Oral Health America Webinar Series
North Dakota: An Example of an Oral Healthcare Program for Older Adults in Long-Term Care Facilities
April 26, 2018
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Webinar is being recorded; for rebroadcast on OHA’s website – OralHealthAmerica.org
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CE Credit Available
ABOUT ORAL HEALTH AMERICA America’s leading national oral health nonprofit focused on the nation’s oral and overall health for 63 years, with particular emphasis on children and youth, older adults and Americans whose voices are not well-represented in oral healthcare conversations. OHA employs strategic partnerships and communications to connect the dots between oral and overall health
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CAMPAIGN FOR ORAL HEALTH EQUITY Addresses oral health inequities in our society and identifies possibilities for closing the oral health divide in America. The campaign strives to: Educate and engage the public, including policymakers, about the importance of oral health for overall health Emphasize the need to prioritize oral disease alongside other chronic health conditions Lead, participate and observe on legislative issues impacting oral health policies critical to OHA, our programs and stakeholders
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Toni Hruby, RDA, CDA DentaQuest Grant Manager North Dakota Department of Health
Shawnda Schroeder, PhD
Research Assistant Professor Center for Rural Health University of North Dakota School of Medicine and Health Sciences
Oral Health in Long-Term Care Facilities Toni Hruby North Dakota Department of Health April 26, 2018
Why older adults? The United States Census Bureau estimates that there are currently 475,720 North Dakota residents aged 18 to 64, accounting for 63% of the State’s population. In 2014, the U.S. reported a 7.7% increase in the Medicaid population. North Dakota also experienced growth, at an increase of 9.1% in the same year.
Background • In 2011, Bridging the Dental Gap, one of North Dakota’s safety net clinics, started a project to provide dental care in long-term care settings and wanted to expand their reach. • In 2012, community forums in all parts of the state were held and highlighted a need for oral health care for the elderly as an often overlooked segment of the population. This reinforced the need to expand to more long-term care facilities.
Expansion of Facilities Bridging the Gap’s pilot program began operation in November 2012, at two long-term care facilities. An oral health care team (dentist, hygienist, and dental assistant) began visiting residents in these facilities once a month to provide oral health information and services such as screening, exams, cleanings, fillings, extractions, and denture repairs. Demand for these services quickly outgrew the capacity.
Expansion of Facilities • As word of this program spread, other long-term care facilities requested visits from Bridging the Dental Gap. They expanded services in two additional facilities. • Bridging the Dental Gap then assisted Northland Community Health Center with setting up services at two other long-term care facilities.
Basic Screening Survey • In 2016, a Basic Screening Survey of older adults residing in long-term care facilities was completed by the Oral Health Program’s Public Health Hygienist. • The survey was conducted in 13 randomly selected facilities in North Dakota. These facilities were stratified by rural/urban status with a total of 579 adults screened.
Key Findings from the BSS • Sixty percent of residents had a regular dentist. • Forty-eight percent had dental insurance through North Dakota Medicaid and 8% stated Medicare was their primary insurer. • Thirty-two percent of residents were edentulous and those insured by ND Medicaid had a significantly higher rate of edentulism than the privately insured (41.1% vs. 17.1%) • Additionally, 31% of those with no dental insurance and/or insured by Medicare were edentulous. • Of the dentate residents, 23% had untreated decay, 30% had substantial oral debris and 34% needed early/urgent care.
The Work With funding from the DentaQuest Foundation, the Oral Health Program has been able to collaborate with the University of North Dakota- Center for Rural Health on numerous projects, including surveying long-term care staff, dentists providing oral health services to long-term care sites, pre and post assessments of facilities participating in an oral health program and the development/dissemination of educational materials.
The Work These projects have brought more attention to the need for oral health care for older adults residing in long-term care facilities.
These resources will be shared in more detail by Dr. Schroeder.
Contact us for more information Toni Hruby tlhruby@nd.gov
600 East Boulevard Ave. Dept. 301 Bismarck, ND 58505 701.328.4515 https://oral.health.nd.gov
Dental Screenings for Nursing Home Residents Presented for Oral Health America April 26, 2018
Shawnda Schroeder, Ph.D. Nathan Fix, MPH Center for Rural Health Toni Hruby North Dakota, Department of Health Center for Rural Health University of North Dakota School of Medicine & Health Sciences
• Established in 1980, at The University of North Dakota (UND) School of Medicine and Health Sciences in Grand Forks, ND • One of the country’s most experienced state rural health offices • UND Center of Excellence in Research, Scholarship, and Creative Activity • Home to seven national programs • Recipient of the UND Award for Departmental Excellence in Research Focus on – Educating and Informing – Policy – Research and Evaluation – Working with Communities – American Indians – Health Workforce – Hospitals and Facilities ruralhealth.und.edu
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Background Center for Rural Health partnership and funding with the North Dakota Department of Health, Oral Health Program (2015) • DentaQuest dollars • Survey of long term care (LTC) facilities oral health policies and attitudes around dental care • Pre/Post assessments for LTC facilities participating in mobile dental program
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Dental Care Provisions among North Dakota LTC Facilities • Only 50% of facilities had a written plan of care for dental needs in place. • Of the 23 with a written plan of care for dental needs in place, only 3 had had any dental professional assist or review said plan. • Nursing facilities were more likely to have a plan of care for dental needs in place (57%) than basic care (25%). • Nursing care facilities were more likely (87%) than basic care (50%) to offer oral health training to nursing and nurse aide staff. 23
More than a quarter of facilities indicate there was no initial dental exam, while only 7% indicated a dental provider was responsible.
Access this figure: https://ruralhealth.und.edu/pdf/north-dakota-oral-health-long-term-care.pdf Access all reports here: https://ruralhealth.und.edu/what-we-do/oral-health/publications 24
How can this Reach Beyond North Dakota?
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National Need Had a Dental Visit in Past Year, 2015 90%
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Roughly 1.4 million U.S. nursing home residents in 2014. People ages 65 or older make up 15% of the U.S. population (49.2 million people). More than three out of every five nursing home residents (63.1%) report between four and five impaired daily living activities
80%
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70% 60% 50% 40% 30%
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84.7% 64.0%
62.7%
20%
10% 0%
Ages 2-17 Ages 18-64 Ages 65+ 26
Oral Health & Overall Health Evidence suggests that poor oral health and gum disease are linked with increased hospitalizations, readmissions, respiratory infections, diabetes, dementia, poor nutrition, pneumonia, chronic obstructive pulmonary disease, and behavioral change in the elderly
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Goal: Create a Standard Dental Screening Tool for Nursing Home Residents • Funding: DentaQuest, North Dakota Department of Health, Oral Health Program • Priority identified by the Older Adult Oral Health Workgroup • Additional interest from: • North Dakota Long Term Care Association • North Dakota Dental Association • Bridging the Dental Gap
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Method and Approach • Crosswalk of Items to Include in the Initial Dental Screen • Code of Federal Regulations (CFR) for nursing home care • CMS Minimum Data Set (MDS) Resident Assessment Instrument (RAI) 3.0 • Basic Screening Survey for Older Adults recommended by the Association of State and Territorial Dental Directors • National and international templates/recommended best practices 29
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Priority Items for the Screening Tool Federal law (42 C.F.R. § 483.20) requires all nursing home facilities conduct an oral health assessment upon admission of a new resident, and periodically. Federal law also requires that long term care facilities: • Obtain routine and emergency dental services from an outside resource to meet resident needs • Assist residents with making appointments and arranging transportation, as requested • Within 3 days, refer patients with lost or damaged dentures • Assist residents in applying for dental service reimbursement 31
Section L of the MDS 3.0 RAI Effective October, 2017 nursing homes will record the following dental problems present in a 7-day look-back period: • • • • • • •
Broken or loosely fitting full or partial denture No natural teeth or tooth fragment(s) Abnormal mouth tissue (ulcers, masses, lesions) Obvious or likely cavity or broken natural teeth Inflamed or bleeding gums or loose natural teeth Mouth or facial pain or discomfort with chewing Unable to examine
For more information on MDS 3.0 RAI, access https://downloads.cms.gov/files/MDS-30-RAI-Manual-v115-October-2017.pdf. 32
Review of the Dental Screening Tool • North Dakota Department of Health, Oral Health Program • North Dakota Older Adult Oral Health Workgroup • North Dakota Dental Association, Board of Directors • Focus Group Review
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Focus Group Representation from: • • • • • •
North Dakota Department of Health Oral Health Program Dental providers Director of Nursing from rural nursing home Nursing home administrator North Dakota Department of Human Services (Medicaid) Bridging the Dental Gap (health center providing mobile dental care for nursing home facilities)
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Promising Practice A dental hygienist (DH) will complete the dental screen in the nursing home facility within 14 days of admission of a new resident (page one). The Unit charge nurse will complete page two of the resident oral health screen and develop the daily dental care plan based off of the recommendations in the screening tool. The DH will provide the screening under indirect supervision of a dentist. The billing will occur under the supervising dentist. The DH will indicate that a dental exam is to be scheduled within 6 months of the screening with a practicing dentist (most likely the dentist supervising the care of the DH).
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A dental hygienist (DH) will complete the dental screen in the nursing home facility within 14 days of admission of a new resident (page one). The DH will provide the screening under indirect supervision of a dentist. The billing will occur under the supervising dentist.
Center for Rural Health
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University of North Dakota School of Medicine & Health Sciences
The Unit charge nurse will complete page two of the resident oral health screen and develop the daily dental care plan based off of the recommendations in the screening tool.
Center for Rural Health
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University of North Dakota School of Medicine & Health Sciences
Barriers • • • • • •
Participation among dental providers Participation among nursing facilities Physical environment needed for dental screens Reimbursement Supervision laws Prescribing authority
Solutions • Dental provider education, referrals, opportunity • Nursing home education • State Medicaid programs – “Dental Screen” billing code • Public health hygienists, preventive screen only
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Daily Oral Care Plans Using the Completed Screening Tool, the unit charge nurse can develop the Daily Oral Care Plan. The plan should • Indicate the resident’s ability to assist in his/her own dental hygiene. • List all supplies included in the individual’s oral health toolkit. • Track frequency of dental care needed and provided (e.g., number of times brushing per day). • Provide a place for direct care providers to note any observed dental concerns.
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Oral Health Toolkit Each resident should be supplied an oral health toolkit containing supplies needed to maintain good oral hygiene. Supplies required in a resident’s oral health toolkit are determined by the initial oral health screen and may include:
Toothbrush Kidney dish Floss handle Floss Toothettes Denture cleaner Toothpaste Facecloth Mouth prop Denture cup Proxabrush Denture brush Prevident Daily oral care plan Chlorhexidine Mouthwash 41
For More Information •
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Standardized Dental Screening for New Nursing Home Residents: A Promising Practice Guide Dental Coverage for Nursing Home Residents Dental Screenings and Daily Care for Nursing Home Residents: A Promising Practice
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Contact us for more information! Shawnda Schroeder Shawnda.Schroeder@med.und.edu The full Promising Practice Guide may be found at: https://ruralhealth.und.edu/assets/1123-4538/standardized-dental-screeningfor-new-nursing-home-residents.pdf
501 North Columbia Road, Stop 9037 Grand Forks, North Dakota 58202-9037 ruralhealth.und.edu/what-we-do/oral-health
Center for Rural Health University of North Dakota School of Medicine & Health Sciences
Question and Answer Session • Questions are welcome! This session may last for 10-15 minutes. • Write your questions in your control panel on the upper right hand of your screen. • Submit questions at any time.
CE Credit Available
Contact Information • Toni Hruby • tlhruby@nd.gov • Shawnda Schroeder • shawnda.schroeder@med.und.edu • Eamari Bell • eamari.bell@oha-chi.org