AUDUBON CLINIC QUALITY IMPROVEMENT PROJECT

2011-2012

Optimizing Dental Health

Background

Background

Dental caries prevalence: 41% of children between age 2-11 years 80% of children between age 5-18 years

Visit to physician/visit to dentist: 250/1 89% of <1 year old have physician visits 1.5% of <1 year old have dentist visits

Average wait time to see a Pediatric dentist in NYC is 3-6 months.

AAP Recommendations

Periodic oral health risk assessmentsDietary counseling and anticipatory guidanceUse of fluoride containing toothpasteFluoride varnish applicationEstablished dental home by 1 year of age

Aim Statement

Pediatric Dental Referrals:

Increase the percentage of patients referred to a pediatric dentist by 1 year of age from 10% to 40% by June 2012

Improve the teaching and anticipatory guidance for dental issues delivered by the pediatricians in our clinic

Include age based counseling for ages 1-3

Increase documentation of dental referrals and counseling

Baseline Measurement: July 2011

10%

90%

12-15 month olds with Referrals to Pediatric DentistNo Referral Given to Pediatric Dentist

Interventions

PDSA Cycle 1 QI Didactic for Health Care Providers Age-Appropriate Dental Information Handouts Dental Clinic Referral Sheets

Age-Appropriate Dental Information Handouts

Dental Clinic Referral Sheets

Interventions

PDSA Cycle 1 QI Didactic for Health Care Providers Age-Appropriate Dental Information Handouts Dental Clinic Referral Sheets

PDSA Cycle 2 Signs hung in Rooms Informed MAs, Nurses, and PFAs PFAs given copies of referral handouts

Dental Screening Poster

Chart ReviewPatient Name

Interventions

PDSA Cycle 1 QI Didactic for Health Care Providers Age-Appropriate Dental Information Handouts Dental Clinic Referral Sheets

PDSA Cycle 2 Signs hung in Rooms Informed MAs, Nurses, and PFAs PFAs given copies of referral handouts

PDSA Cycle 3 Staff Education Dental Board created in Hallways

Dental Board

Chart Review: Results Table

Baseline Measurement

PhaseAfter PDSA

Cycle 1After PDSA

Cycle 2After PDSA

Cycle 3

% of 12mo Dental

Referrals

10

(4/38)

25

(5/20)

80

(20/25)

50

(16/33)

% of 15mo Dental

Referrals

10

(4/38)

40

(4/10)

77

(17/22)

70

(14/20)

% of 18mo Dental

Referrals N/A N/A N/A

70

(7/10)

Percent of Patients Receiving Dental Referrals

Baseli

ne M

easu

re...

After P

DSA Cyc

le 1

After P

DSA Cyc

le 2

After P

DSA Cyc

le 3

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

10%

25%

80%

50%

10%

40%

77%

70% Dental Referrals 12mo

Dental Referrals 15mo

Percent of Patients Receiving Dental Referrals

A Different Way to Look at the Same Data

12mo 15mo0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Perc

ent

of P

atie

nts

Percentage of Patients with Scheduled Dental Appointments

Measurement After PDSA Cycle 1

After PDSA Cycle 2

After PDSA Cycle 3

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

12mo

15mo

QI Project Final Chart Review: May 2012

12mo 15mo 18mo0%

10%

20%

30%

40%

50%

60%

70%

80%

Perc

ent

of P

atie

nts

Aim Statement Revisited

Pediatric Dental Referrals:

Increase the percentage of patients referred to a pediatric dentist by 1 year of age from 10% to 40% by June 2012

Improve the teaching and anticipatory guidance for dental issues delivered by the pediatricians in our clinic

Include age based counseling for ages 1-3

Increase documentation of dental referrals and counseling

✔

✔✔✔

Limitations and Difficulties

“No Teeth” recorded on multiple charts when reviewed No dental referral given at that time

Ultimate outcome measure of the project is that each child has a dental "medical" home Project was limited in its ability to measure this

Anticipatory guidance for 1 year visit in Eclipsys does not prompt dental referrals But the anticipatory guidance page for the 2 year visit does

Limitations and Difficulties

“No Teeth” recorded on multiple charts when reviewed No dental referral given at that time

Ultimate outcome measure of the project is that each child has a dental "medical" home Project was limited in its ability to measure this

Anticipatory guidance for 1 year visit in Eclipsys does not prompt dental referrals But the anticipatory guidance page for the 2 year visit does

Spreading QI Project to Other ACN Sites

Fluoride Varnish: The Next Step?

oFluoride varnish can be applied by a Pediatrician in office and by Pediatric DentistsoFluoride Varnish is recommended for all high risk patients identified

Alex Glick Jennifer Guimbellot Caitlin Haxel Marleine Ishak Elaine Lin Genevieve London Katie Offer Ryan Morgan Erin C. Qualter Shawndip Sen Evan Sherman Rebecca Turcotte

Doctors: Mariellen Lane Connie Kostacos Melissa Stockwell Valerie Niketakis Betsy Pfeffer Karen Soren Nikki Timko Betsy Wedemeyer Larry Williams Daryl Wisler

QI at Audubon

Jackie Baker Kelly Burke Nitin Chanana Wendy Chang Amelie Collins Danis Copenhaver Nina Dadlez Valerio Dorrello Pam Fazzio Cristina Fernandez Sarah Fleet

QI at Audubon

Nurses Beverly Kim Diana Decharo Ernestina Amoah Estela Padron Jasmine Ortiz Adora Brown Vicki Bernstein

Medical Assistants Doreen Pittman Hasse Nolasco Ivette Pinto-Velez Jean Adedipe-Jonadu Jessie Lyons Stacyann Halm

Site Administrators and Patient Financial Advisors

Luis Brito Dulcelyn Caba Kecia Davis Roxanne DeSoto Alfred Mancebo Vivian Yajayra Rojas Yoima Sosa Kim Moore Steele Tina Veloz

QI at Audubon

Nurses Beverly Kim Diana Decharo Ernestina Amoah Estela Padron Jasmine Ortiz Adora Brown Vicki Bernstein

Medical Assistants Doreen Pittman Hasse Nolasco Ivette Pinto-Velez Jean Adedipe-Jonadu Jessie Lyons Stacyann Halm

Site Administrators and Patient Financial Advisors

Luis Brito Dulcelyn Caba Kecia Davis Roxanne DeSoto Alfred Mancebo Vivian Yajayra Rojas Yoima Sosa Kim Moore Steele Tina Veloz

References

o http://www.usetinc.org/Libraries/THPS/Fluoride_Varnish_Manual.sflb.ashxo http://pediatrics.aappublications.org/content/115/1/e69.fullo http://www.youtube.com/watch?v=8A5jrVuxSHco http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdfo http://pediatrics.aappublications.org/content/122/6/1387.full.pdf+html