Oral Care for Residents in LTC Facilities
“Overcoming Common Barriers”
Sarah J. Dirks, DDS
Geriatric Dental Group of South Texas, PA
San Antonio, Texas 78229
December 2, 2011
1.0 AGD CEUs
2
Topics:
1. Two Distinct LTC Goals & the Barriers:
 Provision of Medically Necessary Oral Care
 Provision of Daily Oral Care
2. Three Momentum Makers for Change
• Research Momentum
• Regulatory Momentum
• Culture Change Momentum
3
Long Term Care Goal #1
Provision
of Medically
Necessary
Oral Care
Fee
Schedule
LTCF’s must have a providing dentist.
Provision
of Medically
Necessary
Oral Care
Applied
income
can be
used
to pay for
oral care.
Long Term Care Goal #2
Provision
of Daily
Oral Care
In LTC
Improving Oral Health
for LTC Residents in Texas
1. Two Distinct LTC Goals & the Barriers:
 Provision of Medically Necessary Oral Care
- Dental Profession = primary tactical team
- Primary Champion = _____________
 Provision of Daily Oral Care
- LTC Profession = primary tactical team.
- Primary Champion = ____________
7
Reality Check
Dental Profession:
stagnant
LTC Profession:
in crisis
Goal #1:
Medically Necessary
Oral Care
Goal #2:
Routine Daily Oral Care
Improving Oral Health
for LTC Residents in Texas

Overcoming Common Barriers
• (1) Provision of Medically Necessary Oral Care
- Dental Profession = primary tactical team
• (2) Provision of Daily Oral Care

LTC Profession = primary tactical team.
Three Momentum Makers for Change
9
Medically Necessary Oral Care
is Priority Driven Care
.






- Relieve
- Manage
- Prevent
- Increase
- Improve
- Keep
10
Improving Oral Health
for LTC Residents in Texas

Overcoming Common Barriers
• (1) Provision of Medically Necessary Oral Care
- Dental Profession = primary tactical team
11
Who Provides Medically Necessary
Oral Care to LTC Residents?
• Geriatrics Practices:
Focused on LTC Facilities
• Mobile Services & In Office Services
• Metropolitan Areas & Smaller Communities
• Periodic rotations by contract dentist
• Services may be Provided Room by Room
• Services Provided in Multipurpose Treatment Room
• Partner with Podiatrist? Other Medical Teams?
• New facility construction?
• General Practices: Focused on Continuum of Care
• Mobile hygiene services? & In Office Services
•
Metropolitan Areas & Smaller Communities
12
Report:
Building Better Oral Health





ADA commissioned independent third-party report on the
issue of access to oral health care in Texas
Identify the state’s most pressing issues, needs and
challenges associated with improving the oral health of
all Texans.
Special focus on the state’s most vulnerable.
www.buildingbetteroralhealth.org
Recommendation #5
13
Policy Recommendation (5/5)
Building Better Oral Health

Expand access to oral health services for
older Texans
• Provide incentives to encourage dentists to
practice in LTC facilities:
• Loan payback programs
• young dental graduates/retired dentists
• (experienced foreign trained dentists –
expedited path to licensure?)
• (encourage life cycle continuum of care)
14
Common Barriers: Dental Profession
Mainstream dental office ≠ LTC dental office
• Complex Coordination of Care
• Solution: Develop LTC administrative systems
• Medically Compromised Patients
• Solution: Implement strict clinical protocols
15
Develop Administrative Systems
and Protocols Tailored to LTC






Learn LTC lingo/enter the culture of LTC
Have SW or DON fax medical info to office prior
to exam visit or hygienist visit to NF.
Establish 3rd party protocols
• Medical & Financial RP Consent Forms
Templates for NF premeds, po antibiotics, post-op
orders, oral hygiene orders, etc.
Written authorization for hygienist template
Documentation of phone conversations
16
Solutions Continued:
3rd Party Contacts:
Production musts:
 Set minimum # of pts
 Medical/$ POA
 Plan on compressed tx
 Resident’s Spouse
hours at NF due to lunch
 Primary Care Physician
 Have pt room #’s
 Resident’s dentist of
 Premeds called in the
record
day before
 Director of Nursing
 Confirm pt will be there
 Social Worker
 Be flexible
 Business Manager
 Be positive
17
Solutions: Strict Clinical Protocols






Preprocedural brushing with Chlorhexidine
Cardiac & stress reduction protocols on all
residents
Use high quality pt monitoring device
• Blood pressure/O2 saturation
HVE /minimal water/ more upright
INR monitor, blood glucose monitor
Pre and post blood pressures
18
The Exception becomes the Norm

Complex coordination of care

Compromised patients
• Administrative systems
• Clinical protocols
19
GDG Ideal Protocol – “NF Flow”





Resident needs medically necessary oral care
SW completes IME paperwork & calls our tx
coordinator to initiate treatment
DDS reviews MARS & provides written
authorization for dental hygienist to go to NF:
• Begin initial charting, take x-rays, FMD
DDS reviews x-rays & hygienist notes
DDS goes to NF to provide COE
20
STATE BOARD OF DENTAL
EXAMINERS




Texas Administrative Code
TITLE 22 PART 5 CHAPTER 115
EXTENSION OF DUTIES OF
AUXILIARY PERSONNEL--DENTAL
HYGIENE
RULE §115.5 Dental Hygienists
Practicing in Certain Facilities
21
Improving Oral Health
for LTC Residents in Texas

Overcoming Common Barriers
• (1) Provision of Medically Necessary Oral Care
- Dental Profession = primary tactical team
• (2) Provision of Daily Oral Care

LTC Profession = primary tactical team.
Three Momentum Makers for Change
22
Oral Care Provided by Certified Nursing
Assistants in Nursing Homes



Journal Am Geriatr Soc 54:138-143,
2006
Patricia Coleman, PhD, RN
First observational study in U.S. Nursing
Homes of oral care actually provided to
residents by CNA’s
23
Dentate Nursing Home Residents
CNA Self Report





Teeth brushed: ?
Mouth rinse: ?
Teeth flossed: ?
Time brushing: ?
Clean gloves worn: ?
Actual Care Observed





Teeth brushed: ?
Mouth rinse: ?
Teeth flossed: ?
Time brushing: ?
Clean gloves worn: ?
CNA’s were told that observations
were to understand morning care.
24
Supplies Available to Provide Oral Care




of residents had toothbrush/paste
of residents had mouthwash
of residents had floss
had no visible supplies
25
Three Promising Momentum
Makers for Change



Research Momentum
Regulatory Momentum
Culture Change Momentum
26
Momentum Makers for Change
(1) Research:
• Utilize BSS for residents in LTC facilities
• Basic screening survey for older adults
• Determine financial burden for LTC facility to
provide daily oral care
• Pilot Project: Oral Care Specialty Trained CNA
• How many man hours?
• 1 CNA/100 bed facility/per day?
27
Momentum Makers for Change
(2) Regulatory Pressure/Legal Issues
• Training of CNAs
• BBOH Policy Recommendation #5
•Surveyor Expectations:
• BBOH Policy Recommendation #5
• Oral Neglect
28
Policy Recommendation (5/5)
Building Better Oral Health

Expand access to oral health services
for older Texans
• Mandate that all providers who assist in
activities of daily living for the physically
dependent or elderly be properly trained
in providing oral hygiene.
29
Momentum Makers for Change
(2) Regulatory Pressure/Legal Issues
• Training of CNAs
• BBOH Policy Recommendation #5
•Surveyor Expectations:
• BBOH Policy Recommendation #5
• Oral Neglect
30
Procedures for Review of
Dental/Oral Status of Residents
(1) Interview resident & family
(2) Visual observation of residents’ mouths
(3) Record review
(4) Observation of the oral care furnished
31
Policy Recommendation (5/5)
Building Better Oral Health

Expand access to oral health services
for older Texans
• Require that nursing home inspections
include a mandatory oral health component.
32
Momentum Makers for Change
(2) Regulatory Pressure/Legal Issues
• Training of CNAs
• BBOH Policy Recommendation #5
• Surveyor Expectations:
• BBOH Policy Recommendation #5
• Oral Neglect
33
“Defining Oral Neglect in
Institutionalized Elderly”





“
“A consensus definition for the
protection of vulnerable elderly
people”
Journal of the American
Dental Association
Vol. 141 – April 2010
Katz, R., Smith,B., Berkey,
D.,Guset,A.,O’Connor,M.
Federal payments to nursing
facilities require that there
be no oral neglect.
34
34
Time to qualify as neglect

# of days after which failure to have a dental
consultation would constitute oral neglect
•
•

Acute Condition = 3 days
Chronic Condition = 14 days
# of days after which failure to initiate or reject
treatment would constitute oral neglect
•
•
Acute Condition = 5 days
Chronic Condition = 21 days
35
35
Rapid Oral Decline in Frail Elderly






Multiple co morbid medical conditions
Medication induced xerostomia
Aging restorations
Decreased ability and/or inability for self
daily oral care
Decreased ability to get to dental office
Decreased ability to tolerate routine care
36
Momentum Makers for Change
(2) Regulatory Pressure/Legal Concerns
Oral Neglect and relevance to the:
• Initial screening of resident’s oral status
• Federal mandate
• Within 14 days of admission
• Usually screened by nurse
• Part of Minimum Data Set
37
Minimum Data Sets



Comprehensive health assessment
Includes oral health
• Sections K and L
Goal is to identify oral health problems and
therefore a plan of care and intervention is
triggered
38
Minimum Data Set Items
Related to Oral Cavity:







Chewing Problem
Mouth Pain
Debris in Mouth
Some or all natural teeth missing
Broken, loose, carious teeth
Inflamed gums
Has daily mouth care by resident or staff
39
Promising Momentum Makers
for Change



(1) Research Momentum
(2) Regulatory Momentum
(3) Culture Change Momentum
40
 DON is Key to Geriatric Oral Health
Culture
Change
Momentum Makers for Change
Culture Change
• The Promise of Collaboration:
• Dentistry must enter the world of LTC
• Redefine and discover new relationships
• Trust, unity, shared purpose, & understanding
42
Momentum Makers for Change
Culture Change
• The Promise of Collaboration:
• New Relationships: Examples
• DON and contracted dentist?
• DON and consultant dental hygienist?
• Dental hygienist and oral care aide?
• TSBDE & expanded function hygienist?
43
Example: Trust and Collaboration

Minimum data set

Dental professional
provides initial oral
screening and/or
examination after
admission to NF.
• Sections K and L
• Oral Health
44
Promising Momentum Makers

Culture Change Momentum
• Future Collaborations?
• Dentist Director & Facility Administrator?
• Hygienist Consultant & Facility Administrator?
• Facility Wide Oral Care Program
• Hygienist Consultant & DON?
• Individual Resident Oral Care Plan
45
LTC Facility Oral Health Program
Dental Consultant + Administrator


Oversee/implement facility’s daily oral care program
Coordinate facility’s medically necessary oral care plan








Social worker/family/transportation/pt preferred dentist
Develop yearly/periodic screening or exam schedules
Provide education and in-service training
Specialty training of assigned “Oral Care Aide”
Maintain oral care records/documentation
Maintain needed individualized oral care supplies
Help facility meet federal and state regulations
Conduct periodic quality assurance
46
Individual Resident’s Plan
Dental Hygienist Consultant + DON




Resident Advocate
Family Liaison
Work with Social Worker - Funding options
Provision of:



Initial Oral Screening?
Daily Oral Hygiene Plan
Documentation of daily care
 Coordination of:

Resident’s Medically Necessary Dental Plan
47
LTC Hygienist Consultant (Liaison)

Responsible/reports to:
•
Authorizing dentist
• Requires written authorization: TSBDE Rule 115.5
• Administrator???????

Medical director?????
Coordinates with:
• Resident and resident’s responsible party
• Resident’s preferred dentist/dentist of record
• DON and communicate special precautions
• OT, PT, Speech Pathology
48
The Role of a Liaison?







Answer questions
Find resources
Share information
Facilitate processes
Support efforts
Help connect
Solve problems
49
The promise of transdisciplinary Nurse-dental hygienist
collaboration In achieving health-related quality of life
for elderly nursing home residents




www.dentaliq.com
Grand Rounds in Oral-Systemic Medicine
September 2006, Vol.1. No. 3
Pages 40 - 49
50
Oral health coordinators in long-term care
— a pilot study
Special Care in Dentistry
 Volume 30, Issue 2 - pages 59–65
 March/April 2010


Pronych, G. J., Brown, E. J., Horsch, K. and
Mercer, K.
51
Oral health education for nursing personnel;
experiences among specially trained oral
care aides: One year follow-up
Scand J Caring Sci
 Volume 17: pages 250-256
 2003


Wardh, I. (dentist); Hallberg, L. (RN);
Berggren,U.; Andersson,L.
52
Promise of Future Collaboration?
DON
& LTC Administrator
RDH
& Supervising Dentist
OHA
Resources







www.oralhealthamerica.org
www.buildbetteroralhealth.org
www.thetrecsinstituge.org
www.astdd.org
www.txoralhealthcoalition.org
www.oralhealthamerica.org
Patricia Coleman, RN, PhD
Articles
54
Sarah J. Dirks, DDS
210 - 617- 4446
www.geriatricdentalgroup.com
55