Abstract
Background
A community health center (CHC) implemented a medical–dental integration (MDI) program where children were seen at a pediatric medical clinic or women, infants, and children program location by medical and dental providers in the same visit. Our study aims were to elicit the perspectives and experiences of providers and administrators involved in the MDI program to assess the acceptability, feasibility, and success of a CHC integration strategy in Eastern Washington.
Methods
This is a qualitative study where we conducted semistructured interviews over the phone over a period of 2 months with 12 medical and dental providers and clinical administrators who were involved with the MDI program. Questions addressed perspectives on workflow, patient identification and engagement, leadership support, and barriers and facilitators of the initiative. Qualitative data were analyzed, and emergent themes were identified.
Results
The emergent themes included (a) the MDI program is feasible and acceptable albeit with key considerations regarding the setting, including charting and service integration, progressive leadership and effective communication, and appropriate providers; (b) implementation included structural, systemic, and individual behavior barriers, (c) the program is seen as a benefit to the clinic and patients and a success to date as a way to increase access to quality care.
Conclusions
Findings from this study helped identify facilitators, such as cultural relevancy and progressive office systems, as well as barriers, such as reimbursement, associated with integrating medical and dental care in a rural CHC setting, is acceptable by providers, and can inform future studies and implementation strategies for others wishing to integrate these services.
Keywords
Background
Dental caries is the most common chronic childhood disease (Centers for Disease Control and Prevention, 2011). According to the National Health and Nutrition Examination Survey, prevalence of untreated dental caries was 10% for children aged 2 to 5 years, 16% for 6 to 8 years, 5% for 6 to 11 years, and 17% for 12 to 19 years (Fleming & Afful, 2018), with the highest prevalence (57.1%) among Hispanic youth (Beck et al., 2014).
Migrant farm workers and their children, the majority of whom are Hispanic, have disproportionately higher rates of dental disease than the general population (Lukes & Simon, 2006). Contributing factors include limited access to care, high cost and a complicated insurance structure for dental care, and limited access to health information (Alpert, 2017). In Washington State, at least 25 out of 39 counties have too few dental providers to meet oral health needs (Health Resources and Services Administration, 2020).
Dental and medical providers value the role of oral health care in achieving optimal health and quality of life and recognize that primary prevention is key to managing systemic diseases and requires collaboration and communication between medicine and dentistry (Alpert, 2017). With the fragmented health system, it is difficult to achieve efficient, high-quality, and ethical treatment of shared patients. As a result, the system fails our most marginalized populations (U.S. Department of Health and Human Services Oral Health Coordinating Committee, 2016).
Successful medical–dental integration (MDI) entails more than colocated clinics and enhanced referral processes; it requires organizational changes to engage a diverse workforce and change administrative and clinical practices. The presence of supportive policies, adequate resource allocation, and local strategic leaders can enhance implementation of an integration strategy; conversely, lack of political will and interdisciplinary education, combined with implementation challenges, can hinder MDI (Braun et al., 2013; Harnagea et al., 2017; Shimpi et al., 2018).
Strategies to integrate medical and dental services are diverse, and evaluations are primarily case studies and pilot-level assessments. Integrated organizational changes between medical and dental services have not received system-level assessments comparable with those conducted in primary care and behavioral health (Wakida et al., 2018). Most single-clinic or departmental case studies assessed feasibility of integration models that promoted screenings and referrals for chronic disease management in dental settings (Greenblatt et al., 2017; Northridge et al., 2016), integrated electronic medical records with dental records (MacNeil et al., 2020), or evaluated primary care providers providing preventive oral health services and education (Bernstein et al., 2016; Dooley et al., 2016). One study mobilized the dental hygienist in a medical practice, offering education and preventive services for young children (Braun et al., 2013). The current study focuses on an MDI model implemented by a community health center (CHC) in two distinct clinical sites serving a low-income, rural, mostly Hispanic community—a model that differs from others in the literature based on services provided, population served, and number of clinical sites.
The MDI program was deployed as a pilot by an Eastern Washington CHC and aimed to expand access to care and decrease childhood caries. In 2019, clinicians began offering preventive dental care during well-child visits for children aged 0 to 5 years at two pediatric medical sites. The MDI program dental providers included two full-time dental hygienists trained as community dental health coordinators (American Dental Association, 2020). The program offered oral health assessments, education, and caries preventive services (e.g., fluoride varnish). They provided care coordination, case management, and referrals to the dental clinic when necessary. The CHC implemented these changes based on the Qualis Oral Health Integration Delivery Framework (Hummel et al., 2015) that promotes and enhances clinical integration of medical and dental services with the eventuality of building a quality metrics dashboard to demonstrate the feasibility and health impacts on the community. The program is temporarily operating out of a women, infants, and children program location on-site due to reimbursement challenges. Our study aims were to elicit perspectives and experiences of providers and administrators involved in the MDI program to assess the acceptability, feasibility, and success of an MDI integration strategy in Eastern Washington.
Methods
Study Design and Setting
This descriptive qualitative study conforms to the Standards for Reporting Qualitative Research (O’Brien et al., 2014). The program implementation sites were the pediatric medical departments in two clinic locations of a CHC in Eastern Washington State. The CHC has been functioning for more than 40 years providing patient-centered, culturally sensitive care and enabling services to low-income, migrant/seasonal agricultural workers and others in Washington and Oregon. In one clinic location, the population is more than 93,000, with a poverty rate of 23%, where 38% of the community speaks a primary language other than English. In the second location, the population is almost 9,000, with one of the highest poverty rates in the state (34%), where majority of residents (76%) speak a language other than English. Both areas are designated Dental Health Professional Shortage Areas (Health Resources and Services Administration, 2020).
Sampling Strategy
We used purposeful sampling to identify participants. Inclusion criteria included English-speaking, current employees of the CHC, and direct or indirect involvement in the MDI program. Eligible participants (21) were first approached by the chief dental officer via email invitation, then invited to participate via phone by the primary investigator. Provider participants were evenly distributed between the two clinics, and administrative participants worked across the two clinics. Originally, we planned to include patients and caregivers, but limitations due to clinic closure and stay-at-home orders regarding the COVID-19 (coronavirus disease 2019) pandemic in March 2020 made it impossible to recruit patients.
Data Collection
Data were collected through semistructured key informant interviews in English over a period of 2 months in early 2020 and lasted between 20 and 60 minutes. The interview guide (see Supplemental Material, available in the online version of the journal) included open-ended questions to elicit participants’ views of the MDI program and was framed using an adaptation of the Agency for Healthcare and Research Quality’s (2013) Framework for Measuring Integration of Behavioral Health and Primary Care. Interviews were conducted by phone and audio recorded with verbal consent prior to recording. Recordings were downloaded on a password-protected laptop into an encrypted folder without identifiers, and recordings were subsequently deleted from the recording device.
Data Analysis
Audio recordings were transcribed and reviewed for accuracy and uploaded into Dedoose Version 8.3.17 for coding and thematic analysis (Pope et al., 2000). Prior to analysis, a preliminary codebook was developed based on 9 of the 10 domains of the Agency for Healthcare and Research Quality (2013) framework (Figure 1). The business sustainability domain was not included in the interview guide questions as the organization completed an internal evaluation.
Framework for Measuring Integration of Dental and Primary Care, Identifying 9 of the 10 Functional Domains Incorporated in This Study.
A general inductive, open-coding methodology was executed by two coders (CP and JH) by first separately reading the raw data, identifying key ideas and patterns, labeling these with codes, and reviewing first-level codes together. After reading and independently applying primary and secondary codes, emergent codes were added to the codebook, and the codes were formulated into broader categories. Next, the two coders reconciled missed or disagreed on codes until they reached 100% agreement. Codes were entered into Dedoose to produce code reports. The reports were synthesized into theme domains and subdomains with associated quotes, forming the basis of our findings.
Results
Twelve participants were interviewed (Table 1). Our data revealed three key themes: the MDI program is feasible and acceptable, implementation faced systemic and behavioral barriers, and the program is perceived as beneficial to patients and successful for the CHC. The themes mapped to multiple domains of the MDI framework (Table 2). We present the results by framework domain and explore key themes further in the Discussion section.
Participant Employment and Categorization Information
Note. WIC = women, infants, and children; CHC = community health center.
Thematic Analysis and Framework Domains
Note. MDI = medical–dental integration.
Care Team Expertise
Participants noted advantages to having the dental hygienist as the integrated provider embedded in the medical clinics. Participants noted that the hygienists were flexible, committed, and value oriented. One administrator accounts, She’s very passionate about the community. She started off as a farm worker. She grew up with parents that were farm workers and so she’s very passionate about education and is a type of employee that would see a patient during her lunch hour and skip her lunch, she will do that. She’s extremely flexible and goes above and beyond in a lot of ways.
The hygienists were considered competent clinically and culturally. The dental hygienists are ethnically congruent with patients and are fluent Spanish speakers. Equally important, dental hygienists are billable providers and work independently (with supervision) in the clinical setting.
Clinical Workflow
Participants explained that consistent communication among administrators and providers, such as regular check-in meetings and follow through with requests, allowed team members to feel supported as they adapted to changing workflows. When asked how the MDI program affected daily workflow and tasks, participants mentioned that the CHC setting facilitated a smoother implementation when compared with other settings. One of these aspects was the familiarity with integrated services. As one medical provider explained, I think for us it was not as hard because we already have other integrated services in medical. . . . We have registered behavioral health consultants . . . registered dieticians, a community health worker and they’re integrated so that we bring them within the flow of medical already.
Existing familiarity with integrated services was a contributing factor supporting transitions associated with implementation. The operations and logistics were already in place to coordinate service provision among different providers during appointments.
Alternatively, when the MDI program was introduced, participants noted uncertainty about how adding another provider would affect their daily work and schedules. Some providers noted feeling “uninformed, unconsidered, and unclear” about the new provider, what they would be doing, and that implementation was an “abrupt change with no easing into it.” Their concerns centered on time constraints for appointments and exam room usage, capacity of staff to add new responsibilities to their plate, and workflow between medical and dental departments.
Patient Identification
The MDI program was implemented in two locations serving different patient population densities. This resulted in contrasting responses from each location regarding the number of patients the hygienist was able to see. In one location, a medical provider noted the initial target population as too narrow: The only times we thought “this isn’t working, how do we get you more patients”, was when we identified that the program focused on kids under five. . . . We started offering it to people under 18. After that, we’ve seen the number of kids she was seeing in a week improve every week.
Alternatively, at the other location, a medical provider explained that the hygienist did not have enough time to serve all eligible patients: There were too many patients for her to see. . . . Sometimes patients weren’t able to be seen. We have late hours as well. There were times where her shift was already done, but this patient really could have been seen by her.
This discrepancy in the demand for services illuminates key differences between the two clinical sites.
Patient and Family Engagement
All participants emphasized the impact of the MDI program on efficiently meeting the dental needs of patients. For example, one medical provider stated, Just having that extra layer of specialist within the system versus us trying to convince patients to go upstairs [to the dental clinic]. It’s a lot easier having somebody go to them in a room that they’re not going to leave until their appointment is done versus at the end trying to get them to go and schedule or be seen same day. It just makes a huge difference.
They indicated that the program enabled patients to connect with the dental clinic via warm handoffs when an urgent oral health need was identified that was outside the scope of the hygienist, sometimes securing same-day treatment.
Treatment Monitoring
Participants were asked about this construct, but no significant themes were identified in the data as they were not measuring patient health outcomes at this time.
Leadership Alignment
Progressive leadership was perceived as important for initial adoption and continuation of the MDI program. All participants noted that administrative leadership was optimistic, forward thinking, and value oriented. Administrators observed leadership as “positive about the program” and felt that this sentiment trickled down to all staff. Both providers and administrators noted that executive leadership “is supportive in improving the health of patients and willing to take risks and try new things.”
Operational Reliability
A facilitator specific to this setting was integration of the medical and dental electronic records. One medical provider noted, There was less work once we were integrated into the same EMR [electronic medical record]. Initially, it was a lot more work on both the dental and medical side because not only was the dental receptionist identifying patients, but the hygienist was also filling in things [on the spreadsheet] as well.
The timing of implementation of the project coincided with the integration of health records, creating a more efficient and comprehensive records system.
Data Collection and Use
At the time of interviews, practice-level, production, and visit-related data were being collected but not yet analyzed. Longitudinal data on health outcomes were not being assessed at the time of this study. Participants in leadership positions stated hopes of being able to assess these outcomes in the future in the context of this program.
Desired Outcomes
Participants noted success in terms of patient clinical outcomes, engagement with care, and reduction in time to urgent treatment. One medical provider detailed, There was an instance where I had a patient and was very concerned about a dental abscess, which is not something we get lots of training on. When I was with the patient, I said, “okay, I’m going to have the dental hygienist come in, she’ll take a look. . . .” She has more experience than me. . . . And then we were able to connect them to get an appointment right away to take care of things. Otherwise, would that have happened that day? Probably, but it would’ve taken me going out of the room, walking upstairs, finding a provider. 15 minutes later . . . I have three patients waiting for me. This describes ways in which not only the patient benefitted from services but also medical providers, because the hygienist freed up time for them to see other patients and focus on the services and care they deliver. Participants noted patients were identified who potentially would have fallen through the cracks of the system had they not been screened by the hygienist in the medical clinic. As a dental provider put it, We captured patients who had been missing in the dental department and some really needed it, so, would we have captured those patients regardless? I wasn’t down there and can’t give you that answer. But we did capture them when she was down there. I’ll give her and the current program the credit for that.
The MDI program broke down structural barriers for patients to access dental care and opened avenues in which patients can seek oral care service where they receive medical services.
Medicaid Reimbursement
Initially, MDI program services were rendered in the context of a well-child visit at two pediatric medical clinic locations. A well-child visit (sans MDI program) at this CHC incorporated an oral health assessment as a component of services provided by medical personnel. Due to this appointment structure, the dental services could not be billed out separately by the dental hygienist. One administrator explained, One fall-out we had is [the program] wasn’t receiving dental reimbursement because we were having a hygienist see patients coming in for well child checks and the checks have a component of dental screening that occurs even though that screening is very different to what a dental hygienist is performing. And so that’s why the Health Care Authority decided that obviously we can’t double dip, but at the same time the services being given were drastically different.
CHC administrators understood this argument and temporarily moved the program to a clinic under the auspices of the women, infants, and children program to overcome this barrier.
Discussion
Our results demonstrate that MDI is acceptable and feasible in a CHC setting. Factors identified as contributory to the relative success of MDI include previously integrated providers and charting, leadership alignment and support, consistent and clear communication, and inclusion of a registered dental hygienist as the oral health provider. Overall, the MDI program was seen as a success and beneficial to patients, providers, and the clinic but not without inherent barriers. Participants ran into issues including Medicaid reimbursement and miscommunication during planning stages. We did not anticipate a difference between implementation sites, nor did we find a difference between them, with one exception—participants experienced discrepancies in demand for services between the two clinical sites. Yet the impact was seen as a benefit to patients as a means of breaking down structural barriers, catching patients falling through systemic cracks, and increasing access to care.
With regard to the acceptability and feasibility of the program, the clinic transitioned from separate digital medical and dental health records to integrated records. This points to reasons why this MDI program could gain traction and remain sustainable. Previous strategies to integration noted similar success using the electronic medical record between medical and dental units (Langelier et al., 2015; MacNeil et al., 2020). The current and previous studies identified the dental hygienist as an ideal provider (Braun et al., 2013; Northridge et al., 2016; Theile et al., 2016). Studies that did not incorporate a provider with formal dental education noted barriers, including lack of oral health knowledge, training and confidence in performing oral health services, and providing referrals (Bernstein et al., 2016; Harnagea et al., 2017; Shimpi et al., 2018). The current study participants described the hygienist as motivated, knowledgeable, and a local community champion.
Staff buy-in and communication were identified as facilitators in implementation and are noted in other MDI studies (Bernstein et al., 2016). Conversely, previous studies noted lack of staff buy-in as a barrier to program adoption, underscoring lack of communication between staff members as a key barrier (Braun et al., 2013). Consistent, adequate communication with leadership may enhance staff support to reduce perceived pressures of workflow changes.
Well-child visits may be the most natural appointment type to embed oral health services. The clinic integrates other health services with medical care beyond oral health. The success rate of services completed in well-child visits (e.g., vaccines) and acceptance of additional providers at this visit may point to reasons why well-child visits are targeted for integration. Other studies report that well-child visits catch patients falling through systemic cracks and dental services rendered there are well accepted by caregivers (Bernstein et al., 2016; Dooley et al., 2016). Integration may be successful and sustainable at the organizational level. Yet if reimbursement does not follow, then the program may not be sustainable.
One insurmountable barrier was that Medicaid would not reimburse separately for dental procedures performed by the hygienist during a well-child visit in the pediatric medical clinic. Specific to Washington State, the health care authority does not permit billable dental services where an oral health screening by the medical provider is already allowed during the appointment, particularly when there is a colocated dental clinic. Despite this colocation, participants noted that children regularly attending medical appointments were not necessarily seen in the dental clinic. Medical providers remarked that services they would typically provide versus the services that the hygienist was performing were much different; the hygienists being more comprehensive. This demonstrates that colocation is not the same as integration (Braun et al., 2013; Langelier et al., 2015), and insurance policies act as a systemic barrier to MDI (Harnagea et al., 2017; Shimpi et al., 2018).
Other barriers, such as miscommunication in the planning phase of implementation and discrepancies in the demand for services between the two clinical implementation sites were not found in previous studies and are unique to this study. Settings and populations in future MDI programs should not be overlooked in planning, implementation, and evaluation phases.
In relation to the perception that the MDI program was beneficial to patients and successful for the CHC, participants recalled that it decreased time to treatment for patients who required urgent dental care as well as increased the provision of preventative care. Similarly, one study (Dooley et al., 2016) noted that fluoride applications were significantly higher when applied during the well-child visits than when the patient was simply given a referral to the dentist. Removing barriers such as eliminating multiple visits, reducing the time length per visit, and integrating electronic health records to avoid moving between health record systems were highlighted as ways in which MDI can positively affect the health care system experience for both patients and providers. Apart from evaluating the feasibility and acceptability of specific office procedures and effects on increased access to oral health care (Northridge et al., 2016), current studies have not reported on listing barriers and facilitators of the implementation itself, nor on potential health outcomes for patients. The benefits to patients and providers as well as quality service delivery were novel findings of this study.
Strengths and Limitations
We adopted a conceptual framework promoting integration of behavioral and primary care delivery for evaluating MDI. Although behavioral and oral health care delivery are inherently different, similarities exist in delivery of care that sets achievement of comprehensive health outcomes as the ultimate goal, thereby making this framework acceptable in an environment where MDI is not yet well established. The study population and setting are specific to a Washington State CHC, and findings of this study may not be generalizable to other settings or states. The evaluation was done for one organization during a short observational window, and additional large-scale research will be needed to confirm or contradict these findings as they would apply to other sites. We were unable to include patients and caregivers in our sample because of the COVID-19 pandemic and temporary clinic closure.
Implications
Dental caries is the most common childhood condition and is preventable. MDI is needed to increase access to dental services. This model is accepted by both dental and medical professionals to integrate services for pediatric patients. Future studies could evaluate relative impact on patient outcomes. Public health stakeholders and payers can use our findings so that solutions can be sought to mitigate barriers. To integrate services successfully in primary care settings, systemic barriers such as public insurance policies need to be amended to allow for accurate coding and billing procedures in an MDI model. The research community should strive to broaden the understanding of long-term health outcomes of MDI and how it may influence population health, reduce health care inequities, and promote policy development for systemic health care changes.
Supplemental Material
sj-docx-1-hpp-10.1177_15248399211002832 – Supplemental material for Medical–Dental Integration in a Rural Community Health Center: A Qualitative Program Evaluation
Supplemental material, sj-docx-1-hpp-10.1177_15248399211002832 for Medical–Dental Integration in a Rural Community Health Center: A Qualitative Program Evaluation by Catherine Pawloski, Juliana Hilgert, Kirsten Senturia, Stephen Davis, Mark Koday and Joana Cunha-Cruz in Health Promotion Practice
Footnotes
References
Supplementary Material
Please find the following supplemental material available below.
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