ORAL HEALTH AND PRIMARY CARE INTEGRATION FOR PEOPLE WITH HIVCONNECTING CLIENTS TO ORAL HEALTH SERVICESMission Analytics Group, Inc. under contract with the Health Resources and Services Administration HIV/AIDS Bureau (HRSA HAB)JUNE 6, 2019

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Disclaimer

Today’s webinar is supported by Mission Analytics Group, Inc. as a part of a contract administered by the Division of Community HIV/AIDS Programs (DCHAP) of the HIV/AIDS Bureau (HAB). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by the Health Resources and Services Administration (HRSA), the Department of Health and Human Services (HHS) or the U.S. Government.

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Through the Session, Recipients Can…

Describe components of the integration of primary care and oral health

Learn about strategies and best practices in integrating oral health into primary care practice

Connect with the project team for more information on technical assistance (TA) products and upcoming site visits

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Presentation Outline

Importance of Oral Health Care for People with HIV

Components of Integration Connecting Clients to Oral Health Services Recipient Experiences:

Hudson River Healthcare Lifelong

Next Steps Q&A 4

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Oral Health for People with HIV

Oral health is essential for overall health and quality of life Oral health care is especially important for people with HIV Untreated oral disease may lead to infections, weight loss, malnutrition, and

diseases (e.g., diabetes) Oral diseases impact quality of life (e.g., psycho-social problems and limited

career opportunities)

Oral health is one of the top unmet needs for people with HIV who receive services through the Ryan White HIV/AIDS Program

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Project Goals

Promote the integration of oral health and primary care through the identification and dissemination of best practices

Phase 1 Literature review Site visits with nine RWHAP recipients

Phase 2 Recipient webinar seriesOral Health and Primary Care Integration Toolkit TA site visits with nine recipients/providers

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Meet the Team

HRSA HAB Project Team LCDR Tanya Grandison, Contracting Officer Representative CAPT Mahyar Mofidi LCDR Sayo Adunola

Mission Analytics Group and expert consultants Ellie Coombs AJ Jones Dr. David Reznik Dr. Steve Abel Carol Tobias Jane Fox

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Oral Health SettingCoordinate

Primary Care Setting

Assess

Seven Components of Integration

Act3. Educate

4. Intervene

5. Refer

Provide Services1. Ask

2. Examine 6. Support

7. Share

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Oral Health SettingCoordinate

Primary Care Setting

Assess

Seven Components of Integration

Act3. Educate

4. Intervene

5. Refer

Provide Services1. Ask

2. Examine 6. Support

7. Share

Check out the recording of a May 23 webinar about assessing risk and providing oral health supports in

primary care settings

Models of Oral Health and Primary Care Integration

Referral Based Coordinated, but not Co-Located Co-Located

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Poll

Which model best represents your site? Referral based Coordinated, but not co-located Co-located Lots of variation Not sure

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Refer: Build a Referral Network

Virtually all recipients/providers refer out for some procedures What to look for: Insurance compatibility Welcoming stigma-free environment

How to find them: Local and state dental societies/associations Dental and dental hygiene schools Dental service organizations (DSOs) Social service programs that assist low-income individuals Searchable databases

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Ask Examine Educate Intervene Refer Support Share

Best Practice Ideas

Keep clients with their dentist and consider partnership Formalize agreements Leverage the dependability of RWHAP payment Communicate availability of RWHAP support

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Ask Examine Educate Intervene Refer Support Share

Support: Address Barriers and Facilitate Oral Health Care Access

Referral coordination and managementMatching clients to oral health providers Scheduling appointments Sending appointment reminders

Supporting appointment adherence Financial/insurance enrollment assistance Arranging transportation and other support services Helping clients overcome fear

Appointment follow-up

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Best Practice Idea• Use multiple reminder

methods• Stress the importance of

visit compliance

Ask Examine Educate Intervene Refer Support Share

Oral Health Team

Dentist

Dental Hygienist

Dental Assistant

Primary Care Team

PCP

Medical Assistant

HIV Case Manager

Patient Navigation Models

Dental Patient

Navigator

Ask Examine Educate Intervene Refer Support Share

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Oral Health Team

Dentist

Dental Hygienist

Dental Assistant

Primary Care Team

PCP

Medical Assistant

HIV Case Manager

Patient Navigation Models

Ask Examine Educate Intervene Refer Support Share

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Oral Health Team

Dentist

Dental Hygienist

Dental Assistant

Primary Care Team

PCP

Medical Assistant

HIV Case Manager

Patient Navigation Models

Ask Examine Educate Intervene Refer Support Share

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Ask Examine Educate Intervene Refer Support Share

Best Practice Ideas

Identify an oral health point of contact Bring oral health into the care team Offer regular cross-training

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Share: Exchange Information Across Primary Care and Oral Health Settings

What do dentists need from PCPs?Client health information, including up-to-date labsMedication regimenBarriers to care that could affect dentistry (fear, etc.)

What do PCPs need from dentists?Appointment attendanceClient’s care planPrescribed medicationsRisk factors that may impact primary health

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Ask Examine Educate Intervene Refer Support Share

Models of Data Exchange20

Integrated EHR and electronic dental record (EDR)

Linked through an electronic bridge

Manual entry or uploads

Ask Examine Educate Intervene Refer Support Share

Best Practice Ideas

Keep it standard; develop referral forms (ideally linked to EHR)

Use your data! Strike a balance between what

you want and what you can get Require treatment plans for

payment

Ask Examine Educate Intervene Refer Support Share

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Hudson River HealthCareRyan White Dental Program

Lisa Reid, AVP of Care ManagementVanessa Carolina, Genesis Program CoordinatorOskaya Fleming Duran, Dental Care ManagerBrett Wargo, Data Coordinator

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HRHCare Mission

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To increase access to comprehensive primary and preventive health care and to improve the health status of our community, especially for the underserved and vulnerable.

Hudson River HealthCare Service Area

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HRHCare Services & Model

Medicine

• Family Practice Pediatrics Internal MedicineFamily Planning HIV Primary Care SpecialtyGynecology Prenatal and OB

Behavioral Health

Medication Assisted Treatment

Optometry

Dentistry

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HRHCare Dental Program

25 year history of providing dental care to persons with HIV

Initially funded through RW Part A Utilized Part C and CDC funds to

increase access to care and research and implement best practices

Dental services co-located in 11 of 30 HRHCare Health Centers

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HRHCare Dental Sites & Services

Spotfire

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Ryan White Dental Care Team

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Role of the HIV PCP

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HIV Specialists provide comprehensive HIV primary care in accordance with the HIV Standards of Care• Quarterly visits• Annual Referrals

• Nutrition• Ophthalmology• Behavioral health• Dental care

Role of the HIV Care Manager

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Care coordination responsibilities of the HIV Care Manager:• Initial and on-going assessments to

identify barriers to care & referrals for community services

• Insurance application/navigation• Referral management• Coordination of patient care with Dental

Care Manager• Adherence education• Risk reduction

Role of the Dentist

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Responsibilities of the Dentist:• Cleanings every 6 months• Dental examination • Education • Case conference/QI• Referral to dental specialty care,

if necessary• Treatment adherence

Role of the Dental Care Manager

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Responsibilities of the Dental Care Manager• Determine RW eligibility• Coordinate dental specialty referrals• Provide dental and adherence

education• Resolve dental care issues• Conduct monthly dental QI/Case

conference and coordination of HIV education for dentists

Role of the Patient

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Responsibilities of the Patient

• Provide RW eligibility information

• Adherence• Communicate questions and

concerns• Provide feedback/dental survey• Self-management

Electronic Medical Record (EMR)

Dental and Primary Care utilize the same EMR, eClinical Works (eCW)

Offers automated and staff reminder calls through Patient Portal

Provides access to comprehensive patient information

Promotes re-engagement

Templates standardize documentation

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EMR Integrated Documentation

• Name of HIV Specialist• Date of last HIV monitoring visit• Viral load

Registration form

• Date of last dental visit HIV Annual

• Date of last dental visit Case management assessment

• Date of last dental visitCase conference

• Track percentage of patients who had a dental exam• COGNOS report extracts data from EMR structured data

Quality improvement

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EMR Structured Data Care Management Assessment

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EMR Structured Data HIV Annual

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HRHCare Dental Program Summary

Co-located in HRHC primary care setting

Strong interdisciplinary treatment team component for coordination of care, case conference, QI and training

Integrated electronic medical record

Dental Care Manager: liaison between dental and primary care

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Thanks to:

The Dental Team Clifford Hames, DDS, Chief Dental Officer Iris Arzu, Informatics Analyst

Contact information: Lisa Reid, LCSW, AVP of Care Management, lreid@hrhcare.org Vanessa Carolina, HIV Program Coordinator, vcarolina@hrhcare.org

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LIFELONG DENTAL PROGRAMSEATTLE TGA

D. Mark Baker, Deputy Executive Director

Multiple attempts to create, develop, implement, and maintain an oral health program. Modeled after Boston EMA.

PCP Integration

NeighborCare Health

Whole person health

Relationships with clients

Development41

Each Provider: Signs an MOU with Lifelong for patient referrals and data sharing Contracts with Ryan White for payment

Dentist and Oral Health Providers are selected based on: Capacity and experience serving people with HIV Accepted Insurance with Medicaid Preference Geographic Location Specialty Care Languages spoken

Fee Schedule

Provider Selection42

Data Sharing

Appointments are scheduled through a three-way call. Providers are faxed:

Recent labs Viral Load, CD4 Count

List of medications (at the appointment) Most recent dental visit/dental history Dental fears Demographics Insurance information (if applicable)

Providers confirm monthly appointments and Phase I Treatment data and entered into data system for follow up.

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Referral Relationship

Referrals come from Case Managers, Self-Referral, and from dental providers

Referrals are managed by a centralized eligibility function and entered into the data system once eligibility is determined

Dental Navigators track attempts to schedule initial appointment through data systems

Missed and kept appointments

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Barriers

Dental fears Transportation Eligibility Provider preference Funding, caps and limits

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Funding, Cost, Sustainability

Ryan White Funding Oral Health NMCM

City of Seattle Funding Case Management

Caps/Limits Monitor client level expenses Exception for medically necessary

Provider contract range Monthly monitoring

Fee Schedule

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THANK YOU

Special thanks to Caila Nickerson, Former LDP Manager

Poll

What components are strengths of your organization? Assess (ask, example) Act (educate, intervene, refer) Coordinate (support, share) It varies Not sure

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Poll

What components are most challenging for your organization? Assess (ask, example) Act (educate, intervene, refer) Coordinate (support, share) It varies Not sure

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Next Steps: We Need Your Help!

Nine TA site visits this spring to fall We will work with providers to identify needs and opportunities and

develop an action plan for implementation If you’re a HRSA RWHAP Part C/D recipient interested in receiving

technical assistance for your oral health program, please contact LCDR Tanya Grandison: TGrandison@hrsa.gov

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Stay Tuned for the Integration Toolkit51

Questions/Answers and Comments