Implementing care coordination in a large dental care organization in the United States by upskilling front office personnel.

BACKGROUND: Care coordination is a key strategy used to improve health outcomes and efficiency, yet there are limited examples in dentistry. A large dental accountable care organization piloted care coordination by retraining existing administrative staff to coordinate the care of high-risk patients. Following the pilot's success, a formal "dental care advocate" (DCA) role was integrated system-wide. The goal of this new role is to improve care, patient engagement, and health outcomes while integrating staff into the clinical care team. We aim to describe the process of DCA role implementation and assess staff and clinician perceptions about the role pre- and post-implementation. METHODS: Guided by the Consolidated Framework for Implementation Research, semi-structured interviews with clinical and operational administrative staff and observation at the company-wide training session were combined with pre- and post-implementation electronic surveys. Descriptive statistics and mean scores were tested for significance between each survey sample (t-tests), and qualitative data were thematically analyzed. RESULTS: With preliminary evidence from the pilot and strong executive support, a dedicated leadership team executed a stepwise rollout of the DCA role over 6 months. Success was facilitated by an organizational culture of frequent interventions deployed rapidly through a centralized system, along with supportive buy-in from managerial teams and high staff acceptance and enthusiasm for the DCA role before implementation. Following implementation, significant changes in attitudes and beliefs about the role were measured, though managers held stronger positive impressions than DCAs. DCAs reported high confidence in new skills and dental knowledge post-implementation, including motivational interviewing and the ability to confidently answer patients' questions about their oral health. Overall, the fast-paced implementation of this new role was well received, although consistent and significant differences in mean attitudes between managers and DCAs indicate more work to fine-tune the role is needed. CONCLUSIONS: Successful implementation of the new DCA role was facilitated by a strong organizational commitment to team-based dentistry and positive impressions of care coordination among staff and managers. Upskilling existing administrative staff with the necessary training to manage some high-risk patient needs is one method that can be used to implement care coordination efforts in dentistry.

Tracking oral health in a standardized, evidence-based, prevention-focused dental care system.

OBJECTIVES: Learning health-care systems are foundational for measuring and achieving value in oral health care. This article describes the components of a preventive dental care program and the quality of care in a large dental accountable care organization. METHODS: A retrospective study design describes and evaluates the cross-sectional measures of process of care (PoC), appropriateness of care (AoC), and outcomes of care (OoC) extracted from the electronic health record (EHR), between 2014 and 2019. Annual and composite measures are derived from EHR-based clinical decision support for risk determination, diagnostic and treatment terminology, and decayed-missing-filled-teeth (DMFT) measures. RESULTS: Annually, 253,515 ± 27,850 patients were cared for with 618,084 ± 80,559 visits, 209,366 ± 22,300 exams, and 2,072,844 ± 300,363 clinical procedures. PoC metrics included provider adherence (98.3 percent) in completing caries risk assessments and patient receipt (96.9 percent) of a proactive dental care plan. AoC metrics included patients receiving prevention according to the risk-based protocol. The percent of patients at risk for caries receiving fluoride varnish was 95.4 ± 0.4 percent. OoC metrics included untreated decay and new decay. The 6-year average prevalence of untreated decay was 11.3 ± 0.3 percent, and average incidence of new decay was 13.6 ± 0.5 percent, increasing with risk level: low = 7.5 percent, medium = 18.8 percent, high = 29.4 percent, and extreme = 28.1 percent. CONCLUSIONS: The preventive dental care system demonstrates excellent provider adherence to the evidence-based prevention protocol, with measurably better dental outcomes by patient risk compared to national estimates. These achievements are enabled by a value-centric, accountable model of care and incentivized by a compensation model aligned with performance measures.

Developing and Testing Electronic Health Record-Derived Caries Indices.

Caries indices, the basis of epidemiologic caries measures, are not easily obtained in clinical settings. This study's objective was to design, test, and validate an automated program (Valid Electronic Health Record Dental Caries Indices Calculator Tool [VERDICT]) to calculate caries indices from an electronic health record (EHR). Synthetic use case scenarios and actual patient cases of primary, mixed, and permanent dentition, including decayed, missing, and filled teeth (DMFT/dmft) and tooth surfaces (DMFS/dmfs) were entered into the EHR. VERDICT measures were compared to a previously validated clinical electronic data capture (EDC) system and statistical program to calculate caries indices. Four university clinician-researchers abstracted EHR caries exam data for 45 synthetic use cases into the EDC and post-processed with SAS software creating a gold standard to compare the -VERDICT-derived caries indices. Then, 2 senior researchers abstracted EHR caries exam data and calculated caries indices for 24 patients, allowing further comparisons to VERDICT indices. Agreement statistics were computed among abstractors, and discrepancies were resolved by consensus. Agreement statistics between the 2 final-phase abstractors and the VERDICT measures showed extremely high concordance: Lin's concordance coefficients (LCCs) >0.99 for dmfs, dmft, DS, ds, DT, dt, ms, mt, FS, fs, FT, and ft; LCCs >0.95 for DMFS and DMFT; and LCCs of 0.92-0.93 for MS and MT. Caries indices, essential to developing primary health outcome measures for research, can be reliably derived from an EHR using VERDICT. Using these indices will enable population oral health management approaches and inform quality improvement efforts.

Underrepresented Minority Dentists: Quantifying Their Numbers And Characterizing The Communities They Serve.

The underrepresentation of Blacks, Hispanics or Latinos, and American Indians or Alaska Natives among dentists raises concerns about the diversity of the dental workforce, disparities in access to dental care and in oral health status, and social justice. We quantified the shortage of underrepresented minority dentists and examined these dentists' practice patterns in relation to the characteristics of the communities they serve. The underrepresented minority dentist workforce is disproportionately smaller than, and unevenly distributed in relation to, minority populations in the United States. Members of minority groups represent larger shares of these dentists' patient panels than of the populations in the communities where the dentists are located. Compared to counties with no underrepresented minority dentists, counties with one or more such dentists are more racially diverse and affluent but also have greater economic and social inequality. Current policy approaches to improve the diversity of the dental workforce are a critical first step, but more must be done to improve equity in dental health.