- Email: [email protected]
Impacting Vulnerable Populations Through Integrating Oral Health Care Into Nurse-managed Health Centers
ORIGINAL RESEARCH
Impacting Vulnerable Populations Through Integrating Oral Health Care Into Nurse-managed Health Centers Loretta Vece, DNP, FNP-BC, Rebecca Sutter, DNP, FNP-BC, Caroline Sutter, DNP, FNP-BC, and Cheryl Toulouse, PhD, FNP-BC ABSTRACT
The purpose of this project was to establish an evidence-based integrated oral health care program for children in 3 nurse-managed health centers and to describe the vulnerable populations served by these clinics, their oral health needs, and the impact of the oral health integration program. This project used a mixed method, nonrandomized, cross-sectional design. All children received oral risk screening, oral examinations, oral health education, and appropriate dental referrals. Demographic data, oral health data, and program engagement and satisfaction data were collected. Results reveal unique population demographics, their unmet oral health needs, and the impact of basic oral health teaching on this vulnerable population. Keywords: integration, nurse-managed health centers, oral health, population health, primary care, vulnerable populations Ó 2016 Elsevier Inc. All rights reserved.
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his project originated because of the increasing number of patients presenting at 3 nurse-managed health centers (NMHCs) with unmet oral health needs and an acute need for dental education. Children presented with severe caries, abscesses, poor oral hygiene, and tooth pain. A review of the literature revealed that the population being served in these NMHCs was at high risk for dental caries and poor oral health and that costeffective, easily implemented interventions existed. It also revealed that the population in these clinics was unique. The literature addressed oral health in poor Medicaid populations, but children seen in these clinics were all uninsured. They fell between the cracks in our current health care system, and most did not qualify for Medicaid. Integrating oral health into primary care visits grew out of trying to meet the oral health care needs of these patients. INTRODUCTION AND LITERATURE REVIEW
Oral health care is reported to be the most common unmet health care need.1 Poor oral health is associated with dementia, stroke, cardiovascular www.npjournal.org
disease, breast cancer, pneumonia, ulcers, and autoimmune diseases.2-8 Twenty-five percent of children experience dental caries, making it the number one most prevalent disease of childhood.9 Childhood caries leads to pain, missed school, poor academic performance, low self-esteem, and expensive procedures.1,10-12 Those belonging to ethnic and racial minority groups and of low socioeconomic status are disproportionately affected by oral disease.9 These vulnerable populations often cannot access traditional primary care but instead seek care in safety net settings like NMHCs.13 NMHCs serve those most at risk by age, race, ethnicity, and socioeconomic status.13 Children present to these clinics for acute care sick visits as well as for day care, camp, and school entry physicals. NMHCs hold potential for meeting the unmet oral health care needs of this vulnerable population if oral health care can be integrated into these primary care patient encounters. Evidence supports a variety of effective oral health care interventions in primary care. A meta-analysis supports that fluoride applied in any form (toothpastes, The Journal for Nurse Practitioners - JNP
629
varnishes, or mouthwashes) leads to fewer caries regardless of whether or not water is fluoridated.14 Health care providers advising parents to seek a dental checkup for their child has been shown to nearly double the odds of a child receiving dental care.15 Research supports that oral health care teaching increases parental perception of the importance of oral hygiene, increases intent and involvement in brushing their children’s teeth, increases confidence in teaching and assisting in tooth brushing, and increases the frequency that parents brush their children’s teeth.16,17 Evidence reveals that mean carries rates drops, sippy cup use decreases, intake of fruits and vegetables increases, daily tooth brushing increases, and the rate of those establishing a relationship with a dentist doubles for patients enrolled in an integrated oral health care program through their primary care provider.18 Primary care providers implementing a structured oral health care program can positively impact patient health outcomes. AIM AND OBJECTIVES
The aim of this project was to implement an evidence-based oral health care program into 3 NMHCs. The objectives of this project were to describe the demographics and oral health needs of the vulnerable population served at the NMHCs; to intervene through providing preventive care and teaching related to oral health and hygiene skills; and to improve referral processes, coordination of care, and collaboration with local safety net dental providers. METHODS Design
This project was implemented using a mixed method, nonrandomized, cross-sectional design. Implementation involved integrating oral health care into primary care visits for children presenting for physicals. The program was structured and evaluated according to the Oral Health Delivery Framework 5step process: ask, look, decide, act, and document.19 It took place from November 2015 through February 2016. Children received an oral risk assessment and oral examination. Families received an explanation of the examination results, oral health and hygiene 630
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education, and an appropriate dental referral to a safety net dental provider as part of the routine primary care visit. Families also received toothbrushes, tooth paste, and floss as part of the oral health care program. Setting
The setting for this study was 3 academic NMHCs in Northern Virginia that provide primary care for uninsured, poor, mostly minority patients. Clinicians providing care included 6 nurse practitioners, 4 registered nurses, 2 medical assistants, 16 undergraduate nursing students, and 5 graduate nurse practitioner students. Sample
This project used a convenience sample of all parents with children presenting for physicals. Inclusion criteria required parent participants to be 18 years of age or older and able to understand either English or Spanish. Data Collection and Variables. Demographic data were collected as part of an intake questionnaire including age, race, ethnicity, primary language, and educational level. Oral health background information collected included previous dental experiences; oral health habits; and the availability of toothbrushes, toothpaste, and floss within the home. An exit questionnaire was used to evaluate receipt of care and the educational material provided. The Smiles for Life curriculum and in-service education were used to support clinician education for program implementation.20 Smiles for Life is a free, evidence-based, national oral health care curriculum designed to help integrate oral health into primary care. It is evaluated and updated annually and endorsed by multiple professional organizations. It can be found at http://www.smilesforlifeoralhealth. org. The CAMBRA tool, available in both Spanish and English through Bright Futures and the American Academy of Pediatrics, was used for child and family education. The CAMBRA is a pictorial, low reading level teaching tool for establishing oral health self-management goals. It is also available through the Smiles for Life website under the resources tab. Volume 12, Issue 9, October 2016
Data Analysis
Descriptive statistics were used to examine demographic data, oral health background data, and patient satisfaction level with the oral health education and oral health program. Theme analysis was used for open-ended, short-answer questions relating to previous dental visits, oral health education evaluation, and patient suggestions. All responses were listed, grouped by topic, and then tallied. Lists and groupings were reviewed by 3 doctorally prepared faculty members with research experience for validity and reliability. Ethical Considerations and Human Subjects Protection
Approval for this project was obtained through the institutional review board of the affiliated university. Parents of children presenting for physicals were given project information listing the risks and benefits of program participation and asked to sign a consent form before participation. RESULTS Sample Demographics
The parent sample consisted of 116 parents, which included 221 children who ranged from 2 months to 18 years of age, with 20% of children being < 3 years of age. The presenting parent was female in 60% (n ¼ 69) of families and male in 40% (n ¼ 47) of families. Parental age ranged from 18 to 62 years, with a mean of 35 years. The majority of families were Hispanic (61%) followed by Asian (21%), black (10%), white (5%), and other (3%). Parent participants were from 28 different countries. The top 5 included 30.45% (34) from El Salvador, 15.2% (17) from Guatemala, 9.8% (11) from Afghanistan, 8.6% (10) from Honduras, and 4.5% (5) from Pakistan. There were 21 different primary languages spoken by families. The top 5 included 61.2% (71) Spanish speaking, 5.2% (6) Arabic speaking, 5.2% (6) English speaking, 5.2% (6) Urdu speaking, and 4.3% (5) Pashto speaking. Seventy-one visits were conducted in Spanish, and 41 were conducted in English. The average time in the United States for participants was a mean of 6.2 months, but the median and mode were both only 1 month. Parent participants had a mean of 10.45 years of education, and the range was 0 to 22 years of school. www.npjournal.org
Over 30% had less than 7 years of schooling. Hispanics reported the lowest level of education (mean ¼ 8.5 years). Oral Health Needs
Baseline oral health care assessment data revealed that 11.2% of families did not have toothpaste or a toothbrush for everyone in the home. Brushing frequency was reported to be once daily by 23.3 %, twice daily by 44.8 %, and 3 or more times daily by 29.3% of the sample. Approximately 60% of parents reported helping with or supervising their child’s tooth brushing. Only 11% of parents reported their children flossed daily. Over 50% of parents reported they had no floss in the home. Only 46% of parents (n ¼ 54) reported having ever taken their children to the dentist. For those who had been to the dentist, the average time since a child’s last dental visit was a mean of 9.9 months. The 2 most common reasons for past dental visits included a dental cleaning and examination (n ¼ 25) or having teeth pulled (n ¼ 10). Five families reported caries were found during a dental examination, but they were left unfilled because of the costs of care. Nine families did not answer the question related to their child’s last dental visit. Approximately 60% of families had at least 1 child requiring an urgent referral (obvious caries or oral disease but no pain, abscess, bleeding, or recent trauma requiring immediate attention) or an emergent referral (obvious severe caries with oral pain, signs and symptoms of an abscess, cellulitis, or recent trauma requiring immediate attention). One quarter of families had children presenting with obvious severe caries, inflamed gums, and oral pain requiring emergent referrals. Intervention Measures
Oral risk assessment, oral examination, a verbal explanation of results, and appropriate dental referrals were received by 94.5% to 96.5% of all families with children presenting for physicals. All 116 families found the oral health education including oral hygiene, dietary education, and preventive care education helpful (3), very helpful (4), or extremely helpful (5) with a mean of 4.61 out of 5 on a 5-point The Journal for Nurse Practitioners - JNP
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Likert scale. Scale ratings were 1) very unhelpful, 2) unhelpful, 3) helpful, 4) very helpful, and 5) extremely helpful. Patient engagement was measured by clinical staff using teach back of material and return demonstration with models, as well as an open-ended question in the evaluation tool asking for a description of the most helpful part of the oral health teaching received. Approximately half of the parents responded to this short-answer question. The top 4 themes obtained from analysis of the data were 1) basic tooth brushing instruction (41 parents), 2) the safety and importance of drinking fluoridated tap water (24 parents), 3) diet education (9 parents), and 4) flossing (5 parents). Overall, parents in the clinics were satisfied with the oral health care program. They reported being satisfied (6.1%), very satisfied (19.3%), and extremely satisfied (74.6%) with the oral health care program; mean ¼ 4.68/5 on a 5-point Likert scale. The scale ratings were 1) very unsatisfied, 2) unsatisfied, 3) satisfied, 4) very satisfied, and 5) extremely satisfied. Safety Net Dental Access
Setting up an integrated oral health care program without on-site dental services was a major challenge. Safety net dental services were difficult to connect with, and patients reported problems getting through on phone lines and obtaining appointments. Collaboration with dental professionals was approached by setting up face-to-face meetings with local safety net providers to discuss how to best meet patient needs through the coordination of services, improved referral processes, and collaborative care of patients. Challenges related to working with safety net dental services started with trying to connect with them. Many safety net dental service providers and/or administrators did not return phone calls or e-mails. However, once contact was made, providers were interested in meeting. Local safety net providers reported stressors of limited capacity and tight budgets. There was success in improving referral and coordination of care processes with several providers. Local health departments in the area treat all children, regardless of documented status, who meet financial eligibility. Child access to urgent and emergent care, 632
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referral processes, and collaboration improved with these local health departments. One dental clinic began e-mail communication with the NMHC practitioners. Referrals were e-mailed to the dental clinics from the NMHCs. The dental clinic then contacted parents and made appointments, usually within 48 hours. The dental clinic e-mailed the NMHC practitioners with appointment times and then again with results and treatment plans after the child was seen. For urgent and emergent needs, they waived preregistration for eligibility and helped families with eligibility forms at the child’s first visit. However, most other clinics still required prequalification processes taking days to weeks, and some dental clinics had 2- to 3-month waiting lists. One of the successes with all clinics was the establishment of a specific referral contact person, which facilitated improved coordination of care. An updated referral list with contact information and verified costs structures was made for all local safety net dental providers. This helped streamline referral processes so that providers and social workers at the NMHCs could help patients navigate qualification and appointment processes. Despite these successes, few clinics offered any free dental care, and even with sliding scale discounted rates, dental services remain out of reach financially for many of the NMHCs’ patients. DISCUSSION
Ninety-five percent of parent participants reported minority status. On average, parents had less than a high school education and a primary language other than English. Over half of parents reported their children had received no previous dental care. None had a dental home. The majority of families had been in the US 1 month or less. Families using the NMHCs were mostly recent immigrants and refugees. These sample characteristics placed the NMHCs’ child population at high risk for caries and poor oral health outcomes.12,15 During project implementation, it was discovered that most of those without a toothbrush were children under the age of 3 years whose parents did not understand the importance of oral hygiene beginning with eruption of the first tooth. Urgent/emergent dental referrals were required by 60% of the families. Volume 12, Issue 9, October 2016
These results supported the initial premise that the NMHC population had unmet oral health needs and supported the need for a structured oral health care program. Parents discussed concerns related to the cost of care. This was the reason many reported their children not having seen a dentist or having an examination and leaving with untreated caries. This confirms research listing cost as the primary risk factor of poor access to dental care and poor oral health.21 One of the major findings from this project was the importance of the oral health educational piece to clinic patients. Learning the proper toothbrushing technique was cited as the most helpful part of the patient educational program. Teaching and practicing basic toothbrushing with the children were highly valued by parents. Information related to drinking the fluoridated tap water was second. This was unexpected. Large numbers of clinic patients were buying bottled water or boiling the tap water even though the city water where they lived was safe and fluoridated. Parents perceived and believed that all tap water was unsafe. Many had come from countries where they had to boil or use bottled water for drinking and tooth brushing. They continued those practices upon arrival here in the US. Through the oral health education program, parents learned that they did not need to spend money on bottled water or time boiling tap water in their homes. They learned that the water in the communities where they lived was not only safe but also that the fluoride in the water was beneficial, helping to prevent dental caries and maintain strong tooth enamel. Families were shocked when nurses explained the safety and benefits of the fluoridated tap water. Many thanked clinic staff for sharing information about fluoridated tap water use. In the refugee and immigrant populations these NMHCs serve, oral health education including both hygiene and fluoridated tap water information was crucial to parents. The oral health care program supplied toothbrushes, toothpaste, and floss to all patients. Over 11% did not have these supplies in the home. Often, it was the children under the age of 3, those at most risk for caries development, who were without toothbrushes. One family had children www.npjournal.org
sharing toothbrushes. Families without toothpaste reported using water to brush with because of the cost of toothpaste. The oral health care program impacted the lives of these vulnerable populations in a very concrete way by providing these basic hygiene supplies. Improving referral processes was a major component of the program. This facilitated collaborative relationships between nurse practitioners at the NMHCs and the local safety net providers. Networking and communication allowed for the development of best practice for contact and referral of patients to help insure timely appointments and coordinated care. In-person meetings proved very valuable for improving access to dental care and improving collaboration. These collaborative community relationships improve access to care for vulnerable populations. Limitations
One limitation of this study is the short implementation time. Process change takes time, and continued monitoring, evaluation, and revision are needed to maintain a new program. Data collection was performed by family and not by the individual child for the children presenting with physicals. This was a strength in that the program was able to reach siblings not being seen as patients but a drawback when multiple children in the family had different needs, which were not able to be reflected in the data. Additionally, all data were collected by selfreport, introducing the possibility of bias. RECOMMENDATIONS
Integrating oral health care into primary care safety net environments serving vulnerable populations is imperative to begin to meet the oral health care needs of those most at risk for oral disease. Recommendations include expanding the oral health care integration program in these 3 clinics to include all patients presenting for physicals and all patients presenting for chronic disease management. Maintaining communication and collaborative relationships with safety net dental providers to improve access to care and coordination of care is also important. Lastly, policy work to improve access to dental care for vulnerable populations remains a need because cost The Journal for Nurse Practitioners - JNP
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was the primary factor associated with the lack of dental care and poor oral health in this population. CONCLUSIONS
Integrating oral health care into the NMHCs has made a positive impact on patient care. Children are now receiving evidence-based oral health care including a risk assessment, oral examination, preventive care and hygiene education, and referrals as part of well-child physicals. This addresses the basic oral health care needs of the most vulnerable patient population seen by the NMHCs. The integration of an evidence-based oral health care program into the NMHCs impacted not only the patients presenting for care but also their families. A full 20% of the children reached through the oral health education were under the age of 3, not clinic patients themselves but the siblings of patients presenting for care. Drinking water practices were changed for whole families, saving them time and money. Families without oral hygiene supplies received them. Basic toothbrushing skills were acquired, and appropriate dental referrals were made for all participants. The oral health care integration program significantly impacted patient health practices, potentiating improved outcomes for many of these children in this vulnerable population. References 1. Culyer L, Brown E, Kelly KA. Oral health care for underserved children in the United States. J Community Health Nurs. 2014;31(1):1-7. 2. Freudenheim J, Genco R, LaMonte M, et al. Periodontal disease and breast cancer: prospective cohort study of postmenopausal women. Cancer Epidemiol Biomarkers Prev. 2016;25(1):43-50. 3. Gurav A, Jadhav V. Periodontitis and risk of diabetes mellitus. J Diabetes. 2011;3:21-28. 4. Kamer A, Craig R, Dasanayake A, Brys M, Glodzik-Sobanska L, De Leon M. Inflammation and Alzheimer’s disease: possible role of periodontal diseases. Alzheimers Dement. 2008;4:242-250. 5. Marinez-Maestre M, Gonzales-Cejudo C, Machuca G, Torrejon R, CasteloBranco C. Periodontitis and osteoporosis: a systematic review. Climacteric. 2010;13:523-529. 6. Scannapieco F. Role of oral bacteria in respiratory infection. J Periodontol. 1999;70:793-802. 7. Teles R, Wang C. Mechanisms involved in the association between periodontal diseases and cardiovascular disease. Oral Dis. 2011;17:450-461. 8. Van Lancker A, Verhaeghe S, Vanderwee K, Goossens J, Beekman D. The association between malnutrition and oral health status in elderly in long-term care facilities: a systematic review. Int J Nurs Stud. 2012;49(12):1568-1581.
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9. Dye B, Li X, Thornton-Evans G. Oral health disparities as determined by selected healthy people 2020 oral health objectives for the United States, 2009-2010. NCHS Data Brief. 2012;Aug(104):1-8. 10. Rozier R, Stearns S, Pahel B, Quinonez R, Park J. How a North Carolina program boosted preventive oral health services for low-income children. Health Aff (Millwood). 2010;29:2278-2285. 11. Seirawan H, Faust S, Mulligan R. The impact of oral health on the academic performance of disadvantaged children. Am J Public Health. 2012;102(9):1729-1734. 12. Weatherwax J, Bray K, Williams K, Gadbury-Amyot C. Exploration of the relationship between parent/guardian sociodemographics, intention, and knowledge and the oral health status of their children/wards enrolled in a Central Florida Head Start Program. Int J Dent Hyg. 2015;13(1):49-55. 13. Esperat M, Hanson-Turton T, Richardson M, Debisette A, Rupinata C. Nursemanaged health centers: safety-net care through advanced nursing practice. J Am Acad Nurse Pract. 2012;24:24-31. 14. Marinho V, Higgins J, Logan S, Sheiham A. Topical fluoride (toothpastes, mouth rinses, gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2003;4:CD002782. 15. Huebner C, Bell J, Reed S. Receipt of preventive oral health care by U.S. children: a population-based study of the 2005-2008 Medical Expenditure Panel Surveys. Matern Child Health J. 2013;17(9):1582-1590. 16. Mattheus D. Efficacy of oral health promotion in primary care practice during early childhood: creating positive changes in parent’s oral health beliefs and behaviors. Oral Health Dent Manag. 2014;13(2):316-319. 17. Miller A, Kameka M, Young-Whiting C. The effects of an oral health intervention on caregivers of head start children. J Natl Black Nurses Assoc. 2012;23(1):52-58. 18. Biordi D, Heitzer M, Mundy E, et al. Improving access and provision of preventive oral health care for very young, poor, and low-income children through a new interdisciplinary partnership. Am J Public Health. 2015;105(S2):E23-E29. 19. Hummel J, Phillips K, Holt B, Hayes C. Oral health: an essential component of primary care [white paper]. Seattle, WA: Qualis Health, Safety Net Medical Home Initiative. 2015. http://www.safetynetmedicalhome.org/sites/default/ files/White-Paper-Oral-Health-Primary-Care.pdf. Accessed July, 22, 2016. 20. Society of Teachers of Family Medicine. Smiles for Life: a national oral health curriculum. 2016. http://www.smilesforlifeoralhealth.org. Accessed July 11, 2016. 21. Malecki K, Wisk L, Walsh M, McWilliams C, Eggers S, Olson M. Oral health equity and unmet dental care needs in a population-based sample: findings from the Survey of the Health of Wisconsin. Am J Public Health. 2015;105(3):466-474.
Loretta Vece, DNP, FNP-BC, is a provider at Prosperity Primary Care and volunteers at Mason and Partners Clinics in Fairfax, VA; she can be reached at [email protected]. Rebecca Sutter, DNP, FNP-BC, is an assistant professor at George Mason University and codirector at Mason and Partners Clinics. Caroline Sutter, DNP, FNP-BC, is an assistant professor at George Mason University and codirector at Mason and Partners Clinics. Cheryl Toulouse, PhD, FNP-BC, is an assistant professor at George Mason University. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/16/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.07.028
Volume 12, Issue 9, October 2016
Impacting Vulnerable Populations Through Integrating Oral Health Care Into Nurse-managed Health Centers Loretta Vece, DNP, FNP-BC, Rebecca Sutter, DNP, FNP-BC, Caroline Sutter, DNP, FNP-BC, and Cheryl Toulouse, PhD, FNP-BC ABSTRACT
The purpose of this project was to establish an evidence-based integrated oral health care program for children in 3 nurse-managed health centers and to describe the vulnerable populations served by these clinics, their oral health needs, and the impact of the oral health integration program. This project used a mixed method, nonrandomized, cross-sectional design. All children received oral risk screening, oral examinations, oral health education, and appropriate dental referrals. Demographic data, oral health data, and program engagement and satisfaction data were collected. Results reveal unique population demographics, their unmet oral health needs, and the impact of basic oral health teaching on this vulnerable population. Keywords: integration, nurse-managed health centers, oral health, population health, primary care, vulnerable populations Ó 2016 Elsevier Inc. All rights reserved.
T
his project originated because of the increasing number of patients presenting at 3 nurse-managed health centers (NMHCs) with unmet oral health needs and an acute need for dental education. Children presented with severe caries, abscesses, poor oral hygiene, and tooth pain. A review of the literature revealed that the population being served in these NMHCs was at high risk for dental caries and poor oral health and that costeffective, easily implemented interventions existed. It also revealed that the population in these clinics was unique. The literature addressed oral health in poor Medicaid populations, but children seen in these clinics were all uninsured. They fell between the cracks in our current health care system, and most did not qualify for Medicaid. Integrating oral health into primary care visits grew out of trying to meet the oral health care needs of these patients. INTRODUCTION AND LITERATURE REVIEW
Oral health care is reported to be the most common unmet health care need.1 Poor oral health is associated with dementia, stroke, cardiovascular www.npjournal.org
disease, breast cancer, pneumonia, ulcers, and autoimmune diseases.2-8 Twenty-five percent of children experience dental caries, making it the number one most prevalent disease of childhood.9 Childhood caries leads to pain, missed school, poor academic performance, low self-esteem, and expensive procedures.1,10-12 Those belonging to ethnic and racial minority groups and of low socioeconomic status are disproportionately affected by oral disease.9 These vulnerable populations often cannot access traditional primary care but instead seek care in safety net settings like NMHCs.13 NMHCs serve those most at risk by age, race, ethnicity, and socioeconomic status.13 Children present to these clinics for acute care sick visits as well as for day care, camp, and school entry physicals. NMHCs hold potential for meeting the unmet oral health care needs of this vulnerable population if oral health care can be integrated into these primary care patient encounters. Evidence supports a variety of effective oral health care interventions in primary care. A meta-analysis supports that fluoride applied in any form (toothpastes, The Journal for Nurse Practitioners - JNP
629
varnishes, or mouthwashes) leads to fewer caries regardless of whether or not water is fluoridated.14 Health care providers advising parents to seek a dental checkup for their child has been shown to nearly double the odds of a child receiving dental care.15 Research supports that oral health care teaching increases parental perception of the importance of oral hygiene, increases intent and involvement in brushing their children’s teeth, increases confidence in teaching and assisting in tooth brushing, and increases the frequency that parents brush their children’s teeth.16,17 Evidence reveals that mean carries rates drops, sippy cup use decreases, intake of fruits and vegetables increases, daily tooth brushing increases, and the rate of those establishing a relationship with a dentist doubles for patients enrolled in an integrated oral health care program through their primary care provider.18 Primary care providers implementing a structured oral health care program can positively impact patient health outcomes. AIM AND OBJECTIVES
The aim of this project was to implement an evidence-based oral health care program into 3 NMHCs. The objectives of this project were to describe the demographics and oral health needs of the vulnerable population served at the NMHCs; to intervene through providing preventive care and teaching related to oral health and hygiene skills; and to improve referral processes, coordination of care, and collaboration with local safety net dental providers. METHODS Design
This project was implemented using a mixed method, nonrandomized, cross-sectional design. Implementation involved integrating oral health care into primary care visits for children presenting for physicals. The program was structured and evaluated according to the Oral Health Delivery Framework 5step process: ask, look, decide, act, and document.19 It took place from November 2015 through February 2016. Children received an oral risk assessment and oral examination. Families received an explanation of the examination results, oral health and hygiene 630
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education, and an appropriate dental referral to a safety net dental provider as part of the routine primary care visit. Families also received toothbrushes, tooth paste, and floss as part of the oral health care program. Setting
The setting for this study was 3 academic NMHCs in Northern Virginia that provide primary care for uninsured, poor, mostly minority patients. Clinicians providing care included 6 nurse practitioners, 4 registered nurses, 2 medical assistants, 16 undergraduate nursing students, and 5 graduate nurse practitioner students. Sample
This project used a convenience sample of all parents with children presenting for physicals. Inclusion criteria required parent participants to be 18 years of age or older and able to understand either English or Spanish. Data Collection and Variables. Demographic data were collected as part of an intake questionnaire including age, race, ethnicity, primary language, and educational level. Oral health background information collected included previous dental experiences; oral health habits; and the availability of toothbrushes, toothpaste, and floss within the home. An exit questionnaire was used to evaluate receipt of care and the educational material provided. The Smiles for Life curriculum and in-service education were used to support clinician education for program implementation.20 Smiles for Life is a free, evidence-based, national oral health care curriculum designed to help integrate oral health into primary care. It is evaluated and updated annually and endorsed by multiple professional organizations. It can be found at http://www.smilesforlifeoralhealth. org. The CAMBRA tool, available in both Spanish and English through Bright Futures and the American Academy of Pediatrics, was used for child and family education. The CAMBRA is a pictorial, low reading level teaching tool for establishing oral health self-management goals. It is also available through the Smiles for Life website under the resources tab. Volume 12, Issue 9, October 2016
Data Analysis
Descriptive statistics were used to examine demographic data, oral health background data, and patient satisfaction level with the oral health education and oral health program. Theme analysis was used for open-ended, short-answer questions relating to previous dental visits, oral health education evaluation, and patient suggestions. All responses were listed, grouped by topic, and then tallied. Lists and groupings were reviewed by 3 doctorally prepared faculty members with research experience for validity and reliability. Ethical Considerations and Human Subjects Protection
Approval for this project was obtained through the institutional review board of the affiliated university. Parents of children presenting for physicals were given project information listing the risks and benefits of program participation and asked to sign a consent form before participation. RESULTS Sample Demographics
The parent sample consisted of 116 parents, which included 221 children who ranged from 2 months to 18 years of age, with 20% of children being < 3 years of age. The presenting parent was female in 60% (n ¼ 69) of families and male in 40% (n ¼ 47) of families. Parental age ranged from 18 to 62 years, with a mean of 35 years. The majority of families were Hispanic (61%) followed by Asian (21%), black (10%), white (5%), and other (3%). Parent participants were from 28 different countries. The top 5 included 30.45% (34) from El Salvador, 15.2% (17) from Guatemala, 9.8% (11) from Afghanistan, 8.6% (10) from Honduras, and 4.5% (5) from Pakistan. There were 21 different primary languages spoken by families. The top 5 included 61.2% (71) Spanish speaking, 5.2% (6) Arabic speaking, 5.2% (6) English speaking, 5.2% (6) Urdu speaking, and 4.3% (5) Pashto speaking. Seventy-one visits were conducted in Spanish, and 41 were conducted in English. The average time in the United States for participants was a mean of 6.2 months, but the median and mode were both only 1 month. Parent participants had a mean of 10.45 years of education, and the range was 0 to 22 years of school. www.npjournal.org
Over 30% had less than 7 years of schooling. Hispanics reported the lowest level of education (mean ¼ 8.5 years). Oral Health Needs
Baseline oral health care assessment data revealed that 11.2% of families did not have toothpaste or a toothbrush for everyone in the home. Brushing frequency was reported to be once daily by 23.3 %, twice daily by 44.8 %, and 3 or more times daily by 29.3% of the sample. Approximately 60% of parents reported helping with or supervising their child’s tooth brushing. Only 11% of parents reported their children flossed daily. Over 50% of parents reported they had no floss in the home. Only 46% of parents (n ¼ 54) reported having ever taken their children to the dentist. For those who had been to the dentist, the average time since a child’s last dental visit was a mean of 9.9 months. The 2 most common reasons for past dental visits included a dental cleaning and examination (n ¼ 25) or having teeth pulled (n ¼ 10). Five families reported caries were found during a dental examination, but they were left unfilled because of the costs of care. Nine families did not answer the question related to their child’s last dental visit. Approximately 60% of families had at least 1 child requiring an urgent referral (obvious caries or oral disease but no pain, abscess, bleeding, or recent trauma requiring immediate attention) or an emergent referral (obvious severe caries with oral pain, signs and symptoms of an abscess, cellulitis, or recent trauma requiring immediate attention). One quarter of families had children presenting with obvious severe caries, inflamed gums, and oral pain requiring emergent referrals. Intervention Measures
Oral risk assessment, oral examination, a verbal explanation of results, and appropriate dental referrals were received by 94.5% to 96.5% of all families with children presenting for physicals. All 116 families found the oral health education including oral hygiene, dietary education, and preventive care education helpful (3), very helpful (4), or extremely helpful (5) with a mean of 4.61 out of 5 on a 5-point The Journal for Nurse Practitioners - JNP
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Likert scale. Scale ratings were 1) very unhelpful, 2) unhelpful, 3) helpful, 4) very helpful, and 5) extremely helpful. Patient engagement was measured by clinical staff using teach back of material and return demonstration with models, as well as an open-ended question in the evaluation tool asking for a description of the most helpful part of the oral health teaching received. Approximately half of the parents responded to this short-answer question. The top 4 themes obtained from analysis of the data were 1) basic tooth brushing instruction (41 parents), 2) the safety and importance of drinking fluoridated tap water (24 parents), 3) diet education (9 parents), and 4) flossing (5 parents). Overall, parents in the clinics were satisfied with the oral health care program. They reported being satisfied (6.1%), very satisfied (19.3%), and extremely satisfied (74.6%) with the oral health care program; mean ¼ 4.68/5 on a 5-point Likert scale. The scale ratings were 1) very unsatisfied, 2) unsatisfied, 3) satisfied, 4) very satisfied, and 5) extremely satisfied. Safety Net Dental Access
Setting up an integrated oral health care program without on-site dental services was a major challenge. Safety net dental services were difficult to connect with, and patients reported problems getting through on phone lines and obtaining appointments. Collaboration with dental professionals was approached by setting up face-to-face meetings with local safety net providers to discuss how to best meet patient needs through the coordination of services, improved referral processes, and collaborative care of patients. Challenges related to working with safety net dental services started with trying to connect with them. Many safety net dental service providers and/or administrators did not return phone calls or e-mails. However, once contact was made, providers were interested in meeting. Local safety net providers reported stressors of limited capacity and tight budgets. There was success in improving referral and coordination of care processes with several providers. Local health departments in the area treat all children, regardless of documented status, who meet financial eligibility. Child access to urgent and emergent care, 632
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referral processes, and collaboration improved with these local health departments. One dental clinic began e-mail communication with the NMHC practitioners. Referrals were e-mailed to the dental clinics from the NMHCs. The dental clinic then contacted parents and made appointments, usually within 48 hours. The dental clinic e-mailed the NMHC practitioners with appointment times and then again with results and treatment plans after the child was seen. For urgent and emergent needs, they waived preregistration for eligibility and helped families with eligibility forms at the child’s first visit. However, most other clinics still required prequalification processes taking days to weeks, and some dental clinics had 2- to 3-month waiting lists. One of the successes with all clinics was the establishment of a specific referral contact person, which facilitated improved coordination of care. An updated referral list with contact information and verified costs structures was made for all local safety net dental providers. This helped streamline referral processes so that providers and social workers at the NMHCs could help patients navigate qualification and appointment processes. Despite these successes, few clinics offered any free dental care, and even with sliding scale discounted rates, dental services remain out of reach financially for many of the NMHCs’ patients. DISCUSSION
Ninety-five percent of parent participants reported minority status. On average, parents had less than a high school education and a primary language other than English. Over half of parents reported their children had received no previous dental care. None had a dental home. The majority of families had been in the US 1 month or less. Families using the NMHCs were mostly recent immigrants and refugees. These sample characteristics placed the NMHCs’ child population at high risk for caries and poor oral health outcomes.12,15 During project implementation, it was discovered that most of those without a toothbrush were children under the age of 3 years whose parents did not understand the importance of oral hygiene beginning with eruption of the first tooth. Urgent/emergent dental referrals were required by 60% of the families. Volume 12, Issue 9, October 2016
These results supported the initial premise that the NMHC population had unmet oral health needs and supported the need for a structured oral health care program. Parents discussed concerns related to the cost of care. This was the reason many reported their children not having seen a dentist or having an examination and leaving with untreated caries. This confirms research listing cost as the primary risk factor of poor access to dental care and poor oral health.21 One of the major findings from this project was the importance of the oral health educational piece to clinic patients. Learning the proper toothbrushing technique was cited as the most helpful part of the patient educational program. Teaching and practicing basic toothbrushing with the children were highly valued by parents. Information related to drinking the fluoridated tap water was second. This was unexpected. Large numbers of clinic patients were buying bottled water or boiling the tap water even though the city water where they lived was safe and fluoridated. Parents perceived and believed that all tap water was unsafe. Many had come from countries where they had to boil or use bottled water for drinking and tooth brushing. They continued those practices upon arrival here in the US. Through the oral health education program, parents learned that they did not need to spend money on bottled water or time boiling tap water in their homes. They learned that the water in the communities where they lived was not only safe but also that the fluoride in the water was beneficial, helping to prevent dental caries and maintain strong tooth enamel. Families were shocked when nurses explained the safety and benefits of the fluoridated tap water. Many thanked clinic staff for sharing information about fluoridated tap water use. In the refugee and immigrant populations these NMHCs serve, oral health education including both hygiene and fluoridated tap water information was crucial to parents. The oral health care program supplied toothbrushes, toothpaste, and floss to all patients. Over 11% did not have these supplies in the home. Often, it was the children under the age of 3, those at most risk for caries development, who were without toothbrushes. One family had children www.npjournal.org
sharing toothbrushes. Families without toothpaste reported using water to brush with because of the cost of toothpaste. The oral health care program impacted the lives of these vulnerable populations in a very concrete way by providing these basic hygiene supplies. Improving referral processes was a major component of the program. This facilitated collaborative relationships between nurse practitioners at the NMHCs and the local safety net providers. Networking and communication allowed for the development of best practice for contact and referral of patients to help insure timely appointments and coordinated care. In-person meetings proved very valuable for improving access to dental care and improving collaboration. These collaborative community relationships improve access to care for vulnerable populations. Limitations
One limitation of this study is the short implementation time. Process change takes time, and continued monitoring, evaluation, and revision are needed to maintain a new program. Data collection was performed by family and not by the individual child for the children presenting with physicals. This was a strength in that the program was able to reach siblings not being seen as patients but a drawback when multiple children in the family had different needs, which were not able to be reflected in the data. Additionally, all data were collected by selfreport, introducing the possibility of bias. RECOMMENDATIONS
Integrating oral health care into primary care safety net environments serving vulnerable populations is imperative to begin to meet the oral health care needs of those most at risk for oral disease. Recommendations include expanding the oral health care integration program in these 3 clinics to include all patients presenting for physicals and all patients presenting for chronic disease management. Maintaining communication and collaborative relationships with safety net dental providers to improve access to care and coordination of care is also important. Lastly, policy work to improve access to dental care for vulnerable populations remains a need because cost The Journal for Nurse Practitioners - JNP
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was the primary factor associated with the lack of dental care and poor oral health in this population. CONCLUSIONS
Integrating oral health care into the NMHCs has made a positive impact on patient care. Children are now receiving evidence-based oral health care including a risk assessment, oral examination, preventive care and hygiene education, and referrals as part of well-child physicals. This addresses the basic oral health care needs of the most vulnerable patient population seen by the NMHCs. The integration of an evidence-based oral health care program into the NMHCs impacted not only the patients presenting for care but also their families. A full 20% of the children reached through the oral health education were under the age of 3, not clinic patients themselves but the siblings of patients presenting for care. Drinking water practices were changed for whole families, saving them time and money. Families without oral hygiene supplies received them. Basic toothbrushing skills were acquired, and appropriate dental referrals were made for all participants. The oral health care integration program significantly impacted patient health practices, potentiating improved outcomes for many of these children in this vulnerable population. References 1. Culyer L, Brown E, Kelly KA. Oral health care for underserved children in the United States. J Community Health Nurs. 2014;31(1):1-7. 2. Freudenheim J, Genco R, LaMonte M, et al. Periodontal disease and breast cancer: prospective cohort study of postmenopausal women. Cancer Epidemiol Biomarkers Prev. 2016;25(1):43-50. 3. Gurav A, Jadhav V. Periodontitis and risk of diabetes mellitus. J Diabetes. 2011;3:21-28. 4. Kamer A, Craig R, Dasanayake A, Brys M, Glodzik-Sobanska L, De Leon M. Inflammation and Alzheimer’s disease: possible role of periodontal diseases. Alzheimers Dement. 2008;4:242-250. 5. Marinez-Maestre M, Gonzales-Cejudo C, Machuca G, Torrejon R, CasteloBranco C. Periodontitis and osteoporosis: a systematic review. Climacteric. 2010;13:523-529. 6. Scannapieco F. Role of oral bacteria in respiratory infection. J Periodontol. 1999;70:793-802. 7. Teles R, Wang C. Mechanisms involved in the association between periodontal diseases and cardiovascular disease. Oral Dis. 2011;17:450-461. 8. Van Lancker A, Verhaeghe S, Vanderwee K, Goossens J, Beekman D. The association between malnutrition and oral health status in elderly in long-term care facilities: a systematic review. Int J Nurs Stud. 2012;49(12):1568-1581.
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9. Dye B, Li X, Thornton-Evans G. Oral health disparities as determined by selected healthy people 2020 oral health objectives for the United States, 2009-2010. NCHS Data Brief. 2012;Aug(104):1-8. 10. Rozier R, Stearns S, Pahel B, Quinonez R, Park J. How a North Carolina program boosted preventive oral health services for low-income children. Health Aff (Millwood). 2010;29:2278-2285. 11. Seirawan H, Faust S, Mulligan R. The impact of oral health on the academic performance of disadvantaged children. Am J Public Health. 2012;102(9):1729-1734. 12. Weatherwax J, Bray K, Williams K, Gadbury-Amyot C. Exploration of the relationship between parent/guardian sociodemographics, intention, and knowledge and the oral health status of their children/wards enrolled in a Central Florida Head Start Program. Int J Dent Hyg. 2015;13(1):49-55. 13. Esperat M, Hanson-Turton T, Richardson M, Debisette A, Rupinata C. Nursemanaged health centers: safety-net care through advanced nursing practice. J Am Acad Nurse Pract. 2012;24:24-31. 14. Marinho V, Higgins J, Logan S, Sheiham A. Topical fluoride (toothpastes, mouth rinses, gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2003;4:CD002782. 15. Huebner C, Bell J, Reed S. Receipt of preventive oral health care by U.S. children: a population-based study of the 2005-2008 Medical Expenditure Panel Surveys. Matern Child Health J. 2013;17(9):1582-1590. 16. Mattheus D. Efficacy of oral health promotion in primary care practice during early childhood: creating positive changes in parent’s oral health beliefs and behaviors. Oral Health Dent Manag. 2014;13(2):316-319. 17. Miller A, Kameka M, Young-Whiting C. The effects of an oral health intervention on caregivers of head start children. J Natl Black Nurses Assoc. 2012;23(1):52-58. 18. Biordi D, Heitzer M, Mundy E, et al. Improving access and provision of preventive oral health care for very young, poor, and low-income children through a new interdisciplinary partnership. Am J Public Health. 2015;105(S2):E23-E29. 19. Hummel J, Phillips K, Holt B, Hayes C. Oral health: an essential component of primary care [white paper]. Seattle, WA: Qualis Health, Safety Net Medical Home Initiative. 2015. http://www.safetynetmedicalhome.org/sites/default/ files/White-Paper-Oral-Health-Primary-Care.pdf. Accessed July, 22, 2016. 20. Society of Teachers of Family Medicine. Smiles for Life: a national oral health curriculum. 2016. http://www.smilesforlifeoralhealth.org. Accessed July 11, 2016. 21. Malecki K, Wisk L, Walsh M, McWilliams C, Eggers S, Olson M. Oral health equity and unmet dental care needs in a population-based sample: findings from the Survey of the Health of Wisconsin. Am J Public Health. 2015;105(3):466-474.
Loretta Vece, DNP, FNP-BC, is a provider at Prosperity Primary Care and volunteers at Mason and Partners Clinics in Fairfax, VA; she can be reached at [email protected]. Rebecca Sutter, DNP, FNP-BC, is an assistant professor at George Mason University and codirector at Mason and Partners Clinics. Caroline Sutter, DNP, FNP-BC, is an assistant professor at George Mason University and codirector at Mason and Partners Clinics. Cheryl Toulouse, PhD, FNP-BC, is an assistant professor at George Mason University. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/16/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.07.028
Volume 12, Issue 9, October 2016