Oral health disparities have been long established in rural America. Rural adults
and children are more likely to report unmet need, unlikely to get involved in an
oral health prevention program, and live in health provider shortage areas [1–8].
As the U.S. health care paradigm shift continues toward health as a goal, coordinated
and integrated interprofessional care will become a key driver of health operations
and the health care system’s financial structure. Oral health can serve as a link
to chronic disease conditions that are amenable to team-based care, coordination across
healthcare fields, and reallocation of resources from expensive treatment to more
economical prevention. As successful and replicable oral health interprofessional
practice (IPP) requires investment, ownership, and coordination, the DentaQuest Institute
convened a Rural Oral Health Interprofessional Practice Symposium to build knowledge
and ascertain areas of consensus that can help arch the interdisciplinary divide between
dentistry and medicine. The goals of the symposium were to collect information and
build knowledge around rural IPP as well as develop an understanding of: the current
state of oral health care, what the future vision is in relation to a desired state,
and what interprofessional action planning may close the gap between the two. This
article provides an analysis overview of the discussions and findings of the 2017
Rural Interprofessional Oral Health Practice Symposium.
Symposium process and methodology
The symposium was convened as a private event for 44 participant attendees over the
course of two days in December of 2017. This group was comprised of leaders with different
health backgrounds related to rural health care, oral health care, behavioral health,
and health care policy. The attendees included representatives from State Offices
of Rural Health; large healthcare systems; Schools of Medicine and Dentistry; dental
service organizations, national and state Area Health Education Center Organization
(AHEC), Primary Care Associations; Federally Qualified Health Centers; technology
colleges; private practice; benefits companies; non-profit funders, coalitions and
community based health organizations; and national healthcare organizations from 17
states. In addition, each participant identified their primary area of expertise that
included: rural health (7); medicine (8); dentistry (10); public health (10); behavioral
health (2); payer or funder (7).
Attendees were randomly assigned to a table number ranging from 1 to 6 based on the
date of registration. Each table was assigned a table facilitator to serve as proctor
for eliciting and recording responses to open discussions during three breakout sessions.
Breakout sessions were organized according to a gap-analysis process: current state/what
is happening now; desired state/vision for the future; and action planning to address
the gap between current and desired states. Each breakout session was preceded by
a three member expert panel that discussed the current landscape, the possible outcomes
of healthcare’s paradigm shift to a more health oriented design, and the challenges
and facilitators that can provide opportunity for interprofessional oral health practice.
The Executive Director of the National Rural Health Association and Director of Interprofessional
Practice of the DentaQuest Institute also provided a keynote presentation at the start
of the convening as a means to provide appropriate background of rural interprofessional
oral health practice. Poll Everywhere (San Francisco, CA), a text messaging application
that allows participants to answer questions in real time, was employed throughout
the symposium to solicit response to questions voluntarily submitted by attendees
prior to the event. Table facilitators recorded and transcribed conversations for
each table/small group. The transcribed conversations and Poll Everywhere responses
were collected and collated for evaluation by an independent third party whom did
not attend the symposium.
Presentations and discussions were organized into three sections:
Current State of Oral Health Interprofessional Practice;
The Vision or Desired State of Oral Health Interprofessional Practice; and
Action Planning.
Content from the panel presentations and table discussions, as well as the Poll Everywhere
results, were organized in these three sections.
Symposium findings
Section I: Current state of rural Oral health Interprofessional practice?
The first section opened with a Poll Everywhere survey. Responses are presented in
Tables 1 and 2. The vast majority of attendees indicated a favorable impression of
oral health interprofessional practice while acknowledging the barriers to its adoption,
which included health information technology and workforce readiness. Attendees were
also asked to identify one word that best describes the importance of interprofessional
collaboration. Their responses are summarized in a word cloud in Figs. 1 and 2.
Table 1
Poll Everywhere Results for Section 1: What is Happening Now with Oral Health Interprofessional
Practice
Question
Responses
Agree
Unsure
Disagree
Interprofessional oral health practice contributes to lower per capita cost; improve
patient outcomes, and enhance the experience of care.
37
2
0
I have a growing frustration with the lack of timely progress with interprofessional
practice (the integration and coordination of oral health care).
25
13
1
Health information technology systems and their vendors are currently a laggard that
stagnates the proliferation of rural interprofessional oral health practice.
38a
1
0
The majority (50%) of providers in your state(s) of operation are entering the primary
care setting are prepared to deliver the set of core competencies described by HRSA.
(https://www.hrsa.gov/sites/default/files/hrsa/oralhealth/integrationoforalhealth.pdf)
1
12
25
aThis was the only question that used a Likert scale response: Strongly agree (n = 17),
Agree (n = 16), and Neutral (n = 5)
Table 2
Poll Everywhere Results for Section 1: The Vision/Desired State “Provide your agreement
with the following statement: Value-based oral health care (incorporating interprofessional
practice) will comprise 20% or more of the healthcare market”
Answer Choices
Responses
Within 5 years
8
Between 5 to 10 years
19
More than 10 years
11
Fig. 1
Word Cloud Responses from the Poll Everywhere Question: “In one word, describe the
best opportunity to expand and enhance Interprofessional Oral Health Practice in the
clinical setting”
Fig. 2
Word Cloud Responses from the Poll Everywhere Question: “In one to three words, describe
the most beneficial primary public message/communication when it comes to rural oral
health”
The second activity of Day 1 was a panel presentation moderated by Christine Kavanagh,
Nursing Faculty at Pennsylvania College of Technology and the following panelists
were:
Leah Elsmore, an Education Coordinator at Cavity Free at Three from the Colorado Department
of Public Health and Environment
Mary Ann Rigas, MD, a Pediatrician at the Cole Memorial Hospital System, Coudersport,
Pennsylvania
Christine Veschusio, DrPH, a Research Assistant Professor from the Division of Population
Oral Health at the James B. Edwards College of Dental Medicine, Medical University
of South Carolina in Charleston.
The panelists provided insights about the adoption of rural oral health interprofessional
practice. Ms. Elsmore recalled from her feedback that 26% of her medical partners
expressed concerns about promoting oral health during their patients’ primary care
visits due to time constraints. Billing private insurance for fluoride varnish applications
and general issues with their billing departments were identified by 12 and 11%, respectively.
The number of partners was not provided.
Ms. Elsmore’s program, Cavity Free at Three, was working on a new pilot project at
a federally qualified health center that focuses on providing oral health services
to pregnant women. However, their challenges included (a) lack of communication between
both departments and (b) collecting data on oral health services with limited coding
unification. Ms. Elsmore gave the attendees two recommendations: focus on workforce
development trainings for medical providers and promote oral health initiatives like
Cavity Free at Three, in rural areas.
Dr. Rigas, a pediatrician from rural Pennsylvania, shared her challenges on adopting
oral health interprofessional practices. As with Ms. Elsmore, getting private insurance
to cover the costs of fluoride varnish was a challenge. Additionally, she identified
the following challenges in her communities:
patient recruitment into care,
medical and dental provider shortages, particularly dentists willing to see children
less than 3 years of age
medical providers not trained in oral health
families obtaining dental insurance
families’ oral health literacy and low perceived values of dental care
misperceptions on the safety of fluoridation
socioeconomic factors such as poverty and lack of education
Food quality and diet.
Dr. Rigas recommended attendees to consider taking several courses of action as rural
communities seek to improve oral health interprofessional practice. She recommended
oral health to be better incorporated into medical residency programs. For practicing
clinicians, she also suggested pediatricians be paired with dental hygienists to foster
interprofessional training in practice settings. Finally, she encouraged attendees
to address how dentists can be included in the exchange of health information.
Through her experience, Dr. Veschusio provided an overview of a best practice in her
home state of South Carolina. She and her team have been working with rural health
clinics and dental offices to foster integrated care models that prioritizes adults
with diabetes and children without dental homes. Using electronic health data in the
practices, they were able to identify children in need of dental care. The rural health
clinic staff then facilitated the establishment of a dental home. The program is called
ROADS, Rural Oral Health Advancements in Delivery Systems. Through this experience,
Dr. Veschusio acknowledged that electronic health records systems are nonexistent
in the dental industry, which makes it difficult to rely on technology to facilitate
referral partnerships. Additionally, she learned through ROADS that dentists do not
fully understand their role in making referrals to physicians. Thus, they were unsure
about how to develop formal referral partnerships with primary care providers.
Dr. Veschusio made several recommendations for attendees to consider as they think
about collaborative referral partnerships between primary care and dentistry. One
way to increase care capacity for Medicaid enrollees is to adopt the Safety Net Solutions
business model, available through the DentaQuest Institute. Part of that adoption
relates to how the dental practice can better collect and understand data, particularly
in areas like tracking ‘no show’ rates. She acknowledged more research and data on
the impact interprofessional practice has on patient outcomes are needed and that
such analysis should be used to shape public policy.
At the conclusion of the panelists’ presentation, the moderator facilitated table
discussions by asking three questions related to the current state of oral health
interprofessional practice in rural communities. Each is subsequently explored.
Table Discussion Question #1: What are two best practices currently employed by innovators
and early adopters in the current state of rural IPP practice?
Most of the discussions at the tables focused on recommendations for what participants
would like to see, rather than current best practices. A fluoride varnish application
by primary care providers was the most prevalent ‘best practice’ identified at the
symposium with five tables of participants acknowledging it. Beyond its clinical impact,
two tables discussed its effectiveness with establishing dental homes for patients
and their families. Its weaknesses were also identified. One table discussed how it
is an important tool but is inefficient for solving all a patient’s oral health problems.
One participant confessed his or her practice does not get reimbursed for it because
billing is a ‘time drain.’
The second best practice centered on new or emerging workforce models. Four tables
discussed the role of dental hygienists, identifying them as leaders in primary care
settings and possibly as the ideal team member for oral health-related case management.
One table discussed the success of embedding a hygienist in primary care settings,
particularly as a catalyst for integrated care. Two additional tables discussed community
health workers as an emerging workforce in oral health interprofessional practice.
The advantage of these team members is their presence in the community.
Table Discussion Question #2: What are the two main deficiencies in the system currently?
Why are they deficient?
State policies and health information technology were identified as the two primary
weaknesses for the adoption of oral health interprofessional practice. On the policy
front, tables identified practice acts and reimbursement policies as the chief inhibitors.
Four tables discussed their practice acts. One table specifically indicated the prior
dental examination rule (that a dentist must complete a thorough intraoral examination
prior to a non-dentist provide certain parameters of care) for hygienists to see in
primary care settings as an obstacle to adoption. Four tables identified health information
technology, specifically electronic health records as a difficulty with oral health
interprofessional practice. The lack of clarity on what to chart and the poor functionality
with referral management were discussed as deficiencies for both dental and medical
care teams.
Section II: The vision or desired state for rural Oral health Interprofessional practice
Day 2 continued with a panel presentation on the vision or desired state of rural
oral health interprofessional practice. As seen in Table 3 and Fig. 3, the second
section was framed with two Poll Everywhere questions that included a word cloud response.
Table 3
Poll Everywhere Results for Section 2: The Vision/Desired State “Which of the following
is the MOST important focus area that will result in positive return on investment
for launching remote patient monitoring and treatment programs [teledentistry-tele-oral
health]
Answer Choices
Responses
Cost savings financial business models
17
The creation, development, and proliferation of provider exchanges to provide dentists
for supervision and advanced practitioners for mobile practice
5
A fee-for-service based systems that provides equal reimbursement for teledentistry
1
A pay scale for community based or outreach advanced practice practitioners (expanded
hygienists / dental therapists) that is higher than office-based practitioners
4
Unanswered
17
Fig. 3
Word Cloud Responses from the Poll Everywhere Question: “In one word, describe the
best opportunity to expand and enhance Interprofessional Oral Health Practice in the
clinical setting”
The panel discussion prompted a conversation about the opportunities and challenges
with the next step in IP oral health evolution. The panel discussed areas of active
innovation and best practices that will be more prominent practice in the next 5–10 years.
The moderator was Michelle Mills, Director of the Colorado State Office of Rural Health.
Panelists were:
Mark Deutchman, MD, Professor, Family Medicine, Associate Dean for Rural Health, School
of Medicine, University of Colorado, Aurora, Colorado
William Bailey, DDS, MPH, Endowed Chair in Prevention of Early Childhood Caries, School
of Dental Medicine, University of Colorado, Aurora, Colorado and
Alan Morgan, CEO for the National Rural Health Association.
The panelists discussed the opportunities and challenges with the next step in IPP
and best practices anticipated within the next five to ten years. Dr. Deutchman indicated
that higher education that confers IPP competencies and insurance payment reform were
the two major priorities for advancing IPP. Dr. Deutchman discussed the paradigm with
insurance coverage, more adults have medical insurance than dental insurance and because
of this misalignment, the dental community has to rely heavily upon medical to address
the importance of oral health for a comprehensive referral system to be established.
Dr. Deutchman’s recommendations for best practices are:
Broaden the view of oral health for dentists and start educating them on their role
to other practitioners.
Increase utilization of behaviorists to more adequately improve purposeful health
behaviors.
Medical professionals can help patients reduce anxiety experienced with dental visits.
Since there are only 30 medical schools that offer rural health focused programs,
we need to start finding more students with an interest in rural health and train
them from there.
Dr. Bailey discussed innovation currently occurring with telehealth programs in Colorado,
where he serves as an advisor. This is a virtual dental home based system that will
provide services to patients who live 50 miles away utilizing private practice dentists
in the community utilizing asynchronous and synchronous telehealth capabilities. Within
this innovative model, dental hygienists visit assigned sites (school or workplace)
to take radiographs and send to dentists for assessment and treatment planning. The
importance of utilizing traditional private practice dental care teams to address
access is vital to successful oral health. In addition, he stated that it is not advantageous
to ignore the fact that financial sustainability and viability are necessary for any
system change to occur and continue. Dr. Bailey had recommendations for best practices:
Provide more IPP courses in alignment with accreditation standards.
Federal agencies need to start cooperating with one another
Promote telehealth in rural settings.
According to Mr. Morgan, there are a few ways to promote rural oral health (ROH) at
the state and federal level. For example, policymakers can go to experienced sites
and hear their stories on how they implement OH into their practice and utilize the
media to gain their attention. He also denoted that the lack of coordination and collaboration
at the Federal level and the lack of focus among stakeholders as threats that may
hinder the promotion of ROH. The data on the efficacy of telehealth needs to be stronger,
being that the previous datasets were from 2012, 2013 and 2014. At the completion
of the panelists’ discussion, symposium attendees engaged in table conversations that
addressed three questions relative to the vision or desired state of IPP.
Table Discussion Question #1: What are the two most important and one least important
area of impact for the innovators and early adopters in the rural IPP practice in
five years? Why are they least important?
The attendees were in agreement that technology was the most important, particularly
telehealth technologies. Given its importance, concerns were expressed about rural
communities’ abilities to support technology and the lack of health information technology
interoperability. The second most important area of impact is the referral network.
Having an effective and efficacious method for referral within rural is a key component.
Least important was the use of mobile dentistry without comprehensive and continuous
care. Tables agreed it to be inefficient, increases cost, and does not represent a
dental home concept.
Table Discussion Question #2: In 2022, what do you think will be the main two deficiencies
in the [rural interprofessional oral health] system?
The two main deficiencies expressed by attendees were finances and education, specifically
the cost of obtaining and maintaining a teledentistry model in conjunction with concern
about rural infrastructure capacity to support it. Financial policy out of alignment
with practice was predicted for 2022 as well. Additionally, community support and
education regarding IPP and teledentistry will increasingly become more important.
In summary, the deficiencies identified in Section 1 [Current State] were validated
by the panelists and predicted to remain threats in 2022.
Table Discussion Question #3: Is there one current state best practice that is superiorly
positioned to transition to the future state?
One symposium table suggested participants look internationally, rather than domestically
but did not offer specific successful models. The Mexican Dental Association was identified
as having increased literacy. Lastly, the participants agreed the model presented
by Dr. Bailey during the panel presentation represented the one best practice best
positioned for future replication.
Section III: Closing the gap: Action planning
Attendees were asked to provide resource recommendations for rural organizations and
health systems working to integrate and coordinate oral health and explain why those
resources are important. A few responses echoed findings from Section II [Ideal/Desired
State] regarding the need and utilization of better communication methods between
patients, dentists, and primary care providers. There is a need for more robust data
analysis and evidence-based research to support the efficacy of better communication
methods. Additionally, the implementation of technical assistance teams to assist
practices with understanding oral health integration and operationalizing the available
frameworks.
The attendees were also asked to provide a compelling argument for other health care
providers to understand the value of oral health integration into primary care. The
Smiles for Life Curriculum was offered as a way of bridging the gap for those providers
who don’t understand or don’t see the value in integrated oral health care. Educating
providers that oral health is connected to overall health and how it helps to prevent
diseases is a major component.
The panel discussion within this section centered on closing the gap where they discussed
opportunities and challenges regarding policy implications, challenges and the current
state’s advantages will help with rural IPP. The panel was moderated by Brian Novy,
DMD, Director of Practice Improvement at DentaQuest Institute and President of the
DentaQuest Oral Health Center. Panelists were:
Marcia Brand, PhD, MSD, Senior Dental Advisor, National Oral Health Programs, DentaQuest
Foundation
Carolyn Brown, DDS, President and Founder, Carolyn Brown and Associates, Inc.
Anita Glicken, MSW, Executive Director of the National Interprofessional Initiative
on Oral Health
Dr. Brand provided a few recommendations that are germane to creating an action plan
for IPP, such as, sharing success stores with the champions who have had successful
integration. Engaging with other federal systems, such as Veteran’s Affairs (VA) and
Centers for Medicare and Medicaid Services (CMS) with the understanding that a lot
of the populations served by these federal organizations are rural. She also reflected
that guidelines for how federal agencies issue collaborative funding calls, or coordinate
grants, with philanthropic organizations is unclear, however expressed confidence
that federal agencies see rural oral health as a priority.
Dr. Brown stressed that an important piece in promoting IPP is standardizing the diagnosis
coding system to ease transitions with and to value-based payment models. Dr. Brown’s
recommendations for the action plan were to include more interprofessional education
for dental students and use technology to promote oral health.
Ms. Glicken echoed Dr. Brown emphasizing the importance of interprofessional education
and coupling education with HRSA competencies. She also mentioned establishing a common
language between providers about what IPP means and how to accomplish as a component
of the action plan. Ms. Glicken also noted that there are extremely limited metrics
and data to support the known cost saving benefits of IPP, making the adoption difficult.
Dr. Novy directed a few questions to the symposium attendees:
Table Discussion Question #1: What impact area is the most important to assist with
action planning to close the gap from current state to desired state?
The two most discussed impact areas were policy and communication and education for
both the patient and the provider. As discussed by multiple panelists, the need for
IPP education within medical and dental schools is an area of focus. The need for
more robust data regarding cost savings and the interconnectivity of oral health and
systemic health is important for those providers who are in practice and do not see
IPP as a priority. Educating the patient is crucial to their health literacy and understanding.
Policy changes are necessary to force a significant change in the way that practices
provide care to their patients. Additionally, attendees discussed the importance of
consumer buy-in and the need to enhance and improve the expectation that patients
have of the care experience. Discussion on how to change consumer habits in a way
that empowers patients to demand a care experience that manages health instead of
disease occurred; however, pathways or solutions were not rectified within the table
discussions.
Table Discussion Question #2: Name one high achieving goal to aid the oral health
system transition to the 3.0 [next] era in healthcare.
Technology was noted as the most frequent response from the attendees. This was a
major topic of the symposium and it was mentioned in all sections of the agenda. Technology
and electronic health records are major issues and it needs to be comprehensively
explored within the action planning phase.
Table Discussion Question #3: Name one low hanging goal to aid the oral health system
transition to the 3.0 era in healthcare.
The most frequent response surrounded primary care integration with referrals, building
a coalition and using community health workers for all relevant health issues. Empowering
front desk staffs and nurses to promote oral health care within the primary care setting
was another initiative for the action plan.
Conclusion
Dissemination of the interprofessional practice concept has increased in the last
two decades, most likely as the result of an ongoing paradigm shift that includes:
consumer habit changes, focus on chronic disease management, politicization of U.S.
Healthcare, increased provider dissatisfaction and burnout, and the healthcare cost
crises [9]. This convening brought together stakeholders from or with an interest
in rural health to develop and discuss the current and future state of interprofessional
oral health practice in rural communities. The attendees described a currently fragmented
system that would benefit from more consistency in the experience of care structure,
utilization of payment or financial processes that direct health as a goal, and the
design and agreement on outcomes based in population health. The attendees also recognized
that many resources are available to assist care teams and organizations in integrating
health systems; however, the operationalization of interprofessional practice as a
tool has been slow and more technical assistance is needed to guide health systems
toward truly integrated ventures. The convening concluded with participants focused
on addressing inadequacies in educational standards and accreditation, an effort to
change antiquated financial and practice act policy that impedes health care teams
and systems from interprofessional practice, and involving more patients and consumers
in decision making and education to change the expectation of oral health care.