sarah j. dirks, dds geriatric dental group of south texas, pa san antonio, texas 78229 december 2,...
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Sarah J. Dirks, DDSGeriatric Dental Group of South Texas, PA
San Antonio, Texas 78229
December 2, 2011
1.0 AGD CEUs
Oral Care for Residents in LTC Facilities“Overcoming Common Barriers”
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Topics:
1. Two Distinct LTC Goals & the Barriers: Provision of Medically Necessary Oral Care
Provision of Daily Oral Care
2. Three Momentum Makers for Change• Research Momentum
• Regulatory Momentum
• Culture Change Momentum
Provisionof MedicallyNecessary Oral Care
Long Term Care Goal #1
Provisionof MedicallyNecessary Oral Care
LTCF’s must have a providing dentist.
Applied income can be
usedto pay fororal care.
TSBDE
Rule
115.5
Oral Health
part of M
DS
More LTC
dental practices.
Provisionof Daily
Oral CareIn LTC
Long Term Care Goal #2
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Improving Oral Health for LTC Residents in Texas
1. Two Distinct LTC Goals & the Barriers: Provision of Medically Necessary Oral Care
- Dental Profession = primary tactical team
- Primary Champion = _____________
Provision of Daily Oral Care- LTC Profession = primary tactical team.
- Primary Champion = ____________
Reality Check
Dental Profession: stagnant
LTC Profession: in crisis
Goal #1: Medically Necessary
Oral Care
Goal #2: Routine Daily Oral Care
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Improving Oral Health for LTC Residents in Texas
Overcoming Common Barriers• (1) Provision of Medically Necessary Oral Care
- Dental Profession = primary tactical team
• (2) Provision of Daily Oral Care
- LTC Profession = primary tactical team. Three Momentum Makers for Change
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Medically Necessary Oral Care is Priority Driven Care
. - Relieve - Manage - Prevent - Increase - Improve - Keep
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Improving Oral Health for LTC Residents in Texas
Overcoming Common Barriers• (1) Provision of Medically Necessary Oral Care
- Dental Profession = primary tactical team
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Who Provides Medically Necessary Oral Care to LTC Residents?
• Geriatrics Practices: Focused on LTC Facilities• Mobile Services & In Office Services
• Metropolitan Areas & Smaller Communities
• Periodic rotations by contract dentist
• Services may be Provided Room by Room
• Services Provided in Multipurpose Treatment Room
• Partner with Podiatrist? Other Medical Teams?
• New facility construction?
• General Practices: Focused on Continuum of Care• Mobile hygiene services? & In Office Services
• Metropolitan Areas & Smaller Communities
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Report:Building Better Oral Health ADA commissioned independent third-party report on the
issue of access to oral health care in Texas Identify the state’s most pressing issues, needs and
challenges associated with improving the oral health of all Texans.
Special focus on the state’s most vulnerable. www.buildingbetteroralhealth.org Recommendation #5
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Policy Recommendation (5/5)Building Better Oral Health
Expand access to oral health services for older Texans
• Provide incentives to encourage dentists to practice in LTC facilities:• Loan payback programs
• young dental graduates/retired dentists
• (experienced foreign trained dentists – expedited path to licensure?)
• (encourage life cycle continuum of care)
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Common Barriers: Dental Profession
Mainstream dental office ≠ LTC dental office
• Complex Coordination of Care
•Solution: Develop LTC administrative systems
• Medically Compromised Patients
•Solution: Implement strict clinical protocols
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Develop Administrative Systems and Protocols Tailored to LTC
Learn LTC lingo/enter the culture of LTC Have SW or DON fax medical info to office prior to
exam visit or hygienist visit to NF. Establish 3rd party protocols
• Medical & Financial RP Consent Forms Templates for NF premeds, po antibiotics, post-op
orders, oral hygiene orders, etc. Written authorization for hygienist template Documentation of phone conversations
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Solutions Continued:
3rd Party Contacts: Medical/$ POA Resident’s Spouse Primary Care Physician Resident’s dentist of
record Director of Nursing Social Worker Business Manager
Production musts: Set minimum # of pts Plan on compressed tx hours
at NF due to lunch Have pt room #’s Premeds called in the day
before Confirm pt will be there Be flexible Be positive
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Solutions: Strict Clinical Protocols
Preprocedural brushing with Chlorhexidine Cardiac & stress reduction protocols on all residents Use high quality pt monitoring device
• Blood pressure/O2 saturation HVE /minimal water/ more upright INR monitor, blood glucose monitor Pre and post blood pressures
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The Exception becomes the Norm
Complex coordination of care • Administrative systems
Compromised patients• Clinical protocols
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GDG Ideal Protocol – “NF Flow”
Resident needs medically necessary oral care SW completes IME paperwork & calls our tx
coordinator to initiate treatment DDS reviews MARS & provides written
authorization for dental hygienist to go to NF:
• Begin initial charting, take x-rays, FMD DDS reviews x-rays & hygienist notes DDS goes to NF to provide COE
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STATE BOARD OF DENTAL EXAMINERS
Texas Administrative Code TITLE 22 PART 5 CHAPTER 115 EXTENSION OF DUTIES OF
AUXILIARY PERSONNEL--DENTAL HYGIENE
RULE §115.5 Dental Hygienists Practicing in Certain Facilities
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Improving Oral Health for LTC Residents in Texas
Overcoming Common Barriers• (1) Provision of Medically Necessary Oral Care
- Dental Profession = primary tactical team
• (2) Provision of Daily Oral Care
- LTC Profession = primary tactical team. Three Momentum Makers for Change
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Oral Care Provided by Certified Nursing Assistants in Nursing Homes
Journal Am Geriatr Soc 54:138-143, 2006
Patricia Coleman, PhD, RN First observational study in U.S. Nursing
Homes of oral care actually provided to residents by CNA’s
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Dentate Nursing Home Residents
CNA Self Report
Teeth brushed: ? Mouth rinse: ? Teeth flossed: ? Time brushing: ? Clean gloves worn: ?
Actual Care Observed
Teeth brushed: ? Mouth rinse: ? Teeth flossed: ? Time brushing: ? Clean gloves worn: ?
CNA’s were told that observations were to understand morning care.
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Supplies Available to Provide Oral Care
of residents had toothbrush/paste of residents had mouthwash of residents had floss had no visible supplies
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Three Promising Momentum Makers for Change
Research Momentum Regulatory Momentum Culture Change Momentum
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Momentum Makers for Change
(1) Research:• Utilize BSS for residents in LTC facilities
• Basic screening survey for older adults
• Determine financial burden for LTC facility to provide daily oral care• Pilot Project: Oral Care Specialty Trained CNA
• How many man hours?
• 1 CNA/100 bed facility/per day?
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Momentum Makers for Change
(2) Regulatory Pressure/Legal Issues
•Training of CNAs• BBOH Policy Recommendation #5
•Surveyor Expectations: • BBOH Policy Recommendation #5
•Oral Neglect
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Policy Recommendation (5/5)Building Better Oral Health
Expand access to oral health services for older Texans
• Mandate that all providers who assist in activities of daily living for the physically dependent or elderly be properly trained in providing oral hygiene.
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Momentum Makers for Change
(2) Regulatory Pressure/Legal Issues
•Training of CNAs• BBOH Policy Recommendation #5
•Surveyor Expectations: • BBOH Policy Recommendation #5
•Oral Neglect
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Procedures for Review of Dental/Oral Status of Residents
(1) Interview resident & family
(2) Visual observation of residents’ mouths
(3) Record review
(4) Observation of the oral care furnished
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Policy Recommendation (5/5)Building Better Oral Health
Expand access to oral health services for older Texans• Require that nursing home inspections
include a mandatory oral health component.
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Momentum Makers for Change
(2) Regulatory Pressure/Legal Issues•Training of CNAs
• BBOH Policy Recommendation #5
•Surveyor Expectations: • BBOH Policy Recommendation #5
•Oral Neglect
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“Defining Oral Neglect in Institutionalized Elderly”
“ “A consensus definition for the
protection of vulnerable elderly people”
Journal of the American Dental Association Vol. 141 – April 2010 Katz, R., Smith,B., Berkey,
D.,Guset,A.,O’Connor,M. Federal payments to nursing
facilities require that there be no oral neglect.
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Time to qualify as neglect
# of days after which failure to have a dental consultation would constitute oral neglect• Acute Condition = 3 days
• Chronic Condition = 14 days
# of days after which failure to initiate or reject treatment would constitute oral neglect• Acute Condition = 5 days
• Chronic Condition = 21 days
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Rapid Oral Decline in Frail Elderly
Multiple co morbid medical conditions Medication induced xerostomia Aging restorations Decreased ability and/or inability for self
daily oral care Decreased ability to get to dental office Decreased ability to tolerate routine care
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Momentum Makers for Change
(2) Regulatory Pressure/Legal ConcernsOral Neglect and relevance to the:
• Initial screening of resident’s oral status• Federal mandate
• Within 14 days of admission
• Usually screened by nurse
• Part of Minimum Data Set
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Minimum Data Sets
Comprehensive health assessment Includes oral health
• Sections K and L
Goal is to identify oral health problems and therefore a plan of care and intervention is triggered
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Minimum Data Set Items Related to Oral Cavity:
Chewing Problem Mouth Pain Debris in Mouth Some or all natural teeth missing Broken, loose, carious teeth Inflamed gums Has daily mouth care by resident or staff
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Promising Momentum Makers for Change
(1) Research Momentum (2) Regulatory Momentum (3) Culture Change Momentum
Culture Change
DON is Key to Geriatric Oral Health
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Momentum Makers for Change
Culture Change
• The Promise of Collaboration:
•Dentistry must enter the world of LTC
•Redefine and discover new relationships
•Trust, unity, shared purpose, & understanding
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Momentum Makers for Change
Culture Change
• The Promise of Collaboration:
•New Relationships: Examples
•DON and contracted dentist?
•DON and consultant dental hygienist?
•Dental hygienist and oral care aide?
•TSBDE & expanded function hygienist?
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Example: Trust and Collaboration
Minimum data set • Sections K and L
• Oral Health
Dental professional provides initial oral screening and/or examination after admission to NF.
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Promising Momentum Makers
Culture Change Momentum
• Future Collaborations?
•Dentist Director & Facility Administrator?
•Hygienist Consultant & Facility Administrator?
•Facility Wide Oral Care Program
•Hygienist Consultant & DON?
• Individual Resident Oral Care Plan
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LTC Facility Oral Health Program Dental Consultant + Administrator
Oversee/implement facility’s daily oral care program Coordinate facility’s medically necessary oral care plan
Social worker/family/transportation/pt preferred dentist
Develop yearly/periodic screening or exam schedules Provide education and in-service training Specialty training of assigned “Oral Care Aide” Maintain oral care records/documentation Maintain needed individualized oral care supplies Help facility meet federal and state regulations Conduct periodic quality assurance
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Individual Resident’s PlanDental Hygienist Consultant + DON
Resident Advocate Family Liaison Work with Social Worker - Funding options Provision of:
Initial Oral Screening?
Daily Oral Hygiene Plan
Documentation of daily care
Coordination of: Resident’s Medically Necessary Dental Plan
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LTC Hygienist Consultant (Liaison)
Responsible/reports to:• Authorizing dentist
• Requires written authorization: TSBDE Rule 115.5
• Administrator??????? Medical director?????
Coordinates with:• Resident and resident’s responsible party
• Resident’s preferred dentist/dentist of record
• DON and communicate special precautions
• OT, PT, Speech Pathology
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The Role of a Liaison?
Answer questions Find resources Share information Facilitate processes Support efforts Help connect Solve problems
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The promise of transdisciplinary Nurse-dental hygienist collaboration In achieving health-related quality of life for elderly nursing home residents
www.dentaliq.com Grand Rounds in Oral-Systemic Medicine September 2006, Vol.1. No. 3 Pages 40 - 49
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Oral health coordinators in long-term care — a pilot study
Special Care in DentistryVolume 30, Issue 2 - pages 59–65 March/April 2010 Pronych, G. J., Brown, E. J., Horsch, K. and
Mercer, K.
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Oral health education for nursing personnel; experiences among specially trained oral care aides: One year follow-up
Scand J Caring Sci Volume 17: pages 250-256 2003 Wardh, I. (dentist); Hallberg, L. (RN);
Berggren,U.; Andersson,L.
Promise of Future Collaboration?
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Resources www.oralhealthamerica.org www.buildbetteroralhealth.org www.thetrecsinstituge.org www.astdd.org www.txoralhealthcoalition.org www.oralhealthamerica.org
Patricia Coleman, RN, PhD Articles
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Sarah J. Dirks, DDS
210 - 617- 4446
www.geriatricdentalgroup.com