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

Kaitlyn Cardenas; Taylor Weilnau; Crystal Aguilar; Amal Ali; Alec Eidelman; Sridevi Ponnala; Tiffany Russel; James Schwanderla; Karlynn Sievers; Hongsheng Wu; Hugh Silk; Lindsay Swain Hunt; Jane Barrow; Christine A. Riedy; Russell S. Phillips

doi:10.1370/afm.2918

Article Figures & Data

Figures

Tables
Additional Files

Download figure
Open in new tab
Download powerpoint
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

View popup

Table 1.

TISH Learning Collaborative Curriculum

Component	Topics and Activities
Learning Session I	Teams draft aims statements Review quality improvement methodology, process mapping, goals for data collection, and IRB process
Webinar: Oral Health Integration Care Pathways I	Review the Integration Spectrum Share examples of screening workflows Teams use process mapping to plan unique workflows Highlight anticipated challenges and corresponding solutions
Webinar: Oral Health Integration Care Pathways II	Review oral pathology and indications for dental referrals Present ADA and ACEP guidelines for hypertension and consider creating team guidelines for referral Review how to build referral networks and ensure communication between health care teams
Learning Session II	Share evidence-based strategies to improve patient engagement and teamwork
Webinar: Team Progress	Teams present storyboards with progress updates on PDSA cycles, requests for assistance, and goals for future learning
Webinar: Optimizing Workflows	Review the benefits of visual workflows for quality improvement Share tips for introducing workflows to staff, communicating roles, and recognizing missteps or redundancies
Webinar: Sustain and Spread	Prepare teams to sustain improvements Consider ways to communicate knowledge learned
Learning Session III	Teams share final storyboards that include reflections, lessons learned, and sustainability plans

ACEP = American College of Emergency Physicians; ADA = American Dental Association; IRB = institutional review board; PDSA = Plan-Do-Study-Act; TISH = Teaming and Integrating for Smiles and Health.

View popup

Table 2.

Team Responses on Readiness Assessment Questionnaire (N = 17)

Readiness Statement	Teams Endorsing Statement, %
Quality improvement
A dental measure is part of the primary care team’s quality improvement plan	70.6
A hypertension measure is part of the dental team’s quality improvement plan	76.5
The primary medical care team utilizes telehealth services	88.2
The dental care team utilizes teledentistry services	52.9
Referrals
Team has a formal referral process/system	25.0
Team has an informal referral process/system	56.3
Team has no referral process/system	18.8
Communication between teams
Team has an engrained line of communication	33.3
Team has an informal or loose line of communication	53.3
Team has no communication	13.3
EHR connection between dental and medical teams
Teams’ EHRs are connected	37.5
Teams’ EHRs are not connected	62.5

EHR = electronic health record.

View popup

Table 3.

Team Responses on Interprofessional Assessment Questionnaire

Group and Question	Pre-TISH Score	Post-TISH Score
Primary care teams	(n = 3)	(n =7)
How much do you perceive that dental colleagues are interested in the overall health of patients?	4.67	4.00
How important do you feel good oral health is for the overall health of your patients?	4.67	4.29
How do you rate your skill to counsel patients on oral health?	3.00	3.14
How would you rate your skill level to examine and assess a patient’s mouth?	2.67	2.86
How would you rate your awareness of local dentists and the details of making referrals to/from them?	4.00	3.29
How would you rate your current ability to communicate with local dentists?	3.67	3.14
How confident are you that your patients will get timely referrals to dental colleagues?	3.67	3.43
Dental teams	(n = 8)	(n = 5)
How much do you perceive that medical colleagues are interested in the overall health of patients?	3.63	3.60
How important do you feel that your medical colleagues believe good oral health contributes to the overall health of their patients?	4.13	5.00
How would you rate your skill level to counsel patients on blood pressure?	3.50	4.40
How would you rate your skill level to examine and assess a patient’s blood pressure?	3.63	4.20
How would you rate your awareness of local primary care/medical providers and the details of making referrals to/from them?	3.86	4.75
How would you rate your current ability to communicate with local primary care/medical providers?	4.14	4.75
How confident are you that your patients will get timely referrals to primary care/medical colleagues?	3.43	4.25

TISH = Teaming and Integrating for Smiles and Health.
Note: Scores are means. Possible range of scores is 1 (strongly disagree/lowest) to 5 (strongly agree/highest).

View popup

Table 4.

Summary of Teams’ TISH Experiences and Results

Team	Site Description	Change Ideas	Results	Reflection
The National Health Professions Commission (NHPC) Somaliland	A statutory body that mandates the regulation, accreditation, and licensing of health care professionals, health care facilities, and health training institutions in Somaliland, Africa	Longer first visits/consultations with patients to implement screenings More thorough oral health assessment in primary care setting Physician and dentist have telephone consultation over BP measurements, blood sugar levels, gingivitis Regular biweekly meetings to update the team and discuss weaknesses and strengths	Screened 100 patients (16.1%) for hypertension Referred 57 patients (9.9%) to primary care Screened 339 patients (89.9%) for gingivitis Referred 176 patients (46.7%) to dental care	“When patients come from their … physician and finally understand the importance of oral health, and they seek dental professionals for check-ups/treatment, it is truly a milestone!”
St Barnabas Hospital (SBH) Health System	A teaching hospital with medical and dental residency programs	Education of residents and assistants Medical team evaluates patient initially using the questionnaire and the examination follows Reinforced team cooperativity by presenting a virtual meeting to residents and attendings about progress Developed the spreadsheets on teams so data can be seen by everyone	Screened 861 patients (100%) for hypertension Referred 83 patients (9.6%) to primary care	“Created an awareness of the impact of dental health on overall health”
St Mary’s Medical Center Family Medicine Residency Program	A patient-centered medical home with a focus on training physicians for rural practice; the team partnered with a nearby health center to provide dental services	Begin incorporating gingivitis screen into well-person examinations in adults; results are recorded in the chart Set up referrals to dental partners in Epic to streamline referral process	Screened 409 patients (92.1%) for hypertension Referred 59 patients (13.3%) to primary care Screened 58 patients (63.0%) for gingivitis Referred 11 patients (11.9%) to dental care	“Watching our dental examination numbers and referral numbers improve from zero, showing that we’re starting to take oral health more seriously in our clinic, and that we now have dental partners to help us do better in this goal”
Tiburcio Vasquez Health Center (TVHC)	A Federally Qualified Health Center providing comprehensive medical and dental services	Access to working BP kits in dental operatories; staff are educated on hypertension guidelines Warm hand-off to medical team if BP >160/110 mm Hg Education and training for medical team Trackable and streamlined referral process between dental and medical teams	Referred 557 patients (14.7%) to primary care	“Medical-to-dental process is now so much swifter for adult patients who need to be seen, increased Epic connectivity between the 2 disciplines.”
Pacific Dental Services	A dental support organization with a focus on raising awareness of the link between oral health and overall health on a national scale	Dental front office has patient complete questionnaire at check-in Front office, medical assistants, and dental assistant coordinate to schedule referral appointments while patient still in dental chair or medical examination room Improved EHR referral and launched referral-tracking dashboard Altered marketing material in the medical and dental settings	Referred 114 patients (6.0%) to primary care Referred 287 patients (17.5%) to dental care	“We have had some big wins in getting dental to engage in the referral process with minimal added lift to improve bidirectional flow and the level of care being provided to patients.”
The Partners in Integrated Care (PIC) Place	A nonprofit organization offering medical, dental, vision, and behavioral health services	Train dental staff to take manual BP measurements “Summer Smackdown” to incentivize staff to make cross-discipline referrals; involve staff in the data collection process Implemented checklists for medical team to remember oral screening	Referred 43 patients (2.8%) to primary care Referred 89 patients (7.6%) to dental care	“Summer Smackdown winners really put forth effort in creating referrals and thrived under the positive incentives and recognition.”
Harvard Dental Center	An academic dental clinic with faculty professionals	BP measured at every patient visit Dental assistant takes and records BP at the start of every visit in AxiUm and Excel sheet	Screened 83% of patients for hypertension	“The workflow between a dentist and dental assistant is like doing a dance. This team started working together just 1 month before TISH. TISH helped establish the footwork for at least one part of the clinic workflow. We’re proud to say that we’re now dancing!”
Cambridge Health Alliance (CHA)	A safety net hospital system with a dental center	Studied criteria and process for dental-to-medical referral by tracking hypertension screenings and the action taken by provider Train dental users on Epic	Screened 158 patients for hypertension Counseled 23% of patients with stage 2 hypertension	“Learning what upstream resources our organization has to address structural determinants to health and how they can be applied in the dental setting”

BP = blood pressure; EHR = electronic health record; TISH = Teaming and Integrating for Smiles and Health.

View popup

Table 5.

Team Sustainability Planning

Sustainability Question	Team Plans
What type of training will we use?	Introductory and ongoing training to share TISH material and demonstrate data collection Data scorecard automatically delivered to dental and medical champions monthly to help target training and retraining Literature/journal sharing Team huddles, leading by example, setting daily goals, creating excitement
How will we make it hard to do the wrong thing and easy to do the right thing?	Draft new guidelines for each workflow Documentation and constant coaching to the same message and workflow Checklists and reminders in EMR to prompt screening Questionnaires and brochures at every computer Automating referrals and data tracking in EMR Ensuring more than 1 person is assigned for critical/important steps
Are our changes increasing the overall workload to the system? If so, how can we decrease the workload? If not, how will we communicate about what is?	Slightly yes—but hopefully it becomes the workflow and not an addition to the old workflow Simple system is most sustainable Using standard documentation (dot phrases^{^a}) and referral processes will decrease burden Some day interface between 2 EHRs Continue collecting subjective data from huddle

EHR = electronic health record; EMR = electronic medical record; 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