your value-based oral health program: strategies for success carolina p… · oral health...
TRANSCRIPT
YOUR VALUE-BASED ORAL HEALTH PROGRAM: STRATEGIES FOR SUCCESS
South Carolina Primary Care
Association
January 24, 2019
2
Pre-Training Evaluation & Download Materialswww.surveymonkey.com/r/SCPRE
Go to https://www.dentaquestinstitute.org/learn/online-
learning-center/resource-library/south-carolina-pca-2019 to
download today’s training materials
Download the presentation, activities and handouts
3
Oral Health Value-Based Care Training
Academy
The DentaQuest Partnership for Oral Health Advancement’s Oral Health
Value-Based Care (OHVBC)team is a nationally recognized leader in
practice management consulting and training.
For the last several years, the OHVBC team, operating as Safety Net
Solutions under the former DentaQuest Institute, has been offering
customized training opportunities for national, regional and local
organizations dedicated to professionals working in the oral health
safety net
These trainings have led to the development of a new program, the Oral
Health Value-Based Care Academy.
4
SNS has worked with over 500 dental programs
in 45 states & DC
5
Oral Health Value-Based Care Team
Mark
Doherty,
Executive
Director
Danielle
Apostolon,
OHVBC
Training
Specialist
Dori
Bingham,
Practice
Improvement
Specialist
Caroline
Darcy,
Technical
Assistance
Project
Manager
6
DentaQuest Partnership
The DentaQuest Partnership, a not-for-profit organization,
engages in grantmaking, research, care delivery
improvement programs, and collaborations that transform
the current broken system to achieve better health through
oral health.
By prioritizing the transition to person-centered health, the
DentaQuest Partnership will drive forward as a leading
voice for positive change at the local, state and national
levels in support our common mission to improve the oral
health of all.
7
Today’s Objectives:
After this training, participants will:
• Recognize the top ten areas for defining FQHC dental program
success and identify essential components to developing a business
plan for FQHC dental programs.
• Establish key dental policies and procedures for managing an
efficient and effective FQHC dental program.
• Measure dental program capacity and understand its impact on
access to care.
• Set realistic and achievable financial and productivity goals.
• Continuously monitor dental program performance.
• Develop effective policies and procedures for managing broken
appointments and emergencies.
8
Today’s Objectives Cont.
• Design a strategic scheduling template to maximize access and
dental program financial viability.
• Develop strategies to achieve integrated care.
• Develop an improvement plan for success.
9
AgendaSession One: Laying the Groundwork –
Fundamentals of Operating an FQHC Dental
Program
Dr. Scott Wolpin, Chief Dental Officer,
Eastern Shore Rural Health System, Inc.
Session Two :Measuring Dental Program
Productivity in Access and Finance
Danielle Apostolon, OHVBC Training
Specialist
BREAK
Exercise: Developing Financial and
Productivity Goals
Danielle Apostolon, OHVBC Training
Specialist
Session Three: Strategic Scheduling and
Managing Chaos
Dori Bingham, Practice Improvement
Specialist
LUNCH
Session Four: Comprehensive Health Center
Integration to Improve Overall Health
Dr. Scott Wolpin, Chief Dental Officer,
Eastern Shore Rural Health System, Inc.
Session Five: Creating the Improvement Plan
for Success
Danielle Apostolon, OHVBC Specialist
CLOSING/WRAP UP
10
11
SESSION 1: LAYING THE GROUNDWORK
Dr. Scott Wolpin
Redesign Dental for Maximum Efficiency
13
Chief Dental Officer of Eastern Shore Rural Health System
Expert Advisor for Safety Net Solutions
Health Center Dental Director for more than 25 years
Scott Wolpin, DMD
Safety Net Solutions Expert [email protected]
President, Board of Directors, National Network for Oral Health Access (NNOHA)
Past President, Board of Directors, Association of Clinicians for the Underserved
14
LEARNING OBJECTIVES
•Discuss the key elements to success for a FQHC dental
program.
•Outline the essential components of developing a business
plan for a FQHC dental program.
•Review national data that demonstrates what other safety
net dental programs are doing.
•Review key dental policies and procedures for managing
an efficient and effective FQHC dental program.
15
What we don’t want today to be…
16
Dental Leadership is really about you knowing
where you are going and
how you are going to lead your team there.
“Extreme ownership requires leaders to look at organization challenges through an objective lens, without emotional attachments to agendas or plans. It mandates that a leader set ego aside, accept responsibility for failures, tackle the challenges, and consistently work to build a better and more effective team. Such a leader, however, does not take credit for his or her team’s successes but bestows that honor upon rising leaders and team members.”
Concept of Dental Leadership
17
What does Success look like?
“The ability to generate resources to meet the needs of the
present without compromising the future”
So …Success = Financial Sustainability
from Our Common Future, also known as the Brundtland
Report: International Institute for Sustainable Development
18
19
Success =
• Happy, healthy patients and staff
• Providing quality oral health care, managing chaos
• Assuring a budget neutral bottom-line: with or without
grant funding?
• Collaborating with others in the community to meet
patient needs
20
So how do we get there?
21
Top Ten Priorities for Dental
1. Understanding What Success Should Look Like in Dental
2. Compiling data that is: Accurate, Meaningful and Timely
3. Computing and understanding your actual “Capacity”
4. Setting clear Goals, Roles, Responsibilities and Timelines
5. Utilizing the dental schedule strategically
6. Having the right policy for “Everything”
7. Owning management of Broken Appointments and Emergencies
8. Creating a “Culture of Accountability”
9. Executing a CQI and QA System
10. Teaching Executive Leadership how to best enable and support Dental
23
MEDICAL DENTAL
Are Different!
Different Care Plan and Different
Business Plan
24
Medical
20% of clinic volume
80% of visits = varied
80% of visits = longer
80% of billing varied
80% of visits treatment
80 % of RVU different
0% of governance is designed around dental
EDR silo
Not familiar with dental model
Lack of confidence
80% of clinic volume
80% of visits = similar
80% of visits = shorter
80% of billing similar
80% of visits diagnostic
80% of RVUs similar
100% of governance is designed around medical
EMR silo
Familiar with medical model
Confident leadership
Dental
25
Capacity=Quality
26
Defining Capacity
We are limited by our structure
o Chairs-Rooms-Operatories, Dentists,
RDHs, DAs, Staff, Hours of Operation
Our structure determines our capacity, not our hearts
We cannot be all things to all patients
We only have 20% of the capacity of Medicine
Understanding and defining capacity is essential to the
creation of the dental business plan
We need to decide WHO gets the care by creating priority
populations
Equitable, quality care mandates that
we work within our capacity
27
28
29
DentaQuest Online Learning Center
30
31
Defining Capacity
• We are limited by our structure
• Chairs-Rooms-Operatories, Dentists,
RDHs, DAs, Staff, Hours of Operation
• Our structure determines our capacity, not our hearts
• We cannot be all things to all patients
• We only have 20% of the capacity of Medicine
• Understanding and defining capacity is essential to the creation of
the dental business plan
• We need to decide WHO gets the care by creating priority
populations
Equitable, quality care mandates that
we work within our capacity
32
2,500-3,200encounters/year/FTE dentist
2,700 encounters/year with 1,100 patient
base/dentist
1.7 patients/houror 13.6 patients/day/dentist
Access Benchmarks
2.6 Visits/Year/Patient
2 Chairs/dentist (3:1 is ideal)
1.5 Assistants/dentist (1 DA per chair is ideal)
33
1,300-1,600encounters/year/FTE hygienist
230 work days/year (or 1,600 work hours/year after
holidays and vacations)
2 ADA coded servicesas the diagnostic part of a recall or comprehensive visit (exam, FMX)
1.2patients/hour/hygienist
or 10 patients/day/hygienist
5 days/week x 46 weeks = 230 work
days/year
Access Benchmarks
34
15% Broken Appointment Rate
<10% Emergency Rate
33% Comp TX. Plan is Fair
#New Patients = #Completed Treatment
Plans
Access Benchmarks
Booking out 30-45 days
Designated AccessScheduling
35
$200 average cost per encounter (UDS 2017)
330 Allocation = Average of 15%
Gross Charges =
>$500K-$600K per dentist per year
% of total A/R due past 90 days =
10-15%
95% Collection Rate
Financial Benchmarks
36
$40Nominal fee
3 Slide Categories100-199% FPG
Full Fee Schedule70-80% of UCR
Financial Benchmarks
37
FQHC Budget Breakdown
Total Budget: 100%• Dental Practice Overhead: 70-85%
• See breakdown below*
• Allocation for Administrative Costs: 5-10%
• Costs for CEO, CFO, COO, etc.
• Health Center Support Allocation: 10-20%
• Costs for Human Resources, Security, Medical records, IT, etc.
Breakdown of the 70-85% Dental Practice Overhead:• Payroll (salary, taxes, & fringe benefits): 68%
• Lab fees: 5%
• Office Supplies: 2%
• Depreciation: 4%
• Dental Supplies: 7%
• Repairs: 2%
• Marketing/Promotion: 1%
• Recruitment: 1%
• Building, Utilities, telephone: 9%
• Continuing Education: 1%
38
• 27.1 million unduplicated FQHC patients
• 84.2% accessed medical services (22.9 million patients)
• 22.5% accessed dental services (6.1 million patients)
– Dental capacity is a little over 1/4th of medical capacity
• 2,599 visits/year/FTE Dentist
• 1,180 visits/year/FTE Dental Hygienist
• 902 visits/year/FTE Dental Therapist
• 2.6 visits/year per unduplicated dental patient
• Average cost/visit in dental = $200 per visit
• Average admin cost allocation to dental = 12.8%
• Sealant metric average = 50.7%
2017 FQHC UDS National Averages
39
The Business Plan
GOVERNANCE
QUALITY
Productivity in Access-Finance-Outcomes
We get what we measure
We get the results we tolerate
We now establish productivity goals for the
program as a unit and for each individual
Remembering: Clarity around Goals, Roles,
Responsibilities and Timelines establishes how
we will hold the program and each individual
Accountable
40
Strategies to Set Goals
Defining Capacity
Utilizing Benchmarks
41
Setting Goals
AccessTotal
number of visits
Number of unduplicated
patients
Number of new patients
Provider Productivity
Visits/dayProcedures/
visit
Expected net revenue/day
Quality Outcomes
Percentage of completed Phase 1 treatment plans
Percentage of high and moderate risk children ages 6-
9 who received at least one sealant
Financial Outcomes
Gross charges
Net revenue & expenses
Bottom line
42
Scope of Service Benchmarks
Service Type Procedure Codes % of
Total
Diagnostic D0100-D0999 (excluding
D0140)
30-40%
Preventive D1000-D1999 25-35%
Restorative D2000-D2999 18-25%
Endodontics D3000-D3999 1-2%
Periodontics D4000-D4999 2-5%
Removable Prostho D5000-D5899 1-3%
Fixed
Prosthodontics
D6200-D6999 <1%
Oral Surgery D7000-D7999 5-10%
Emergency D0140, D9110 2-6%
43
Access is everything associated with the visit:
VisitMeasures
Services: Type – diagnostic, preventive, therapeutic, specialty
How many services by ADA code?
Charges for the services
Revenue received for the charges
Health Outcomes as a result of the services
Quality of the services and of the customer service
Compliance with Governance
Safe-Equitable-Efficient-Effective-Timely-Patient Centric
AccessOutcomes
Health Outcomes
Oral Health Outcomes
Financial Outcomes
HRSA Goal Outcomes
Treatment Plan Completion Outcomes
Focus Population Care Outcomes
Access
Not Just Visits!
44
Creation of a high-quality, affordable, oral health program
that documents the improvement of the oral health status
of the patients we treat while being financially responsible
Finance
Vision
What the dental practice needs to accomplish
to be financially sustainable, maximize patient access and
provide meaningful quality outcomes
Financial Plan
REMEMBER: Knowing who you are and being able
to define that with data; defining who you want to be and
what success looks like for you; creating a simple and
clear plan to achieve that success and then
communicating that plan to the team and thus creating a
culture of accountability is the road to accomplishing
financial success
The Profitand Loss
If I had only one report!
Success in Finance, Outcomes & Quality
45
• HRSA Sealant Measure Compliance for FQHCs
• Completion of phase 1 treatment plans
• Children seen 0-5 years old
• Children seen getting a preventive service
• #Fluoride Varnish applications
• Pregnant women seen and treated
• Diabetic patients with HbA1C > 7 seen
• Patients seen who have not been seen for 12 months
• Patients seen getting a Risk Assessment
• Patients with moderate or high risk who lower risk at recare
• #Sealants provided
http://www.nnoha.org/nnoha-content/uploads/2015/12/Demystifying-HRSA-SEALANT-PRESENTATION_FINAL.pdf
Outcomes
46
• Quality Management System
• Quality Assurance Policy and Tool
• Continuous Quality Improvement Policy
• Dental Quality Compliance Officer
• Dental Representation on FQHC CQI team
• Credentialing Policy
• Privileging Policy/Competencies
• Policy and Procedure Manual
• Patient Satisfaction Survey (At least 1X year)
Quality
47
• Compliance with Federal, State and Local Regulations
and with the State Practice Act
• Credentialing Policies and CEU Compliance
• Privileging Policy/Competencies
• Annual Safety/Infection Control/Hazardous Waste
Training
• Preparation for a OSV/Regulatory Site Visit
• After Hours Coverage Policy
• Extended Service Hours
• Malpractice, Liability Policies & Coverage/Gap Insurance
• FTCA Deeming/Annual Redeeming/Compliance
Governance
48
Aligning with HRSA Governance
Accessibility to Patients
• Provides services at times and locations that assure accessibility
and meet the needs of the population to be served.
• Provides professional coverage for medical emergencies during
hours when the center is closed.
Fees and Sliding Fee Schedule Discounts
• System in place to determine eligibility for patient discounts
adjusted on the basis of the patient’s ability to pay.
Quality Management
• Ongoing Quality Improvement/Quality Assurance (QI/QA) program
that includes clinical services and management, and that maintains
the confidentiality of patient records.
49
Aligning with HRSA Governance
Program Performance
• Systems which accurately collect and organize data for
program reporting & which support management decision
making.
Billing and Collections
• Systems in place to maximize collections and reimbursement
for its costs in providing health services, including written
billing, credit and collection policies and procedures.
50
We Get the ResultsWe Tolerate
What We Measure
Gets Done
Remember……..
51
QUESTIONS/DISCUSSION
SESSION 2: PLANNING FOR DENTAL PROGRAM SUCCESS Access and Finance
Danielle Apostolon
53
LEARNING OBJECTIVES
• Recognize the key practice
• Learn the calculations to use with the
data
• Setting access, financial & outcome
goals
54
What Does Success Look Like to
You?• Serve our community by providing access to high quality,
affordable dental services
• Generate enough revenue to cover our expenses
• Patients and staff are satisfied
55
Data to Evaluate Program
Performance• Number of visits • Number of unduplicated
patients• Number of new patients• Procedures by ADA code• Procedures per visit• Broken Appointment rate• Emergency rate• Gross charges• Total expenses (direct and
indirect) • Net revenue (including all
sources of revenue)
• Expense per visit• Revenue per visit• Aging report past 90 days• Payer and patient mix• Percentage of completed
treatments• Percentage of children
needing sealants who received sealants
• HRSA Sealant metric
56
Capacity=Quality
57
Define Capacity
Capacity is defined by Structure:
• Number of operatories
• Hours of operation
• Number and types of staff
• Utilization of Benchmarks and SNS Tools
58
Benchmark Guide
59
Example
Staff and Operatories:
• 2 FTE General Dentists
• 3.0 FTE Dental Assistants
• 1 FTE Hygienist
• 5 Operatories
• Each Dentists works out of 2 Ops
Hours:
• Monday through Friday 8:00-5:00 (1 hour lunch)
• 8 clinical hours per day
60
Determining Capacity Goals Based
on Our Structure
61
# of
Providers
# of total
clinical hours
worked
x recommended
# of visits/
clinical hour
Potential
Daily Visit
Capacity
Mon. 2 16 1.7 27
Tues. 2 16 1.7 27
Wed. 2 16 1.7 27
Thurs 2 16 1.7 27
Fri 2 16 1.7 27
Potential Weekly Capacity = 135 Dentist Visits
Actual
Visits
% of
Capacity
Achieved
20 74%
26 96%
19 70%
18 66%
10 37%
*At least two operatories and 1.5 dental assistants
Setting Productivity/Access Goals: Visits
Potential vs. Actual – FTE Dentists
62
# of
Providers
# of total
clinical hours
worked
x recommended
# of visits/
clinical hour
Potential
Daily Visit
Capacity
Mon. 1 8 1.2 9
Tues. 1 8 1.2 9
Wed. 1 8 1.2 9
Thurs 1 8 1.2 9
Fri 1 8 1.2 9
Potential Weekly Capacity = 45 Hygiene Visits
Actual
Visits
% of
Capacity
Achieved
7 77%
8 89%
6 66%
7 77%
6 66%
*Benchmark of 1.2 is ideal for a practice with a patient mix of both adults and children
Setting Productivity/Access Goals: Visits
Potential vs. Actual – FTE Hygienists
WHY?
63
GOAL CALCULATION TARGET
Visits/Day 27 Dental Visits + 9 Hygiene Visits = 36 visits
per day *same for each day
36
Visits/Week 135 Dental Visits + 45 Hygiene visits = 180
visits per week
180
Visits/Year 180 weekly visits x 46 weeks = 8,280 Visits 8,280
Dental Visits Based on Capacity
64
Only fill in peach
colored cells Provider Type
General
Dentist A
General
Dentist B
General
Dentist C
Pediatric
Dentist Resident RDH A RDH B
Visit per Hour Benchmark 1.7 1.7 1.9 1
Daily Clinical Provider Hours 7 7 8 7 Monday 46 50 4
Visits 11.9 11.9 0 15.2 0 7 0
Daily Clinical Provider Hours 7 7 7 Tuesday 30.8 32 1.2
Visits 11.9 11.9 0 0 0 7 0
Daily Clinical Provider Hours 7 7 7 Wednesday 30.8 33 2.2
Visits 11.9 11.9 0 0 0 7 0
Daily Clinical Provider Hours 7 9 7 Thursday 34.2 35 0.8
Visits 11.9 15.3 0 0 0 7 0
Daily Clinical Provider Hours 7 7 7 Friday 30.8 32 1.2
Visits 11.9 11.9 0 0 0 7 0
Daily Clinical Provider Hours 4 4 Saturday 10.8 11 0.2
Visits 6.8 0 0 0 0 4 0
Weekly Visits per Provider 66.3 62.9 0 15.2 0 39 0 Weekly Visit Goal 183.4
Enter number of
weeks/year 46
Yearly Visit Goal 8436.4
Daily Provider Visit Goals Clinic Productivity Goals
Day of the Week Daily Visit Goal Actual Visits Variance
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
65
# of
Providers
# of total
clinical
hours
worked
x recommended
# of visits/
clinical hour
Potential Daily Visit
Capacity
Mon. 2 16 1.4 22
Tues. 2 16 1.4 22
Wed. 2 16 1.4 22
Thurs 2 16 1.4 22
Fri 2 16 1.4 22
Potential Weekly Capacity = 110 Dentist Visits
2 Dentists each working out of 2 Operatories with 1 dental assistant
Model 1
66
Potential Weekly Capacity = 135 Dentist Visits
2 Dentists each working out of 2 Operatories with 1.5 dental
Model 2
# of
Providers
# of total
clinical
hours
worked
x recommended
# of visits/
clinical hour
Potential Daily Visit
Capacity
Mon. 2 16 1.7 27
Tues. 2 16 1.7 27
Wed. 2 16 1.7 27
Thurs 2 16 1.7 27
Fri 2 16 1.7 27
67
Cost of Adding Dental Assistant
$16/hour x 40 hrs = $640/week
Fringe benefits @ 25% = $160
Total cost = $800/week
68
Additional 25 Visits per week
• 20% Self pay visits = 5 @ $40 = $200
• 65% Medicaid visits = 17@ $135 = $2,295
• 10% Commercial Insurance = 3 @ $165 = $495
• 5% Homeless (Free Care) = $0
• Total Revenue = $2,990 - $900 (cost of adding a Dental Assistant)
Weekly profit = $2,090
Yearly profit = $108,680
Increases access by providing nearly 1,150 additional visits for the year!
Cost vs. Benefit of Adding Dental
Assistant
69
Dental Procedures
Benchmark for Procedures per Visit: 2.5
Total the number of procedures by ADA code and divide that by the total number of yearly visits
• Total annual visits = 3,600
• Total procedures by ADA/CDT code = 4,000
• 4,000/3,600 = 1.1 procedures per visit
70
Scope of Service BenchmarksService Type Procedure Codes % of
Total
Diagnostic D0100-D0999 (excluding
D0140)
30-40%
Preventive D1000-D1999 25-35%
Restorative D2000-D2999 18-25%
Endodontics D3000-D3999 1-2%
Periodontics D4000-D4999 2-5%
Removable Prostho D5000-D5899 1-3%
Fixed
Prosthodontics
D6200-D6999 <1%
Oral Surgery D7000-D7999 5-10%
Emergency D0140, D9110 2-6%
71
What Happens at the Visit
TimeProviders level of competency
Patient need
Patient tolerance
Reimbursement
72
Balancing the Mission and Margin:
Expenses Revenue
• Visits
• Payer mix
• Grants and donations
• Staff and Resources
73
Define what Financial Success
Looks Like:• Create a profit?
• Break even or zero variance?
• With grants or without grants?
• Willing to accept a loss? If so how much?
74
Net Revenue
75
Individual Production GoalsProvider FTE Gross
Charges
Net
Revenue
(60%)
Annual
Days
Worked
Charges/Day Revenue/Day
Dr. D 1.0 $541,667 $325,000 230 $2,355 $1,413
Dr. G 1.0 $541,667 $325,000 230 $2,355 $1,413
Total
Dentist
2.0 $1,083,333 $650,000 460 $4,710 $2,826
RDH 1.O $291,667 $175,000 230 $1,268 $761
RDH 1.0 $291,667 $175,000 230 $1,268 $761
Total
RDH
2.0 $583,333 $350,000 460 $2,536 $1,522
TOTAL $1,666,666 $1,000,000
76
Predictability is Key
Ability to predict expected reimbursement based
on:
• Payer Mix
• 3rd Party insurance reimbursement
• Sliding fee discounts and nominal fees
• Visits
77
Payer Mix
• Huge impact on financial sustainability
• Big challenge to manage
• Determine the average revenue per visit per payer type
• Use that information to create a payer mix that ensures
financial sustainability while preserving access for all
patients
78
Impact of Payer Mix on Sustainability
7,500 visits
35% Medicaid =2,625 visits x $100 = $262,500
55% Self-Pay/SFS =4,125 visits x $30 = $123,750
10% Commercial =750 visits x $125 = $93,750
Total revenue = $480,000
Total expenses = $500,000
Operating loss = ($20,000)
7,500 visits
40% Medicaid =3,000 visits x 100 = $300,000
50% Self-Pay/SFS =3,750 visits x $30 = $112,500
10% Commercial=750 visits x $125 = $93,750
Total revenue = $506,250
Total expenses = $500,000
Operating surplus = $6,250
79
Average Reimbursement by Payer
Type
80
Financial Projections Projected Visits
Actual Visits
Difference -6500
Patient/Insurance mix: Yearly visits
Percent Medicaid -
Percent Self Pay -
Percent Commercial Insurance -
Percent Other -
Total 0% -
Reimbursement Rate (per visit): Yearly Revenue
Medicaid -$
Self Pay -$
Commercial Insurance -$
Other -$
Total Projected Revenue -$
Total Expenses
Projected Bottom Line -$
Payer Mix Tool
81
Obstacles to Success
• Unfavorable Payer Mix• Working under or over capacity• Lack of goals and accountability
• High broken appointment rate
• Scheduling issues (types of patients)
• Insufficient support staff (dental assistants)
• Staff turnover
• Insufficient instruments, supplies
• Equipment issues (chairs, outdated, missing, broken)
• Lack of EDR/PMS (or not being fully utilized)• Billing and collections • Fees are set too low
82
Obstacles to Success, Cont.
Change in Healthcare Environment
83
Cost of Healthcare
2017 U.S.
Healthcare Costs:
3.5 Trillion/22% of GDP
U.S. spends
6-11% more on healththan other countries
The U.S. is ranked
37th in health
outcomesby the WHO
84
30% of Health Care Resources are Wasted
Source: Institute of Medicine Report – The Healthcare Imperative
Unnecessary Services
$210 Billion
Fraud
$75 Billion
ExcessiveAdministrative Costs
$190 Billion
Inefficiently Delivered Services
$130 Billion
Prices That Are Too High
$105 BillionMissed Prevention
Opportunities$55 Billion
= 1 Billion
85
30% = $37.2Bthat could have been spent
on care
30% = $4.47Bthat could have been spent
on care
2016 Dental Expenditures =
$124B2016 Medicaid Dental Costs
= $14.9B
Oral Health Care Dollars Wasted
86
Access to Care
Environment
Genetics
Health
Behaviors
Influence on
Health
10%
20%
20%
50%
Access to Care
OtherHealth Behaviors
National Health Expenditures$3.5 Trillion
88%
8%
4%
Health Status: Determinants of Health
and Health Care Expenditures
Source: Centers for Disease Control and Prevention, University of California at San Francisco,
Institute for the Future, http://www.cdc.gov/nchs/fastats/health-expenditures.htm
87
Value-based healthcare is a
healthcare delivery model in which
providers are paid based upon
making patients healthier while
reducing costs of care.
87
88
OHVBC : Not yet created!
The fact that an alternative payment model
is different from fee-for-service does not
necessarily mean it is better.
www.chqpr.org/downloads/WhyVBPIsNotWorking.pdf
DESIGN
Fee-For-ServiceWhat Works What Does not Work
• Providers are only paid when they provide a service
• Pays for more care when patients need it (volume)
• Payment does not depend upon variables the provider can’t control
• Predictable payment, Providers know what they will be paid before they provide a service
• Care is not linked to quality or results
• Care provided is not predictable
• Cost of care can exceed the payment for care
• No fees for many needed services
• Costs for care are not predictable or comparable
www.chqpr.org/downloads/WhyVBPIsNotWorking.pdf
Pay For PerformanceWhat Does not Work
• P4P services provided may not be the ones that a particular patient needs
• Payments may not be enough to cover the costs of care
• There may be needed services that are not covered by the P4P plan
• Costs for care are not predictable or comparable
• Providers still have to deliver services to be paid. P4P is just an adjustment to FFS provided
• Providers could get paid less for treating patients with greater needs
• Providers could get paid less for things they can’t control
www.chqpr.org/downloads/WhyVBPIsNotWorking.pdf
92
OHVBC is Not:
• Simple
• One size fits all
• Guaranteed to work
• Going away
• Instant
93
OHVBP: An Opportunity
94
Opportunity to be at the Table
and not on the Menu
Domains of VBC• Leadership, Vision and Will
• Structure, Systems and Operations
• Care Pathways and Provider Buy-In
• Data and Analytics Technology and Personnel
• Financial Viability
95
96
QUESTIONS/DISCUSSION
97
98
EXERCISEDeveloping Financial and Productivity Goals
99
Open the Financial and Productivity Goals Tool Excel spreadsheet (1st tab –Productivity Goals Exercise)
Using the Productivity Benchmark Guide & Data Sheet for Financial and Productivity Goals Exercise (both in word), we are going to identify the following productivity goals:
• Visits per day
• Weekly visits per provider
• Visits per week
• Visits per year
Exercise: Creating Capacity and Productivity in Access Goal
Financial and Productivity Goals Tool1st Tab
Sample Data
102
Answers
SCHEDULING FOR SUCCESS
South Carolina Primary Care
Association
January 24, 2019
104
LEARNING OBJECTIVES
• Provide information on the basics of successful
dental scheduling
• Discuss the common scheduling pitfalls
• Provide guidance in effective scheduling for
various provider types
• Talk about how to schedule new adult patient visits
• Discuss strategies for overcoming schedule
busters
105
Associate Vice President, Morton Hospital and Medical Center, 1992-2006
Publications Coordinator, Norwood Hospital, 1986-1992
Freelance Editor, 1982-1986
President, Board of Directors, Taunton Oral Health Center, 2008-present
Member, National Network for Oral Health Access
Member, American Association of Public Health Dentistry
Associate Member, Association of State and Territorial Dental Directors
Dori Bingham, Practice Improvement
Specialist
DentaQuest Partnership for Oral Health
Advancement
106
GUIDING PRINCIPLES
The dental schedule should be used to achieve three key
strategic objectives:
1. Improved oral health status for patients
2. Maximum access to care for patients
3. Financial viability of the dental program
107
MAXIMUM PATIENT ACCESS
• All patients
• Priority populations (eg, children, pregnant women)
108
MAXIMIZING OUTCOMES: COMPLETION OF
PHASE 1 TREATMENTS
• What is Phase 1 Treatment?
109
FINANCIAL VIABILITY
• Net revenue = total direct and indirect expenses
• Patient revenue plus grants/other
110
DEFINE THE SCHEDULING PROCESS
• How far out to schedule?
• How many appointments at a time?
• How to use available operatories?
• Define appointment lengths for various procedures
• Who is needed when in each appointment?
• What types of appointments can be double-booked?
111
THE SCHEDULE PROCESS (CONT.)
• Start and end times for appointments each day
• Who can schedule appointments?
• Providers should always be working to the top of their
licenses
112
COMMON SCHEDULING PITFALLS
• Scheduling appointments out too far
• Scheduling multiple appointments for patients
• Putting too many new patients into the schedule
• Appointments that are too long or too short
• Not using provider time strategically
• Not being strategic about how and when to double-book
• Open time in the daily schedule (10 minutes here and
there adds up!)
• Not being strategic about who can schedule
appointments
113
COMMON SCHEDULING PITFALLS (CONT.)
• Hygiene appointments
in the dentists’
schedules
• Not maximizing the
potential of auxiliary
staff with expanded
functions
• Not identifying focus
populations or using
designated access to
preserve appointments
for focus populations
114
DEFINING PROGRAM CAPACITY
• Capacity is finite
• Capacity = structure and resources
115
# of
Providers
# of total
clinical hours
worked
x recommended
# of visits/
clinical hour
Potential
Daily Visit
Capacity
Mon. 2 16 1.7 27
Tues. 2 16 1.7 27
Wed. 2 16 1.7 27
Thurs 2 16 1.7 27
Fri 2 16 1.7 27
Potential Weekly Capacity = 135 Dentist Visits
Actual
Visits
% of
Capacity
Achieved
20 74%
26 96%
19 70%
18 66%
10 37%
*At least two operatories and 1.5 dental assistants
SETTING PRODUCTIVITY/ACCESS GOALS: VISITS
POTENTIAL VS. ACTUAL – FTE DENTISTS
116
# of
Providers
# of total
clinical hours
worked
x recommended
# of visits/
clinical hour
Potential
Daily Visit
Capacity
Mon. 1 8 1 8
Tues. 1 8 1 8
Wed. 1 8 1 8
Thurs 1 8 1 8
Fri 1 8 1 8
Potential Weekly Capacity = 40 Hygiene Visits
Actual
Visits
% of
Capacity
Achieved
7 87%
8 100%
6 75%
4 50%
6 75%
SETTING PRODUCTIVITY/ACCESS GOALS: VISITS
POTENTIAL VS. ACTUAL – FTE HYGIENISTS
117
GOAL CALCULATION TARGET
Visits/Day 27 Dental Visits + 8 Hygiene Visits = 35 visits
per day
35
Visits/Week 135 Dental Visits + 40 Hygiene visits = 175
visits per week
175
Visits/Year 175 weekly visits x 46 weeks = 8,050 Visits 8,050
DETERMINING ANNUAL POTENTIAL VISITS
FOR THE DENTAL PROGRAM
This shows how to take the daily visit capacity and
determine weekly and annual goals for the dental
program. 46 weeks is the standard number of weeks
we use in a health center year to account for holidays
118
FOCUS POPULATIONS
• Children
• Pregnant women
• Patients with chronic diseases such as diabetes, heart disease
and HIV/AIDS
119
DESIGNATED ACCESS
• The daily schedule ensures access
for all patients
• But a certain number of
appointments are reserved
• These reserved appointments
can’t be filled with other patient
types until the day before
120
PHASE 1 TREATMENT COMPLETION
• Treatment or procedures that lead to the “Elimination of dental disease”
• Oral cancer prevention and early diagnosis
• Prevention education and services
• Emergency treatment
• Diagnostic services and treatment planning
• Restorative treatment
• Basic periodontal therapy (nonsurgical)
• Basic oral surgery that includes simple extractions
121
WHY TRACK PHASE 1 TREATMENT COMPLETION?
• Important quality metric
• Promotes continuous coordinated care
• Enables balance of new and existing patients
122
FINANCIAL GOALS
• Gross charges
• Net patient-generated
revenue
• Bottom line (revenue after
expenses)
123
DETERMINING THE DAILY REVENUE GOAL
Total direct and indirect expenses ÷ Number of clinic days per year = daily net revenue goal to break even
For example:
Total expenses = $950,000
5 days per week x 46 weeks = 230 clinic days per year
$950,000 ÷ 230 = daily net revenue goal of $4,131
124
DAILY REVENUE GOAL (CONT.)
• Gross Charges – Contractual Adjustments = Adjusted Net Revenue
125
SCHEDULING BASICS
• Ideal patient mix
• Available practice resources
• Hourly visit goals for each provider type (general dentists,
specialists, residents/externs, hygienists, EFDAs)
• Appropriate appointment lengths for various visit types
• Build and test the templates
• Use 10-minute increments if possible
126
COMMON STAFFING BENCHMARKS
• General dentist, 2+ operatories, 2 assistants = 1.7 visits/hour
• General dentist, 1-2 operatories, 1 assistant = 1 visit/hour
• General dentist, 3+ operatories, 1 EFDA and 1-2 assistants = 2.5
visits/hour
• 4th year dental students = 0.5 visit/hour
• GPR Resident, Q1 = 1 visit/hour
• GPR Resident, Q2 = 1.2 visits/hour
• GPR Resident, Q3 = 1.5 visits/hour
• GPR Resident, Q4 = 1.7 visits/hour
• Hygienist, 1 operatory, unassisted = 1 visit/hour (typically, unless lots
of kids)
• Hygienist, 2 operatories, assisted = 1.5 visits/hour
127
SCHEDULING FOR DENTISTS
• Minimum of two operatories and ideally two assistants
• Staggered appointments in two columns (possible use of 3rd
column for overflow)
• Define workflow for each standard visit - where and for how
long the dentist is needed
• Line up the blocks so the dentist’s time is maximized
• Consider each dentist’s individual characteristics but aim for
standardization
128
SAMPLE TEMPLATE, DENTIST
Morning Schedule: Afternoon Schedule:Time Op1 Op2
Op3 (Overflow for
emergencies)
8:00 Emergency
8:10
8:20
8:30
8:40
8:50
9:00
9:10
9:20
9:30
9:40
9:50
10:00
10:10
10:20
10:30
10:40
10:50
11:00
11:10
11:20
11:30
11:40 Emergency
11:50 HOLD
12:00
12:10
12:20
12:30
12:40
12:50
Time Op1 Op2Op3 (Overflow for
emergencies)
1:00 Emergency
1:10
1:20
1:30
1:40
1:50
2:00
2:10
2:20
2:30
2:40
2:50
3:00
3:10
3:20
3:30
3:40
3:50
4:00
4:10
4:20
4:30
4:40 Emergency
4:50 HOLD
5:00
Intake10-minute appointments for medical hx review, blood pressure, etc.
Operative
40-minute appointments for Fillings/extractions. Can expand to 60 minutes for more procedures
Anesthesia
First 10 minutes of operative appointment, if anesthesia is provided, where the dentist might be available for a brief side-booked appointment (eg, denture try-in, suture removal) or to provide a POE or LOE
Lunch 30 minutes
Color Code:
129
SCHEDULING FOR HYGIENISTS
• Easiest schedules to fill; hardest to KEEP full!
• Broken appointments can wreak havoc
• Limit 6-month recall appointments
• Limit new patients in the daily schedule
• Develop tasks for hygienists whose patients fail to show
• Assisted hygiene may be a fit
130
ASSISTED HYGIENE
• Requires two operatories and dedicated hygiene assistant
• Hygienist can see 1.5 patients/hour or 12-13 patients in an 8-
hour day
• Assistant facilitates visit
• Eliminates RDH waiting for dentist to do exam
• Must rigorously manage broken appointments
• Must have demand for hygiene
131
COMPARISON:Unassisted vs. Assisted Hygienists
Unassisted
Hygienist
Assisted
Hygienist
Visits/hour 1 1.5
Visits/day 8 12-13
Visits/week (factors in
25% BA rate)
30 45
Revenue ($140/visit) $4,200 $6,300
Salary costs (includes
22% fringe)
$1,464 $2,149
Net revenue after salary $2,764 $4,151
Annual net revenue $127,144 $190,946
132
SAMPLE TEMPLATE, ASSISTED HYGIENE
Time Room 1 Room 28:00 greet, seat, update, BP (Patient 1)
8:10 x-rays
8:20 Prophy greet, seat, update, BP (Patient 2)
8:30 OHI review, disclose, anesth
8:40 OHI/dentist exam SRP (one quad)
8:50 Unseat patient/clean OP
9:00
9:10
9:20 greet, seat, update, BP (Patient 3)
9:30 Prophy Unseat patient/clean OP
9:40
9:50 greet, seat, update, BP (Patient 4)
10:00 Unseat patient/clean OP Prophy
10:10
10:20 greet, seat, update, BP (Patient 5)
10:30 x-rays
10:40 Prophy OHI/dentist exam
10:50 Unseat patient/clean OP
11:00 Greet, seat, update, BP (Patient 6)
11:10 OHI/dentist exam Prophy
11:20 Unseat patient/clean OP
11:30 Greet, seat, update (Patient 7)
11:40 Sealants x 4 OHI/dentist exam
11:50 Unseat patient/clean OP
12:00 Unseat patient/clean OP
The Result: 7 patients in 4 hours! Patients have the same amount of time in
the dental chair, the work is just redistributed to provide more access.
133
SCHEDULING ADULT NEW PATIENT VISITS:
REASONS FOR NOT BREAKING VISITS UP• Can be red flag for insurance audits
• Not patient-focused care
• Clogs the schedule
134
RATIONALE FOR BREAKING UP VISITS
• Oral health status unknown
• How much calculus in mouth?
• May not be able to complete exam until calculus removed
• Not enough time to do all required work in one visit
135
TWO POSSIBLE SCENARIOS Scenario A:
Unable to Do Comp Exam due to Heavy Calculus/Plaque
Visit 1: D0210 (FMX) and either D1110 (prophy) or D4355 (full mouth debridement)
Visit 2: D0150 (comp exam) and either PSR or full perio charting (likely needed)
Scenario B:
Able to Do Comp Exam
Visit 1: D0210 (FMX), D0150 (comp exam) and D1110 (plus PSR or full perio charting)
136
RECOMMENDATIONS
• 60 minutes with hygienist
• Scenario A or B depending on how patient presents
• Practice policy: as much care as possible in time allotted
• Document why if patient needs separate exam visit with the dentist
• Exam visits 30 minutes in dentist’s overflow chair
• PSR first and comprehensive periodontal exam if indicated
• Pilot, test and tweak as necessary
137
DOCUMENT THE SCHEDULING PROCESS
• Create a formal scheduling policy
• Include scheduling templates as attachments
• Review the policy with entire staff
• Train staff how to use the templates
• Monitor, provide feedback and tweak as necessary
138
SCHEDULE BUSTERS
• Last minute cancellations
• No-shows
• Late patients
• Too many emergencies/walk-ins
• Too many new patients
• Overbooking
• Logjams at check-in or out
• Providers who fall behind
• Not enough support staff
• Wrong appointment types
• Wrong appointment lengths
• Insufficient instruments
• Technology issues
139
STRATEGIES FOR RESOLVING SCHEDULE
BUSTERS
• Attack broken appointments
• Be strategic with double-booking
• Control emergencies/walk-ins
• Limit new patients
• Revisit capacity
• Resolve logjams at check-in/out
• Determine why providers/practice fall behind
• Resolve scheduling errors
• Ensure sufficient instruments
• Tackle technology issues
140
QUESTIONS/DISCUSSION
141
MANAGING CHAOS:BROKEN APPOINTMENTS AND EMERGENCIES
South Carolina Primary Care
Association
January 24, 2019
143
LEARNING OBJECTIVES
• Understand the negative impact of BAs and
emergencies on the practice
• Learn strategies for managing emergencies
• Learn strategies for reducing BAs
144
MANAGINGEMERGENCIESEmergency care important
but capacity must be
managed
145
WHY DOES THIS MATTER?
• Dental ER or Dental Home?
• Unpredictability
• Extra Work
• Reimbursement
• Disruption
• Patient/Staff Satisfaction
146
OPERATIONAL EMERGENCY MANAGEMENT
• Quantify demand for emergency care
• Develop system to meet demand
• Create an emergency policy and triage tool
147
QUANTIFY DEMAND
• Average Per Day
• Reality vs. Perception
• Tracking
148
WHEN DEMAND EXCEEDS CAPACITY
• Patients of record
• Patients in service area
• Waivered patient policy
• Are all area safety nets doing their part?
149
HAVE A SYSTEM IN PLACE
• Where do emergencies fit?
• Who will provide care?
• What care will be provided?
• Morning huddle
150
BEWARE OF WALK-INS
151
THE ROLE OF TRIAGE
• What constitutes an emergency?
• Who decides?
• Objective criteria
152
Ask the Patient MUST BE SEEN
TODAY!See tomorrow or this
week
See when available
“On a scale of 1
to 10 how badly
are you hurting?”
Pain level 7 to 10 Pain level 4 to 6 Pain level 3 or below
“How long have
you been
hurting?”
This level for a
week or less This level of pain for a
month or less Had these symptoms for
over a month
“Describe the
type of pain or
discomfort you
feel.”
Throbbing Broken tooth, lost a filling Chip tooth, broken filling
“How are you
sleeping at
night?”
Keeps me awake
at night Able to sleep with
medication Able to sleep
“What occurred to
make the tooth
begin to hurt?”
Unknown or bit
down on
something hard
Bit down on something or
other cause Sweets; candy causes it to
hurt
“Have you
noticed any other
symptoms?”
Fever and
swelling ------ ------
Two or more
checkmarks in this
section results in the
patient needing to be
seen today
Three or more checkmarks in
this section results in the
patient needing an
appointment this week
Three or more checkmarks in
this section results in the patient
being given the next available
standard appointment time
Sample Triage FormPatient Name: ___________________________________ Date: _____________________Last Dental Visit: ________________________ Location of Pain: Bottom left, Bottom right, Top left, Top right________Patient Address: __________________________________ Contact Number: ____________________________________
153
DEFINITIVE VS. PALLIATIVE CARE
• Definitive whenever possible
• Time
• Impact on BAs
• Patient/provider satisfaction
154
HAVE A POLICY
• Define it all
• Share with staff
• Communicate to patients
155
REDUCING BROKENAPPOINTMENTSBroken Appointment
Rate Goal: 15%
156
157
BROKEN APPOINTMENTS:
#1 cited problem for all safety net dental clinics
5 Key Areas Negatively Impacted:
Access to Care
Oral Health Outcomes
Staff Satisfaction
Patient Satisfaction
Financial Sustainability
158
WHY DOES THIS MATTER?
• Lost productivity
• Lost revenue
• Wasted chair time
• Diminished access
• Incomplete treatment
• Chaos/unpredictability
• Staff/provider frustration
• Patient frustration
159
FACTORS LIKELY TO INCREASE BA
RATES• No policy
• Policy weak or not enforced
• No understanding of why keeping
appointments matters
• Misinterpretation of governance related to no-
shows
• No culture of accountability (staff or patients)
• No consequences for broken appointments
160
BROKEN APPOINTMENTS DEFINED
No-Show:A patient is scheduled for an appointment and they do not show up for that appointment.
Late Cancellation:
A patient cancels an appointment less than 24 hours prior to the start of the appointment.
Late Arrival:A patient does not arrive by 10 minutes after the start of their appointment.
161
MANAGING MOST LIKELY TO “NO-SHOW”
New Patients
Recare Visits
• Require new (non-emergent) patient registration prior to scheduling 1st appt.
• Limit the number of new patients/day
• Book new patient visits within 2 weeks
Emergency Follow-up
• Teach patients to value the hygiene visit
• Consider moving to a “designated access” 2-5 week schedule for hygiene patients
• Require emergency patients who need follow-up care to call to schedule their next visit
162
PUNISHMENT VS. CONSEQUENCES
EVERY time the policy is breached:
• Call, letter, document/flag account
STRIKE ONE• Reminder and (only) warning
STRIKE TWO• Consequence occurs; requires a
proactive response from patient
STRIKE THREE• Strongest consequence
implemented by dental staff
163
“PROACTIVE RESPONSE” CONSEQUENCES:
Broken Appointment
Retraining Session
Write a Letter to the
Dental Director1. Explanation
2. Understand the impact
3. Promise never again
164
“STRONGER” CONSEQUENCES
Dismissal letter
• 30 days of emergency
care access
Same-Day-Only Scheduling Status
• Quick call lists
• Patient required to call
165
LESS FAVORABLE CONSEQUENCES
Charging for No-Shows
• Rarely works
• Can’t charge Medicaid
patients
Double-Booking
• Feast or famine
https://www.medicaid.gov/medicaid/benefits/downloads/policy-issues-in-the-delivery-of-dental-services.pdf (see question 11a)
166
Source: http://www.aapd.org/media/Policies_Guidelines/D_DentalNeglect.pdf
CONSIDERATIONS FOR CHILDREN UNDER AGE 18
167
STRATEGIES FOR SUCCESS
▪Provide reminder messages for upcoming
appointments
✓ Text/e-mail plus phone
✓ 48 hours in advance
✓ What if: Non-working numbers
✓ What if: Voice mail
168
▪ 30-45 days out
▪ One appointment at a time
▪ New (nonemergent) patients register in advance
▪ Limit appointments for multiple family members
▪ Limit new hygiene patients
▪ Ask emergency patients to call for follow-up
appointment
▪ Use alerts to warn schedulers
169
THE BIG FIVE BEST PRACTICES FOR EVERY
PROGRAM
• Strong policy with clearly communicated consequences
• Consistent enforcement
• Patient education
• Culture of accountability for patients and staff
• Track and evaluate BA rate
170
CDT TRACKING CODES FOR BROKENAPPOINTMENTS D9986:
Missed Appointment
D9987: Cancelled
appointment
D9991: Dental Case Management – addressing appointment compliance
barriers
171
NO-SHOW RATE CALCULATION
• Formula is: Number of broken appointments (numerator) divided by the Number of scheduled appointments (denominator)
• The number of scheduled appointments (denominator) is defined as the number of broken appointments + the number of visits.
• For example, if 20 patients broke, and 80 patients came, the percentage of broken appointments = 20/100 = 20% broken appointments
• Target is 15%
172
QUESTIONS/DISCUSSION
SESSION FIVE:COMPREHENSIVE HEALTH CENTER INTEGRATION TO IMPROVE OVERALL HEALTH
Dr. Scott Wolpin
174
OBJECTIVES
Session Objectives:
• Identify the benefits and barriers to integration
• Discuss the various aspects of integration
• Provide examples of integrated care
175
176
Why is session relevant?
• Oral health is a critical component of patient-centered,
comprehensive healthcare and well-being
• Better health outcomes = reduced costs
• PCAs are a great network to share tools, resources, and best
practices needed for improving oral health
177
What is integrated care?
Collaboration = primary care and oral health working with one another
Integration = oral health working within and as part of primary care or vice versa….provision of oral health services within
primary care
178
What Can Integration Look like?h
ttp://w
ww
.inte
gra
tion
.sa
mh
sa
.gov/in
tegra
ted
-care
-mo
dels
/CIH
S_F
ram
ew
ork
_F
ina
l_cha
rts.p
df
179
180
How do we get to Level 6?
Oral
Health
181
Integration efforts need to occur around three key
areas:
• Administration
• Clinicians
• Infrastructure
182
Administration
➢ Does the health center leadership believe in the
importance of integrating oral health into primary care?
➢ Is health center leadership not just supportive but
actively involved in making integration happen?
➢ Is the health center willing and able to allocate the
resources necessary to implement integration? (staff
time and funding)
➢ Is there an dental program representative on the health
center’s leadership team?
➢ Is oral health an important priority in the strategic plan
for the health center?
It starts with the CEO reinforcing the same message throughout the
organization “Treating the patient as a whole part is the mission and
culture of our health center”
183
Clinicians
➢ Providers and support staff must be able to communicate
both formally and informally across disciplines
➢ Providers need to participate in health center
committees, meetings, in-services together
➢ Mutual respect must exist with warm handoffs
➢ Providers must be willing to practice transdisciplinary
care:
Medical staff provides caries risk assessments, fluoride varnish
Dental staff provides diabetes, depression screenings, BPs
184
185
Infrastructure
➢ Sharing and access to patient information across
disciplines is necessary, are EMR and EDR systems
integrated?
➢ Are care coordination and other patient-enabling services
available for the dental program?
➢ Bilateral referrals must be supported (i.e. non-medical
user presenting with a toothache but his pre-operative BP
is extremely high)
➢ The health center’s system (policies and procedures)
must support standardized processes, forms, and
tracking of medical consults
186
Creating the Integration Plan
1. Forming the team
2. Creating the action steps and timeline
3. Strategic plan
4. Business plan- operations and systems
5. Policies and procedures
6. Goals
7. Evaluation plan - metrics
187
Who is on the Integration Team?
o Primary Care Providers
o Clinical Support Staff
o Front Office Staff
o Care Management Staff
o Quality Management
o Informatics
o Senior Leadership
188
The Primary Care Team’s Role
➢ Screen for dental disease and assess caries risk
➢ Educate patients on the nature of dental disease and self-
care strategies to prevent/reverse disease
➢ Provide primary (Fluoride) and secondary
(remineralization) prevention
➢ Triage emergent dental concerns
➢ Make appropriate referrals for oral health care - the
medical health history form should determine whether the
patient has a dental home (especially for vulnerable
populations like pregnant women, diabetics, etc.)
Be the primary oral health care provider for low risk pre-school
children??
189
➢ The oral health history should determine whether the
patient has an ongoing medical home
➢ Incorporate screening for common health
problems (e.g., high blood pressure, diabetes)
➢ The oral health health history should ask about
chronic and special conditions affected by oral
health disease (e.g., diabetes, heart disease,
HIV/AIDS, pregnancy)
➢ Substance Use screenings, Behavior Health
screenings
➢ Provide continuous (trending) health
information to patient’s medical providers
Oral Health Provider’s Role
190
191
Challenges of Integration
• Capacity – will the dental program’s physical capacity
accommodate increased visits resulting from referrals
from medical?
• Health Information Technology – how do we create caries
risk assessment tools for the EMR? Are the electronic
dental and medical records connected?
• Training - how can we assure timely completion of oral
health assessment and fluoride varnish during a medical
visit?
• Reimbursement – does the state Medicaid plan permit
both dental and medical visits to occur on same date of
service? Does the state Medicaid plan offer dental
benefits for adult patients?
192
Examples of Medical- Dental Integration Efforts at
Eastern Shore Rural Health System (ESRHS)
o Embedding a Dental Hygienist in the pediatric wing of
Onley Community Health Center
o Combined 9 month well child check/initial dental visits at
Franktown Community Health Center
o Quarterly Provider Meeting Case Study Exercises
193
Eastern Shore
Rural Health
System (ESRHS)
A federally qualified,
community health center
Five medical centers
and four dental
locations serving
residents of the eastern
shore of Virginia.
WWW.ESRH.ORG
Chesapeake
Bay
Chincoteague CHC
Atlantic CHC
Onley CHC
ESRHS Corporate Office
Franktown CHC(with Dental Services)
Bayview CHC
ESRHS &
Accomack County
School Dental
Program
The Hermitage on
The Eastern Shore
ESRHS &
Accomack County
School Dental
Program
Riverside Shore
Memorial Hospital
Chesapeake Bay
Bridge Tunnel
194
➢ DH joins the daily medical huddles
➢ Provides oral health assessments for vulnerable, target populations (i.e. diabetics, pregnant, children)
➢ Provides risk-based, evidence-based prevention interventions: Primary (fluoride varnish) secondary (SDF) and oral health education
➢ Makes referrals to the dental program for patients with untreated dental disease requiring restorative or surgical care
DH = The primary oral health care provider for low risk adult patients???
Embedding a Hygienist in Medical
195
ESRHS Vision for Population Health - Oral
196
Combined well child check/initial dental
visits
• An in-service was provided for the medical providers using online curriculum (http://smilesforlifeoralhealth.org) that provides guidance on how to perform oral health screenings and fluoride treatment in the medical setting
• Hands-on fluoride varnish demonstration was provided
• Determined that the 9 month old well check visit is the best visit to incorporate an initial dental visit because children have teeth and do not receive vaccines at this visit
• The dentist/DH sees the child at nine months and the medical team serves as the dental home for the first two years unless the child has treatment needs
• Has increased number of new insured patients for the dental program and decreased OR referrals
197
198
6-36 Month Olds with a Dental Visit(there are approximately 1400 ESRHS Medical Users < 36 months)
1
1524
32
38
40
0
20
40
60
80
100
120
2013 2014 2015 2016 2017 2018
Column1 Linear (Column1)
%
199
Interdisciplinary Case Studies
200
Mrs. J
201
202
203
204
5 Simple Implementation Steps for
Achieving Integration at your Health
Center
First:Add questions to patient medical history about oral health.
➢Do you have a regular dentist?
➢When was your last oral health visit?
➢Have you ever been told your gums bleed?
205
Implementation Steps for Integration in
your health center (cont.)
Second:Perform a workflow analysis to see what works best in your
practice.
➢Do you have a small practice or a large practice?
➢Are medical and oral health co-located?
➢What types of providers/support staff do you have to provide
integration?
206
Third:Choose a provider (RDH, DA,CDHC, MA, MD) who will integrate oral
health into medical.
➢Which days of the week?
➢Which hours per day?
➢Which patient population will you begin with?
Regardless of where or how your integration practice
begins, the goal is to pursue progressively higher levels
of integration, so that over time all patients can expect to
receive oral health preventive services and structured
referrals from their primary care team.
Implementation Steps for Integration
in your health center (cont.)
207
FourthProvide a Structured Referral
• A “structured” oral health referral should include the
information the dentist needs to participate appropriately in
the patient’s care, for example: the patient’s problem list,
current medication and allergy lists, the specific reason for the
referral, and a statement that the patient is healthy enough to
undergo routine oral health procedures.
Implementation Steps for Integration
in your health center (cont.)
208
Fifth
Develop a Referral Network
A Care Coordinator is a good liaison to work between medical
and oral health, to complete and follow through on all referrals
and to make sure target patients are seen in the dental program –
they can trouble soot barriers to accessing care
Implementation Steps for Integration
in your health center (cont.)
209
The cost of not providing integrated care…
210
211
At Risk Reversible Irreversible
Primary Prevention Secondary Prevention Tertiary Prevention
Primary Care Specialty
• Dietary counseling
• Behavior
modification
• Fluoride varnish
• oral health sealant
Remineralization • Restorations
• Pulpotomy
• Simple endodontics
• Simple extractions
• Endodontics
• Perio surgery
• Complex
prosthodontics
• Oral surgery
• Orthodontics
• oral health Assistant
$17.13
• Medical Assistant
$14.80
• Nursing Assistants
$12.51
• Dietetic Tech $13.74
• oral health Hygienist
$34.39
• Physician Assistant
$45.36
• Nurse Practitioner
$45.71
• General Dentist
$79.12
• Pediatric Dentist
• Oral Surgeon
$105.27
• Orthodontist $94.36
Non-Dentist oral health Surgeon
212
213
Questions ?
214
Helpful Resources
National Network for Oral Health Access
www.nnoha.org
DentaQuest Institute Online Learning Center (free Disease Management Modules)
www.dentaquestinstitute.org
Health Resources and Services Administration
www.hrsa.gov
National Interprofessional Initiative on Oral Health www.niioh.org
U.S. National Health Alliance
www.usalliancefororalhealth.org
215
216
QUESTIONS/DISCUSSION
CREATING THE IMPROVEMENT PLAN
Danielle Apostolon
218
The Improvement Plan (IP)
219
Recipe to a Successful IP
Identify and state the Problem or Problems
Apply Strategies to address each of the problems
Define the Actions Steps to execute each strategy
Assign a Person or Person’s responsible
Attach Due Dates
Set goals and performance Metrics
220
Step 1: Identify the Area in Need of
Improvement
Observation
Data
Staff Meetings
Patient Satisfaction Survey
Environmental Changes
Organizational Changes
221
Examples
The broken appointment rate is 30%
Providers are working late and somedays do not get a lunch break
High number of walk-ins and emergencies
Patients have been complaining about the long waits
Providers feel burnt out
Patients cannot schedule an appointment for at least another 3 months
222
Step 1: State the Problem
The no show rate is 30%
No-shows and last-minute cancelations are negatively impacting access
to care and productivity. The policy is not consistently enforced.
• By reducing the no-show rate the practice can increase revenue
and decrease chaos and stress for dental staff. A major impact will
be an increase in the percentage of patients who complete their
phase 1 treatment within 12 months.
223
Step 2: Identify Strategies
Revise and distribute a strong, no-tolerance Broken Appointment policy
to establish accountability with the patient and staff. Post signs
prominently within the practice explaining the policy.
Flag patient charts of those who breach the policy and send letters
reminding those patients of the policy they agreed to abide by.
224
Step 3: Create Action Steps
1. Revise the current policy
2. Obtain Board approval
3. Educate staff and patients about the new policy
4. Require all new patients to sign the policy
5. Monitor the BA rate and access policy after 3 months
225
Step 4: Assign Due Dates & Responsibilities
Action Steps Due Date Person(s) Responsible
Revise the current policy 6/30/17 Dental Director and Practice
Manager
Obtain Board approval 7/15/17 Dental Director and CEO
Educate staff and patients about the
new
8/1/17 All staff
Require all new patients to sign 8/30/17 Front Desk
Monitor the BA rate and access policy
after 3 months and report to leadership
Ongoing Practice Manager
226
Step 5: Set a Target Goal for the Metric
Current BA rate = 30%
Year 1: 20%
Year 2: 15%
Every quarter the broken appointment will be monitored to ensure:
• Policy is effective
• Everyone is consistent with enforcing the policy
• BA’s are being documented accurately
227
Step 6: Execute and Monitor Results
Create Buy-In and Accountability among staff
Collect data to monitor result; have a measurable goal for everything!
Regular meetings to discuss the progress in executing the actions steps
Discuss barriers that arise
Brainstorm ways to overcome barriers as a team
Celebrate successes
Recognize and award staff
Coach and offer feedback when there are setbacks
228
Resources
Improvement plan template
Best Practice Manual
Tools to create goals
Sample policies
DQI Resource Library
Online Learning Modules
229
Next Steps
Utilizing the Best Practice Manual and Improvement Plan Template
1. Download the Best Practice Manual (pdf)
2. Download the Improvement Plan Template (Word)
3. Identify 1 area for improvement that your clinic can work on in the
short term (next 3 months)
4. Decide on at least 1 strategy
5. Create specific actions steps for each strategy
CLOSING/WRAP-UP
Da-Nell Pedersen
231
Sample Policies & Tools
• Dental Policy & Procedure Manual Template
• Sample Clinical Protocols
• Sample Dental Job Descriptions
• Sample Broken Appointment Policies
• Scripting for CHC Dental Staff
• Profit & Loss Budget Variance Tool
• Sample Scheduling Policy
• Sample Emergency Policy
• Sample Quality Assurance Policy
• Dental Clinic Performance Monitoring/Tracking Tool
• And much, much more!
https://www.dentaquestinstitute.org/learn/safety-net-solutions/sns-sample-policies-and-tools
232
Online Practice Management
Courseware • Developing Billing Excellence
• Fee Schedules, Sliding Fee Scales, & Management of
the Self-Pay Patient
• Safety Net Dental Program Finance and Productivity:
Your Mission and Your Margins
• Front Desk Customer Service
• The Front Desk: Creating Your Dream Team
• Managing Chaos in the Dental Program
• Scheduling by Design
Free continuing dental education credits!
https://www.dentaquestinstitute.org/learn/online-learning-center/online-courseware/safety-net-dental-
practice-management-series
233
Additional Online Learning Center
Resources Other Learning Modules/Online Courseware
• Disease Management Series
• Special Topic Series (e.g. Payment Reform in Oral
Health)
Resource Library
• Best Practices Manual
Dental Caries Management Virtual Practicum
Instructional Webinars/SNS Lunch & Learn Webinars
PrevenTips Videos
https://www.dentaquestinstitute.org/learn/online-learning-center
https://www.dentaquestinstitute.org/learn/safety-net-solutions/sns-webinars
234
Post-Training Evaluation
www.surveymonkey.com/r/SCPOST
235