Abstract
Access to high-quality, preventive oral health care is fundamental for an individual to achieve positive health outcomes. Recognizing that health is influenced by where a person lives, it is important to consider how systems of care must adapt to meet the changing needs of a community over time. Medical-dental integration is a critical component designed to enhance and broaden the oral health care delivery model. MORE Care® is a framework for communities to leverage their resources and relationships by providing tools and resources to integrate preventive oral health services into primary care settings. This report will show how local stakeholders advocated for an innovative approach to improve oral health gaps for children in Ohio. The MORE Care Ohio pilot is expanding access to preventive oral health services by featuring medical-dental integration to close patient care gaps and build an integrated oral health network. Providing a framework for medical and dental teams to collaborate, seven clinical practices (three medical and four dental) agreed to participate in a 9-month learning collaborative and 16-months of performance monitoring.
INTRODUCTION
Dental caries remains the most prevalent and preventable disease affecting children in the United States as well as globally. The severity and prevalence of caries among children also disproportionately affects children of marginalized groups and those most affected by social determinants of health.1 Nearly one in four US children ages 2-5 and 52% of children ages 6-8 experience dental caries which can lead to pain, development issues, lack of social confidence, and poor academic performance.2,3 Interdisciplinary approaches are needed to reduce the disease burden and encourage prevention.
Medical-dental integration serves as a mechanism for putting the mouth back into the body by ensuring that medical and dental teams work together to improve patient outcomes. Improving collaboration and communication between care teams results in better care coordination for the patient. Recommendations for Preventive Pediatric Health Care from the American Academy of Pediatrics (AAP) have long included recommendations reflecting the role pediatricians and primary care can play in addressing oral health needs of pediatric populations. The recommendations highlight the importance of oral health screening, anticipatory guidance, and referrals to a dental practice as important interventions to accompany fluoride varnish application, going beyond episodic interventions alone during well-child visits to support the ongoing focus on oral health through referral and coordination with dentistry.4
Although medical-dental integration is not a novel approach to improving oral health access, it can be demonstrated in many ways. When primary care providers are able to offer oral health education and leverage oral health tools like oral health risk assessments and self-management goals during well-child visits there is an increased likelihood for the utilization of a preventive dental visit by children of all ages.5 Additionally, the AAP oral health practice tools encourage pediatricians to refer and assist patients with finding local dentists to establish a dental home.
Constraints to this approach often relate to limited communication with dental providers, and lack of interoperability between medical and dental health record systems.6,7 This lack of integration creates barriers that prevent medical and dental teams from accessing mutual patient records, making referrals, or sharing data. Until interoperability within the healthcare system improves, medical-dental integration will depend on community driven solutions to test solutions and create sustainable change.
Medical Oral Expanded Care, MORE Care®, is a program developed by the CareQuest Institute for Oral Health that provides a framework, tools, and guidance for medical providers to integrate oral health competencies and capabilities into the primary care practice and address oral health systemic challenges within the community. This program aims to increase the number of primary care teams providing oral health services, the number of patients receiving preventive oral care, and equips communities to create and sustain equitable, accessible, and integrated oral health care systems to reduce oral disease burden. The MORE Care framework is adaptive to population focus by allowing partnering providers to decide what medical-dental integration can look like in their community.
Additionally, MORE Care acknowledges that systems change cannot occur by only working in clinical settings: partnerships with community, regional and state-wide stakeholders are critical to sustain success and may support place-based improvements.8 Through curriculum instruction, value-based payment, and empowering partnerships between primary care and dental teams, MORE Care provides a modern framework for communities to be able to explore interventions and build evidence that addresses oral health needs at the local, as well as the systems level.
Community Application
In Ohio, the prevalence of caries among children is a significant concern. While 74% of children receive annual dental visits, this number falls very short when compared to other states, ranking Ohio 45 out of 50. Additionally, Black or Hispanic children are also more likely to have unmet dental needs, according to analysis by the Ohio Medicaid program.9 Nearly half of Ohio’s 2.6 million children are covered by Medicaid,10 and poverty is one of the strongest determinants of tooth decay in children.11
With insight into these disparities, Oral Health Ohio (OHO) convened diverse stakeholders from across the state in 2021 for a series of listening sessions to identify opportunities for actionable value-based care implementation. While value-based care is an emerging care delivery model in dentistry, it focuses on aligning the system of care, the provider, and the community to achieve better health outcomes at lower costs.2
Stakeholders were presented with the MORE Care model as an interprofessional quality improvement project to test integrated, coordinated care and value-based payment in Ohio. Stakeholders, which included policymakers, regulators, payors, academia and oral health care providers in both public health and private practice, recognized two important opportunities in testing MORE Care in Ohio. First was piloting integrated value-based care in private dental practices. Second was pursuing integrated, value-based care for oral health which complemented the State’s vision for transforming care delivery in the Next Generation of Ohio’s Medicaid Managed Care Program.
CASE DESCRIPTION
MORE Care Ohio features a medical-dental integration model where primary care providers perform oral health services to close patient care gaps between siloed healthcare professions. Primary health care and dental providers collaborate to cultivate care coordination, promote shared goals, and provide comprehensive patient care. Based on an analysis of Ohio Department of Medicaid provider data and area-level data from the Opportunity Index published by the Government Resource Center at Ohio State University, Northwest and Southeast Ohio were identified as key geographic regions for oral health improvement. Pilot participants include seven health system affiliated or private pediatric medical and dental practices within dental Health Professional Shortage Areas (HPSA) that provide care for individuals covered by Medicaid. These shortage areas are often rural and commonly suffer from health inequities relating to variables such as geographic isolation, access to care, and other social determinants of health. The 24-month pilot began in November of 2022 and includes a virtual 9-month learning collaborative community and 16-months of performance monitoring until October 2024.
In addition, the pilot includes a value-based payment simulation which spans the 24-month program duration. To assist in performance monitoring, participants submit monthly demographic and clinical data such as number of preventive oral services provided (oral health risk assessments, fluoride varnish applications, patient self-management goals), and the number of dental referrals completed. Qualitative interviews with participants, OHO, and CareQuest Institute were conducted to further explore the program’s impact.
Learning Collaborative
Led by OHO, all participants completed a 9-month Learning Collaborative that provided educational opportunities and activities to improve clinical knowledge and skills and to establish a foundation for quality improvement. Practices completed the AAP’s nationally recognized Smiles for Life modules and custom MORE Care education modules on oral health integration, developing workflows and referral processes and sustainability planning. Additionally, participants attended monthly meetings hosted by OHO aimed at connecting participants to share their progress, challenges, and discuss solutions. OHO scheduled additional monthly touchpoints with each individual practice to problem solve and maintain engagement. Barriers to implementing integration uncovered during these touchpoint sessions were addressed with additional technical assistance for reporting data, fluoride varnish application training and patient education resources. Despite known differences in electronic health records (EHR), touchpoint sessions allowed teams to share their experience with documenting oral health services, reimbursement coding, and efficient processes to integrate these new oral health services and engage patients.
The monthly touchpoints also helped CareQuest Institute and OHO understand the reality and challenges that both rural and urban practices had in implementing medical-dental integration across a variety of practice settings. The Learning Collaborative provided all of the teams a shared understanding of the value of oral health care and solid foundation to implement medical-dental integration.
DISCUSSION
While the project remains underway, insights are accumulating to clarify and support place-based opportunities in Ohio.
Bundled Coding
The Ohio Department of Medicaid used Code of Procedural Terminology (CPT) code 99188 to report the application of fluoride varnish by non-dental providers for children up to age 6. The Department of Medicaid’s reimbursement for the code is inclusive of risk assessment and education, when provided the same day as the preventive service and reflecting on the AAP’s Recommendations for Preventive Pediatric Health Care.
Although the use of code 99188 does not inherently signify an issue, complications arise when the corresponding services are not provided on the same day. Care teams have encountered difficulties in documenting their work due to limitations within the EHR system under these circumstances. Despite this challenge, practices have shown improvement in integrating oral health preventive services into their practices. As of January 2024, MORE Care medical practices have increased preventive services by as much as 8% over baseline. These findings are preliminary, and participants are continuing to monitor their progress through October 2024 (Figure 1).
Oral health services provided by primary care providers
Dental Referrals
When the MORE Care Ohio pilot launched in November 2022, medical and dental providers could not formally track referrals and referral outcomes. This can be attributed to many factors, but the need for integration between the EHR of the medical team and electronic dental records (EDR) of the dental team was a primary contributor. As a result, it took several months to develop, deploy, and integrate a manual process for reporting and tracking dental referrals. However, once the reporting and tracking process was adopted, every primary care team made at least one referral, with 231 dental referrals between March 2023 and January 2024
Stakeholder Feedback
Throughout the pilot, OHO actively engaged a diverse range of stakeholders, including academic institutions, policymakers, community organizations, professional organizations, payors, and regulators. Efforts included presentations at national and state conferences, routine project updates and communication to policymakers to ensure the pilot’s visibility and potential impact.
Since value-based care is a new approach to dental care in Ohio, OHO formed an advisory committee early in planning stakeholder listening sessions. This committee has been crucial in guiding the value-based care pilot program for the past four years, offering valuable advice throughout the exploration and implementation phases.
Feedback from participating care teams have included their positive experience in gaining new skills in collaboration and care coordination and has reinforced the impact of whole-person care.
While our medical partners in MORE Care are not utilizing dental hygienists in their practice settings, they did find great value in receiving hands-on training in fluoride varnish application and guidance provided by a dental hygienist representative from the manufacturer. A dental distributor supported the pilot by providing oral hygiene kits to care teams to give to patients. Some patients have reported that they are surprised to receive oral hygiene products from their medical provider and that receiving them from a physician has helped reinforce the importance of daily oral hygiene and oral health to overall health.
RECOMMENDATIONS
As valued health professionals and experts in prevention, dental hygienists can support medical-dental integration in a variety of ways that address their community’s common and unique needs. In MORE Care OH, dental hygienists across participating dental teams are engaged in providing and coordinating care for the patients referred by partner medical providers. As oral health educators and clinicians, dental hygienists within this pilot contribute to a person-centered approach to care and improving integration of care by supporting patient information sharing through the bidirectional referral process with their collaborating medical partner.
While this project remains underway and the findings presented are preliminary, the insights are offering Ohioans a perspective on opportunities to enhance medical-dental integration. Dental hygienists in Ohio and elsewhere can look to medical-dental integration efforts like MORE Care to identify and test promising strategies for improving medical-dental integration in ways that meet community needs. Awareness of community-driven integration models by dental hygienists is integral for advancing their role in both the dental and medical setting.
CONCLUSION
The importance of oral health care and preventive services for pediatric populations is clear however access to dental services may be challenging. Integration efforts like MORE Care can enable medical and dental professionals to identify community-focused solutions for high-quality, integrated oral health care by overcoming local challenges. Allowing primary care providers to deliver oral health services during routine well-child visits is one approach to improve patient awareness and increase access to oral health care. Although data collection is ongoing, preliminary data show improvement for primary care teams providing oral health services provided in a medical setting and buy-in for enhancing medical-dental integration in Ohio.
DISCLOSURES
CareQuest Institute was the majority funder for the MORE Care Ohio pilot implementation and evaluation.
ACKNOWLEDGEMENTS
The authors would like to acknowledge Marla Morse and Julie Geiler with Oral Health Ohio for their leadership and operational support of the project and the MORE Care OH clinical participants. We would also like to thank Caroline McLeod, RDH, MS with CareQuest Institute for Oral Health for her contributions to this manuscript.
Footnotes
NDHRA priority area, Population level: Health services (community interventions).
- Received April 8, 2024.
- Accepted May 8, 2024.
- Copyright © 2024 The American Dental Hygienists’ Association
