference Objectives
• To define what risk management is • To discuss ways to prevent common risks and protect patient and staff safety • To review how compliance standards guide health center risk management protocols • To describe how ethics and professionalism guide risk management protocols Definition of Risk Management
Identification, assessment, and prioritization of risks (the effect of uncertainty) and the application of resources to minimize, monitor, and control the probability or impact of adverse events.
It specifies information needed by providers, leaders, and staff to minimize risks for their oral health programs, and next steps if an error occurs. Sentinel Events
Errors that are: • Serious • Preventable • Definable and measurable • Unexpected and iatrogenic
https://psnet.ahrq.gov/primers/pr imer/3/never-events Examples of Dental Sentinel Event
• The unplanned removal of non-diseased tooth structure (cutting, drilling, or extraction).
• The un-consented removal of non-diseased tooth structure (cutting, drilling, or extraction).
• Performing a procedure on the wrong patient or tooth.
• A medication error that results in death or serious injury or disability.
Oregon Dental Services Dental Provider Handbook Format of Presentation . Quality Assurance . Compliance . Ethics and Professionalism
Life Alert symbols: Quality Assurance
A program which monitors a process or facility to ensure that standards of quality are being met. Informed Consent & Refusal
• Providing the patient or guardians with relevant information regarding diagnosis and treatment needs so that an educated decision regarding treatment can be made. • Includes: • Conversation between provider and decision- maker. • Description of dental problem. • Nature or proposed treatment. • Potential benefits and risks. • Alternatives to proposed treatment. Informed Consent & Refusal
• Must comply with state laws • Staff should understand: • Implied or waived consent. • Written or verbal consent. • Common procedures vs. invasive/high risk procedures. • Consent for Minors • Guardians: Divorced Parents, Legal Guardians, Foster Parents • Emancipated Minors . Informed Consent and Informed Refusal are irrelevant and will not protect the dentist if malpractice is done. Patient Follow-up
• Establish standards for routine follow-up: • Emergency Care • Complex Surgical Care • Medically Fragile Patients • Best Practices: • Develop written procedures for follow-up care • Utilize support staff • Document calls to/from patients. New Dental Provider Orientation Plan
• Orientation is a critical step in risk management. • Having a provider manual is ideal. Standards of Care and Clinical Guidelines Manual
• Critical for prospective, retrospective, and concurrent reviews. • Reduces subjectivity. • Defines quality for your program. • Informs providers of expectations. • Reviewed with providers at orientation. Standard of Care
• [A dentist is] under a duty to use that degree of care and skill which is expected of a reasonably competent [dentist] acting in the same or similar circumstances Standard of Care (Examples)
Standard of Content to Include & Best Clinical Guideline Reference Care Practices Oral Surgery Case Selection, Consent http://www.exodontia.info/Indices_of_Diffic Process, Documentation ulty_of_3rd_Molar_Removal.html Endodontics Case Selection, http://www.aae.org/uploadedFiles/Publicati Documentation, Radiographs, ons_and_Research/Guidelines_and_Position Technique _Statements/EducatorGuidetoCDAF.pdf Pain Narcotic Prescriptions, Refills, http://www.aae.org/uploadedfiles/publicatio Management Documentation ns_and_research/newsletters/endodontics_c olleagues_for_excellence_newsletter/ecfeac utedentalpain.pdf Radiography Quality, Quantity, Pt Refusal, https://www.ada.org/~/media/ADA/Member Documentation %20Center/FIles/Dental_Radiographic_Exami nations_2012.pdf Standard of Care • Diagnosis & Examination • Comprehensive examination - first line in patient safety and in a provider’s defense. Findings & Diagnosis Treatment Requirements: Pathology • Medical & Dental History • Occlusion • Periodontal Exam, Charting, and Diagnosis • Soft Tissue & Oral Cancer Evaluation • Appropriate Diagnostic Evaluations & Consultations: Radiographs, Pulp Testing, Referrals to Other Health Professionals, Etc. • Documenting All Findings, Treatment Recommended, Procedures Completed, and Medications Administered and Prescribed Chart Audits: Retrospective Reviews • Limited by the # of charts reviewed. • Identifies basic charting issues that may not comply with Standards of Care. • Identifies gaps in program guidelines. • Raises overall awareness of QA issues. • Chart Review Guidelines: Critical!!!! Chart Audit Guideline - Sample Question
Does the documentation support the diagnosis?
This category covers diagnosis and what is needed for an appropriate and accurate diagnosis. No Issues Found: • There were enough clinical tests listed to make a reasonable diagnosis.
Needs Improvement (examples): • There are not enough diagnostic tests listed to arrive at a reasonable diagnosis. • The symptoms do not match the diagnosis? • There is an emergency encounter with no listed diagnosis Documentation
If it isn’t documented, then it didn’t happen.
DOCUMENT DOCUMENT DOCUMENT
ADA Documentation Standards http://www.ada.org/~/media/ADA/Public%20Programs/Files/MPRG_ Dental_Records.pdf?la=en Poor Documentation = Larger Underlying Issues??? Patient Satisfaction
• Happy patients generally do not take action to report even when things go wrong.
• Example Survey Tools • Consumer Assessment of Healthcare Providers & Systems: https://www.ahrq.gov/cahps/index. html Addressing Patient Complaints
• Determine if there were any violations of the state dental law. • Determine any standard of care violations. • Good care/bad outcome vs. poor care/bad outcome. • Understand clinic policy for when to contact an attorney. • Must make decisions and contact patient in a timely manner. Provider Action Plans
• Does your clinic have a process and policy for dealing with providers that violate standards of care? • Possible Action Plan components: • Chart reviews • Concurrent peer review • Procedure mentoring • Who do you report to? Time Outs
• Your entire dental team (and the patient) should know the who, what, why and where of each procedure before it is done. • Determine which member of the team should initiate the time out. • If anyone has a question of what needs to be done, stop and get the questions answered. • Record the time out in the chart notes. COMPLIANCE Healthcare compliance is the process of following rules, regulations, and laws that relate to healthcare practices. Common Compliance Issues
• Billing issues • Record storage • License: expiration • CE requirements • BLS • Amalgam separators • OSHA and CDC regulations • DEA compliance • HIPPA Supervision of Students and Residents
• Need to have a formal arrangement with the teaching institution – “affiliation agreement” • Students must practice within the supervising dentist’s approved privileging • Student liability is normally covered by the academic institution • Supervising dentists may be liable for residents' negligence • Need to understand how FTCA works • Students and residents should not be viewed as another way to advance productivity Record Release and Retention
• Understand your state law requirements for record release. • Failure to release records is a common complaint sent to Dental Boards. • Know who can release the records, who can you release records to and what is required before release. • Know what is included in the definition of ‘legal record’ so you release the full record. • Know what your clinic’s policy is when an attorney requests records. Compliance
• Community Health Centers have to be compliant with regulations from multiple organizations such as: • State Dental Practice Act • OHSA and CDC • HIPAA • HRSA • Community Health Centers normally have a Compliance Officer and a Compliance Committee to focus on this topic • Ideally your Compliance Committee would have dental representation or knowledge HIPAA
• The Health Insurance Portability and Accountability Act (HIPAA) • According to HHS, the most common issues reported (according to frequency): • Misuse and disclosures of PHI • No protection in place of health information • Patient unable to access their health information • Using or disclosing more than the minimum necessary protected health information • No safeguards of electronic protected health information. • Failure to comply with HIPAA regulations can result in fines and even criminal charges or lawsuits Infection Prevention and Control (IPC)
• Food and Drink Policy • Surface Disinfection of Common Areas • Hand Hygiene Policy • Personal Protective Equipment (PPE) • Dental Operatory Disinfection • Offsite Dental Infection Prevention and Control • Safe Injection Practices (SIP) • Dental Unit Waterline Quality (DUWLQ) Infection Prevention and Control (IPC) cont.
• Dental Sterilization • Spore Testing/Failed Spore Testing • Immunization/Vaccination Policy • Post Exposure Prophylaxis • Hazardous/Regulated Waste • Dental Radiation Safety • Spill Protocol • Incident Reporting HRSA Compliance Credentialing
Credentialing: • Assessing and confirming the license or certification, education, training, and other qualifications of a licensed or certified health care practitioner. • Granted for a specified period of time, typically not exceeding 2 years
The health center must have operating procedures for the initial and recurring review of credentials for all clinical staff members Dental Privileging
Privileging:
• Authorizing a health care practitioner’s specific scope and content of patient care services. • Education, training, and assessment requirements for each procedure(s) performed in the dental program • Granted for a specified period of time, typically not exceeding 2 years (periodic privileging is recommended) Volunteer and Temporary Dentists
• Volunteers can be covered by FTCA • Free does not always mean no cost • Dentists and hygienists must be credentialed and privileged in your system • They should be included in your chart audits • An orientation plan should be established for them Federal Tort Claims Act (FTCA)
• Health Center employees treated as employees of U.S. Public Health Service for malpractice liability coverage. • Health Center’s scope of project defines approved service sites, providers, service areas, and target population(s). • Part time contract dentists and students/residents are NOT covered. • Volunteer dentists can get FTCA coverage • Must submit annual application to continue coverage. Federal Tort Claims Act (FTCA)
• HRSA may conduct a site visit, randomly or for cause, to any initial applicant or deemed grantee to ensure implementation • FTCA has been doing site visits for the last 8 years • Approximately 20-22 site visits per year • If a site visit results in a finding of a lack of implementation of the FTCA program requirements, this may be grounds for not receiving FTCA deeming or redeeming and may receive conditions upon their Health Center Program grant Federal Tort Claims Act (FTCA)
• Factors that may prompt a site visit may include: • Submission of an initial FTCA deeming application • Non-compliance with requirements during the review of the health center’s FTCA application • Need for follow-up based on prior site visit findings • History of repeated conditions, or current conditions, placed by HRSA on the health center’s Health Center Program grant • History of medical malpractice claims PROFESSIONALISM AND ETHICS ADA Principles of Ethics Ethical Patient Care
• Focus on patient autonomy and respect their barriers to care • Your patients won’t always be able to afford the “ideal” treatment • Some patients won’t be able to make it to every appointment due to barriers • Don’t rush to label the patient as “non-compliant” • Diagnose the patient • You must inform the patient of his/her diagnosis • If you cannot treat the patient’s needs, then you must offer a referral to someone who can Sexual/Relationship Issues
• Single dentists in rural areas • Patients or guardians • Legal and ethical issues • Time frame on when a person was a patient • Staff relationships Encounter Churning
Churning: Systematic, institutionalized practice of maximizing revenues by maximizing visits/encounters • Unethical • Not patient centric • Average patient centric appointment time is 45 minutes • Not standard of care • Must document justification for deviation from the expected “Standard of Care” when that scenario arises • Can be considered fraud • Creates a two tiered system Examples of Churning
• One visit = One procedure without justification • Separation of exam & imaging procedures • Separation of exam, imaging & P&F for children • Lack of quadrant dentistry, especially if small restorations • Separation of sealant placements • Lack of definitive treatment for emergencies • 15 minute restorative appointments Medicaid Audits • Most Common Audit Findings: • Lack of/inadequate documentation • Claim an unusually large number of services per day • High payments per child • Do not always verify or document medical necessity • Improper claims - Services not rendered • Improper coding • Unbundling services Start With Your Biggest Risks
• Identify and triage your own center’s risks • Develop policies to mitigate those risks 48
NNOHA Dental Program Operation Resources
• Operations Manual for Health Center Oral Health Programs • Fundamentals • Leadership • Financials • Risk Management • Workforce and Staffing • Quality
http://www.nnoha.org/resources/operations-manual/ Questions?
Ethan Kerns, DDS Chief Dental Officer Salud Family Health Centers, Colorado [email protected]
Donna Bridge, DMD Chief Dental Officer Daughters of Charity Health Pic to come Centers [email protected] This image cannot currently be displayed.
Leadership: The Path To Excellence as a Health Center Dental Director Tena Springer, RDH, MA Leah Schulz, DDS 2019 NNOHA Annual Conference This image cannot currently be displayed.
The Concept of Dental Leadership
Dental Leadership is really about you knowing where you are going and how you are going to lead your team there.
“Extreme ownership requires leaders to look at organization challenges through an objective lens, without emotional attachments to agendas or plans. It mandates that a leader set ego aside, accept responsibility for failures, tackle the challenges, and consistently work to build a better and more effective team. Such a leader, however, does not take credit for his or her team’s successes but bestows that honor upon rising leaders and team members.” Nancy J. Stern, CEO Eastern Shore Rural Health Systems, Inc. This image cannot currently be displayed.
Health Centers with new or rapidly growing oral health programs may have dentists who assume leadership roles before they’ve had an opportunity to fully develop their skills as both good dental clinicians and leaders. This image cannot currently be displayed.
Transition from Dental Provider to Effective Program Administrator
Major Program Focuses • Population Health • Patient Centered Medical Home • Medical-Dental Integration • Quality Metrics/Assurance • Finance/Grant Management • Mission/Vision This image cannot currently be displayed.
How to Build a Knowledge Bank
A Health Center Dental Program should not be managed the same as a private practice, nor as the medical program at your health center
Valuable online resources: www.nnoha.org www.dentalclinicmanual.com This image cannot currently be displayed.
NNOHA listserve (for example) This image cannot currently be displayed.
Sociology of Dental Directors
Dental Clinicians Administrators A. Doers A. Designers B. 1:1 interactions B. 1:n interactions C. Reactive C. Proactive personalities personalities D. Seek immediate D. Accept delayed gratification gratification E. Decision-makers E. Delegators This image cannot currently be displayed. Transition from Dental Provider to Effective Program Administrator
Asked to serve as an Expert and Consultant of…
Financial management Public health Government functions Clinical Competencies Organizational structure Legal issues Ethical issues Management information systems Quality improvement Accreditation requirements This image cannot currently be displayed. This image cannot currently be displayed.
Sociology of Dental Directors
Dental Clinicians Administrators
F. Value autonomy F. Value collaboration G. Independent G. Participatory H. Patient H. Advocate for the advocate community, organization I. Identify with I. Identify with profession organization J. Independent J. Interdependent This image cannot currently be displayed.
A Master of Negotiation
• I want, I need… • I don’t know why the numbers don’t add up… • My staff can’t meet those targets/the targets are not realistic… • My staff said they can not work any harder! This image cannot currently be displayed.
As Administrator…
• Be prepared for meetings, think of how an issue may affect the dental program, regardless of what it is • Take effort to understand the budget and productivity measures. • Connect with other more experienced Dental Directors, take Digging Deeper sessions at NNOHA Conference • Strive to increase your Emotional Intelligence. This image cannot currently be displayed.
Roles and Responsibilities
Board of Directors
• Participation • Ask to present to the Board at least quarterly and share quality metrics, program developments • Attend all meetings and contribute to your CEO:s monthly report
• Advisor and educator • Be prepared to respond to questions and educate board members on dental clinical matters. They need to understand how medical and dental programs are alike and how they are different. This image cannot currently be displayed.
“The Health Center Dental Director must function as the “eyes and ears” of the Executive Director in all oral health related activities and constantly scan the environment for possible problems and opportunities for the Health Center.” Always “talk teeth” at every meeting and opportunity. This image cannot currently be displayed.
The health center dental director should review relevant oral health and health policy publications to track trends and updates in environmental and dental program practice knowledge. This image cannot currently be displayed.
The Benefits of Good Data: Internal and Network Use • Helps in the planning process • Provides information on the challenges ahead • Allows for tracking changes and corrections in strategic outlook • Compliance with federal rules • Improves quality of care • Helps to know the territory and makes for more predictable outcomes! This image cannot currently be displayed. Management Decisions are Based on Information • Monitoring quality of care - basic outcome measures • Peer review protocols • Patient satisfaction surveys • Community needs assessment • Efficiencies in treatment applications • Financial Management • Cost control and supply utilization • Revenue and service cost tracking • Provider productivity tracking This image cannot currently be displayed.
Use your Vision to Plan your Future
• What are your short term (2 years) and long term (> 5 years) plans for yourself and the health center’s dental program? • Have a “growth mindset” This image cannot currently be displayed.
Set Your Priorities Right!
Build a realistic vision with service priorities based on the needs of your community:
• availability of resources • space and design of dental program • service prioritization • size of the target population • dental disease prevalence and types • demand of the population This image cannot currently be displayed.
Attributes Needed
• Trust defined as “vulnerability” Dare to take a risk and let someone on your team help you • Creativity; “I have more ideas, than good ideas, I will share them if you tell me which ones are good and which ones are not” • Commitment to a common purpose • Accountability – write down what you wish to do better or differently (i.e. Listening. ) • Emotional Intelligence: ability to manage yourself as well as relationship with others This image cannot currently be displayed.
Teamwork
“A team is a small number of people with complimentary skills who are committed to a common purpose, a set of performance goals, and an approach for which they hold themselves mutually accountable.”
Katzenbach, J.R. & Smith, D.K. (1993) The wisdom of teams. Cambridge: Harvard Business School Press, 1993 This image cannot currently be displayed.
Teamwork – “the why”
• Better outcomes • Enhance efficiency • Reduced turnover • Lower cost • Less waste • Enhance professional satisfaction This image cannot currently be displayed. Leadership Strategies for Managing Conflict • Reframe conflict • Honor the value of different perspectives • Actively solicit from those who don’t speak up • Use “what if(s)” to explore options and views • Establish clear rules and expectations • Know that sometimes resolution is not possible This image cannot currently be displayed.
Coaching This image cannot currently be displayed.
Other Leadership Tools This image cannot currently be displayed.
10 Thoughts About Leadership from Jon Gordon 1. People follow the leader first and the leader's vision second. 2. TRUST is the force that connects people to the leader and his/her vision. 3. Leadership is not just about what you do but what you can inspire, encourage and empower others to do. 4. A leader brings out the best within others by sharing the best within themselves. 5. Just because you're driving the bus doesn't mean you have the right to run people over 6. “Rules without Relationship Leads to Rebellion” 7. Lead with optimism, enthusiasm and positive energy, guard against pessimism and weed out negativity. 8. Great leaders know they don't have all the answers. 9. Leaders inspire and teach their people to focus on solutions, not complaints. 10. Great leaders know that success is a process not a destination This image cannot currently be displayed.
Effective Communication Strategies
• Listen! • Use Open Body Language • Be Clear and Concise • Be Personable • Utilize Repair Attempts • Use “I” versus “you” Statements • Give and Receive Feedback This image cannot currently be displayed.
Giving and Receiving Feedback • Feedback is Feedback. • When GIVING Feedback: • Assume positive intent • Specific, observable behaviors • Act Immediately • Verify Communication • When RECEIVING Feedback: • Avoid defensiveness • Seek specifics • Verify Communication
http://www.baird-group.com/articles/10-tips-for-giving-and-receiving-feedback-effectively This image cannot currently be displayed.
Giving and Receiving Feedback • Feedback is Feedback. • When GIVING Feedback: • Assume positive intent • Specific, observable behaviors • Act Immediately • Verify Communication • When RECEIVING Feedback: • Avoid defensiveness • Seek specifics • Verify Communication
http://www.baird-group.com/articles/10-tips-for-giving-and-receiving-feedback-effectively This image cannot currently be displayed.
Rounding for Outcomes
What staff are looking for from their supervisors:
1. A good relationship 2. Approachability 3. Willingness to work side by side 4. Efficient systems 5. Training and Development 6. Tools and equipment to do the job 7. Appreciation This image cannot currently be displayed.
How to ‘Round for Outcomes’
• Start with a personal question then ask … • What is working well today? • Is there anyone I should recognize for doing great work? • Do you have the tools and equipment you need to take care of patients safely today? • Are there any systems or processes that need improvement today? • Is there anything I can help you with right now? This image cannot currently be displayed.
Team Member One-on-Ones ACME CHC, Inc. Team Member One-to-One Meeting Agenda Employee: ______Date: ______Leader Feedback (Feedback on Employee Individual Performance, Development, etc.)
Review of Results (How is our unit performing? Data, etc.)
Employee Feedback (What is needed from supervisor, areas for improvement, resources needed, training needed, etc.) Other This image cannot currently be displayed.
Staff Performance
• Recognize and retain your high performers first • Recognize and develop skills for your middle performers • Confront low performers, outlining specific steps to improvement (it’s up or out …) This image cannot currently be displayed.
Building and Maintaining Your Dream Team
• Hire the right person – strive for the “right person in the right seat on the right bus” • The right people require more than technical skills. • Provide structure for your team • Hold regularly scheduled, effective and short meetings • Team building exercises and professional development • Facilitate! Delegate! Obligate! • Team organization through accurate job descriptions • Responsibility • Authority • Accountability This image cannot currently be displayed.
Providing structure for your team Clear communication is key!
• Chain of authority and reporting • Written protocols and procedures • Verify understanding of priorities and requests • Give and receive feedback • Provide training and evaluation This image cannot currently be displayed.
Meeting Guidelines
• Agendas • Facilitators • Focus • Solutions-oriented • Benefit of the Doubt • Action Items • Accountability This image cannot currently be displayed. This image cannot currently be displayed.
Communication Update This image cannot currently be displayed.
Vision + Skills +Incentives +Resources +Action Plan = Successful Change http://online.creighton.edu/edd/doctorate-leadership/resources/5-ingredients-for-change This image cannot currently be displayed.
Group Activity! This image cannot currently be displayed.
Your tools
1 This image cannot currently be displayed.
Paper fold exercise
• This exercises requires listening and following directions. • As you hear the instructions, perform the task • You may not ask questions • You must close your eyes This image cannot currently be displayed.
Share! (5 min)
• Show your rendition of your paper with your neighbor 1. How different are your results? 2. How were the directions? 3. How does this activity relate to leadership?
Discuss! This image cannot currently be displayed.
Lessons Learned
• What would have helped? • More detailed instructions – as a leader, take time to clearly communicate with your team. • Ability to ask questions – as a leader, communication channels must be open! • Another chance – as a leader, constructive debriefing is critical to the success of future endeavors
• Communication is key! • Must be clear and adaptable in your communication • Communication and teaching is better when you know your audience! • Change your communication strategies based on your audience • Feedback is important for success This image cannot currently be displayed.
Conclusion
• CHC Dental Director Roles and Responsibilities • Working effectively on the Administrative Team • Importance of Vision as a powerful leadership tool • Financial Management and Fiscal Oversight • Data Monitoring, Priorities and Evaluating Program Conditions • Staff Development and Team Building This image cannot currently be displayed.
Leadership Resources
• NNOHA Operations Manual • Chapter 2: Leadership • National Oral Health Learning Institute This image cannot currently be displayed.
Thank you! Dr. Leah Schulz Site Dental and Medical Director at Fort Collins West Clinic Salud Family Health Centers, Fort Collins, Colorado [email protected]
Tena Springer, RDH, MA Dental Division Administrator Family Health Center, Marshfield Clinic [email protected] This image cannot currently be displayed.
Breakout Sessions in Palace 1 and 2 Topics Leads 1. Fee Schedule/Sliding Fee Domenic Caluori and Donna Bridge 2. Peer Review Lisa Kearney and Sybil Fortner 3. No Shows/Scheduling Nick Pfannenstiel and Jeffery Moeller 4. Medical/Dental Integration An Nguyen and Randi Wingate 5. Infection Control Beverly Foster and Debby Myers 6. Managing Pts Experiencing Substance Scott Wolpin and Janine Burkhardt Abuse 7. School-Based Ethan Kerns and Duane Mata 8. Advocacy In and Out Tina Sopiwnik and Leah Schulz 9. Referral Follow Up Ryan Tuscher and Stacey Robben 10. Emerging Trends: Teledentistry and Bob Russell and David Kadar Dental Therapists This image cannot currently be displayed. Quality: Striving to Provide the Highest Quality Care Possible Janine Burkhardt, DMD, FAGD Ryan Tuscher, DDS 2019 NNOHA Annual Conference Objectives
• Define quality and quality improvement • Explain the importance of quality in oral health • Introduce tools used to measure quality • Present sample metrics and benchmarks • Discuss the impact of quality data • Present future influences on quality What is Quality?
“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”
Institute of Medicine (IOM) – National Academy of Medicine IOM Quality Domains
• Safety • Timeliness • Effectiveness • Efficiency • Patient-centeredness • Equity The Quadruple Aim
• Better care (improve quality of care, more patient centered, increased patient satisfaction)
• Improve health of the population
• Reduce cost
• Improve care team satisfaction Source Image: Lippincott Solutions Why is Quality Important?
• Section 330 of Public Health Service Act requires health centers to have an ongoing QI/QA process • Section 330(k)(3)(C) of the PHS Act; and 42 CFR 51c.110, 42 CFR 51c.303(b), 42 CFR 51c.303(c), 42 CFR 51c.304(d)(3)(iv-vi), 42 CFR 56.111, 42 CFR 56.303(b), 42 CFR 56.303(c), and 42 CFR 56.304(d)(4)(v-vii) • Federal Tort Claim Act deeming application process requirements • Positive patient outcomes • Focus on Population health What is driving the emphasis on quality?
• Increasing cost of healthcare without improvement of health outcomes • Problems with fragmented health system • Profound healthcare disparities in population • Increasing consumer awareness of these problems
Glassman P, Oral Health Quality Improvement in the Era of Accountability. WK Kellogg Foundation and Dentaquest Institute, 2012. Evidence of Drivers • As a nation, we spend much more of our gross domestic product on health care than the rest of the developed world and have poorer health outcomes.
https://www.commonwealthfund.org/publications/infographic/2013/mar/cost-30-years-unsustainable-health-spending-growth-united-states Evidence of Drivers
• IOM report To Err is Human: Building a Safer health System and Crossing the Quality Chasm highlighted the problems with the US Health Care system in the areas 1) patient safety 2) inefficient use of resources 3) fragmentation of the delivery system 4) need to re-design the way healthcare is delivered.
The Institute of Medicine. To Err is Human: Building a Safer Health System. 2000 National Academies Press. Washington D.C. The Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001. National Academies Press. Washington DC
Evolution of the Changing Landscape
From To Provider Centric FOCUS Patient Centric/Consumer
Value-based Reimbursement and Value Blind Reimbursement VALUE Accountabilitly Episodic Fragmented Care PATIENT FLOW Continuous and Coordinated Inpatient-Focused DELIVERY SETTING Amulatory/Office/Home Focused Individuals APPROACH Population Based Diesease and Treatment OBJECTIVE Health/Wellness Prevention
Glassman P, Oral Health Quality Improvement in the Era of Accountability. WK Kellogg Foundation and Dentaquest Institute, 2012. Dentistry and Quality • Quality in dental care is in a relatively primitive state • Measures used for quality are little changed in the past three decades • Emphasis on surgical treatment • Evaluation is on clinician rather than the effect of clinician’s effort on improving patient health
Bader.J. Challenges in quality assessment of dental care. JADA 2009:140;1456-1464 Quality Assurance vs. Quality Improvement
QUALITY ASSURANCE (QA) QUALITY IMPROVEMENT (QI) “What went wrong?” “What can we do to improve?” Delegated to a few. Embraced by all as everyone’s job. Focus on individuals, outliers. Focus on processes. Works towards endpoints. Has no endpoints (continuous). Ensures minimum standard is met. Works towards maximum potential. Retrospective, detection. Proactive, preventive. Provider focused. Population focused. Punitive, finds blame. Rewards innovation, permits failure. Quality Improvement (QI)
• An approach to the analysis of performance and efforts to improve it • Measuring where you are, figuring out ways to improve • Data collected establishes “baseline” for an aspect of the dental program, and QI process develops methods to improve from the baseline • Avoids attributing blame • Creates systems to increase/decrease outcome • Proactive prevention approach Health Center QI/QA Program
• QI/QA Committee • team made up of members from various departments • Be based on the systematic collection and evaluation of patient records, while maintaining the confidentiality of patient records • System for identification, data collection review, root cause analysis, system improvement Poll: Is a member of your oral health team on your health center’s quality committee?
•Yes •No •I don’t know An Effective QI Plan
• Directly aligns services to program goals • Provides specific measurable milestones or targets • Identifies timelines • Improvement decisions influenced by numerous variables including population needs, resources, motivation, Board priorities QI Process
• Establish a culture of quality in your practice. • Determine potential areas of improvement • Collect and analyze data • Communicate your results • Commit to ongoing evaluation • Spread your successes Quality Improvement Tools and Data
• Tools used for Quality Improvement • Chronic Care Model • Model for Improvement • Run charts
• Data Collection and Reporting • Electronic dental record • Spreadsheets • Dashboards
The Chronic Care Model
1) Health Care Organization 2) Community Resources and Policies 3) Self-Management Support 4) Delivery System Design 5) Decision Support 6) Clinical Information Model for Improvement • The Model for Improvement enables an organization to approach quality improvement through rapid cycles of change and continual feedback on the effectiveness of those changes. • When used in conjunction with the Chronic Care Model, the Model for Improvement can lead to positive, sustainable changes in the quality of health care. Opportunity for Improvement
Desired The Gap
• Access to care (visit) • Type of service (sealant) • Cost (lower) Actual • Adverse patient event (latex allergy) • Oral health outcomes (BP) Plan-Do-Study-Act Cycle Ideas Action Learning Improvement
• Demonstrate improvement • Identify problems and create • What changes are to be made? a plan • What is the next cycle? Act Plan Study Do • Complete the data analysis • Implement the plan • Compare data to predictions • Monitor and document • Summarize what was learned results • Begin analysis of the data Using the Cycle to Improve
Improvement
D S
A P Spread Implementation of Change Wide-Scale Tests of Change
A P Follow-up Tests Ideas S D Very Small Scale Test Stephen Klein Wellness Center
• PACHC Oral Health Into Primary Care Initiative • Aim: Reduce rates of caries in pediatric population • Methods: • Risk Assessment • Oral Health Screenings • Preventive Intervention (Fluoride) • Education • Referrals to Dental Home Driver Diagram for Oral Health Prevention Stephen Klein Wellness Center QI plan for Fluoride • Problem identified: Co-located medical and dental departments, but many pediatric patients unable to access dental care • Project goal: To increase the number of 0-14 year old patients that at least 1 fluoride varnish application in medical clinic from baseline to 20% during course of initiative • Project Team: Medical Champion (MD), Dental Champions (DMD & PHDHP), Clinical Director, IT Data Analyst • Established baseline: 0% • Timeframe: course of initiative - 8 months • Meeting time: every other week; frequent emails; tracking on shared PDSA log Fluoride Varnish Applications • % of 0-14 year old children who have at least 1 fluoride varnish application • Denominator: number of unique 0- 14 year old patients who come to the medical clinic for any reason during a 12 month period • Numerator: number of patients in the denominator who received at least one application of fluoride varnish by a medical provider (MD/DO, PA-C, NP) Stephen Klein Wellness Center - PDSAs
• Train 1 provider for Fl varnish applications using Smiles for Life Curriculum • Create and test a template for CRA / OHA / Fl Varnish application • Track Fl varnish applications using EHR oral health template • Train all providers to apply fluoride varnish using Healthy Teeth Healthy Children live course • PHDHP for chairside support during Fl varnish applications • Add fluoride to i2i huddle sheets • Medical Assistants place open fluoride packet on countertops • Friendly competition for providers Example of PDSA: Apply fluoride varnish .Adapt & test again .Our medical champion (trained with Smiles for Life) Next Steps: .Provider will call PHDHP Small Scale Test! for chairside assistance will apply fluoride varnish on Adapt, next time a patient 1 child at a well child visit. 1 patient, 1 Abandon, or presents for well child .We predict that she may be time, 1 session Adopt visit hesitant since this is the first .Reassure provider of time she is applying it, but minimal time needed for that it should go smoothly. varnish Act Plan Study Do . The provider felt .She saw a patient eligible too busy to apply it for fluoride varnish during during the session. the session, but no fluoride .She also didn’t feel varnish was applied. as confident as we What thought by just Carry out the happened? watching the online trainings. plan Stephen Klein Wellness Center PCC’s PDSA: Same Day Sealants • Problem Identified: Few patients were returning for sealants • Project Goal: To increase the number of patients 6-9 years of age at moderate to high caries risk who had a sealant placed on an eligible molar • Team: Dr. Tuscher, Justyna, Stefanie • Established Baseline: 21% • Timeline: 6 months • Team Meeting Schedule: weekly PCC’s PDSA first steps • Plan • Plan: If we place sealants on the same day that the need is identified, will our sealant rate increase? Prediction: Yes • Do • Started with one patient, on one day, in one provider’s schedule at one clinic • Collected data: number of sealants completed, patient feedback, staff feedback, appointment length • Met weekly and began implementation based on data PCC’s PDSA Continued • Study • Act • Result: 66% • Did we demonstrate • Increased appointment time improvement? • Improved patient and staff • Changes we needed to make? satisfaction • What’s next? Future PDSAs • Same day sealant placement was • Same day sealant set ups a success! • Using schedule markers to identify sealant eligible patients • Patient sealant brochures
4. Sealants (6-9 Year Olds) 100
80
60
per cent 40
20
0 Jan-18 Apr-18 Jul-18 Oct-18 Jan-19 Apr-19 Jul-19 Oct-19 “You can’t change what you don’t measure.”
But you can’t measure unless you make it easy. Quality and Information Systems
Health Information Technology • Data must be measureable, trackable and able to be extracted from the patient record
Benefits Challenges
More data vs sample measure System limitations
Easier/Faster to access data Each EDR is different
Information sharing opportunities Getting accurate and complete data Improved care coordination EDR/EMR communication History 2017 2013 Updates to User’s Convening Guide and new of Expert data collection Advisors tool developed
2015 Launch of Health Center Dental Dashboard© User’s Guide and data collection tool Development
Participants from: • CMS • NNOHA • Institute for Oral Health • Colorado and Washington CHCs working on oral health • Arcora (Formerly WA Dental Service Foundation) • Delta Dental of Colorado Foundation • Primary Care Associations
Summary of Initiatives Utilizing the Dashboard© • Learning Collaborative Pilot (2016) • 5 Health Centers, customized subset of Dashboard© measures used for Quality Improvement (QI) • Dashboard Learning Collaborative (2016-2017) • 26 Health Centers, customized subset of Dashboard© measures used for Quality Improvement (QI) • Benchmarking Initiative (2017) • Health Centers, customized subset of Dashboard© measures used for Benchmarking • Oral Health Improvement Collaborative (2017-2018) • 39 Health Centers, customized subset of Dashboard© measures used for Quality Improvement (QI) NNOHA Dental Dashboard
• http://www.nnoha.org/resources/dental- dashboard-information/dental-dashboard- access/
“Quality measurement implementation needs to be easy in routine practice for clinicians with measures captured as part of the clinical workflow”. -The Future of Quality Measurement for Improvement and Accountability Process Measures
Evaluate the degree to which a step in the process or clinical activity occurred • Sample process measures: • Annual Oral Health Visit (populations) • Treatment Plan Completed • Topical Fluoride Treatment • Dental Sealants • Oral Health Education (medical setting) • Periodontal Exam (i.e HIV, diabetic) Outcome Measures
Evaluate the impact of an intervention on patient health • Sample Outcome Measures: • Percentage who have new decay at recall • Percentage of patients that are caries free • Percentage of patients that have moved from high to medium risk Poll: What oral health quality measures are you currently tracking in your health center?
• Sealants 6-9 • Sealants 10-14 • Fluoride varnish • Caries at recall • Direct cost per visit • Caries risk assessment • Treatment plan completion Who will create and define oral health quality measures? • Nationally defined measures: • Dental Quality Alliance • HEDIS measures • National Quality Forum • Meaningful use measures • NNOHA Dashboard • Healthy People 2030 • Center for Oral health systems Integration and Improvement
• All include different measures and different definitions of those measures Nationally defined measure: HRSA Sealant Measure • Numerator: number of dental patients 6-9 years old who received a sealant on the permanent first molar in the calendar year
• Denominator: number of dental patients 6- 9 years old who had a comprehensive or periodic exam and an elevated caries risk who needed a sealant on their permanent first molar in the calendar year
• Is this our best oral health measure? Questions about the sealant measure • Are you doing a Caries Risk Assessment? • No standard CRA • Can you track the exclusions with your EDR? • Sealants are a preventive measure – should all kids should receive sealants regardless of risk? • Skewed results due to school sealant programs • Measure exclusively for patients 6-9 What is the future of Quality?
• Standardization of Measures • Risk-Based Care • Value-based reimbursement • Patient and Provider Satisfaction • Improvements in health information systems • New UDS measure Shift from Volume to Value
• Value-Based Reimbursement or P4P • Shared savings and shared risk methodologies • Health Centers reimbursed for achieving certain benchmarks • Will require more robust IT • ~8 states are participating in some sort of value based payment initiatives
Poll: Is your health center receiving value-based payments?
•Yes for medical only •Yes for dental only •Yes for both •No •I don’t know Patient and Provider Satisfaction
• Patient Experience • Patient’s perception of health outcomes • Measured by PREMs or PROMs
• Provider • High rates of burnout related to electronic health record and volume demands • More attention given to methods for increasing provider wellness and satisfaction New measure? Fluoride
• HRSA plans to continue aligning several clinical measures reported in the UDS with the Centers for Medicare & Medicaid Services' (CMS) electronic specified clinical quality measures (eCQM) and is considering the following change for 2020 UDS data collection: Replacing Dental Sealants for Children Between 6-9 years with CMS74v9 Primary Caries Prevention Intervention as Offered by Primary Care Providers, Including Dentists Caries Prevention Partnership: White Paper on Dental Caries Prevention and Management, Pitts & Zero http://www.fdiworlddental.org/ What will our future oral health measures look like? • WE NEED YOU! NNOHA’s Resources
• Quality Improvement tools • http://www.nnoha.org/resources/clinical- excellence/quality-improvement/
• NNOHA Dashboard website • https://www.nnoha.org/resources/dental- dashboard-information/ NNOHA Operations Manual Chapter 6: Quality https://www.nnoha.org/resources/operations- manual/ Questions?
Ryan Tuscher, DDS PCC Community Wellness Center Chicago, IL (773)413-1920 [email protected]
Janine Burkhardt, DMD, FAGD Project HOME Philadelphia, PA (215)320-6187 [email protected] Breakout Sessions in Palace 1 and 2 Topics Leads 1. Fee Schedule/Sliding Fee Domenic Caluori and Donna Bridge 2. Peer Review Lisa Kearney and Sybil Fortner 3. No Shows/Scheduling Nick Pfannenstiel and Jeffery Moeller 4. Medical/Dental Integration An Nguyen and Randi Wingate 5. Infection Control Beverly Foster and Debby Myers 6. Managing Pts Experiencing Substance Scott Wolpin and Janine Burkhardt Abuse 7. School-Based Ethan Kerns and Duane Mata 8. Advocacy In and Out Tina Sopiwnik and Leah Schulz 9. Referral Follow Up Ryan Tuscher and Stacey Robben 10. Emerging Trends: Teledentistry and Bob Russell and David Kadar Dental Therapists