The Patient-Centered Dental Home - Tennessee Primary Care

Transformation: The Patient-Centered Dental Home

May 13, 2017

An Nguyen, DDS, MPH Vice-President of Dental Services

Objectives • To understand the Chronic Care Model as a quality improvement framework and how it can be applied to dental practice transformation. • To understand the “Big 6” redesign elements and how they have been leveraged to improve quality of processes and outcomes in patient-centered ways in Clinica’s dental program. • To identify the importance of change management in supporting system redesign. • To identify a process change to take back home to consider or test.

An • Clinica’s Journey: A Transformative Process • A Quality Improvement Framework – Chronic Care Model – Patient Centered Medical Home – “The Big 6”

Southern Roots

Our Mission

To be the medical and dental care provider of choice for low income and other underserved people in south Boulder, Broomfield and west Adams counties. We believe that health care shall be culturally appropriate and prevention focused.

Dental Established 2002  17 Providers 

  

General Dentistry Pediatric Dentistry Integrated Dental Hygiene

2 Clinic Locations  13,000 Patients 

People’s Medical Clinic Boulder, CO

Lafayette Medical Clinic Lafayette, CO Administration Lafayette, CO Thornton Medical & Dental Clinic Thornton, CO

Clinica       

Founded 1977 in Lafayette, CO Integrated Physical, Behavioral, Dental Health Care NCQA PCMH Level III and Diabetes Recognition 50,000 Patients & 240,000 Visits 56% Medicaid, 30% Uninsured, 6% Private, 5% Medicare 42% Non-English Preference; 75% Hispanic or Minority 6 Clinic Sites 530 Employees (120 Providers)

Westminster Medical Clinic Westminster, CO

Pecos Medical & Dental Clinic Denver, CO

“Every system is perfectly designed to get the results it gets.” Paul B. Batalden, MD Co-Founder Institute for Health Care Improvement

Chronic (Planned) Care Model ● Foundation for Patient-Centered Medical Home Model ● Interventions that contain one or more Chronic Care Model elements improved clinical outcomes and processes of care.1

The Chronic or Planned Care Model

Key Redesign Elements: The “Big 6” To improve patient-centered, population health management.




NOTE: Not sequential in nature.




Redesign Element #1


Continuity “Continuity of care is rooted in a long-term patientphysician partnership…with the goal of high quality, cost effective medical care…in which the physician knows the patient’s history from experience and can integrate new information and decisions from a whole-patient perspective efficiently without extensive investigation or record review.” American Academy of Family Physicians

Continuity is King!

Continuity “If a primary tenet of the Medical [or Health] Home is the continuous relationship between a team of providers and an informed patient…then we must provide a mechanism for allowing that relationship to happen in our systems.” Amit Shah, MD, Medical Director, Multnomah County Health Department

That mechanism is empanelment. 1

Continuity • Most important!1 • Data shows that improved continuity results in: – Fewer visits to the emergency room.2 – Improved patient satisfaction.3 – Improved rates of preventive services completion (pap, mammograms, vaccinations).4


Continuity • Assigned Primary Dental Provider (PDP)

• Defined Dental Panels – Group of unique patients, whose care for which a provider is responsible. – Inclusion of only: • Active Patients • Comprehensive Care Patients

– Adjusted by: • Provider Type • Provider FTE • Patient Age


Continuity A Simple Formula for Panel Size 1. Determine capacity. Average Visits per Day by Provider Type X # of Working Days per Year

2. Determine panel size. # Visits Available per Year Average Visits per Year by Patient Type 1

Continuity • Adjustments for Panel Size VARIABLE



Provider Type

General Dentists Pediatric Dentists Hygienists

Visits per Day Visits per Year

Provider FTE

Any FTE Worked

# of Working Days per Year

Patient Types or Risk Factors Age* Gender Comorbidity • Diabetes • Periodontal Disease • Pregnancy

Patient Visits per Year

*Age is most predictable determinant of visits per year.

• Requires understanding your patients and program. 1

Continuity An Example: Clinica’s Panels (Based on 1 FTE)

1. Determine capacity. General Dentist: 14 Visits per Day X 240 Working Days per Year = 3360 Visits per Year

Pediatric Dentist: 22 Visits per Day X 240 Working Days per Year = 5280 Visits per Year Hygienist: 7 Visits per Day X 240 Working Days per Year = 1680 Visits per Year


Continuity An Example: Clinica’s Panels (Based on 1 FTE)

2. Determine panel size. General Dentist:

3360 Visits per Year = ~1,200 Patients 2.75 Visits per Year per Patient ≥ 12YO Pediatric Dentist: 5280 Visits per Year = ~2500 Patients 2.1 Visits per Year per Patient < 12YO Hygienist: 1680 Visits per Year = ~950 Patients 1.77 Visits per Year per Patient ≥ 12YO


Continuity An Example: Clinica’s Panels (Based on 1 FTE)

3. Determine adjustments. • By Age – YES! • Children under 12YO consume half the number of annual dental visits. • Visits per Year for <12YO = 2.1. • Visits per year for ≥12YO = 4.58. • Panels adjusted by <12YO = 0.5 ≥12YO. • Adjusting by age, panel sizes are larger when they are comprised of more patients <12YO.

• By Comorbidity – NO! • Visits per year based on comorbidity (e.g., diabetes, periodontal disease, etc.) were distributed according to age. • Therefore, panel sizes are adjusted according to age, rather than diagnosis.


Continuity • General Dentist Panel Report (If ≥12YO Only = 1200 Pts)

• Pediatric Dentist Panel Report (If <12YO Only = 2500 Pts)


Continuity Other Important Metrics & Processes • • • •

Patient Deactivation Process Attrition Rate Continuity will never be 100% Process Barrier Removal – Simplified scheduling processes. – Scripts for staff for when patients request appointments with “Anyone.” – Contingency plans for challenges to continuity. • Defects in Schedules • Provider Time Off &Turnover


New Patient

New Patient

Patient B

New Patient

Patient A Patient C


Redesign Element #2


Access • 150,000 medically and 170,000 dentally underserved…folks who can’t get in.

• High Leverage Changes for Access a. b.

c. d. e.


Match demand & supply daily. Decrease appointment types & times (reduce “carve-outs”). Develop contingency plans. Reduce demand for visits. Optimize the care team.

Access Match Supply & Demand • Backlog of Demand: Lack of Medical & Dental Parity • Managing Demand: Populations of Focus •

Comprehensive Care • • •

Diabetics Pregnant Women Children

Acute Care: Panel size adjustment to allow for acute care patients.

Clinica’s UDS Access Trends 80,000 70,000 60,000


50,000 39,592





40,000 30,000 20,000
















10,000 0

Unique Dental Patients


13,076 2016

Unique Medical Patients

In 2016, 27% of all Clinica patients were able to access Clinica’s dental services.


Access Comprehensive Care Populations of Focus • Executive and Board support are essential. • Support the team to implement. • • •


Feels like saying “no.” Scripts for staff. Education for all staff.

Match Supply and Demand

Access Scheduling: The “Old” Way • Procedure-based scheduling. • Procedure carve-outs. – Demand may not match supply. – Unfilled slots filled with new patients and LOEs.

• Simple for staff to implement.


Access Scheduling: A New Way Appt Type (Code) Perio (P60, P80)

60 - 80 mins

Dental Routine Procedure (D20, D40, D60, D80)

20 - 80 mins

Complex (C20, C40, C60, C80, C100, C120)


Time Options (20 min increments)

20 - 120 mins

Scheduling “Rule”

Example Procedures

Max 3 per day per hygienist.

SRPs, Gross Debridements


Exams, FVs, Sealants, Prophies, Perio Maintenances, Fillings, Extractions, Crowns

All other columns blocked.

ARTs, Root Canals, Immobilizations

• Features •

• •

Appointment type-based scheduling (“building blocks”). Minimal procedure carve-outs. Clinical staff control time allotted per appointment. Scheduling rules are implemented and owned by operations team.

• Considerations • •

Team commitment to access. Monitor outcomes with data.

Access An Example: Patient needs a fillling.



• Diagnoses need for filling. • Determines time needed. • Plans OP40 in EDR.


• Sees provider’s request for OP40. • Finds opening for OP40 in EPM.

Access Dental Call Center • Standardized tools and pre-determined flows are essential. • Empowered/trusted to manage the schedule. • Improved patient satisfaction. • •


Average Wait Time = 25.4 seconds. Calls Answered within 90 Seconds = 93%. Dropped Calls = 4.7%

Dental Call Center Attendants use assessment tools and simplified scheduling procedures to optimize access in patient-centered ways.

Access Managing Acute Needs • When access is limited, acute care needs increase. • Gap in dentistry for nurse triage functions. •

• •


Assessment tools for non-clinical dental team members. Right appointment at the right time. Ensures routine vs. acute care capacity is balanced.



Access Optimize the Care Team • Ask: – – – –

Who can do the care? What care can each team member render? Where can the care happen? How can we optimize the Dental Practice Act?

• In Colorado/At Clinica… – Independently practicing hygienists. – Expanded duty dental assistants (EDDAs). – Reimbursement for same-day medical & dental encounters. – Emerging teledental models.


Access • Other Considerations – Advanced Access for Dentistry • Challenging in a procedure-based field. • Elements can be applied.

– Measure Access: Time to Third? – Improving continuity reduces demand for visits by 5% (IHI 2000).


Continuity + Access = Outcomes! Clinica Trimester of Entry of Prenatal Care 100% 90% 80% 70% 60% 50% 40% 30% 20% 10%

3rd Trimester 2nd Trimester 1st Trimester



1, 2

Continuity + Access = Outcomes!

Access Management Empanelment

1, 2

Redesign Element #3


3. Improved Care Delivery Model Alternative Care Modalities & Settings • Engage the activated patient. • Health happens in any/many environment(s). • •

Effective, consistent, overlapping messaging. Put “the mouth back in the body.”

• Avoid the “high cost surgical suite.” • • •


Change the treat to maintain paradigm. Lowers overall cost of care. Increases appropriate access to care in the dental operatory. Improves outcomes.

Improved Care Delivery Model Dental Integration • Hygienists on medical care team. • Scope

• •

OB, Peds Education Caries Risk Assessment, SelfManagement Support Preventive Services Direct Dental Scheduling

• Minimal dental equipment needs.


Average Age at First Dental Visit (Pediatric Dentist Visits Only) 8 6


• •

4 2 0

Average Age (In Years)







3. Improved Care Delivery Model Group Visits • Facilitated group process for patient activation. • Care in space designed for groups. • Patients invited on basis of chronic disease history and utilization patterns. • Goal is patient activation. • Patients remain in same group for continuity. • Improved access & outcomes! 3

• Access Group Visits: New Patients, Back-to-School, Flu • Cohort-Based Group Visits: Pregnancy, Parenting, Diabetes

3. Improved Care Delivery Model Team-Based Care • Who can do the care? • What care can each team member render? • Where can the care happen? • How can we optimize the Dental Practice Act?


3. Improved Care Delivery Model Team-Based Care The Jelly Bean Game Who on the team… 1. SETS the intervals for exam recalls for high caries risk patients? 2. DECIDES when to call a patient with periodontal disease to come in for a visit? 3. SELECTS the types of preventive care to be given to a 12-month-old patient? 4. DECIDES to arrange a referral for oral biopsy? 5. ORDERS the placement of sealants for a 14-year-old patient with caries? 6. INITIATES the application of fluoride varnish? 7. FINDS the patients with chronic periodontitis who have not been in for routine periodontal maintenance and brings them in for an appointment? 8. DECIDES when an appointment can be double-booked? 9. DECIDES when a patient with an acute need should get an appointment? 10. ADMINISTERS caries risk assessments?


3. Improved Care Delivery Model Team-Based Care Jelly Bean Game: Debrief • What are your AH-HAs? • What are some OH-NOs? • Were there any differences between groups?


3. Improved Care Delivery Model Team-Based Care When providers work without teams… • Most providers deliver only 55% of recommended care; 42% report not having enough time with their patients.5, 6 • Providers are spending 13% of their day in care coordination and only using their clinical knowledge 50% of the time. 7, 8 • Patient care is fragmented and patients are dissatisfied with the level of attention they receive. 9 3


Source: From Building Teams in Primary Care: Lessons Learned (California Healthcare Foundation, 2007)

10.6 additional hours to manage chronic conditions

3. Improved Care Delivery Model Team-Based Care From triple to quadruple aim.

Care Team Experience


Redesign Element #4


4. Improved Office Efficiency Facility & Process Design • Medical-Dental Clinic Colocation • Shared, Centralized Processes • •


Financial Screening Call Center

4. Improved Office Efficiency The “Dental Pod” •

Color-coded, team-based seating.

Team owns outcomes and productivity for a panel of patients.

Operatories Workstations Blue Team Red Team Yellow Team


4. Improved Office Efficiency Red Team

• • • •








Team-Based Seating Top of License Work Real-Time Huddling Efficiency  Fewer Visits per Patient

Redesign Element #5


5. Improved Information System Design

Organizational structure supports collaboration and clinical quality.


5. Improved Information System Design • Electronic records and standard data entry processes. • Monthly review of quality outcomes by care team and administrative staff. • Business intelligence tools that help plan care for individual patients and focus populations. 5

5. Improved Information System Design


5. Improved Information System Design


5. Improved Information System Design Dental CarePlanner


Redesign Element #6


6. Patient Activation & Self-Management • We take care of 99.995% of our own health care decisions…so do our patients. • It is our job to find ways to help motivate patients to make the necessary behavioral change: smoking, exercise, brushing, seeking dental care! • What to do? Adopt an approach to: – Support patients’ autonomy and responsibility for their behavior. – Increases the likelihood that patients will make healthier choices. 6

6. Patient Activation & Self-Management If you’re interested in outcomes, then you have be invested in the biggest part of the pie that we can influence.


6. Patient Activation & Self-Management


6. Patient Activation & Self-Management • • •

• • •


Motivational Interviewing (MI) Sets aside the tendency to educate patients. Emphasizes eliciting from patients what they know and what most concerns them. Leads to patient behavior change goals that are more likely to be realistic and attainable. Reduces provider frustration and burnout due to patient nonadherence to treatment or recommended lifestyle change. Nurtures better-quality provider-patient relationships. Has some evidence of effectiveness (grade B).5

6. Patient Activation & Self-Management • Motivational Interviewing training for all dental team members. • Orientation • Champions • Pocket Cards

• Widely popular amongst dental provider team. • Hunger for strategies to improve health. • How to have “tough” conversations. 6

6. Patient Activation & Self-Management 5 Questions for MI Practitioners 1. 2. 3. 4.

Why would you want to make this change? How might you go about it in order to succeed? What are the three best reasons for you to do it? On a scale of 1-10, 1 being not confident and 10 being completely confident, how confident are you that you can make this change? 5. So what will you do?


6. Patient Activation and Self-Management

• • • • •


DOs of SMG Setting Be curious. Ask questions. Go with the flow. Trust the patient. Let the patient pick one.

• • • •

DON’Ts of SMG Setting Assume. Tell them. Diminish the patient’s ideas. Use fear.

6. Patient Activation & Self-Management • Change Talk: “I don’t want to have more cavities, but I don’t brush regularly.” • I Will Get This Done By: “I think I can start brushing in the morning in the shower and rinse with ACT after I eat dinner at work.” • Confidence (1-10): “8 out of 10, because rinsing is something that I already do.” • Patient leaves with documentation of chosen goal.

• Provider documents goal, and team follows up on progress. 6

Potential in the System Caries at Recall: Clinica’s Journey 50 46.11

45 40

38.52 37.84

35 30 25 20



Clinica % Caries

Clinica - % Caries Median

Building the Toolbox


Universal Quality Improvement Language Plan-Do-Study-Act (PDSA) Cycle Ideas



Improvement • Identify problems and create a plan

• Demonstrate improvement • What changes are to be made? • What is the next cycle?



Study Do • Complete the data analysis • Compare data to predictions • Summarize what was learned

• Implement the plan • Monitor and document results • Begin analysis of the data

Universal Quality Improvement Language Model for Improvement Improvement

Using the cycle to improve.



Implementation of Change Wide-Scale Tests of Change Ideas


Follow-up Tests Very Small Scale Test

MULTIPLE successful PDSA cycles build knowledge and accelerate the adoption of proven and effective changes.


Leadership & Vision When leaders are at their personal best there are five core practices common to all: 1. 2. 3. 4. 5.

Model the Way Inspire a Shared Vision Challenge the Process Enable Others to Act Encourage the Heart.

Leadership & Vision Building Blocks of

Leadership and vision. “A vision is not just a picture of what could be; it is an appeal to our better selves, a call to become something more.” (RosabethMossKanter)

Data is a powerful storyteller. Give it a voice, and let it speak frequently. Support good habits.

6. Patient Activation & Self-Management

5. Information Systems

4. Office Efficiency

3. Care Delivery Model

2. Continuity

1. Access


Thank you! Questions? An Nguyen, DDS, MPH Vice-President of Dental Services

[email protected] (303) 412-8180, Ext. 4035

References 1.

Tsai AC, Morton SC, Mangione CM, Keeler EB. Am J Manag Care. 2005 Aug;11(8):478-88. 2. Brousseau DC, Meurer JR, Isenberg ML, Kuhn EM, Gorelick MH. Association between infant continuity of care and pediatric emergency department utilization. Pediatrics. 2004 Apr;113(4):738-41. 3. Christakis DA, Wright JA, Zimmerman FJ, Bassett AL, Connell FA. Continuity of care is associated with high-quality care by parental report. Pediatrics. 2002 Apr;109(4):e54. 4. Cabana MD, Jee SH. Does continuity of care improve patient outcomes? J Fam Pract. 2004 Dec;53(12):974-80. 5. Center for Studying Health System Change, 2008. 6. Bodenheimer and Liang, 2007. 7. Gottschalk, 2005. 8. Margolis and Bodenheimer, 2010. 9. Bodenheimer, 2008. 10. VanBuskirk KA,Wetherell JL. Motivational interviewing with primary care populations: a systematic review and meta-analysis [published online August 11, 2013]. J Behav Med. doi:10.1007/s10865-013-9527-4.


The Patient-Centered Dental Home - Tennessee Primary Care

Transformation: The Patient-Centered Dental Home May 13, 2017 An Nguyen, DDS, MPH Vice-President of Dental Services Objectives • To understand the...

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