Abstract
CareQuest Institute for Oral Health’s mission is to improve the oral health of all. One way to achieve this is through programmatic initiatives, which train dental clinics to provide equitable, integrated and accessible care for their communities. The Community Oral Health Transformation (COrHT) Initiative, allowed CareQuest Institute to collaborate with the North Carolina Oral Health Collaboration (NCOHC) and Blue Cross Blue Shield (BCBS) of North Carolina Foundation to implement and support the initiative in North Carolina. This mixed methods study was designed to collect quantitative and qualitative data while 11 dental clinics and a control clinic participated in the program through the end of the program. Quantitative data included patient demographics, claims data, and financial and data measures. Descriptive statistics of participating clinics and the control clinic were analyzed, and aggregated clinic data showed improvements in patient care delivery measures. Qualitative interviews were also conducted at midpoint and conclusion, and an outcome evaluation was completed. This short report will provide readers with results from the COrHT Initiative, with an emphasis on medical-dental integration (MDI) as an integral component of comprehensive, person-centered care. The evaluation of programmatic strengths and weaknesses has been included to identify the potential for future implementation, sustainability, and policy making.
- access to care
- oral health equity
- oral health care
- oral health policy
- medical dental integration
- person-centered care
INTRODUCTION
As the first state to implement a state oral health program nearly 100 years ago, North Carolina (NC) has been a leader in oral health even though oral health inequities care continue to exist. North Carolina’s oral health status presents an extremely complex picture. In the southeast region, NC has the second highest Dental Health Provider Shortage Areas (HPSA), where only 11% of the population’s dental needs are met1 and as few as 35% of NC dentists participate in Medicaid.2 Inadequate reimbursement levels for these Medicaid providers result in dentists struggling to cover their costs. North Carolina is at approximately 34% of the “usual, customary, and reasonable” (UCR) rate defined by the United States (US) Department of Health and Human Services, while dental practice overhead averages 60%. Consequently, the current network of dental providers is not adequate to provide the minimum necessary access to care for Medicaid beneficiaries, making it very difficult for North Carolinians covered by Medicaid to find a dental home.6 These barriers lead many North Carolinians to seek oral health care in hospital emergency departments (ED) for non-traumatic dental conditions (NTDCs). In 2019, the American Dental Association (ADA) reported there were over 99,000 emergency room visits for NTDCs in North Carolina alone, costing an estimated 187 million dollars.6 While a disproportionate number of these visits occur in rural areas adults (aged 25-34) have the highest rate of emergency room dental visits.3 Black NC residents in all age groups have the highest rate of emergency room dental visits in the state; twice the rate of Whites, and more than four times that of Hispanic residents.3
Recognizing these disparities, NCOHC has been at the forefront of promoting and advancing oral health access and equity in oral health care. Through collaborative efforts with the North Carolina Dental Society (NCDS), North Carolina Department of Health and Human Services (NCDHHS), safety-net dental clinics, and community organizations and members, progress has been made in the state, including codifying teledentistry in the NC Dental Practice Act, allowing dental hygienists to provide preventive services to patients in community settings, and payment reform for asynchronous teledentistry and silver diamine fluoride. While these policy changes have made a systemic impact on oral health care in NC, the NCOHC recognized a need to promote value-based care and emphasize a medical-dental integration model in safety-net clinics that offer medical and dental services.
This led the NCOHC to seek out opportunities to demonstrate how oral health providers can bridge the gap for patients who are detached from the rest of the healthcare system and are unable to receive equitable, integrated and accessible care.4 After exploring the Community Oral Health Transformation Initiative (COrHT) developed by the CareQuest Institute for Oral Health, NCOHC formed a partnership with CareQuest Institute and Blue Cross Blue Shield of NC Foundation (BCBS) to implement value-based care in clinics throughout North Carolina with strategies focused on the underlying social, economic, and political causes of oral health inequalities.
North Carolina COrHT Initiative
The COrHT Initiative was launched in North Carolina in 2022. The initiative engaged multiple stakeholders across the state bringing together dental professionals, community partners, and funders all dedicated to identifying and implementing strategies to address the widespread challenges in oral health care delivery. The objective of the initiative was to provide education, testing grounds, and financial support for dental clinics to embrace an equitable, integrated and accessible model of care.
Eleven participating dental clinics worked to identify and act on systems-level barriers to promote more widespread adoption of an alternative payment method (APM), that focused on reporting clinical, demographic, and financial data. Each clinic improved data collection and utilization processes through collaboration and networking with other COrHT participants to support interventions.
Value-Based Approach to Medical Dental Integration
The integration of medical and dental care through a value-based approach is paramount to enhance patient outcomes and optimize healthcare efficiency. By aligning incentives across both disciplines, it encourages a more holistic view of health that encompasses oral care as an integral component of overall wellness.4 This synergy fosters interdisciplinary collaboration and drives down costs by preventing more serious health complications through early intervention and comprehensive care strategies.
The implementation of the COrHT Initiatives key drivers were focused on clinical and operational strategies dental clinics executed to support the transition towards VBC, where improving patients’ oral and systemic health outcomes are essential. Obvious approaches to improving health outcomes include areas such as increased preventive services, which are fundamental to VBC. Other strategies required more innovative approaches and collaborative efforts. Fortunately, the dental clinics involved joined the initiative with a trailblazer’s desire to transform the siloed health system and be catalysts for change to break down the walls between dentistry and other medical professionals. These dental clinics included federally qualified health centers (FQHC), local health departments, and non-profit organizations, who were well-poised to initiate conversations with their medical colleagues. Once the participants began to consider the essential elements of work required to support their goals, they recognized some of the greatest repositories for resources existed at their own organizations: initiating collaborative conversations with other health professionals at their organization aided in extensive support of their goals to promote whole-person health by integrating medical-dental integration (MDI).
The teams chose various actions to work toward their goal to improve MDI. Recognizing the small steps are vital to establish a relationship and baseline for collaboration, some teams started small by creating in-service trainings where nurses from the medical team reviewed and calibrated on blood pressure techniques and blood glucose testing for diabetic screenings while establishing a referral system. Another team collaborated with affiliate medical nurses to provide human papillomavirus (HPV) vaccinations in the dental clinic.
Medical dental integration is multifaceted and the relationships the COrHT Initiative dental clinics, cultivated with medical professionals, began to build a bridge between the siloed professionals to promote whole-person health benefiting patients and communities. Some additional examples of MDI in the COrHT Initiative included improvements towards referrals, case management, and medical consultations. Many clinics began implementing additional health screenings and worked with their organizations’ social workers and health advocates to extend their reach to screen for social determinants of health (SDOH) to identify barriers and resources to overcome them.
RESULTS
Preliminary aggregated data evaluated during the COrHT Initiative has demonstrated improvements in patient care delivery, from baseline to program end, for patient care delivery measures, financial measures, and data collection measures. Periodic qualitative interviews with internal and external stakeholders were categorized based on stakeholder’s needs and support for the initiative with key themes related to program buy-in, transforming attitudes, policy/advocacy, and the benefits of networking. Participants then uplifted necessary system-level changes, such as addressing workforce shortages and payment reform.
The COrHT Initiative captured services under three categories related to teledentistry, minimally invasive care, and integrated and personalized care. Services related to medical-dental integration fall under the umbrella of integrated and personalized care and include care coordination and referral codes and chronic disease screenings. The percentage of aggregated integrated and personalized care-coordination and care referrals increased by 0.50% after the COrHT Initiative began in 2022 followed by a decline of 1% by program end in 2023 (Figure 1). A second category of integrated and personalized care included chronic disease screenings with comparable results as coordinated care and referrals identified by an initial 0.9% increase from baseline to January 2023 followed by a 0.9% decline from January 2023 to February 2023 (Figure 2).
Aggregated Clinic Data for Integrated and Personalized Care: Coordinated Care and Referrals
In June 2023 (2.3%) care coordination and referrals was at the highest compared with baseline (1.0%). From June 2023 there had been a steep decline in the service provided by dental cinics until program end (0.5%).
Aggregated Clinic Data for Integrated and Personalized Care: Chronic Disease Screening
In June 2023 (2.3%) care coordination and referrals was at the highest compared with baseline (1.0%). From June 2023 there had been a steep decline in the service provided by dental cinics until program end (0.5%).
The COrHT initiative included the use of a control clinic within NC, which was similar in structure and size to the initiative dental clinics. In comparison to before the initiative, the percentage of chronic disease screening claims after the initiative increased by 0.86% while adjusting for the chronic disease screening rate in the control clinic (Figure 3).
Monthly Chronic Disease Screening Claim Percent
Additionally, the seasonality effect was controlled by introducing month variables in the difference in difference (DiD) model. Chronic disease screenings increased significantly with the participants after the COrHT intervention. The COrHT Initiative encourages clinics to code for what they do even if there is no financial reimbursement. The data shown in Figure 3 may indicate the difference between recording and not recording chronic disease screenings.
Arguably, one of the fundamental metrics to indicate improved outcomes over time would be the impact the COrHT participants had on surgical intervention rates (restorations, endodontic treatment, and extractions). In the one-year intervention period between baseline and interventions, the COrHT cohort had an overall 1% reduction in surgical interventions, while the control group’s surgical interventions increased. Overtime, COrHT’s increased interventions of preventive services and personalized care are projected to continue the reduced need for surgical interventions.
An essential component in transitioning to towards VBC is for services related to improving patient outcomes as captured by codes to validate improvement. This is challenging for many clinics because these types of services are typically completed without an associated fee with Medicaid and private practice insurances; therefore, if there is not a fee associated with a code, most offices do not use the codes. A component of the COrHT Initiative is to encourage clinics to code for what they do, even if there is no financial reimbursement. Having this data provides insights to personalized care and outcomes, and aggregated patient population health data.
Electronic health record data, claims data, and financial reporting throughout the COrHT Initiative has provided extensive insights. However, the implementation of qualitative interviews provided even more insights. The decline in metrics at program end regarding the decrease in coordinated care and referrals and chronic disease screenings can likely be explained from some of the insights provided by the participants during qualitative interviews. The challenges related to workforce and low Medicaid reimbursement rates caused obstacles frequently noted throughout the initiative. One participant stated: “We get so busy in the busy of trying to do… all those things, that sometimes we overlook some of the things that are really meaningful. This really gave us an opportunity to measure some things that we take for granted a little bit, especially with the care coordination piece of it.”
DISCUSSION
Dental hygienists hold a unique perspective on the work in a dental team, highlighted by the key roles they played throughout the COrHT initiative. Each COrHT Initiative dental clinic created an implementation group of three staff members. Of the 11 cohorts, 9 internal implementation groups had at least one dental hygienist on the team. The dental hygienists within the initiative were already advocates for preventive care and recognized the importance of medical-dental integration to move toward a person-centered mindset where oral health is a component of overall health. Findings from the COrHT initiative validates the knowledge and leadership skills of dental hygienists to play key roles in the transformation of the health care system.
Working at the top of their licenses was one area where COrHT Initiative clinicians excelled. Whether it was becoming certified in local anesthesia, completing NC state statutes for public health training, or reaching out to marginalized and rural populations through community-based services, dental hygienists within the COrHT Initiative recognized their role to improve oral health outcomes for their fellow North Carolinians.
The COrHT participants are currently in a sustainability phase, and data is still being reported. This will provide valuable insights into which specific areas of the initiative will have lasting impacts. Qualitative feedback suggests teams are still enthusiastic about the advances they have made in improving oral health outcomes and acknowledge that some of the goals initially slated to be completed need a longer timeline. Some of those goals refer to collaborative opportunities with MDI, including mobile units in rural communities and telehealth with medical teams.
As COrHT Initiative dental clinics are now looking to sustain their improvements, the next step is advocacy. The COrHT Initiative and the transition to value-based care provides opportunities for dental hygienists to continue to amplify their roles. One of the key barriers to advocacy is the lack of confidence individuals may have with public speaking; however, this obstacle can be reduced by having opportunities to speak about their personal involvement in the work.5 Participants involved in the COrHT Initiative are leaders in the field and are well poised to use their experiences supported by data to improve the health of their communities by advocating for policy and system-changes that will make VBC programs, such as medical-dental integration and care coordination, more feasible.
CONCLUSION
The COrHT initiative in NC has been a successful journey for participants to improve oral health delivery to reach underserved and marginalized communities through VBC. To accomplish this, preventive services highlighted by person-centered care and MDI were integrated into dental clinics serving populations who are in the highest need of care. Throughout the initiative, the strengths of the collaborative mindset led the mission to continue the work in the clinic as well as advocating for system-level changes demonstrated by their efforts to transform the oral health system of the future.
DISCLOSURES
Funding for this program was provided by CareQuest Institute for Oral Health and the Blue Cross Blue Shield Foundation of North Carolina.
Footnotes
NDHRA priority area, Population level: Health services (community interventions).
- Received April 8, 2024.
- Accepted May 10, 2024.
- Copyright © 2024 The American Dental Hygienists’ Association
