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APHA health home.

"The mouth is part of the body." With these words, the first Surgeon General's Conference on Oral Health in America began in 2000.1 When the concepts of the mouth and the body are mentioned in a "health" context, it is natural to think of the practices of dentistry and medicine. Polarization is immediate. But, polarization, unfortunately, turns the discussion to talk of medical homes and dental homes, which prompts the question: Do two homes necessarily ensure comprehensive, continuous and coordinated care, or only the perpetuation of fragmented care? The purpose of this article is to encourage open discussion of the new concept of the single-silo health home, rather than the separate, and not necessarily equal, silos of medical home and dental home. This discussion is consistent with the thrust of health care reform's call for evidence-based health care that is well coordinated, continuous and comprehensive.

The Medical Home Concept

The concept of the medical home was first introduced in 1967, in a book written in response to the need to improve medical care for children with special health care needs by the American Academy of Pediatrics (AAP) Council on Pediatric Practice and published by AAP.2 In the pursuit of more comprehensive care, it was proposed that the medical home be a program of comprehensive, integrated and coordinated primary and specialty care medical services to ensure the best evidence-based and most cost-effective care for those special children. The medical home was not intended to be a physical structure but rather a virtual space which involved a patient-centered model of care that addressed all of the patient's health care needs by coordinating the patient's complex clinical and social service needs.

The Dental Home Concept

More recently, in response to AAP's effort to define medical home, various dental organizations took on the task of developing a similar concept for dentistry. This was perhaps also driven by the opening words of the Surgeon General's Conference, at which the concept of the dental home first surfaced. The initial concepts of the dental home, as proposed by organized dentistry, were built on the definition first proposed by AAP, and then subsumed within and promulgated as a policy statement by the Academy of Pediatric Dentistry (AAPD) in 2001 (revised 2004).3 That statement focused on the essential services and guidance a child had to receive in order to be deemed within a dental home. That initial definition did not focus on the specific provider type, but rather emphasized cross-disciplinary collaboration and essential services, and it called for a dental referral when treatment was required.

In 2005, the American Dental Association (ADA) House of Delegates adopted language in its dental home model that was more provider-specific. The delegates' concept called for an ongoing relationship between the dentist, who is the primary dental care provider, and the patient,4 and included comprehensive oral health care beginning no later than age 1. This provider-specific concept with the dentist as primary was formalized as a joint "dental home" definition created through collaboration between AAPD, the Dental Trade Alliance, and the ADA in February 2007. AAP subsequently further redefined its initial dental home policy on May 2007 to be more consistent with both ADA and AAPD, pursuant to an AAP policy update. (5)

In 2009, the American Dental Hygienists' Association (ADHA) adopted its definition of the dental home "as a relationship between a person and a specific team of health professionals, led by a licensed dental provider. The dental home is an ongoing partnership that coordinates comprehensive, accessible and culturally sensi tive care through delivery of oral health services as part of integrated care." (6)

It should be noted, however, that both national and state initiatives have, in the name of health reform, continued to define more precisely the best-quality indicators to identify the medical home. Among these proposed indicators are the need for an electronic record system, an improved method of communications, and an efficient referral system connecting all aspects of the health care system. Such discussions have led to the realization that the mouth and body are part of a single unit--the body--and that disease manifestation in either region has implications for total health.

The Health Home Concept

The term "health home" began to arise from these initiatives and discussions and seemed the most appropriate setting in which to integrate oral health and medical care. While medical and dental homes are still commonly used terms, the health home is rapidly becoming the preferred term that defines the goals and objectives envisioned in the "health home" concept. Ideally, the health home concept should lead to more productive interprofessional communication and better care for all patients by virtue of the critical mass of providers under the virtual roof of the health home, each with special expertise but working together on behalf of patients. In order to maximize the success of the model, all providers must be true to the core components of the model; e.g., values, definitions of practice, necessary skills and training for practice, and the roles of patient and family. In addition, providers are attuned to the barriers to success that need to be considered and overcome to maximize quality services; 1) Health Insurance Portability and Accountability Act (HIPAA), 2) the mechanics of multidisciplinary coordination, 3) resistance to collaboration, 4) uncertainty about public and political support, 5) costs in general and the inherent difficulty in controlling them, 6) no universal Electronic Health Record (EHR) at present that is able to facilitate communication among all categories of providers while handling the necessary billing/accounting needs, 7) health care insurance coverage or lack thereof, and 8) trust of the system by patients and providers.

The health home will have many types of providers. If one merely looks at the sections of the American Public Health Association, it is easy to identify at least 12 whose members should be located in the single health home silo in order to achieve best practices and best patient care outcomes. Members of those 12 sections would be, in alphabetical order, from chiropracty, epidemiology, food and nutrition, gerontology, maternal and child health, medical care, mental health, oral health, podiatry, public health nursing, public health planning, and social work. To this list should also be added pharmacy for education purposes and a pro bono legal program to assist patients whose needs cannot be addressed by social workers (e.g., dealing with owners of rental property who will not address a lead issue).

Variations on the Theme

AAP reviewed the medical home model in 2000, 2002 and 2004, and added new policy statements. In 2006, a variation on the theme, "The Advanced Medical Home," was published by the American College of Physicians that stressed patient-centered, physician-guided care.7 That statement discusses physicians as partners and physicians as practitioners, but it is very limited in its discussion of interdisciplinary relationships. That position was then supplemented by the patient-centered medical home concept, which was promulgated by the American Academies of Family Physicians and Pediatrics. That concept emphasizes having a personal primary care medical provider (physician, nurse practitioner, physician assistant). However, the emphasis on a sole practitioner is inconsistent with a truly interdisciplinary model of care.

In 2008, the idea of an intense medical home, which articulates the concept of a health home, was promulgated. This model is a multidis-ciplinary one designed particularly to integrate oral health care and mental health care because they are the two most frequently needed yet most difficult to access services for vulnerable populations. It considers co-locating these services with primary care whenever possible or prudent, but making sure that even if they are co-located, they are legitimately integrated. One way to integrate a lot of services, which works better with primary care and mental health care rather than primary care and dental health care, is the shared electronic health record (EHR), currently referred to as the electronic medical record (EMR). The problem with trying to create an EHR is that, though the electronic oral health record is an excellent electronic platform, it does not communicate with the electronic records of other disciplines. For the health home concept to succeed, all disciplines must have continuous, integrated care not only within their own discipline but also across all disciplines to have legitimately coordinated care.

Bringing Dentistry Inside

The overarching goal for any health care system should be to provide efficient, effective and equitable health services to the population and its subgroups. When it comes to including dentistry in the virtual health home, it is necessary to understand how dentistry is structured today and why it is necessary to consider a new approach.

There is, today, a shortage of dentists as well as a maldistribution of dentists which more often affects rural rather than urban dwellers. In addition, access to dental care is limited for large numbers of underserved and high-risk children and young adults, and also the geriatric population, those with special care needs, and individuals who, regardless of age or place of residence, do not have commercial dental coverage or the financial means to pay full dollar out-of-pocket for care. There is supposedly a dental safety net that is growing and starting to serve many underserved individuals. In theory, provided the safety net system continues to grow and becomes extensive enough, the dental needs of every American presumptively can be met. In reality, the safety net has flaws: many participating dentists have dropped out or are difficult to recruit to fill provider slots in safety net clinics because of low reimbursement levels, intense schedules, difficult treatment cases, and other administrative problems. Many dentists look at safety net service as a transition into private practice and not a career goal.

In the private sector, dentists often fail to provide services to Medicaid recipients for a number of reasons, including low reimbursement rates and administrative hassles with the Medicaid/CHIP programs, and because Medicaid patients are known to move or change telephone numbers suddenly and frequently, and have a high no-show history. Finally, the private general (not pediatric) dentists generally won't accept very young (under age 3) children. To complicate matters further, many individuals are not aware of the importance of oral health and so, despite having coverage or the finances to pay for dental care, do not attempt to gain access to the dental care system on a regular non-crisis basis.

Risk Assessment

As the health home concept with an oral health component is developed, the dental functions that should be part of this oral health component must be defined. A caries risk assessment tool must be used. It is essential that those individuals who are high-risk be given priority for care. This includes initiating care for children by age 1 year. (3), (5) To make sure that the high-risk child gets care first, it is important to avoid clogging the dental care delivery system with children who are low-risk, at least at the beginning of the health home concept. Anticipatory guidance, i.e., oral health education, must be provided to caregivers about caries etiology and the caregiver's role in prevention and the importance of comprehensive dental care (i.e., care whenever necessary and regardless of the need), starting at age 1.

Though an oral health assessment is an essential part of the evaluation of every patient, does it require a dentist or dental hygienist to do it? The answer is a resounding no! Within the context of a multi-disciplinary model of care, more individuals should be involved in the assessment. Following specific education, nurse practitioners, school nurses, dieticians and social workers who have many high-risk children in their case loads should be able to do the risk assessment and refer those at risk to a dentist. For this interdisciplinary model to work well, coordination will be essential and can be done by, for example, a social worker, case manager, promotora, or, a person trained under the ADA's unlicensed Community Dental Health Coordinators program from which, following an education, graduates are prepared to work specifically in the communities from which they may come or to which they have been assigned. Such individuals will be key in the successful implementation of an oral health component in the health home.

Beyond Risk Assessment

While still controversial, it seems prudent that provision of certain noninvasive, nonsurgical care and perhaps some minor aspects of invasive dental care should not be limited to dentists; dental hygienists, expanded function dental assistants (EFDAs) and the newer types of dental providers such as dental therapists could provide these functions. Other health care providers, such as physicians, nurses, physician assistants, certified medical assistants and nursing assistants should also be providing preventive care, such as applying fluoride varnish quarterly to high-risk children according to ADA recommendations and providing anticipatory guidance (i.e., caregiver education about caries etiology and the caregiver's role in prevention) at every EPSDT examination. Whatever methods or provider types used, the outcome should aim for efficiencies that not only control the rising costs of providing care, but extending that care so it comes within reach of all underserved groups.

Challenges and Solutions

What are the challenges? This health home endeavor will require additional money, time and training. Staff will have to be trained to perform new functions; costs will have to be coordinated; a new type of staff person will need to be hired, e.g., a case manager or social worker There is literature on the medical home that has shown that when a case manager gets involved, costs of providing primary care go down over the long term because of the effectiveness of prevention strategies when compared to earlier times when individuals were referred to a specialist. (8) Paying for fewer dental restorative treatments long-term would free up dollars to pay for the case manager. Regarding the scope of practice, although there are many states with dental practice acts that limit what non-dental oral health care providers can do, no medical practice act precludes a physician from doing primary caries prevention (gross oral examination, paper-and-pencil caries risk assessment, application of fluoride varnish, educating the caregiver about caries etiology and the caregiver's role in prevention, referring those who need care to a dentist and informing the caregiver about the importance of the child's having a dental home by age 1).

The health home quite appropriately could be located on Prevention Avenue. The health home concept goes beyond medical or dental treatment. It fosters education for prevention of diseases along with addressing social needs in a culturally sensitive way. This concept opens the door for general nutrition education and physical activity promotion to facilitate good health, which will ultimately prevent disease. Ambivalence around the medical home term may surface, not so much around the word "medical" as around the word "home." In particular, the ambivalence may have to do with a great deal of concern by the parents of children with disabilities. To them, the term "home" implies some kind of residential care model they have spent years trying to avoid by bringing their children-even those with very complex medical situations--home for care.

Conclusion: Five Elements

When constructing the virtual health home, five elements need to be considered. The first element is that the practice has to partner with patients. It cannot just be interdisciplinary in the sense that medical providers do a better job talking to each other. They must also be culturally sensitive in order to talk to the children and the parents. A partnership with parents, with families and with patients must be created in some very formalized way, whether through a community health plan that the family joins or one that goes beyond that by institutionalizing the practice in a clinical setting so that practices begin to have family advisory groups, hire parent consultants who act as liaisons to other families, and play a critical role in critiquing how care is delivered. It is a mistake to describe it as a model for children with special health care needs because if it is in a pediatric or family medicine practice that serves children in general, it is there for whenever the child--with or without special health care needs--needs it, and if the child is defined as a child with special needs, their needs require enhanced care. The crux is for medical providers to know, for example, which children are having trouble in school, which are obese, which have speech problems, etc.

The second element is to deliver a proactive approach to the identification of children with special needs. This is a complicated one, for the underlying prescription is that the health home concept is relevant to every population whether it be a healthy child or a child with complex nutrition, speech, or hearing issues or multiple medical issues involving some mix of medical, dental, and mental health issues, etc., and where medical needs may be combined with a fragile or complicated social situation. The health home model has the potential to operationalize the notion of the pediatric or family practice primary care primary care practice for children as an arm of public health. It allows thought about how it connects systems, which is public health thinking.

The third element is a clear link to community services. This is where the social service linkage for vulnerable populations becomes essential.

The fourth element is that it engages in conscious quality practice.

Finally, the fifth and most important element--in the sense that it is most costly--is that there needs to be active, conscious, explicit care coordination by a person other than the doctor or dentist. Doctors and dentists do not have time and are not necessarily temperamentally the best people to do this. And nurses are expensive too, although they are more predisposed to play the role. Consideration should be given to whether this can be a paraprofessional role.

It seems clear that the future of the health home will require a supportive and flexible workforce with a variety of professional skills and training that go beyond the provision of medical and dental care. The allied health workforce and service coordinators may perhaps become even more important in this new delivery system than physicians and dentists, since in the new, virtual health home, it will be necessary to extend health care and access to that care to rural and low-income populations as well as to seniors and to mesh the multidisciplinary workforce into an efficient and effective health service delivery system in a manner that promotes collaboration and communication that will improve patient health outcomes and control the costs of that care.

References

(1.) U.S. Department of Health and Human Services. Oral health in America; a report of the Surgeon General. Rockville, Md.: U.S. Dept of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

(2.) American Academy of Pediatrics, Council on Pediatric Practice. Pediatric records and a "medical home." In: Standards of child care. Evanston, III.: American Academy of Pediatrics; 1967. Pp. 77-9.

(3.) Academy of Pediatric Dentistry Council on Clinical Affairs. Policy on the dental home. Chicago: AAPD; 2001, revised 2004.

(4.) American Dental Association. Definition of dental home (2005:322). Current policies adopted 1954-2009. Chicago: ADA; 2010. p. 88.

(5.) American Academy of Pediatric Dentistry reference manual 2007-2008. Pediatr Dent. 2007-2008; 29(7 Suppl): 1-271.

(6.) American Dental Hygienists' Association. Dental home American Dental Hygienists' Association Policy manual. Chicago: ADHA; 2008, updated 2011.

(7.) American College of Physicians. The advanced medical home: a patient-centered, physician-guided model of health care, a policy monograph. Philadelphia: ACP; 2006.

(8.) Lee JG, Dayal G, Fontaine D. Starting a medical home: better health at lower cost. Healthc Financ Manage. 2011 Jun; 65(6): 70-6, 78, 80.

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RELATED ARTICLE: I-Smile Dental Home

In response to Medicaid reform passed in the Iowa Legislature in 2005--ich called for the creation of a dental home for every child receiving state medical assistance--e Iowa Department of Human Services, the Iowa Department of Public Health (IDPH), the Iowa Dental Association, the Iowa Dental Hygienists' Association, Delta Dental of Iowa, and the University of Iowa College of Dentistry partnered together to develop the I-Smile [TM] Dental Home Initiative.

The I-Smil [TM] dental home consists of a team of health care providers including dentists, dental hygienists, physicians, nurse practitioners, registered nurses, physician assistants and dietitians. The four objectives of I-Smile [TM] are to improve the dental Medicaid program, recruit and retain dentists in underserved areas, incorporate dental clinics within rural hospitals, and improve the dental support system for families. The I-Smile [TM] Coordinator (ISC) position was created to meet this last goal; ISCs are registered dental hygienists who serve as the point of contact for public health agencies, families, health care providers, school districts and dental offices. They facilitate referrals, coordinate care among providers, and act as a liaison between patients, their providers and community organizations.

There is one ISC for each of the 24 pre-existing Title V Child Health Agency locations in Iowa. IDPH contracts with private/ non-profit and public health agencies throughout the state to be Title V screening centers. The agencies provide maternal and child health services, including oral health, in all 99 Iowa counties. The existing health care system now also includes the I-Smile [TM] dental services to meet the needs of underserved families.

According to Angela Halfwassen, RDH, an ISC in the Webster County Health Department, the dental home parallels the concept of a medical/health home in that it "is not a physical structure, nor is it a specific set of services. It is an integrated system involving multiple providers and settings coordinated to ensure comprehensive preventive, educational and restorative oral health care services to achieve and maintain optimal health for individual children ... The larger focus of the I-Smile[TM] program is on infrastructure building and care coordination."

Sonja M. Clemons, RDH--an ISC in Linn, Jones and Benton Counties--said the dental home acts to remove barriers that might prohibit families from seeking dental treatment, including not knowing which practitioners accept their insurance, especially if they are covered by Title XIX/Medicaid or hawk-i (Iowa's Child Health Insurance Program), and lack of transportation to and from appointments. She added that "the best thing that creating a dental home does is give the family confidence that they have a safe, consistent place to take their child to for all types of dental care needs."

An additional program that Clemons offers to her clients is dental vouchers for uninsured persons up to 22 years of age. "I have a network of providers in my three-county service area that take my dental vouchers as a form of payment," she said. "The clients are simply instructed to call certain providers and let them know that a dental voucher from I-Smile [TM] will be used to pay for the dental visit. That's it. They go to their appointment and the office staff makes out a claim using a Title XIX form and mails to our corporate headquarters, and we send them a reimbursement check to pay for the patient's visit. [The patients] bring nothing to the appointment and thus there is no obvious stigma for that client utilizing our vouchers. The office processes it basically like any other patient visit."

There are many ways for clients to enter the I-Smile [TM] program, including WIC clinics, Head Start, school screening audits, immunization clinics, or referrals by Community Health Centers and physicians' offices. They are also identified on the Medicaid "newly eligible" list. ISCs work on various outreach events like health fairs, preschool and school-age dental screenings, as well as community-wide events, to connect with people in need of the assistance. Children are initially assessed using an oral screening in which, according to demons, "the clinician uses a light source like a handheld flashlight and simply does a visual assessment of the mouth to assess the client's oral health status. No explorers are used, but occasionally a disposable mirror is used for visual access." Halfwassen described the open-mouth survey as, "a random sample of children that are screened and reported on for data collection. Different variables are selected depending on the group being assessed. Training is provided so all dental hygienists participating are assessing each child by the same criteria."

Providers enter the program voluntarily, and are generally practitioners who already accept Medicaid. According to Halfwassen, medical providers can be trained by their area ISC to provide preventive screenings and fluoride varnish applications, plus education for parents to have healthy dental habits at home. Dentists sign a Memorandum of Understanding (MOU) to accept referrals. If a referred child is eligible for Medicaid or hawk-i, the dental office bills those programs. For an uninsured child, a Title V voucher can cover the cost of a preventive check-up.

The number of cases an individual ISC handles varies, demons has around 400 kids in Head Start alone in her three-county service area. "My settings are varied as I have one large urban county and two that are rural. So while the number of kids in the urban area may be greater, the access to care is generally more difficult in my rural communities due to various barriers," she said, "There is always that next health fair or school audit so a concrete number is impossible to configure."

Halfwassen added that, "Any child seen needing either treatment or preventive services requires care coordination. Each family is called and arrangements made for services. If necessary, transportation is arranged to get the family to the appointment. Once care is complete, the child is 'released.' However, if we see that child again in 3 to 6 months with additional problems, the cycle starts over again in establishing care coordination."

ISCs may also provide direct care and clinical dental hygiene services. Halfwassen explained that the I-Smile [TM] program requires that ISCs spend a minimum of 20 hours a week building infrastructure and care coordination. For those coordinators working over 20 hours a week, a certain percentage of time can be used for direct service. "Personally, I work 32 hours a week in a nine-county service area, doing infrastructure, care coordination, population-based services and limited direct care services," Halfwassen said.

Clemons envisions I-Smile [TM] will grow to include non-Title V agencies such as Iowa Caregivers and nursing home agencies, WIC, school-based dental clinics, etc. She also sees it as an opportunity to advance the dental hygiene profession through establishing a new type of dental practitioner to provide tertiary preventive services in rural locations and improve access to care.

--Mariam Pera

Amos S. Deinard, MD, MPH, is associate professor, Department of Pediatrics, School of Medicine, and adjunct associate professor, Division of Epidemiology and Community Health, School of Public Health, both within University of Minnesota. He has developed training materials for primary care medical providers to include primary caries prevention during well-child care and is instrumental in ongoing efforts to achieve Medicaid reimbursement nationwide for these providers to apply fluoride varnish.

Bob D. Russell, DDS, MPH, is public health dental director, Iowa Department of Public Health. He fulfilled a governmental appoint ment to the Iowa Commission on Tobacco Use Prevention and Control and has served in many public service positions related to public health, oral health and health education. He is the recipient of numerous prestigious awards and has been published in several professional publications.
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Title Annotation:American Public Health Association; special feature
Author:Deinard, Amos; Russell, Bob D.
Publication:Access
Date:Aug 1, 2011
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