With funding from The Duke Endowment, we have designed an integrated care model (primary care and oral health) to improve diabetes-related clinical indicators. Our design focuses on equipping rural family medicine residents with oral health interprofessional practice competencies and cultivating a referral network of community dentists to participate in diabetes management. We are currently developing a new rural dental medicine faculty member for the McLeod Rural Family Medicine Residency program to provide ongoing leadership to MOLAR.
Goals for MOLAR
- Improved clinical diabetes-related outcomes (reduced A-1-c levels)
- Improved access to dental care;
- Reduced likelihood of inpatient hospitalizations due to poorly controlled diabetes;
- Reduced emergency room visits due to unmet dental needs and diabetes control;
- Cost efficiencies to the system (providers and insurers).
Florence County is designated as a Dental Health Professional Shortage Area for Low Income Populations. That means there is an adequate supply of dentists for the general population but not for people Medicaid enrollees or the uninsured. The good news is there is a pool of dentists to whom we can appeal as potential partners for our project. One of our principle partners is HopeHealth Inc., a federally qualified health center who recently received a federal oral health expansion grant. The two-year award provides basic funding for them to establish a new dental program to serve the vulnerable residents of Florence. They have agreed to be a care partner for our patients.
It has been established for people with uncontrolled diabetes that addressing unmet dental needs improves oral health and chronic disease outcomes. Systemic inflammation, which can originate in the gums (periodontal tissue) elevate A-1-c levels. By controlling the inflammation through routine cleaning that involves going below the gumline, the clinical team has a better chance of reducing A-1-c levels.
There have been only three population-based analyses that assess the impact of integrating oral health services as a part of chronic disease management. A meta-analysis demonstrates that a savings of $10,000 per person per annum is realized when periodontal care and inflammation management are provided for adults with elevated A-1-c levels. These cost savings are more likely to be realized through reductions in inpatient admissions due to elevated A-1-c levels. For Medicaid alone, there were 214 inpatient discharges for elevated A-1-C levels totaling over $1 million in paid claims (2016). Therefore, we propose to engage in collaborative care management for our patients with uncontrolled diabetes by integrating oral health promotion, risk assessment, and treatment completion within our system including community partners.
Our project purpose is to demonstrate a model that achieves the Triple Aim for priority populations through evidence-based oral health integration and interprofessional practice. Priority patients are defined as those with uncontrolled diabetes and have unmet dental needs. Our model is organized in four domains: integrated care delivery, integrated residency training, technical assistance, and sustainable evidence-based reimbursement policy.
Partnerships are essential to operationalizing our four domains. For the integrated care delivery component, we will hire a new rural Dental Medicine Faculty member. As a System Oral Health Champion, he/she will cultivate referral networks and provide consults for emergency room patients. He/she will work with MUSC, community dentists, and Hope Health to ensure priority patients receive collaborative referral management services so that oral health becomes an integrated component of overall diabetes management. He/she will become provider of record for patients without or unable to find reliable dental care. He/she will provide dental services on HopeHealth’s campus as McLeod will lease three dental suites for care completion.
The new faculty will spend half his/her time at McLeod engaged in residency education and remaining effort providing direct care. As a residency educator, he/she will have three primary duties/deliverables: provide instruction for residents on oral health interprofessional practice; initiate treatment planning for priority patients without regular source of dental care; and refer patients with no regular source of dental care.
The integrated residency training program partner is MUSC. The partnership will be enhanced by faculty working collaboratively to improve the residency curriculum. The technical assistance partners include MUSC and its network of national experts from the DentaQuest Institute and the National Interprofessional Initiative in Oral Health. Technical assistance will include business model development, curriculum enhancements, dental partnership development, and patient engagement.
The sustainable evidence-based policy partners include Medicaid and SelectHealth as previously described.
Measures of Success
- Improved Outcomes & Capacity for Dental Care. We will hire a new Rural Dental Medicine Faculty member who will serve two broad roles: residency educator and systems-level oral health champion.
- Improved Skills. Our network of family medicine residents and providers involved in caring will adopt oral health interprofessional competencies including: oral health risk assessments, preventive oral health services, risk-based oral health promotion/education, and collaborative care management with dentists.
- Improved Functionality of Health Information Technology. We will achieve an optimal configuration of our health information technology tools, including our electronic health record and telehealth resources that support the data capture and exchange of patient information that ensures oral health needs are addressed throughout the system.
- Evidence-Based Policy for Oral Health Integration with Diabetes Management. We have been working for the past year with Medicaid and SelectHealth to explore how an incentive payment or bonus might codify dentists’ participation in diabetes management. They are committed to implementing the proposed project and using our findings to shape future managed care payment models or waivers that improve oral health and diabetes-related outcomes.