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Oral Health Toolkit A Guide to Promoting Oral Health in Pediatric Primary Care and Achieving Medical-Dental Integration September 2016

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Table of Contents Oral Health Integration Sub Committee Member Organizations ......... 2 Introduction ...................................................................................................................... 3 Purpose .............................................................................................................................. 3 How to Use This Toolkit .............................................................................................. 3 Oregon Oral Health Statistics................................................................................... 4 First Tooth Training Program ................................................................................. 5 Oral Health in Children ............................................................................................... 6 Early Childhood Caries ........................................................................................... 6 Priority Populations................................................................................................. 6 Prevention ...................................................................................................................... 6 Dental Care and Pregnancy ....................................................................................... 7 Child Oral Health Resources ............................................................................... 8 Medical-Dental Integration ....................................................................................... 9 Systemic Health .......................................................................................................... 9 Dental Referral Strategies ................................................................................. 10 Changing Dental Providers ..................................................................................... 11 Payment and Reimbursement .............................................................................. 12 Appendix A: First Tooth Training and Integration Process Map ...... 13 Appendix B: Readiness Assessment .................................................................. 14 Appendix C: Caries Risk Assessment Form Examples ............................. 15 Appendix D: Sample Referral Forms................................................................. 19 Appendix E: EMR Examples.................................................................................... 21 Appendix F: Care Team Workflow Example ................................................. 27 Appendix G: Clinic Policy Example..................................................................... 28 Appendix H: Reimbursement Codes ................................................................. 30 Appendix I: Supply Orders ..................................................................................... 31 Appendix J: Oral Health Education and Resources for Providers ..... 33 Appendix K: Oral Health Education and Resources for Staff ............... 34 Appendix L: Oral Health Education and Resources for Leadership. 35 Appendix M: Additional Resources ................................................................... 36

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Oral Health Integration Sub Committee Member Organizations The following organizations contributed to the creation of this toolkit: CareOregon Dental

Providence St. Vincent Medical Center

FamilyCare

Tuality Healthcare

Legacy Meridian Park Medical Center

Virginia Garcia Memorial Health Center

Oregon Oral Health Coalition

Washington County Public Health Division

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Introduction Dental disease is universally prevalent among the general population. In 2000, the U.S. Surgeon General labeled it a “silent epidemic.” Children, adolescents, low-income families, minorities, and those with special health care needs are particularly vulnerable to dental disease. The lack of access to oral health services for these populations contributes to the oral health disparities in the United States. Historically, oral health was not considered a significant component of overall health. However, over the years, research has found oral health to be an integral part of systemic health. “Simple cavities” can escalate through childhood and into adulthood, causing youth to miss significant numbers of school days and even causing difficulties in finding a job. Poor oral health has also been linked to cardiovascular disease, dementia, respiratory infections, and diabetic complications. The American Academy of Pediatric Dentistry (AAPD) recommends that children see a pediatric dentist when the first tooth appears or no later than the first birthday. The AAPD also recommends a check-up every six months in order to prevent cavities or other dental problems. Yet, approximately 17 million low-income children in the United States go without dental care each year. In February 2014, the Health Resources and Services Administration (HRSA) released a report, Integration of Oral Health and Primary Care Practice, which provides a framework for medical-dental integration in primary care. The integration of medical and dental services is key to reducing oral health disparities. The integration of medical and dental services will improve capacity and utilization of preventive oral health services for priority populations.

Purpose This toolkit was developed by the Washington County Access to Integrated Care Oral Health Integration SubCommittee in collaboration with the Oregon Oral Health Coalition and the Washington County Public Health Division. It was developed through a quality improvement process to address integration barriers faced by local providers. The toolkit was also developed to promote awareness among pediatric primary care medical providers and ancillary staff of the impact of oral health on systemic health. It includes recommendations and tools and will serve as a resource for pediatric primary care providers as they look to achieve medical-dental integration through the use of the First Tooth program.

How to Use This Toolkit This toolkit consists of 4 sections: 1. 2. 3. 4.

Oral Health in Children Medical-Dental Integration Payment and Reimbursement Appendix

The first section contains information regarding oral health in children. This section includes key dental terms with the goal of creating a common medical-dental language regarding oral health prevention and disease. The second section includes recommendations and techniques on how to best integrate the four components of the First Tooth Training into primary care. The third section focuses on payment and reimbursement, and provides resources related to billing and coding. The appendix contains tools and sample documents as referenced in the text that will help facilitate ease of integration of the First Tooth Program. 3

Oregon Oral Health Statistics 2012 Oregon Smile Survey 1

Among 6- to 9-year-olds: • Children from lower-income households had substantially higher cavity rates compared to children from higher-income households (63% vs. 38%), almost twice the rate of untreated decay (25% vs. 13%) and more than twice the rate of rampant decay (19% vs. 8%). • Hispanic/Latino children had substantially higher rates of cavities, untreated decay, and rampant decay when compared to white children, black/African American children had even higher rates of untreated decay. • One in five children (20%) had untreated decay in their primary or permanent teeth. • More than one in two children (52%) has had a cavity, representing about 66,000 Oregon school children. • 19% of children were in need of early or urgent dental care, representing more than 24,000 children needing access to professional care.

2011/12 National Survey of Children’s Health (NSCH)2 • • • • • •

48% of children ages 1-5 compared to 11% of children ages 6-11 had no preventive dental care visits in the past year. 10% of children ages 1-5 had one or more oral health problems in the past 12 months, in comparison with 28% of children 6-11 year olds. 3 1/3 (30%) of Hispanic children versus 17% of white, non-Hispanic children had one or more oral health problem in the past 12 months. 4 One in three children (30%) 0 - 99% of the Federal Poverty Level (FPL) had decayed teeth or cavities in the past 12 months, versus 27% of children 100-199% FPL, 17% of children 200-399% FPL, and 11% of children 400% or higher of the FPL.5 One in five children (20%) who experienced gaps in insurance coverage in the last year had fair/poor teeth condition compared to 10% who had no gaps in insurance. Only 5% of children whose care met all criteria for a medical home had teeth in fair/poor condition, in comparison with 19% of children whose care did not meet all medical home criteria. 6

2009-2011 Pregnancy Risk Assessment Monitoring System (PRAMS) 7 • • •

74% of 2 year olds in Washington County had not been to a dentist or dental clinic. 36% of Washington County 2 year olds had not been to a dentist or dental clinic because the parent/caregiver didn’t know their child needed to go to a dentist. 20% of Washington County 2 year olds had not been to a dentist or dental clinic because a health care or dental provider told them their child was too young to see the dentist.

The Oregon Smile survey involves a clinical examination, where a specially trained dental hygienist screens (5,258) children in 1st, 2nd and 3rd grades from a statewide representative sample of (82) elementary schools in Oregon. The survey focuses on caries experience, untreated tooth decay, sealants, and early childhood caries. 2 The NSCH is a random digit dial phone sampling of parents regarding one child in the household - data includes children ages 1-17. 3 The jump in preventive dental care visits and oral health problems for ages 6-11 could highlight a lack of access to preventive care for children ages 0-5, a lack of oral health knowledge, insufficient provider outreach, and/or social barriers preventing utilization of services. 4 Oral health problems including toothaches, decayed teeth, or unfilled cavities were included in this measure. 5 A household between 0 and 99% of the federal poverty level (FPL) is considered low-income, while 100% to 199% FPL is considered moderate income. Households at or above 300% FPL are considered high-income. 6 Medical home is a multidimensional measure which uses the American Academy of Pediatrics criteria for quality care delivery among children. For more information on how medical home is defined and measured, please see the CAHMI at medical home manual 7 PRAMS collects state-specific, population-based data on maternal attitudes and experiences before, during, and shortly after pregnancy. 1

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First Tooth Training Program In 2009, The Oregon Oral Health Program in collaboration with the Oregon Oral Health Coalition (OrOHC) launched First Tooth. The program transitioned to OrOHC operational control in 2012. The goal of First Tooth is to reduce early childhood caries in Oregon by training medical and dental providers to implement preventive oral health services for infants and toddlers ages three and under. Both the American Academy of Pediatrics and the American Academy of Pediatric Dentistry recommend an oral health risk assessment, including a visual screening, anticipatory guidance, preventive strategies, (such as fluoride varnish), and the establishment of a dental home by age 1. (Research studies show that application of fluoride varnish can reduce tooth decay between 30% - 69% in primary teeth of high-risk children.) To achieve these goals, First Tooth offers a no-cost training for dental and medical communities. The training is also available to WIC programs, Head Start programs and other entities that have a vested interest in the oral health of young children. First Tooth training topics cover: the prevalence and impact of oral disease, risk assessment, culturally appropriate anticipatory guidance, fluoride varnish application, program implementation, workflow tips and access to dental care and a dental home. First Tooth also provides on-site support to build collaboration between dental and medical providers. The First Tooth training includes: • In-office continuing education, in-service training times or evenings, approximately 1.5 - 2 hours depending on need • Training for all providers and staff on how oral health preventive services can easily be integrated into current services • Instruction on fluoride varnish application • Culturally appropriate handouts, exam/waiting room posters and anticipatory guidance that can be shared with parents and caregivers • Guidelines to help refer children to a dental home by age one • Continued support and technical assistance from FIRST TOOTH staff on systems-based implementation, workflow and clinical instruction Since 2010, First Tooth has trained over 3,800 medical and dental staff throughout Oregon. Visit http://www.orohc.org/content/first-tooth for more information.

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Oral Health in Children Despite improvements in oral health outcomes for Oregonian children over the past 9 years, oral disease still remains a major public health issue that disproportionately affects socially disadvantaged children. Oral disease can not only affect the quality of life of a child, but also has social and economic consequences into adulthood.

Early Childhood Caries

Oral disease in very young children is a major determinant of the quality of their overall health. In addition to infection, pain, and a high risk of developing tooth decay in permanent teeth, childhood oral disease is directly linked to a child’s ability to concentrate, impaired language development, low self-esteem, and other critical developmental issues. Early childhood caries (ECC, also known as tooth decay) is the most common chronic disease in children, affecting five times more children than asthma. Over 52% of 1st graders in Oregon have had a cavity, and 34% currently have untreated cavities.

Priority Populations

Cavity rates among 6- to 9-year-old children in 2012 were generally at or above 50% throughout the state of Oregon. 8 Children from low income families have an increased risk, with low-income minority children at an even higher risk.

Prevention

Early childhood caries is transmissible, preventable, and treatable. By using simple tools, like those that First Tooth offers, we can improve overall health of young children and help equalize the balance of health equity by reducing the oral disease that disproportionately impacts the lives of low income children. The First Tooth program trains dental providers and staff, caregivers (such as those working in Head Start and Early Head Start programs), and pediatric and family practice providers and staff about how to include preventive services in their daily work. 8

These pictures show the progression of early childhood caries. See AAP flipchart and pocket guide for progression of early childhood caries.

Oregon Health Authority. (2013). Oregon Smile Survey 2012 Report (Rep.). OR.

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Attendees are educated about the importance of oral health care during pregnancy, how to identify signs of early childhood caries, behavioral strategies for caries prevention, and how to apply fluoride varnish. Trainers also discuss program implementation, workflow tips, and strategies for creating access to dental care and a dental home. First Tooth trainers also provide on-site support to build collaboration between dental and medical providers. Prevention should also be practiced on daily basis at home. Community health workers, pediatricians and family practice clinicians, dentists, and WIC and Head Start or Early Head Start staff can all promote healthy habits through education for parents and children. Habits that help prevent early childhood caries include: • Ensure mother’s mouth is healthy before baby is born. • Put babies to sleep without a bottle; fill it with water if the baby must have a bottle. • Clean babies’ teeth and gums with a clean washcloth or small, soft toothbrush at bedtime. • Provide babies with a clean pacifier, not one dipped in something sweet. • Avoid giving children soda pop, juice, and other sweet drinks. • Make sure children brush their teeth for two minutes a day, twice a day, with fluoride toothpaste. • Provide healthy snacks between meals and only give treats at meal times. Babies should see a dentist or dental hygienist by their first birthday. Teeth and gums can be checked yearly. By age 3, children should already be seeing a dentist regularly and have an established “dental home”. When children are old enough, they can use an alcohol-free fluoride rinse after brushing, provided they spit (not swallow) the rinse.

Dental Care and Pregnancy

Addressing oral health in pregnancy is the most upstream approach to preventing early childhood caries. Not only is poor oral health associated with poor pregnancy outcomes, but mothers/primary caregivers are also the main source of the bacteria responsible for causing caries in children. Improving maternal oral health reduces caries transmission from mother to baby and improves the overall health of the mother and child. Among recent postpartum mothers in Washington County: • 63% of mothers had their teeth cleaned during the 12 months before they got pregnant with their new baby. • 45% of mothers did not go to a dentist or dental clinic during their most recent pregnancy. • 58% of mothers said a dental or other health care worker talked with them about how to care for their teeth and gums.

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Child Oral Health Resources

American Academy of Pediatric Dentistry (AAPD) Informational brochures for parents: www.aapd.org/pediatricinformation/brochurelist.asp Campaign for Dental Health http://ilikemyteeth.org/ Help Me Be Healthy Tools and Resources for a healthy start set of educational pamphlets developed by WIC's health professionals for an active and healthy community http://www.helpmebehealthy.net/ National Center for Fluoridation Policy and Research (NCFPR) http://waterfluoridationcenter.org/ New Resources on Special Health Care Needs for Providers and Caregivers http://dental.washington.edu/departments/omed/decod/special_needs_facts.php Oral Health America Develops, implements, and facilitates educational and service programs designed to improve the oral health of all Americans. www.oralhealthamerica.org Smiles Across America This site is an application to receive donated fluoride varnish. http://oralhealthamerica.org/wp-content/uploads/Product-Donation-Form-2011.pdf Washington Dental Service Foundation http://kidsoralhealth.org/

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Medical-Dental Integration The integration of oral health into medical care is quickly becoming a best practice in order to address prevention at an early age. Many states have developed similar successful programs utilizing medical providers as the entry point for preventive oral health care. By the age of 3, a child has many well-child checkups, yet many parents wouldn’t know to bring their child to the dentist by their first birthday, which is the recommended first visit to a dentist. It is ideal for the initial assessment, guidance for parents, and referral to a dentist, to occur during one of these routine well-child visits with the medical provider. Early preventive intervention for a young child and parent can lead to decreased risk of future cavities and decreased dental costs. If a parent learns to not put their infant to bed with a bottle of milk, for instance, cavities in the front teeth can be prevented. A toddler with severe cavities of the front teeth often requires treatment with general anesthesia in a hospital setting which can be risky and very costly. A medical provider doing an oral health assessment with a referral to a dentist can result in a timely referral into dental care that might not happen otherwise. By embracing an approach to comprehensive health care, integrating oral health into medical care can provide the perfect environment for strengthening access to oral health care, improve both provider and parent understanding of oral health, and provide the needed oral health care screening, preventive, and referral services that are essential to optimal health.

Systemic Health

The Surgeon General’s Report in 2000 on the silent epidemic of oral health, clearly indicates that poor oral health in childhood can lead to much more serious problems later in life. There is a growing body of evidence indicating that periodontal (gum) disease is linked to cardiovascular disease, stroke, and diabetes. Diabetes is known to be linked to worsening gum disease and diabetics with uncontrolled gum disease have more difficulty controlling their blood sugar. The oral health of pregnant women and new moms is critically important because bacteria causing cavities are passed on from parents to their children. Many adults experience xerostomia or dry mouth, an adverse effect of many common medications and chronic conditions. Xerostomia increases the risk of oral infections and increases the rate of cavities, leading to increased dental expenditures and a decreased quality of life. A United Health Care study published in 2013 looked specifically at the impact of various dental treatments on the medical and pharmacy costs for individuals with chronic medical conditions. Overall the net cost of medical treatment for those who had dental treatments was lower, even when adjusted for the cost of the dental treatment. This is a reminder of the importance of oral health care and maintenance when related to overall health. The benefits of prevention and promotion of oral health from an early age are substantial.

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Dental Referral Strategies

For Medicaid Members: If the patient has an established dental home: Refer the patient to their dental home for dental care. Assist the patient by providing care coordination or calling/faxing/emailing the referral directly to the dental home. If the patient DOES NOT have an established dental home: For a dental referral, determine the patient’s assigned Dental Care Organization (DCO), which may be listed on the member OHP/CCO card or letter, or call the patient’s CCO customer service number. CCOs (Coordinated Care Organizations) delegate dental care to the DCOs rather than a dental provider network. When determining where to establish dental care, contact the DCO instead of calling individual providers to set up a dental home. The DCO will list the health centers/providers that participate in the patient’s dental benefit plan. • Some patients are assigned to a specific dental clinic by their DCO. If the patient knows which clinic they are assigned to, they can contact that clinic directly. If it is difficult to determine the patient’s assigned DCO, call the patient’s CCO customer service number. • If there is no assigned CCO, contact OHP Client Services at 1-800-273-0557 (TTY 711). • If resources are available, provide navigation and care coordination for the patient (aid in determining the DCO and/or participating health centers/providers, scheduling, sending the referral). If the patient is private pay/insurance or uninsured: Ask if the patient has established care at a dental home. • If yes, refer the patient to their dental home for dental care. Assist the patient by providing care coordination or calling/faxing/emailing the referral directly to the dental home. •

If no dental home has been established, refer patient back to their commercial insurance carrier to find a contracted dental provider, or provide patient with a list of dental providers that will accept their private insurance. Utilize safety net clinics for those below federal poverty line and/or uninsured. If resources are available, provide care coordination by calling/faxing/emailing the referral directly to the dental provider.

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Changing Dental Providers

For Medicaid members: To change dental providers at the health center or dental clinic where the member has already established care: Ask the site to change the dental provider of record (Primary Dental Provider). • There may be frequency limitations for changing Primary Dental Providers per the health center/dental clinic. To change to a dental provider at a different health center or dental clinic: Contact the patient’s DCO (Dental Care Organization). The DCO is contracted with specific health centers/dental clinics. The DCO will inform the patient which health center/dental clinic or Primary Dental Provider they may choose from. • This information may be found on the DCO website (links to DCO websites can be found within the member’s CCO website) or by calling the DCO customer service number. • There may be frequency limitations for changing health centers/dental clinics per the DCO. To change the patient’s assigned DCO: DCOs partner with CCOs (Coordinate Care Organizations) to provide and coordinate dental health care. Members are assigned to a DCO through their CCO. To change the DCO assignment, contact the CCO customer service number. • If there is no assigned CCO, contact OHP Client Services at 1-800-273-0557 (TTY 711). • There may be frequency limitations for changing DCOs per the CCO. If the patient is private pay/insurance or uninsured: The patient needs to contact their new provider of choice to discuss transferring care from the current provider of record. The dental offices will coordinate the transfer of any pertinent records.

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Payment and Reimbursement - D0191, D1206/99188 D0191

Medical Providers: MD/DO/APN/PA • Have a certification of completion from Smiles for Life or First Tooth (OrOHC). Per the OHA, D0191 is reimbursed up to age 6. Some CCOs have elected to provide an enhanced age benefit for D0191. Please check with your CCO on the age limit for this benefit. The mechanism for reimbursement by a medical provider is to add the code directly to the medical claim. Dental Providers: Dentist • May submit D0191 for oral assessment twice a year for children under 19 years of age and once yearly for adults 19 and older. • May be reimbursed for D0191if there is not a dental exam (D0120-0180) performed on the same date assessment of a patient is included as part of an exam. An assessment does not take the place of the need for oral evaluations/exams. • May be reimbursed if D0191 is performed outside of a dental office. For patients who do not have a CCO or DCO assignment, bill DMAP directly. EPDH • May submit D0191 for oral assessment twice a year for children under 19 years of age and once yearly for adults 19 and older. • May be reimbursed for D0191 if there is not a dental exam (D0120-0180) performed on the same date. Assessment of a patient is included as part of an exam. An assessment does not take the place of the need for oral evaluations/exams. • May be reimbursed if D0191 is performed within or outside of the dental office setting. D0191 assessment of a patient from a medical provider does not count toward the maximum number of D0191 services allowed by a dental provider. D0191 is reimbursable to medical and dental providers at $11.83 on the DMAP fee schedule for open card clients. If the child's receives physical health services through open card/fee-for service, bill DMAP directly. The FQHC encounter rate is inclusive of this service when performed during the medical or dental visit. First Tooth recommends all ECCP services, including an oral assessment, to be done at each well-child visit. This code will not be reimbursed at all visits, but hopefully it will encourage more time to be built into the well-child visit to incorporate more comprehensive education at least once a year for the child's first 6 years. For more information on payment and/or reimbursement, refer to OAR 410-123-1260.

D1206/99188

Medical providers: CDT D1206 or CPT 99188 fluoride application in a medical office is now to be covered by CCOs effective 1/1/14. Medical providers need to be trained in the application of fluoride varnish to bill for this procedure. If a medical provider delegates this procedure to a staff member, the staff member needs to be trained on the application of fluoride varnish.

The maximum limits of fluoride varnish application for a patient is cumulative from both Medical and Dental claims. Reimbursement for a child with low risk of decay is twice yearly. If a child is at high risk of decay, and it is documented in the chart, reimbursement is up to four times a year. 12

Appendix A: First Tooth Training and Integration Process Map

The complete First Tooth Training and Integration Process Map can be found here:

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Appendix B: Readiness Assessment Ready, Set, Implement Medical Office 1. Determine who will deliver the services a. History/risk assessment: ____________________________ b. Screening (provider): ________________________________________________ c. Anticipatory guidance/patient education (oral hygiene, nutrition):____________________ d. Fluoride varnish education: ___________________________________ e. Fluoride varnish application: ___________________________________ 2. Decide when the services will be delivered (ex: Coordinate fluoride varnish with immunizations/wellchild visits 6 mo, 9 mo, 12 mo, 15-18 mo, 24 mo, 36 mo. Separate visits for high-risk patients). _________________________________________________________________________________ _________________________________________________________________________________ _______________________________________________________________ 3. Identify an oral health champion in the office to: a. Order supplies (varnish and materials) and oral health education materials ______________ b. Identify and incorporate prompts for providers and patients _______________ c. Ensure new employees receive training___________________ 4. Create plan for fluoride varnish and oral health education materials a. Who will order: ____________________________________________ b. Where will they be stored: ____________________________________ c. For patient visit, who will get supplies ready (ex: clip dose to chart): ________________ 5. Who will coordinate dental referrals and ensure that dental referral information is in exam room or at front desk _______________________________ 6. Establish process for documentation (ex: for paper charts- stickers or other prompts, intake form, exam form, determine location for tracking-immunization flip tab, dental tab, graphs, history section, etc.) 7. Create process for eligibility determination (ex: flag chart) and billing 14

Appendix C: Caries Risk Assessment Form Examples You will need to select one of the following Caries Risk Assessment Forms endorsed by the OrOHC.

American Academy of Pediatrics (AAP)

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American Academy of Pediatric Dentistry (AAPD)

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American Dental Association (ADA)

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Oregon Oral Health Coalition (OrOHC)

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Appendix D: Sample Referral Forms Medical to Dental

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Dental to Medical

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Appendix E: EMR Examples Smart or Dot Phrases for Documentation of the Oral Health Assessment and Fluoride Varnish Application in the EMR ORAL HEALTH ASSESSMENT Caregiver Does mother/caregiver have a history of caries? {YES/NO:63} Does mother/caregiver have a dentist? {YES/NO:63} Referral for mother? {YES/NO:63} Child History Existing dental home? {YES/NO:63} Premature or low birth weight? {YES/NO:63} Frequent snacking/juice intake? {YES/NO:63} Special needs? {YES/NO:63} SES? {LOW/MED/HIGH:10045} Exam Caries? {YES/NO:63} Plaque? {YES/NO:63} Demineralization? {YES/NO:63} Fluoride Supplement? {YES/NO:63} Varnish indicated? ("Yes" to any two of the above indicates high risk) {YES/NO:63} Applied? {YES/NO:63} Referral? {YES/NO:63} Comments: ***

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OCHIN Update

New Orders Sections in WCC SmartSets

In order to better comply with USPSTF recommendations, OCHIN has added a new subsection (Oral Health) to the Orders section of the Well Child Check SmartSets. This affects all WCC SmartSets from ages 9 months to 18 years.

Mosaic Medical- FQHC

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Kaiser

Customized training for Kaiser with Kaiser specific EHR and workflow.

Multnomah County

Workflow and EHR documentation examples from 2012.

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Multnomah County, continued

4 Clinic staff roles Role

Main Duties Scrubs for children between 6-36 months Requests fluoride varnish procedure (provider signs) Applies fluoride varnish Provides oral health education

Support Staff (CMA)

• • • •

Provider

• Performs oral health examination • Refers child to PCARD

TCA

• Moves First Tooth referrals to PCARD

PCARD

• Contacts parent and refers to treatment

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Multnomah County, continued

4 Smart phrases .MCFIRSTTOOTH smart phrase • Has child had fluoride varnish applied to teeth in last 3 months? {YES***/NO:60} • Does {GUARDIAN:61} want fluoride varnish applied to child's teeth if not done in last 3 months? {YES/NO***:64} • Demonstrated to {GUARDIAN:61} of @[email protected] how to lift the child's lip and examine teeth for signs of decay, and how to brush child's teeth using only rice-sized amount of fluoride toothpaste. • Fluoride Varnish {WAS/WAS NOT:9033} applied.

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Metropolitan Pediatrics LLC

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Appendix F: Care Team Workflow Example Care Team completes Visual Assessment and documents in EMR* 1. 2. 3. 4. 5. 6. 7.

Receptionist gives patient Lifestyle Assessment Patient/Caregiver completes Lifestyle Assessment Patient returns Lifestyle Assessment to Medical Assistant Medical Assistant enters Lifestyle Assessment into EMR Provider reviews Lifestyle Assessment Provider completes Visual Assessment on patient Provider documents assessment exam in progress note by using MA Oral Health Risk Assessment note i. Follow “make me an author” process 8. Complete documentation of Visual Assessment on progress note i. Example: (dot phrase) Oral Health Coalition Caries Risk Assessment <6 Lifestyle Assessment Does the child’s mother /primary caregiver have active decay? {YES/NO:11221} Does the child consume carbohydrates between meals? {YES/NO:11221} Does the child receive inadequate systemic fluoride? (Fluoridated water, supplements) {YES/NO:11221} Does the childe use fluoride toothpaste less than twice daily? {YES/NO:11221} Does the child receive fluoride varnish less than twice a year? {YES/NO:11221} Does the child need a dental home? {YES/NO:11221} Is the child receiving any services from WIC, head Start or Medicaid? {YES/NO:11221} Does the child have any special healthcare needs? (Physical Limitations, medications) {YES/NO:11221} Visual Assessment Are there visible white spot lesions or decay on the child’s teeth? {YES/NO:11221} Has the child experienced previous caries? (Both treated or untreated) {YES/NO:11221} Does the child have plaque? {YES/NO:11221} The child is at high risk if there are two or more Yes responses. Risk: ***Low***High 9. Care Team provides oral health education 10. If Fluoride Varnish is needed, add D1206 or 99188 11. Add D0191Oral Assessment and enter the following diagnosis for assessments i. Diagnosis code z13.84 “screening for dental disorder” (see list of codes on page 31) ii. z91.89 risk of dental problems, or appropriate diagnosis when actual caries identified 12. If dental referral needed, order RF100012 Referral to dentist *This is a modifiable example for OCHIN and EPIC Systems. Adapted from La Clinica (2016). 27

Appendix G: Clinic Policy Example Section: Number Procedure: First Tooth Number of pages: 5

Approved by: Adopted Date: Review Dates: Revision Dates: 11/21/13 Retired Date:

Purpose: Basic Protocol for Medical Providers performing Oral Screenings for patients 0-5 years old. Scope: MD, FNP, RN, LPN Definition Related Forms Appendices 1: Varnish Workflow Appendices 2: Knee to Knee technique Procedure: Medical Assistant: If patient presents for Well Child: 1. Open Progress Note 2. Insert .CHCORAL to complete risk assessment smartset

3. Insert .CHCFIRSTTOOTH to complete varnish smartset

4. Order “Fluoride Varnish Treatment” or “TR050” 5. Order “Fluoride Varnish” or “EX021” 6. Order “Oral Assessment of a Patient” or “D0191”

7. Associate with WCC (V20.2) 28

8. Pend for Provider signature For Interim Visits: 1. Open Progress Note 2. Insert .CHCORAL to complete risk assessment smartset

3. Insert .CHCFIRSTTOOTH to complete varnish smart phrase

4. Order “Topical Application of Fluoride” or “TX409” 5. Order “Fluoride Varnish” or “EX021”

6. If child does not see a dentist then the Provider must perform the oral health examination prior to varnish being applied. 7. If a child does see a dentist and the child has not received varnish in the past 3 months, proceed with applying varnish as described below and provide oral health education. (see attached diagram) Varnish Application: 1. Open Fluoride pouch stir if needed. 2. Dry mouth/teeth with 2x2 cotton sponge if needed, (mouth does not need to be completely dry). 3. Brush Fluoride lightly on the biting (occlusal) and cheek side (bucal) surfaces of the teeth. 4. Have patient spit out any excess if they are able, for younger patients wipe around tongue if there is any excess fluoride in the mouth. 5. Sit patient up and advise parent/guardian not to brush patient’s teeth for at least 4 hours. If you are using Vanish Varnish and ProFlu. 29

Appendix H: Reimbursement Codes I.

II.

Fluoride Varnish a. Diagnostic codes i. Z41.8-Encounter for other procedures for purposes other than remedying health state ii. Z00.129- Encounter for routine child health examination without abnormal findings iii. Z00.121- Encounter for routine child health examination with abnormal findings iv. Z13.84- Encounter for screening for dental disorders b. Procedure codes i. D1206 ii. CPT 99188 1. F Varnish is reimbursed 2 X year up to age 19. If the child is at high risk of caries, as is documented in the chart, F Varnish is reimbursed 4 X year. 2. Person applying F varnish must be trained, but the training is not specified. 3. F Varnish is not reimbursed as a stand-alone procedure in an FQHC Oral Health Assessment a. Diagnostic codes i. Z41.8-Encounter for other procedures for purposes other than remedying health state ii. Z00.129- Encounter for routine child health examination without abnormal findings iii. Z00.121- Encounter for routine child health examination with abnormal findings iv. Z13.84- Encounter for screening for dental disorders b. Procedure codes i. D0191- Oral Assessment of a Patient ii. Reimbursed up to a maximum of once every 12 months for children. Check with CCO for ages of eligibility. iii. For reimbursement, the performing provider must meet all of the following criteria: 1. Be a physician (MD or DO), an advance practice nurse, or a licensed physician assistant; 2. Hold a certificate of completion from one of the following approved training programs within the previous three years- First Tooth (through the Oregon Oral Health Coalition;) or Smiles for Life iv. For reimbursement in a medical setting, D0191-Assessment of a patient must include all of the following components: 1. Caries risk assessment using a standardized tool endorsed by Oregon Oral Health Coalition, the American Dental Association, the American Academy of Pediatric Dentistry, or the American Academy of Pediatrics; 2. Anticipatory guidance and counseling with the client’s caregiver on good oral hygiene practices and nutrition; 3. Referral to a dentist in order to establish a dental home; 4. Documentation in medical chart of risk assessment findings and service components provide

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Appendix I: Supply Orders

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Appendix J: Oral Health Education and Resources for Providers Smiles for Life Smiles for Life produces educational resources to ensure the integration of oral health and primary care. www.smilesforlifeoralhealth.org Access to Baby and Child Dentistry (ABCD): A Manual for Dental Providers Developed by the University of Washington, School of Dentistry, this guide is for clinicians who intend to implement effective preventive and early intervention oral health therapies for infants and toddlers. http://www.scribd.com/doc/11827499/ABCD-Pedodontia American Academy of Pediatrics (AAP) AAP offers an extensive list of and easy access to on-line resources for the pediatric health provider. www.aap.org/oralhealth Oregon Health Plan dental benefits Providers or organizations who work with Oregon Health Plan (OHP) clients can download the brochure from the Oregon Health Authority's website. http://apps.state.or.us/Forms/Served/HE7224.pdf PACT Training PACT curriculum trains pediatricians to become more knowledgeable about child oral health, more competent in providing oral health guidance and preventive care, and more comfortable sharing the responsibility of oral health with dental colleagues. http://www2.aap.org/ORALHEALTH/pact/index-cme.cfm EQIPP: Oral Health The EQIPP online course helps providers recognize the role pediatric primary healthcare providers (PPHPs) play in providing oral health care. http://shop.aap.org/EQIPP-Oral-Health All 4 Oral Health The All 4 Oral Health Blog is the combined effort of the Oral Health Nursing and Education Practice (OHNEP) and Teaching Oral-Systemic Health (TOSH) programs. Collectively, these programs aim to build interprofessional oral health competencies among future primary care providers in order to develop a primary care workforce that is collaborative practice-ready for providing quality, patient-centered oral health care. http://all4oralhealth.wordpress.com/

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Appendix K: Oral Health Education and Resources for Staff Bright Futures in Practice: Oral Health This guide is designed to help health professionals implement specific oral health guidelines during infancy, early childhood, middle childhood, and adolescence. http://www.brightfutures.org/bf2/pdf/index.html The CDA Foundation CDA Produced Cavity Keep Away and Oral Health during Pregnancy & Early Childhood: Evidence-based Guidelines for Health Professionals. The resources are available on the CDA Foundation Web site free of charge. http://www.cdafoundation.org/cavitykeepaway Health Literacy Universal Precautions Toolkit The toolkit offers primary care practices a way to assess their services for health literacy considerations, raise awareness of the entire staff, and work on specific areas. http://www.ahrq.gov/qual/literacy/ National Maternal and Child Oral Health Resource Center Website contains a variety of information for individuals working in oral health. The site contains a database of oral health programs, which is used to collect and provide contact and program information to those working in oral health. It also contains the brochures about Head Start and the Two Healthy Smiles brochures. www.mchoralhealth.org The 2000 Report of the Surgeon General: Oral Health in America: The Surgeon General of the Public Health Service has focused the Nation's attention on important public health issues. Reports have heightened America's awareness of important public health issues and generated major public health initiatives. http://www.surgeongeneral.gov/library/reports/oralhealth Oral Health: An Essential Component of Primary Care Watch this video for information about actions primary care teams can take to improve their patients' oral health. http://www.youtube.com/watch?v=8XPxDSiR9ig&feature=youtu.be Oral Health-Primary Care Integration Model The Rural Health Information Hub provides a toolkit to aid in integration of oral health and primary care. http://www.ruralhealthinfo.org/community-health/oral-health/2/primary-care-integration-model

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Appendix L: Oral Health Education and Resources for Leadership Centers for Disease Control and Prevention (CDC) This site provides resources for oral health across the lifespan. www.cdc.gov/OralHealth/index.htm U.S. Preventive Services Task Force – Recommendations for Primary Care Practice: This site contains tools that can help a variety of audiences better understand what clinical preventive services are and how they can be implemented in the real world. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/dental-caries-inchildren-from-birth-through-age-5-years-screening HRSA: Integration of Oral Health and Primary Care Practice The report and its recommendations serve as guiding principles and provide a framework for the design of a competency-based, interprofessional practice model to integrate oral health and primary care. http://www.hrsa.gov/publichealth/clinical/oralhealth/primarycare/ HHS Oral Health Strategic Framework 2014–2017 The HHS Oral Health Strategic Framework 2014–2017 provides a roadmap to prevent oral disease; increase access to services; develop and disseminate oral health information; advance public policy and research and translate policy and research into practice; strengthen the oral health workforce; and eliminate oral health disparities. http://www.nccpa.net/Uploads/docs/HHSOralHealthFramework.pdf Healthy People 2020 Oral Health This site contains science-based, 10-year national objectives for improving the health of all Americans. http://www.healthypeople.gov/2020/topics-objectives/topic/oral-health/ Integrating Primary Care and Oral Health This site contains ideas and best practices for implementing the right practices and new ideas for programs that build the health of communities. http://www.careinnovations.org/knowledge-center/facilitating-careintegration/integrating-primary-care-and-oral-health Virginia Oral Health Coalition Integration Toolkit: Integrating Oral and Overall Health This site contains several resources for integrating oral health and physical health care. http://www.vaoralhealth.org Oral Health Toolkit: A Guide to Promoting Oral Health in Community Health Centers and Achieving MedicalDental Integration This site contains several resources aimed at promoting interprofessional activities among medical and dental programs in Community Health Centers. http://www.aachc.org/resources/clinical-resources/dental/

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Appendix M: Additional Resources The National Institute of Dental and Craniofacial Research (NICDR) provides free brochures and educational handouts for oral health across the lifespan. These resources can be found: http://www.nidcr.nih.gov/OralHealth/

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The Oregon Oral Health Coalition (OrOHC) provides resources for First Tooth as well as oral health across the lifespan. These resources can be found: http://www.orohc.org/

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Oral Health Toolkit A Guide to Promoting Oral Health in Pediatric Primary Care and Achieving Medical-Dental Integration September 2016 0 Table of C...

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