e-Solutions January 2015
Feature article: Oral Care is Rooted in Whole Health
Grantee Feature: Bringing Oral Health to Integrated Care
Quick Tips: 5 Ways to Incorporate Dental Care in Integrated Settings
Featured resource: Advancing Behavioral Health Integration within NCQA Recognized Patient-Centered Medical Homes
Based on an interview with Jen Koberstein, Vice President of Program Services, Dental Lifeline Network
Oral health is essential to whole health. Good oral health improves a person’s ability to speak, smile, smell, taste, and show feelings and emotions.
Dental health contributes to general health and wellness, self-esteem and quality of life. When left untreated, dental infections and can cause numerous physical health problems, including pain, complications of other chronic conditions, loss of teeth, nutritional problems, and even death.
It is important for integrated primary and behavioral health care providers to pay attention to the relationship between dental health and whole health. Individuals with diabetes or those taking certain medications for mental illnesses are at increased risk for oral health problems and dental infections, and those infections can compromise the management of co-morbid health conditions. Oral health problems can prevent individuals from being able to undergo necessary medical care, including surgeries and chemotherapy.
Including dental services in integrated health care is about more than improving health and preventing disease. It is about supporting people to not feel isolated, to have confidence, to smile again. Getting dental care can be life-changing. When a community mental health center in Colorado began a mobile dental care program, on the first day, each person came out of their appointment with tears of joy, having received comprehensive oral health care for the first time in their life.
In one study, 61 percent of people with severe mental illness reported fair to poor dental health, and more than a third had oral health problems that made it difficult for them to eat. Another study found people with severe mental illness are 3.4 times more likely to lose all their teeth than the general population.
Access and Cost
According to the National Association of Dental Plans, more than 120 million Americans do not have dental coverage, and those without coverage are 67% more likely to have heart disease and 29% more likely to have diabetes than people with dental coverage.
Preventable oral health conditions are far too often addressed in emergency departments with pain medications and antibiotics. As with all forms of health care, barriers to care can include access and cost, yet oral health also can be excluded or overlooked in whole health discussions.
How can integrated primary and behavioral health providers address oral care?
Integrated care providers do not need to have an in-house dentist to address oral health. Primary care and behavioral health providers can take steps that stress the importance of dental care to overall health and self-esteem, and play a part in the prevention and intervention of dental infections for those you serve.
Providers can begin by simply asking basic questions about oral care habits, such as the last time they visited a dentist or if they experience any tooth pain or bleeding gums. Beginning the conversation opens up the discussion for how oral care fits into health and quality of life.
It is also important for pharmacists and providers to be aware of the effect medications can have on oral health. Many antipsychotic medications can cause dry mouth or decrease resistance to infection, which can exacerbate decay and increase risk of systemic complications. People who are immunosuppressed, have had chemotherapy or have had recent surgery can be at higher risk for dental infection.
It is important for integrated care providers to be mindful of those who have had a traumatic experience and as a result may be uncomfortable seeking dental care. Integrated care providers can ask questions about past experiences to gauge the appropriate supports and comfort level of each individual in getting dental services. A brochure from the Western Massachusetts Training Consortium, a SAMHSA PBHCI grantee, outlines provider considerations for trauma survivors in dental settings.
Integrated care providers should know where to refer people for care. Many states have low-cost dental clinics and many federally-qualified health centers (FQHCs) provide dental services to individuals without dental coverage. Donated Dental Services (DDS), a program of Dental Lifeline Network, was born out of the need for comprehensive dental care for those who otherwise would have no access. Through a nationwide volunteer network, the program provides free comprehensive dental care to the elderly, to people who are medically compromised and to people living with disabilities. Social workers act as care coordinators for the program, certifying qualification for the program, assessing individuals’ needs, and connecting people to appropriate services. Providers can look up contacts in their state and refer individuals for care.
Building a relationship with dental care providers also opens the opportunity for bidirectional referrals. Oral health specialists can conduct informal behavioral health screening if they notice signs of trauma, self-injury, or substance use (e.g., meth mouth, smell of alcohol on breath) during dental exams.
It is also important to know what coverage might exist in each state. In states where there is a Medicaid Dental Benefit for adults, be sure to let enrollees know how they can access dental care.
For more on what providers can do to address oral health, check out this month’s quick tips.
Leslie DeHart, Director of Administrative Services, Central Oklahoma Community Mental Health Center
When submitting their application for SAMHSA’s Primary and Behavioral Health Care Integration (PBHCI) grant program, the Central Oklahoma Community Mental Health Center knew it would be important to include dental care. Many of the people they saw were in their twenties and couldn’t afford procedures that might save a tooth; instead they were left with only one option: tooth extraction.
For those in recovery from behavioral health conditions, poor oral care can hamper confidence. As outlined in a recent article, the benefits of a healthy smile (and the implications and misperceptions of an unhealthy one) extend well beyond health – affecting self-esteem, employment, and personal relationships. Staff at the center noted that conversations about finding employment would bring up concerns of confidence in going to job interviews – not necessarily from concerns about prior experience, but specifically concerns about the first impression.
Initially, the center struggled to find a local partner to offer dental services, and in their research for other local resources, came across the Oklahoma Dental Foundation (ODF) – a charitable dentistry focused on access and affordability. ODF established the first mobile dental care program in Oklahoma, and although the population they typically served – children and women returning from incarceration–didn’t match the center’s target population, they agreed to work with the center.
Through ODF’s MobileSmiles program, dentists and dental hygienists volunteer their time for basic services at the center. Twice a month, the mobile unit would visit the center and individuals could line up or make appointments to get basic services, including cleanings. Center staff would coordinate consent forms, schedule payments, and take care of paperwork to make it easy for individuals to use the program. The center would pay $600 per day for the van to visit. Word of mouth about the service led to requests from other individuals in the community not enrolled in the center’s care calling up to ask about taking advantage of this program.
Realizing that many clients need more than just basic care, the center partnered with Neighborhood Services, a low cost dental clinic in Oklahoma City, and the University of Oklahoma School Of Dentistry to provide a tiered system of care. Dentists and hygienists from Neighborhood Services would arrive onsite and convert an entire exam room into a setting where they could offer a more extensive suite of services, such as root canals and dentures. Surgeries and other complex procedures would be coordinated with the School of Dentistry. Coordination allowed all care providers to share records, follow up, and provide necessary aftercare. The center would pay for care, but found the program was successful when clients contributed what they could – even if it was $10.
Today, the center has yet another way to bring dental care to those they serve – through partnering with their local community health center with a complete dental clinic. Their close partnership enables them to coordinate all care – primary medical, behavioral and dental –through a shared central electronic health record.
Center staff finds it essential to include oral care in every assessment and knows that without creative community partnerships, they wouldn’t have been able to address oral health. The people they serve have noted their appreciation as well – and the goodwill from word of mouth across the community has brought new people and partnerships to the center.
How does your organization address oral care through community partnerships? Share your strategies, email firstname.lastname@example.org.
Dental health is a critical component of whole health. Here are some ways you can address oral care in your integrated care environment.
- Ask basic oral care questions during appointments to engage individuals and encourage preventive care. Questions can include if they experience any dental pain, if they have bleeding gums, or when they last visited a dentist.
- Provide educational materials on the importance of regular oral care in your center’s common areas and exam rooms. The National Institute of Dental and Craniofacial Research and the Health Resources and Sercives Administration’s Maternal and Child Oral Health Resource Center have brochures and fact sheets on a number of oral health topics.
- Know about your community’s free and no cost clinics iso that you can make referrals, as appropriate, and visit Donated Dental Services to find programs in your state.
Consider the various ways you can bring dental care to your organization such as setting up a mobile van, inviting dental professionals to your center on a regular basis, partnering with local community health centers that offer dental services, or connecting with local dental providers as part of your coordinated care efforts. Check out these resources to get this process started:
- HRSA’s Integration of Oral Health and Primary Care Practice report
- User’s Guide for Implementation of Interprofessional Oral Health Core Clinical Competencies
- Increasing Access to Dental Care through Public Private Partnerships: Contracting Between Private Dentists and Federally Qualified Health Centers
- Know your state insurance coverage laws, including whether Medicaid offers any dental benefits.
Visit our Oral Care webpage for more resources.
Advancing Behavioral Health Integration within NCQA Recognized Patient-Centered Medical Homes reviews the National Committee for Quality Assurance's (NCQA) patient-centered medical home (PCMH) standards and how they relate to the integration of behavioral health into primary care. HRSA-supported safety-net providers that have integrated behavioral health services can use this resource as a guide when preparing to apply to be recognized as a PCMH with NCQA.
The National Health Services Corps (NHSC) is accepting applications through March 30 for their Loan Repayment Program. Primary care medical, dental and behavioral health clinicians can get up to $50,000 to repay their health profession student loans in exchange for a two year commitment to work at an approved NHSC site in a high-need, underserved area. Want to learn more about the NHSC? Check out our guide to Understanding the National Health Service Corps.
SAMHSA’s new mobile app, Suicide Safe, can help primary care and behavioral health providers integrate suicide prevention strategies into their practice and reduce suicide risk among their patients. Sign up to be notified when it is released.
SAMHSA’s Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorders: A Brief Guide offers guidance on the use of medication assisted treatment (MAT) with extended-release injectable naltrexone for the treatment of opioid use disorder. It covers patient assessment, initiating MAT, monitoring progress, adjusting treatment, and deciding when to end treatment.
The CDC Division of Community Health developed a new online training, Community Approaches to Advance Health Equity, to help practitioners learn how to incorporate health equity principles into all aspects of their work. Participants will be encouraged to consider proven policy, systems, and environmental improvement strategies that address health disparities in chronic diseases. The course is available through CDC Train.
Designing Medicaid Health Homes for Individuals with Opioid Dependency: Considerations for States, from the Center for Health Care Strategies and the Centers for Medicare & Medicaid Services, identifies important considerations for states in developing opioid dependence-focused health homes, including opioid treatment program requirements, collaboration across multiple state agencies, supporting providers in transforming into health homes, and encouraging information sharing.
Coming soon from CIHS: February webinars will feature national experts to discuss best practices for integrating behavioral health into rural primary care settings and in positioning health and wellness programs as a priority in behavioral health organizations.
Check out CIHS’ archived webinars for past presentations on a variety of integrated care topics. Financing webinars include a focus on financing the health home and billing for integrated services.
Have a topic you’d like CIHS to explore on a future webinar? Let us know, email Integration@TheNationalCouncil.org.