Article Figures & Data
Tables
Characteristic Respondents, No. (%) Groupa Clinician 12 (30) Nonclinician 28 (70) Educator 18 (45) Administrator 10 (25) Researcher 7 (18) Otherb 19 (47) Profession Physician (MD/DO)c 4 (10) Nurse practitioner 1 (3) Administrator 6 (15) Dentist 5 (12) Dental hygienist 15 (37) Otherd 9 (23) Type of practice/work setting Community health center/FQHC 2 (5) University 5 (12) Hospital 1 (3) Private practice 1 (3) Nonprofit organization 11 (27) State agency 14 (35) Othere 6 (15) Length of time in practice ≤5 years 4 (10) 6-10 years 4 (10) 11-15 years 5 (12) 16-20 years 3 (8) ≥21 years 18 (45) N/A (not currently in practice) 6 (15) Location of practice New England/Mid-Atlantic 17 (43) South 4 (10) Midwest 11 (27) West 8 (20) Sex Male 5 (12) Female 32 (80) Prefer not to say 3 (8) DHSc = doctor of health science; DO = doctor of osteopathic medicine; FQHC = Federally Qualified Health Center; JD = juris doctor; MD = doctor of medicine; MPH = master of public health; MSW = master of social work; N/A = not applicable; NP = nurse practitioner; OHKN = Oral Health Knowledge Network.
Note: Numbers may not add up to the total number of participants because of sporadic missing data.
↵a Participants could select more than 1 option, so percentages total to more than 100%.
↵b Consultants, members of health care coalitions, policy advocates, regional oral health coordinators, program managers, etc.
↵c Family medicine (1 physician) and pediatrics (3 physicians).
↵d DHSc, MPH, MSW/JD, NP director, mental health professional, nonprofit program director, public health practitioner, public health professional, regional oral health coordinator.
↵e Dental care organization, dental insurance plan, Medicaid clinician, national nonprofit, safety net clinic (not FQHC), and “work on a national level.”
Measure Respondents, No. (%) Level of oral health care integration at primary clinical site None 3 (18) Minimal collaboration 1 (6) Basic collaboration at a distance 2 (12) Basic collaboration on site 5 (29) Close collaboration on site with system integration 2 (12) Full collaboration in transformed/merged practice 3 (18) Othera 1 (6) OHKN engagement Time engaged with OHKN sessions <1 year 16 (39) 1-2 years 11 (27) >2 years 14 (34) Number of OHKN sessions attended Continuous Mean (SD) [range] 7 (7) [0-24] Median 4 Categoricalb 1-8 sessions 20 (59) 9-16 sessions 10 (29) 17-24 sessions 4 (12) OHKN impact Knowledge changes Rated level of knowledge of medical-dental integration before OHKN participation Very knowledgeable 10 (26) Moderately knowledgeable 17 (44) Somewhat knowledgeable 5 (13) Slightly knowledgeable 6 (15) Not at all knowledgeable 1 (2) Rated level of knowledge of medical-dental integration after OHKN participation Very knowledgeable 19 (50) Moderately knowledgeable 17 (45) Somewhat knowledgeable 1 (3) Slightly knowledgeable 1 (3) Not at all knowledgeable 0 (0) Clinical and nonclinical practice changes Number of clinical practice changes reportedc 1-2 changes 3 (38) 3-4 changes 4 (50) ≥5 changes 1 (12) Number of nonclinical practice changes reportedd 1-2 changes 6 (17) 3-4 changes 22 (65) ≥5 changes 6 (17) Number of additional activities participated in after attending OHKN sessions 0 activities 3 (8) 1-2 activities 12 (32) 3-4 activities 23 (60) Types of additional activities participated in related to oral health knowledge (past 3 years) Oral health conference 34 (89) Oral health webinar 31 (82) Fluoride varnish course 13 (34) Administrative webinar on dental integration 7 (18) Joined oral health professional organization 4 (11) Types of additional activities participated in after attending OHKN sessions (influenced by attending) Networking 31 (94) Further training on oral health 28 (88) Engaging with others on medical-dental integration 32 (97) Policy change 9 (38) Grant application 7 (33) Scholarship 7 (33) OHKN = Oral Health Knowledge Network.
Note: Numbers may not add to the total number of participants because of sporadic missing data.
↵a Administrate and provide grant funding to community programs.
↵b Analyses omitted 7 respondents who reported that they did not attend any sessions.
↵c Asked only of clinicians.
↵d Asked of all participants (clinicians and nonclinicians).
- Table 3.
Respondents’ Assessment of OHKN Sessions and Integration of Oral Health and Primary Care (N = 41)
Measure Respondents, No. (%) Helpfulness of OHKN in working toward integrating oral health and primary care Extremely/very helpful 30 (81) Moderately/somewhat/not helpful 7 (19) Helpfulness of OHKN sessions in working toward integrating oral health and primary care, leading to clinical change Increased fluoride varnish 8 (73) Increased referrals to clinicians 7 (70) Hired oral health coordinator or dental team member 2 (22) Developed dedicated patient education on oral health 9 (69) Incorporated oral health examination 6 (67) Incorporated oral health training for medical team 9 (82) Most important factors in participating in OHKN networking Networking 30 (77) Learning new information 33 (85) Learning new skills 11 (28) Interest in practice change around medical-dental integration 29 (74) Interest in practice transformation 12 (31) Asked to participate by employer/organization 2 (5) Number of barriers to attending OHKN sessions 0 barriers 5 (12) 1 barrier 19 (48) 2 barriers 15 (37) 3 barriers 1 (3) Types of barriers to attending OHKN sessions Too much of a time commitment 3 (7) Program’s format provided insufficient learning opportunities 0 (0) Program’s content did not build on what I already knew 2 (5) No longer in the field/career change 0 (0) Competing priorities 19 (48) Scheduling conflicts 27 (67) Number of barriers to implementing practice changes following OHKN sessions 0 barriers 10 (26) 1 barrier 16 (42) 2 barriers 12 (32) Types of implementation barriers Workflow 7 (18) Lack of institutional support 7 (18) Lack of support from colleagues 5 (13) Lack of financial support 6 (16) Need more training 3 (8) Time 4 (11) Recommendations for improving OHKNa More frequent sessions 3 (8) Less frequent sessions 0 (0) More networking events 13 (33) More resource sharing 14 (36) Introduce different topics 7 (18) Ability for small group discussions 12 (31) Intend to participate in future OHKN sessions 39 (100) Likelihood of participating in future OHKN sessions if the following were offered Continuing education credits More likely 10 (26) No preference 27 (69) Less likely 2 (5) Transformed to a Project ECHO format More likely 5 (13) No preference 29 (74) Less likely 5 (13) ECHO = Extension for Community Healthcare Outcomes; OHKN = Oral Health Knowledge Network.
Note: Numbers may not add to the total number of participants because of sporadic missing data.
↵a Participants could select more than 1 option, so percentages total to more than 100%.
Theme and Subthemes Respondents, No. (%) Examples of Subthemes Sample Quotations Impact of OHKN Clinical 10 (91) Plans for future clinical outcome measures, increased number of fluoride varnish applications, referrals to oral health professionals, dedicated patient education around oral health, incorporated oral health training, incorporated oral examination “I remember there was once a presentation for organizations that were using dental referral passports as an incentive for the patient to take that to the dental office, so that was really helpful to test that out with us as well.” Nonclinical 11 (100) Peer-to-peer learning, knowing what others are doing, support system/community, further training in oral health, applied for grant, presenting work to OHKN, policy change “…this network is a chance to go into the weeds and figure out some best practices and see what others are doing in detail, instead of just big-picture stuff.” Influencing nonclinicians 1 (9) N/A “But, of course, I can help, especially for mailing. They need another voice from western Maryland, I can help. You know what I mean? Because more voices, the better.” Cannot trace impact 6 (55) N/A “[I cannot trace it] to the network itself and that’s not a criticism, but as you know, it is one, I would say the word, nexus or gathering point, but people also work in other areas, other arenas.” Commitment to MDI before involvement in OHKN 10 (91) N/A “I have written a couple of white papers on opioids in dentistry and the role of dentists in the opioid epidemic, especially in the use for third molar extractions. I have written a paper on vaping and the oral health risks associated with vaping, and basically that requires a medical-dental integrated model.” Evaluation of OHKN Strengths of OHKN 11 (100) N/A “We’ll work on that same topic but approach it and tackle it in a different way, and so it’s sometimes those creative ideas and original ideas. They might not even get published, but they’ll talk to each other, and I find that really of value.” Areas for improvement 11 (100) N/A “One suggestion that I can think of would be maybe having a location for all of these resources to be shared in. I know that there’s a website, but there’s a lot of times that presenters had recordings that I wanted to go back and listen to again. But because I’ve transitioned positions, I lost my old e-mails, and so I didn’t have the links through the e-mails. But if there’s a place or a website where everything was housed, then that would make it super simple to go back in and get access to those resources again.” Drivers of MDI Buy-in 10 (91) Leadership, clinicians, staff “…someone takes a hold, hold it in front of people to continue the push, because practice change and behavior change is so difficult… leadership buy-in is super important.” Finances 10 (91) Reimbursement for fluoride varnish “Our reimbursement is a significant contributor to making things sustainable and for a lot of clinics.” Epidemiology of local disease 5 (45) N/A “I would say that, given my patient population, and again, there’s lots of reasons that Latino children have increased incidence of caries and rampant disease that has a little bit to do with culture, but probably a lot to do with access.” Did OHKN influence these drivers? 8 (73) N/A “She had a slide…that showed some metrics and how they looked at…the encounter, and what age-groups they broke it down into, and it mirrored what the AAP was doing. So I mirrored that too…I really did a copy and paste. I was like, well, there’s nothing else I need to do. This makes sense when comparing metrics and looking [at] numbers.” Funding 11 (100) External vs internal to organization, funding to develop vs maintain oral health services “The program initially was grant funded years and years ago. Now I’d say it pretty much just kind of runs on its own. We don’t have any special grants in the works now. The only thing that we do pay for separately is, we are approved to offer ACCME credit through the American Academy of Family Physicians, so that’s an additional fee, but that’s really just picked up by the Division of Public Health, so no longer really a grant-funded program anymore.” Relationships 11 (100) State, federal/national, individual, local organization, clinic to clinic “Even though the dental office is not part of our Federally Qualified Health Center, we do help them with some of the billing for those referrals, so we’re able to collect data on the number of dental exams that they provide on those referrals that we have.” Training 8 (73) Medical, dental “…we arranged a special 2-hour webinar on motivational interviewing. And then, well, unrelated to this project, but it was related to the broader HRSA grant, we also require a 1-hour training on the relationship between obesity and caries and caries prevention developed by one of our other team members.” Better/improved care 9 (82) N/A “And, basically, want to try to get medical providers to refer to dental providers …if they see children with visible cavities or something else going wrong in their mouth…When we see things that look suspicious and we think there might be something else going on besides dental…tell them to go to their physician…we’re just trying to bridge that gap.” Improved processes/breaking down barriers 10 (91) N/A “But in our particular area, people aren’t really focused on their health…And people might go to the dentist more often than they see a doctor. So…the hygienist takes their blood pressure and checks their blood sugar and [can refer them] because they might not see their primary care physician yearly.” Champions 7 (64) N/A “But in my experience, we get leadership buy-in…but then over time, they’re on to other things, and so there’s no longer the leadership buy-in. So, I think champions at the local level are super important, and ongoing technical assistance and support.” Literature/evidence 3 (27) N/A “Well, I look to different literature. I mean, Patty Braun has done some great articles, and Into Mouths of Babes has some great articles. The US Preventive Services Task Force, obviously. Now, for participating in the Affinity of the CMS, Affinity Group, they have some resources.” Patient demand 2 (18) N/A “And patients who expect it, patients who actually come in and say, ‘I’m going to see the hygienist today, too, right? My child’s going to see the hygienist?’ So it really is becoming even a bit of a demand, and I think that’s really exciting.” Barriers to MDI Barriers to implementing oral health activities 11 (100) Buy-in, reimbursement, need training/lack of education, time/competing priorities, scope of practice/dental practice acts “People are resistant to change: ‘This is one more thing you’re adding to my incredibly busy schedule.’” Barriers to maintaining oral health activities 9 (82) COVID-19 pandemic “There are just so many distractions in health care, and of course, the pandemic has been a huge one. But [there are] ongoing electronic medical record changes and providers leaving, and all of the things that disrupt the flow.” How barriers were overcome 8 (73) How OHKN has or can help overcome these barriers “Misery loves company…hearing other people with similar challenges is reassuring. And then hearing different people’s strategies to how they’re getting data, and how they’re working with practices is just super helpful and enlightening and hopeful.” Barriers to implementing something learned through OHKN 3 (27) N/A “… I don’t incorporate it into my practice, only because I’m limited in that practice. I’m just a hygienist. Let’s say if I was a clinical lead [I may be able to incorporate it]…” Policies 7 (64) N/A “I know everybody’s pushing to get Medicaid to have a dental aspect of it, and in Medicare, because the adults and older adults have nothing.” Future efforts for OHKN in MDI 9 (82) N/A “I think the American Academy of Pediatrics [has] got to broaden its network among its own members…Organized dentistry is going to fight this…So, why wouldn’t pediatricians want to allow dental? Why wouldn’t dentists want to allow one of their revenue streams to go work for a pediatrician?” Interest in using a Project ECHO approach for future OHKN work 9 (82) N/A “I know that ECHO models are certainly starting to really take off, and I like that model because it allows for the participants to engage a little bit more than just listening to a presentation, saying, ‘Okay, alright, see you, bye, thanks.’” AAP = American Academy of Pediatrics; ACCME = Accreditation Council for Continuing Medical Education; CMS = Centers for Medicare & Medicaid Services; ECHO = Extension for Community Healthcare Outcomes; HRSA = Health Resources and Services Administration; MDI = medical-dental integration; N/A = not applicable; OHKN = Oral Health Knowledge Network.
Additional Files
SUPPLEMENTAL APPENDIXES 1-3 IN PDF FILE BELOW
- JiangSuppApps.pdf -
PDF file
- JiangSuppApps.pdf -
