Partnering for Integrated Care: A Learning Collaborative for Primary Care and Oral Health Teams

INTRODUCTION

Primary and oral health care professionals nationally perceive a need to expand the capacity of the health care workforce through the integration of services. Chronic illness and poor oral health are increasingly prevalent, and patients are more often living with undiagnosed conditions or poorly managed symptoms because of barriers to patient-centered, integrated care.¹ Each year, more than 100 million people in the United States receive care from a physician but not a dentist, and 27 million people visit a dentist but not a physician.² In this context, it is logical to use both clinical settings as opportunities for screening, counseling, and referral.³

Most physicians and dentists believe screening for oral and systemic conditions in both the medical and dental settings is critical and are willing to accept and offer a referral to or from their medical or dental counterparts.^4,5 Inadequate time and training, limited interoperability of information systems, and poor care coordination between these teams pose challenges to integration in practice, however.^6,7 At this stage, testing innovative solutions is critical to driving progress to improve access and health outcomes.

A Learning Collaborative offers the structure for teams motivated toward a common goal to learn from experts, test real-world change, and document progress for quality improvement. The Institute for Healthcare Improvement’s Breakthrough Series model for collaborative learning produces accelerated progress in a range of health care applications, and work by CoImagine Health has shown the benefit of a quality improvement framework in guiding oral health integration into primary care.^8,9 These experiences support the creation of a Breakthrough Series collaborative targeted at bidirectional oral and primary care integration. The Center for Integration of Primary Care and Oral Health (CIPCOH), with help from the Harvard School of Dental Medicine’s Initiative to Integrate Oral Health and Medicine, developed and implemented the Teaming and Integrating for Smiles and Health (TISH) virtual Learning Collaborative. The project had 2 overall goals: (1) to increase the early detection of hypertension in the oral care setting and gingivitis in the primary care setting and (2) to improve referral rates between primary care and oral health partners. Both are attainable objectives of clinical importance.

Hypertension and gingivitis were selected as targets for improved detection based on their high prevalence, ease of screening, and potential for identifying patients needing preventive primary or oral health care. Gingivitis is a common condition of the oral cavity that presents as inflammation of the gingiva, which can be reversed with appropriate treatment. Without intervention, gingivitis can sometimes progress to more severe forms of periodontal disease, such as periodontitis. Although periodontitis is acknowledged for its risks to systemic health, the project targeted gingivitis for the ease of screening by visual oral examination and because the higher prevalence can identify more patients in need of preventive dental care.^10-12

Similarly, hypertension, defined by the Seventh Report of the Joint National Committee as a systolic blood pressure greater than 140 mm Hg or a diastolic blood pressure greater than 90 mm Hg,¹³ is highly prevalent among adults in the United States. Furthermore, many patients have uncontrolled disease or are unaware of their hypertensive status.^14,15 In this context, the dental setting is an opportunity to identify undiagnosed or poorly managed hypertension and to make a referral for proper care. Screening for hypertension is also relevant in the immediate dental appointment, as nonemergent dental procedures are recommended to be postponed for patients with blood pressures greater than 180/110 mm Hg.¹⁶

The TISH Learning Collaborative describes medical and dental teams working together to implement screening and referral processes in tandem and thereby improve the detection and management of gingivitis and hypertension. The Learning Collaborative framework and finalized driver diagram, described below, serve as a model and a tool for primary and oral care integration for broad dissemination.

METHODS

The TISH Learning Collaborative was developed by CIPCOH and funded by the Health Resources and Services Administration (HRSA). Project development began in November 2020 with the assembly of a core team responsible for site recruitment, curriculum development, and ultimate implementation of the virtual project. Project methods were approved by the Harvard Longwood Campus Institutional Review Board.

The initial goal was to recruit 20 teams, 2 from each HRSA region. Many teams, however, lacked the bandwidth to participate while negotiating the COVID-19 vaccine rollout. On the basis of this feedback, the project start date was postponed until April 2021. Ultimately, 17 sites from 7 of the 10 HRSA regions, and 1 site from Somaliland, Africa, joined the project. The inclusion of a site outside the United States was not part of the initial recruitment plan but contributed to the diverse assortment of teams.

Driver Diagram

From the current understanding of primary care and oral health integration, the core team constructed a driver diagram to illustrate the steps necessary to achieve the project aim (Figure 1). Primary drivers directly contributed to the project aim, while secondary drivers represented the norms, processes, and structures that promoted the primary drivers. The driver diagram was used to create a curriculum presenting the knowledge and evidence-based strategies needed to achieve the primary and secondary drivers (Table 1). At project closure, teams had the opportunity to refine the driver diagram based on lessons learned and to contribute their actionable change ideas to the logic map.

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Figure 1.

Driver diagram for the TISH Learning Collaborative.

BP = blood pressure; EDR = electronic dental record; EHR = electronic health record; PCP = primary care professional; ROI = return on investment; TISH = Teaming and Integrating for Smiles and Health.

^a Blocks of text that can be inserted by typing a period (dot) followed by a short phrase.²⁵

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Table 1.

TISH Learning Collaborative Curriculum

RESULTS

All 17 recruited sites completed the Readiness Assessment questionnaire. Of those, 10 completed the initial Team-STEPPS and Interprofessional Assessment questionnaires, and 8 sustained active participation through biweekly calls and data collection. The participating sites were preferentially from HRSA regions 2, 8, and 9.

The Readiness Assessment results (Table 2) and qualitative feedback indicated that sites were at varying stages of integration at the start of the TISH project. The Interprofessional Assessment results showed moderate levels of confidence in cross-disciplinary care at that time (Table 3).

Table 4 summarizes characteristics of the participating sites and their respective TISH-related workflow changes, screening and referral data, and reflections on the experience. Given the mix in readiness levels and the diversity of practice styles, teams naturally prioritized different objectives and tested unique change ideas.

Aggregate team data showed a nonrandom improvement from baseline to the end of the 3-month TISH project in the percentage of patients screened for hypertension, the percentage referred to primary care, the percentage referred for hypertension, and the percentage referred for gingivitis (Supplemental Figure 1). Data for the percentage of patients assessed for oral health status and the percentage of patients referred to a dental partner crossed the median 3 times and, therefore, are not considered a nonrandom improvement.

Qualitative responses from the teams in their final storyboards supported the TISH project’s success. Teams expressed improvement in their referral process and in their communication within and between medical and dental teams, and attained a greater understanding of the connection between oral and systemic health among patients and staff. Highlights of team reflections are shown in Table 4.

In presenting their lessons learned, many sites noted the continuous effort required to maintain momentum. Consistent coaching in team meetings, identifying areas for retraining, and creating incentives for staff were some strategies teams used to promote enthusiasm toward integrated care. Participants also noted strategies that increased their referral success, such as an initial patient questionnaire to prime patients for future conversations about cross-disciplinary care. In such conversations, some teams worked to communicate the oral-systemic link and, when possible, drew connections between a patient’s oral and primary care concerns. Teams also suggested warm hand-offs to medical and dental partners or leveraging assistants and front office staff to schedule the referral while the patient was still in the office. Sites planned to use various strategies to sustain and build on these lessons learned (Table 5).

Results from the Interprofessional Assessment questionnaire showed that by the end of TISH, dental respondents had markedly improved their self-reported ability to counsel patients on blood pressure (Table 3). Although other responses did not change appreciably, dental respondents unanimously believed that their medical colleagues regarded oral health as strongly important to patients’ overall health at the project’s closure. TeamSTEPPS scores did not show a statistically significant change (results not shown)

DISCUSSION

The TISH project demonstrates that the Breakthrough Series model can be modified to a shortened, virtual format to accelerate progress in integrating primary and oral health care. With the insight of experts in the field, we synthesized knowledge about facilitators of integration into a driver diagram and provided the structure for teams to work toward these elements and address barriers to progress.^6,7 Team revisions to the diagram provide practical suggestions for other organizations to implement this work (Figure 1).

Our results show that cross-disciplinary screening is a means for dental professionals to identify undiagnosed or poorly managed hypertension and for medical professionals to improve access to oral health monitoring and care. The financial sustainability of these efforts is a primary concern in the existing literature, however. An analysis by Nasseh et al²⁰ finds that collaboration among team members maximizes cost-effectiveness and suggests training dental assistants to conduct the screenings. Our work aligns with their proposal by presenting a model for interprofessional training and showing teams leveraging assistants and front office personnel in their workflows.

To our knowledge, TISH is the first Learning Collaborative focused on bidirectional referrals between dental and medical teams. This is particularly relevant as the analysis of Nasseh et al²⁰ asserts the importance of successful referral for financial sustainability, but building referral processes is an acknowledged challenge in other studies. Among the pilot projects described by Linabarger et al,⁷ clinical sites faced difficulty gaining clinician buy-in and adjusting workflows. The support TISH offered for the creation of screening and referral processes simultaneously and the ability of teams to accomplish this goal are a notable success. It is possible that the groundwork required for participation—including designating a leadership team and choosing a dental or medical partner to receive referrals—mitigated some of these challenges. Harnagea et al⁶ found through a scoping review that integrating oral health into primary care faces specific resistance because of the perception that oral care is less valuable given that oral conditions are usually non–life-threatening. Concerns over the scope of practice and shared responsibility can also impede progress. Potentially, the TISH project alleviated some of this resistance because medical and dental teams convened with a common motivation to integrate care. Additionally, teams mentioned that they attained better understanding of the importance of oral health among staff and patients throughout the project.

Past research highlights the need to address inadequate training and confidence in achieving cross-disciplinary care. A survey by Vernon et al²¹ found that 87.7% of physicians regard their medical training as inadequate to evaluate oral conditions, and work by dela Cruz et al²² determined that physicians with high confidence in their screening ability are more likely to initiate referrals for pediatric patients. Although the TISH curriculum presented the clinical information relevant for screening, only dental professionals showed quantitative improvement in self-reported screening confidence; thus, a Learning Collaborative is a potential way to address these concerns but may benefit from revision. Past work on improving interprofessional education demonstrates the success of hands-on instruction for physicians learning to conduct fluoride varnish and oral cancer screenings.^23,24 Although the virtual format had numerous benefits—especially in the context of the COVID-19 pandemic—a future collaborative could incorporate in-person meetings between local teams to supplement virtual education.

The characteristics of our recruited sites align with the observation by Atchinson et al³ that health care organizations caring for Medicaid-enrolled populations tend to be leaders in promoting integration. We chose to recruit practice sites with an overall goal of integrating primary and oral health care, even if they did not aim to improve both screening and bidirectional referrals. The option for teams to individualize their work was a benefit of the collaborative structure but also posed a challenge to data collection because many sites tailored collection to their specific goals. The lack of financial incentives likely also contributed to inconsistent participation and the lower site retention rate. Altogether, these factors limited the amount of data available as evidence of the project. This shortcoming is particularly relevant when examining the TeamSTEPPS and Interprofessional Assessment results. For these measures, the identity of respondents and the sample size of respondent cohorts changed between the start and end questionnaires; therefore, responses may not represent individual changes in attitude or may inaccurately show improvement or lack thereof.

Although the data collection and participation challenges are limitations of this work, we also note that teams were negotiating the demands of COVID-19 during the project’s timespan. The diligent work of 8 sites without financial support therefore suggests the level of motivation present to integrate care and the potential interest to build on this model. A future collaborative could focus on optimizing electronic health record systems because participating teams noted this as both a challenge to overcome and a means to streamline their referral and data-tracking processes.

In conclusion, the TISH project demonstrates that a Learning Collaborative adapted from the Breakthrough Series model is a viable strategy to disseminate knowledge of and ignite progress in the integration of oral and primary care. The virtual format was accessible to health care organizations across the country and internationally, and the tools and strategies presented were relevant to a diverse network of health care sites. The progress made through the TISH project suggests the multitude of ways in which integration can be achieved and shows that progress is feasible with proper support and innovation.