Medical Dental Integration – The Journal of Healthcare Contracting

By Pete Mercer

March 2024 – The Journal of Healthcare Contracting

Researchers and healthcare professionals have studied the connection between oral health and systemic health for some time. The U.S. Surgeon General drew attention to that connection in its 2000 report, “Oral Health in America.” Subsequent reports have only strengthened the case for integrating medical and dental care.

Understanding and accepting the connection represents progress, but doing something about it is another matter. Integrating oral and medical care can mean co-locating dental and medical professionals and equipment; integrating digital dental and medical records; and enlisting professionals who are eager to stretch their understanding of healthcare and work with people they never worked with before. In other words, it’s a lot of work.

Despite the challenges, integrating oral and systemic health at the practice level is occurring throughout the country. For example, in December 2022, UCSF Health and UCSF Dentistry in San Francisco merged their medical and oral health records into an electronic health record. Here are some other examples:

Delta Dental of Colorado administers the Colorado Medical-Dental Integration (CO MDI) project, which integrates registered dental hygienists into medical care teams. Its clinics have provided more than 60,000 visits for patients who otherwise may not receive care due to insurance status, transportation, geography or socioeconomic status. (Delta Dental Plans Association is a not-for-profit organization which offers dental coverage in 50 states through its network of Delta Dental companies, including Delta Dental of Colorado.)
Zufall Health, headquartered in Dover, New Jersey, with service locations in seven counties, has provided primary care in the region since 1990 and oral health since 2000. “This allows our dental team to consult on medical patients who may appear with oral issues, and to help them address acute or chronic medical conditions that are affecting medical care,” says Rina Ramirez, M.D., chief medical officer.
In December 2022, Pacific Dental Services, a nationwide dental support organization (DSO), announced a partnership with MemorialCare, an integrated health system in Southern California, to open at least 25 joint locations in MemorialCare Medical Group health centers throughout Orange and Los Angeles counties over the next five years. The two organizations use the Epic electronic health record system, which is expected to facilitate sharing of medical and dental information. Already, PDS supports four medical practices in the Las Vegas, Nevada, area, and it was the first DSO to partner with an accountable care organization – Commonwealth Primary Care ACO in Arizona.

Colorado

Delta Dental of Colorado began co-locating dental hygienists in selected Colorado medical practices in 2007 and has expanded the program to more than 20 locations. “We started by co-locating dental hygienists into medical clinics, meaning the hygienists had their dental operatory in the same building and saw medical patients who were referred to them,” says Patricia Braun, M.D., a Denver pediatrician and program evaluator for the Colorado Medical-Dental Integration project. “As the program evolved, the dental hygienists became integrated members of the medical team. They either saw the patient before or after the medical provider or scheduled a future visit if the dental hygienist was busy with another patient.”

Hygienists provide a broad scope of dental hygiene services, including sealants, X-rays, and scaling and root planing in the medical setting, says Dr. Braun. Many practices have seen a reduction in untreated dental disease in patients with more than one integrated dental hygiene visit. This is a result of preventing dental caries as well as navigating patients with untreated dental decay to dentists.

New Jersey

Zufall Health takes seriously the synergistic relationship between medical and dental teams, says Dr. Ramirez. “Untreated oral disease can be associated with infections, diabetes, weight loss and malnutrition, and can negatively affect individuals’ eating, sleep, work performance and social life,” she says.

Most of Zufall Health’s facilities provide medical and dental care within the same building or adjacent buildings. At its Somerville, New Jersey, site, where a forthcoming construction project will add dental exam rooms, the community center’s mobile dental van is available to patients weekly. “The proximity of medical and dental care, coupled with an integrated electronic dental/medical record, allow patients to receive medical and dental care at the same location and strengthens interdisciplinary provider collaboration,” she says. The medical and dental teams both use eClinicalWorks software to maintain patient information.

The following programs and initiatives exemplify the cross-functional approach to medical and dental care at Zufall Health:

Pediatric HPV vaccinations as prevention for oropharyngeal cancer. Human papillomavirus (HPV) causes six types of cancer and is spread through sexual skin-to-skin contact, Ramirez points out. HPV vaccination can prevent 90% of cancers caused by the virus, and it is most effective for children between ages 9-12 and provides prevention before exposure. To overcome parents’ aversion to HPV vaccination, Zufall Community Dental Health Coordinators provide education and motivational interviewing that focus on oropharyngeal cancer, the fastest growing HPV-related cancer. The HPV vaccination rate nearly tripled in a project cohort.

Periodontal disease and diabetes management. Diabetes can increase the amount of glucose in saliva, leading to bacterial growth and plaque accumulation, says Dr. Ramirez. Zufall dentists identify patients with high A1C levels and provide deep cleanings to prevent or treat periodontal disease.

Coordinating dental care for Ryan White (HIV services) patients: People living with HIV and AIDS often face numerous barriers to accessing affordable preventive and restorative dental services, resulting in higher burdens of oral disease.

Medical and dental services offered in mobile medical van: Dental care is part of Zufall’s Peds in the Park program, which uses a mobile medical van to conduct pediatric assessment and vaccination events throughout low-income neighborhoods. “It was created to counter the dramatic drop in the number of children receiving their routine childhood immunizations due to the pandemic,” says Ramirez.

Pediatric obesity prevention: During dental visits, pediatric patients are evaluated for BMI, and families receive appropriate nutritional counseling. Additionally, Zufall’s Children’s Oral Health Program provides fluoride treatments and education in its pediatric fitness program – Ándale – and at asthma clinics.

Cross-disciplinary training and referrals: Zufall’s pediatric medical providers apply fluoride varnish to children who are not actively seeing dentists, perform caries risk assessments, and make directed referrals to dental care. Conversely, the dental team frequently does blood pressure screenings and refers patients unvaccinated for HPV to the medical office for vaccination.

Southern California

Stephen E. Thorne IV founded Pacific Dental Services in 1994 with his first dental practice management contract in Costa Mesa, California. His interest in integrating dental and medical care came soon after.

“I wanted to understand more about the connection between oral health and overall health, so in 2015, I put together a team to study the science on what was then called the oral-systemic link,” he says. “We ended up defining the Mouth-Body Connection^® as the link between oral health and overall systemic health, and the role that harmful bacteria, inflammation, and bone loss in our mouths plays in chronic, systemic disease.” In 2018 PDS created a digital book titled “32 Reasons to Learn About the Mouth-Body Connection^®” and began providing chairside education on the topic to patients.

“We’ve redesigned the look and feel of our newest supported practices to provide for an immersive, educational experience as soon as patients enter the door,” says Thorne. The phrase “Oral Health Means Better Health” is displayed prominently on the lobby walls, along with supporting collateral and interactive educational opportunities.

Through its “Smile Generation” brand, PDS-supported dental practices distribute a quarterly digital magazine focused on the connection between oral health and whole-body health. Patients receive oral health and Mouth-Body Connection^® education through their MyChart app and monthly emails with information. “In addition, we share news and updates on this topic through our websites and social media channels. One of our most important initial learnings has been that patients quickly get it. Patients accept the Mouth-Body Connection^® as obvious. For them, it seems common sense.”

The fact that both Pacific Dental Services and MemorialCare use Epic electronic records was a factor in their partnership. “The interoperability of Epic, along with chart reconciliation, make it easier to close care gaps, enable early intervention and ultimately reduce overall healthcare treatment costs,” says Thorne.

“This will naturally create opportunities for physicians and dentists to collaborate on medical and dental issues,” says Mark Schafer, M.D., CEO, MemorialCare Medical Group. “For example, a dentist may see in a patient’s record that they are diabetic but have not recently had a check-up. The dentist could touch base with the MemorialCare physician to see what is recommended. This may lead to a blood test that day and a follow-up visit with the doctor, or a same-day visit with a nurse practitioner.”

At press time, PDS was still in the planning phase for its first office in the MemorialCare partnership. “We are envisioning having a shared reception area/lobby for patients, advertising both medical services and dental services,” says Thorne. “In the clinical areas, there will be a dental clinical space operated by PDS and a medical space operated by MemorialCare.”

Social determinants

Studies support that oral/systemic health integration can benefit just about anyone. But it may be particularly important to those who live with challenging social determinants of health.

“The benefits of integration are greatest for Zufall Health patients who are most vulnerable or who experience the highest barriers to care,” says President and CEO Frances Palm, MPA. This includes people who have little to no English language skills (about 66 percent of Zufall patients), low health literacy, low income (88 percent of Zufall patients), limited transportation access, and no health insurance (more than half of Zufall patients).

Zufall Health dental patients receive oral healthcare from dentists, including dental residents; registered dental hygienists, and community dental health coordinators, or CDHCs, who help vulnerable patients overcome barriers to dental care and navigate the dental care system, she says.

Where’s it headed?

“The concept of having a doctor and dentist together in the same office is new, so we may encounter some questions and it may take time for patients to understand and take advantage of the opportunities,” says Dr. Schafer at MemorialCare Medical Group. “But we believe the added convenience and access to both medical care and dental care will quickly create many supporters of the concept.”

“Health care systems, including hospitals and federally qualified health centers, are thinking of patient-centered care and building healthcare provider teams,” says Tamanna Tiwari, BDS, MDS, MPH, a board member of Delta Dental of Colorado and an author of Delta Dental Institute’s white paper on medical-dental integration models. “However, the sustainability of [medical dental integration] models also depends on bi-directional interprofessional training and practice, including training medical professionals on oral healthcare, and dental providers on overall health.”

Says Thorne, “Given the linkages between oral health and certain systemic diseases, it is clear there are many benefits to reimagining healthcare around each patient, including reducing medical costs and annual hospitalizations. But the biggest benefit of collaboration is the overall improvement of patient health.

Still, he says, “Revolutionizing healthcare is not easy.”

Sidebar 1:

Five ways oral health can influence overall health

Respiratory health. Patients with ventilator-associated pneumonia (VAP) who engaged in regular toothbrushing spent significantly less time on mechanical ventilation than other VAP patients.
Adverse birth outcomes. Gum disease among pregnant women is associated with preterm births, low birthweight babies and preeclampsia, a pregnancy complication that can cause organ damage and can be fatal.
Diabetes. Diabetes raises the risk of developing gum disease by 86%.
Stroke. People with gum disease are three times more likely to have a stroke involving blood vessels in the back of the brain, which controls vision and other bodily functions.
Blood pressure. People who delayed dental care during their teens and early adult years are more likely to be diagnosed with high blood pressure.

Source: DentaQuest, whatsnew.dentaquest.com/critical-connections-five-facts-about-oral-healths-influence-on-the-body

Sidebar 2:

Putting together the medical/dental team

Medical dental integration works best in offices with shared electronic patient records and physical layouts that facilitate collaboration. But it can’t work without medical and dental professionals who embrace the concept and welcome a new way of practicing healthcare.

“We have learned that integrating a new kind of provider into a medical team is challenging and takes time and support, but that with the right people and commitment, it can be successful,” says Patricia Braun, M.D., a Denver pediatrician and program evaluator for the Colorado Medical-Dental Integration project. “We have developed a change package, which is a set of key drivers of successful medical-dental integration. These include buy-in from leadership and providers, the right hygienist who is willing to work in a non-traditional setting with a very different team, and time to create efficient workflows. Communication is key.

“The medical team members must buy in to the importance of oral health and add it to their priorities for the visit,” she says. “This means identifying patients who would most benefit from seeing the hygienist and completing a warm hand-off to the hygienist. Prioritizing the needs of the patient is also important. Sometimes their oral health is one of the biggest needs, and at other visits, there are more important health priorities.”

Mark Schafer, M.D., CEO, MemorialCare Medical Group in Southern California, says, “While there has been a lot of medical literature over the last 20 years about the mouth/body connection, it is not emphasized in medical school or subsequent training. MemorialCare and Pacific Dental Services physicians and staff will spend some time at the beginning of our partnership to educate each other and become more knowledgeable about each other’s area of expertise.”

Organizational culture is a key ingredient to integrating medical and dental teams, according to Frances Palm, MPA, president and CEO of Zufall Health, headquartered in Dover, New Jersey. “Medical and dental providers and staff are motivated by the same goal – reducing barriers to healthcare and facilitating improved health outcomes for patients. They recognize the essential nature and connection between oral health and the rest of medical care, and Zufall providers participate in continuing education training that covers both medical and dental topics.”

Sidebar 3:

CDC encouraging medical dental integration

In 2021 the Centers for Disease Control and Prevention’s Division of Oral Health awarded funding to the National Association of Chronic Disease Directors to develop a National Action Framework for medical dental integration. The framework would outline opportunities to integrate medical and dental services in different healthcare and public health settings to support populations with unmet oral health needs and associated chronic diseases.

Following research on oral health and chronic disease plans, NACDD, CDC and KDH Research & Communication (KDHRC) identified four pillars that are necessary to support whole-person integrated care, says Barbara Park, RDH, MPH, public health consultant for NACDD:

Awareness. Increase recognition, knowledge, understanding and perception about equitable, whole-person integrated care and the oral-systemic connection across the lifespan.
Workforce development and operations. Prepare healthcare professionals and other professionals to work across disciplines; establish organizational structures to facilitate collaboration; and empower staff to use systems that support whole-person integrated care.
Information exchange. Share and promote access to meaningful and actionable information.
Payment. Implement sustainable financing, reimbursement and incentives for systems and patient care that support equity and optimal patient health outcomes.

“We have learned … that medical dental integration is ‘easier’ to implement in closed systems of care,” says Park. Such systems include Federally Qualified Health Centers; HMOs such as Kaiser Permanente, which include dental services; Veterans Affairs facilities; and safety net clinics that provide coordination of health services – medical, behavioral, dental, etc. – for their clients, many of whom have multiple chronic conditions that put them at high-risk for complications from unmet dental needs.