Table 4.

Themes and Subthemes From Qualitative Interviews (N = 11)

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.