Minnesota Extends Oral Healthcare Delivery to Impact Population Health.

UNLABELLED: Collaborative leadership and stakeholder engagement have created the concept of dental therapist intraprofessional dental team members who are expanding and extending the reach of oral health care to help meet the public need in Minnesota. BACKGROUND AND PURPOSE: Partially owing to inadequate access to affordable oral health care, health disparities exist within Minnesota's population with significant numbers of residents lacking access to basic oral health care. Policymakers, advocacy organizations, and dental professionals recommended action to address these issues. In 2009, Minnesota became the first state government in the United States to license 2 levels of practitioners, the dental therapist and the advanced dental therapist to primarily treat underserved patients. The purpose of this article is to explain the evolution of the dental therapist and guide other constituencies toward innovative dental hygiene-based workforce models. METHODS: The evolution and educational preparation of the dental therapist and advanced dental therapist are explained in the context of a unique working relationship between educators, legislators, educational institutions, and the Minnesota Department of Health. Pivotal societal, public health, and legislative issues are described from the initial stages in 2005 until 2014 when early data are emerging regarding the impact of dental therapists. CONCLUSIONS: Dental therapist oral health care providers are working in a variety of settings in Minnesota including community clinics, hospitals, and private practices. As of early February 2014, there were 32 licensed dental therapists, and 6 of whom also held certifications as advanced dental therapists. Initial public health impacts are positive; research regarding the benefits to the public is in its infancy. Further evaluation of outcomes will ascertain the viability of this new professional.

Integrating tobacco dependence counseling into electronic dental records: a multi-method approach.

Dentistry has historically seen tobacco dependence as a medical problem. As a consequence, dentistry has not adopted or developed effective interventions to deal with tobacco dependence. With the expanded use of electronic dental records, the authors identified an opportunity to incorporate standardized expert support for tobacco dependence counseling during the dental visit. Using qualitative results from observations and focus groups, a decision support system was designed that suggested discussion topics based on the patient's desire to quit and his or her level of nicotine addiction. Because dental providers are always pressed for time, the goal was a three-minute average intervention interval. To fulfill the provider's need for an easy way to track ongoing interventions, script usage was recorded. This process helped the provider track what he or she had said to the patient about tobacco dependence during previous encounters and to vary the messages. While the individual elements of the design process were not new, the combination of them proved to be very effective in designing a usable and accepted intervention. The heavy involvement of stakeholders in all components of the design gave providers and administrators ownership of the final product, which was ultimately adopted for use in all the clinics of a large dental group practice in Minnesota.

Computer-assisted guidance for dental office tobacco-cessation counseling: a randomized controlled trial.

BACKGROUND: Decreases in smoking prevalence from recent decades have slowed, and national goals to reduce tobacco use remain unmet. Healthcare providers, including those in physician and dental teams, have access to evidence-based guidelines to help patients quit smoking. Translation of those guidelines into practice, however, remains low. Approaches that involve screening for drug use, brief intervention, and referral to treatment (SBIRT) are a promising, practical solution. PURPOSE: This study examined whether dentists and dental hygienists would assess interest in quitting, deliver a brief tobacco intervention, and refer to a tobacco quitline more frequently as reported by patients if given computer-assisted guidance in an electronic patient record versus a control group providing usual care. DESIGN: A blocked, group-randomized trial was conducted from November 2010 to April 2011. Randomization was conducted at the clinic level. Patients nested within clinics represented the lowest-level unit of observation. SETTING/PARTICIPANTS: Participants were patients in HealthPartners dental clinics. INTERVENTION: Intervention clinics were given a computer-assisted tool that suggested scripts for patient discussions. Usual care clinics provided care without the tool. MAIN OUTCOME MEASURES: Primary outcomes were post-appointment patient reports of the provider assessing interest in quitting, delivering a brief intervention, and referring them to a quitline. RESULTS: Patient telephone surveys (72% response rate) indicated that providers assessed interest in quitting (control 70% vs intervention 87%, p=0.0006); discussed specific strategies for quitting (control 26% vs intervention 47%, p=0.003); and referred the patient to a tobacco quitline (control 17% vs intervention 37%, p=0.007) more frequently with the support of a computer-assisted tool integrated into the electronic health record. CONCLUSIONS: Clinical decision support embedded in electronic health records can effectively help providers deliver tobacco interventions. These results build on evidence in medical settings supporting this approach to improve provider-delivered tobacco cessation. TRIAL REGISTRATION: This study is registered at ClinicalTrials.govNCT01584882.

The effect of electronic health records on the use of clinical care guidelines for patients with medically complex conditions.

BACKGROUND: The emergence of health information technology provides an opportunity for health care providers to improve the quality and safety of dental care, particularly for patients with medically complex conditions. METHODS: The authors randomized each of 15 dental clinics (HealthPartners, Bloomington, Minn.) to one of three groups to evaluate the impact of two clinical decision support (CDS) approaches during an 18-month study period. In the first approach--provider activation through electronic dental records (EDRs)--a flashing alert was generated at the dental visit to identify patients with medically complex conditions and to direct the dental care provider to Web-based personalized care guidelines. In the second approach--patient activation through personal health records--a secure e-mail was generated or a letter was mailed to patients before dental visits encouraging them to ask their dental care provider to review the care guidelines specific to their medical conditions. RESULTS: The authors evaluated the rate of reviewing care guidelines among 102 providers. Participants in the provider and patient activation groups increased their use of the system during the first six months, which had a generalized effect of increasing use of the guidelines for all patients, even if they were not part of the study (P < .05). The study results showed that provider activation was more effective than was patient activation. However, providers did not sustain their high level of use of the system, and by the end of the study, the rate of use had returned to baseline levels despite participants' continued receipt of electronic alerts. CONCLUSIONS: The study results demonstrated that review of clinical care guidelines for patients with medically complex conditions can be improved with CDS systems that involve the use of electronic health records. CLINICAL IMPLICATIONS: As the U.S. population ages, dentists must be vigilant in adapting care for patients with medically complex conditions to ensure therapeutic safety and effectiveness. Expanded use of CDS via EDRs can help dental care providers achieve this objective.

Measuring practice systems for chronic illness care: accuracy of self-reports from clinical personnel.

BACKGROUND: Purchasers, plans, and clinical practices involved in quality improvement initiatives are increasingly interested in measuring practice systems, particularly in relation to clinical quality and as part of pay-for-quality initiatives. The validity of self-reports of the use of practice systems was examined. METHODS: In 11 medical groups in Minnesota, the Physician Practice Connections Readiness Survey, which was developed on the basis of the concepts and evidence base of the Chronic Care Model, was used to survey office practice personnel about practice systems. Participation rates by medical group ranged from 61% to 94%, with a mean of 76%, yielding surveys from 32 lead physicians and 241 other personnel. Survey results were compared with an on-site audit by trained surveyors. RESULTS: Overall agreement with the on-site audit ranged from 40.9% to 96.7% among lead physicians and from 33.9% to 81.9% among other personnel. Mean agreement was high for quality improvement (96.7% for lead physicians and 81.9% for other personnel), moderate for clinical information systems (71.2% for lead physicians and 66.0% for others), and low for the use of care management (less than 50% for both groups). Mean positive predictive value ranged from 55.2% to 100% among lead physicians and from 49.6% to 100% among other personnel. Both the presence of systems and the accuracy of reporting varied across medical groups. DISCUSSION: The accuracy of self-reports of practice systems varies by type of system being assessed and by type of respondent. Although self-assessment may be useful for quality improvement purposes, self-reported information on clinical practices systems should not be used for accountability purposes, including pay-for-quality efforts or public reporting unless additional documentation is required to ensure fair comparisons.

Young adult smokers: are they different?

OBJECTIVE: To compare smoking-cessation interest and behaviors in younger and older smokers to develop better smoking-cessation strategies for younger smokers. STUDY DESIGN: Mail survey with phone follow-up of age-stratified members of a large Midwestern health plan to identify current and former smokers, followed by a second follow-up survey of this subgroup 12 months later. METHODS: The follow-up survey asked about change in smoking status, quit attempts, interest in quitting, and experience with various aids to quitting. Analyses compared adults age 18-24 years with adults age 25-65 years. RESULTS: Follow-up surveys were completed by 66.5% of subjects. Young adults smoked at much higher rates than older adults (24.5% vs 17.1%), but were less likely to smoke daily or to smoke as many cigarettes. Young adults were as likely to be interested in quitting and more likely to report a quit attempt in the past year (60.6% vs 49.6%; P = .009), but these attempts were much more likely to be unaided (51.2% vs 33.7%; P = .0003). They also were more likely to report decreasing smoking in response to new restrictions on smoking in restaurants and bars (37.2 % vs 24.7%; P = .001). CONCLUSIONS: Higher rates of smoking among young adults don't reflect less interest in quitting, fewer quit attempts, or less success in quitting compared with older adults. However, their reports of receiving or using much less help in quitting suggest that health plans and clinicians might be able to increase this group's cessation with more active support.

Smoking and cessation behaviors among young adults of various educational backgrounds.

OBJECTIVES: We sought to determine whether the educational backgrounds of young adult smokers (aged 18 to 24 years) affect their cessation attitudes or behaviors in ways that could be used to improve smoking interventions. METHODS: We surveyed 5580 members of the HealthPartners health plan and conducted a follow-up survey 12 months later of current and former smokers. Respondents were divided into subgroups according to educational level. RESULTS: Higher levels of education were associated with lower smoking rates (16% among students in 4-year colleges, 31% among those in technical or 2-year colleges, and 48% among those with a high school education or less) as well as less frequent or heavy smoking. However, number of quit attempts in the past year, level of interest in quitting, and smoking relapse rates did not vary according to educational level. Seventy-three percent of those who had attempted to quit had not used some form of assistance. CONCLUSIONS: Rates of smoking among young adults, especially those at low educational levels, are relatively high. However, most members of this age group are interested in quitting, regardless of educational background.

Practice systems for chronic care: frequency and dependence on an electronic medical record.

OBJECTIVES: To document the presence and functioning of different practice systems in a small sample of medical groups in Minnesota and to examine the relationship between the presence of practice systems and prior adoption of an electronic medical record (EMR). STUDY DESIGN: Descriptive study of the frequency of practice systems in 11 medical groups. METHODS: We recruited 11 medical groups for the study. Four groups had an EMR; the other groups used paper medical records, often supplemented by electronic ordering or data systems. Using an on-site audit team, we validated the presence of practice systems organized under 8 categories. RESULTS: All of the medical groups had implemented a substantial number of practice systems for care management of patients with chronic conditions. Although the medical groups with an EMR tended to have more comprehensive practice systems in place, the medical groups without an EMR also had most of the practice systems. CONCLUSIONS: Although required in some functions, an EMR may not be necessary in facilitating practice systems that support consistent management of patients with chronic illness. Approaches are needed that will encourage the implementation of practice systems in medical groups with and without an EMR.