Borrowing a Medical Model to Create an Oral Health Intervention

Innovative Models of Healthcare Delivery and Addressing Health Disparities

Brian J. Swann, DDS, MPHChief of Oral Health

Cambridge Health AllianceHarvard School of Dental Medicine

September 28, 2016

The Story

• Cambridge Health Alliance• Windsor Street Health Center

– Oral health– Primary care– Mental health– Cambridge Public Health Department– WIC Program

• Accountable Care Organization/Medical Home

Group/Shared Medical Model

• Kaiser Hospitals (Santa Clara, CA) • Ed Noffsinger (diabetes and asthma patients)• Increased access• 85% patient approval rate• Provider satisfaction• Reduced anxiety• Peer learning• Growth potential in the practice• Integrated training and learning

“How can we use this in oral health?”

Group Models

• Diabetes• Prenatal• Infant/Toddler• Dentures• New Patient Orientation

The Patient

• 69 year old white female• Past medical hx: oral cancer• Family hx: husband deceased (heart condition)• Social hx: human resource administrator• Insurance: MassHealth• Oral health: rampant tooth decay from radiation

therapy (dry mouth syndrome)• Treatment plan: full mouth extractions and

upper/lower full dentures

Removable Dentures

• Full Denture– an artificial substitute for missing natural

teeth and adjacent tissues

• Partial Denture– a dental prosthesis that supplies teeth and

associated structures on both sides of a semi-edentulous arch.

Mosby’s Dental Dictionary, ed 2; pt 163

Denture and Partial Denture

Removable Denture Statistics• 10% decline in edentulism each decade for the past 30 years

will be offset by the 79% increase in the adult population older than 55 years.

• Edentulism has increased globally by 30%.Douglass CW et al. J Prosthet Dent. 2002; 87(1): 5-8 www.WHO.int

Denture Advantages

• Most economical way to replace teeth• Mastication• Word pronunciation• Improved esthetics• Increased self-esteem

Denture Disadvantages

• Removable• Plastic• Affects taste• Reduced mastication (up to 85%)• Comfort level• Replacement is necessary• Easy to lose/break

What if?

• Lips and cheeks are supported by boneand teeth.

• Tooth loss accelerates bone loss.

Reasons for Tooth Loss

• Periodontal disease• Decay• Trauma• Medical (radiation, dry mouth)• Drugs (alcohol, tobacco, methamphetamine)• Acid reflux• Bulimia

Periodontal Disease Rampant Tooth Decay

Trauma Meth Mouth

Facts

• Dental insurance has limited benefits• Private benefit coverage (average

$1,000/year)• Public benefit coverage (limited services)• 138,000,000 no dental benefits (mostly

adults)• 93% of dentistry is private• 4% public health• Increased Emergency Department visits (ED)• Poverty and health literacy

Denture Groups

Checking Wax Bite

Results

10 weeks compared to 15-20 weeks to delivery

1.5 chair time hours = 10 patients (group)

5 chair time hours = 10 patients (individual)

Treatment TimeShared vs. Single Visits

• Time in minutes for treatment of 10 denture cases• 710 minutes for shared• 1500 minutes for single visits• 790 minutes saved

Overhead Costs, Reimbursement and Net Profit

$651

$477

$77

$1,806

$1,002

$602

$1,155

$525

$525

$0 $200 $400 $600 $800 $1,000 $1,200 $1,400 $1,600 $1,800 $2,000

Shared visits (3 patients)

Single visits with 2 periodic patients each visit

Single visits

Expenditure Reimbursement Net profit

•Net profit over the span of treatment (five 30-minute appointments - initial impression to delivery)•For shared visit - $651•For single visits - $77•For single visit with two periodic exams- $477

Drop-off Rates

• Single visits – 18%

• Shared visits – 4%

• December 2013 - December 2015

• Drop-offs were predominantly partial denture cases

Group Model Advantages

• Increases access to care• Classroom setting (educational environment)• Peer learning/support system• Reduces stress for patient and provider (survey)• Relaxing atmosphere (outside the traditional dental operatory)• Reduces wait time (appointment and delivery)• Reduces overhead (supplies and lab costs and personnel)• Increases utilization of operatory space• Increases profitability• Reduces no show rates • Integrates health disciplines (primary care, nutrition)

Group Model Disadvantages

• Limited privacy (HIPAA)• Limited treatment options• Concern about sterilization• Patients seen on a first come first serve basis• Provider ergonomics

Lessons Learned

• Innovation stems from learning and applying• Innovative efforts outweigh the risk of failure• Compliance is expected to have a direct

impact on revenue and patient/provider satisfaction

The Patient

Partner With Us

• What do we need

– Demographic information– Number of providers– Number of patients – Number of denture cases (CD & RPD)