Prevention and collaboration were the key themes as state policymakers explored innovative and cost-effective strategies to integrate oral health and primary care during #NASHPCONF18’s session, Cross Currents: Integration of Oral Health and Primary Care.
Speakers underscored the importance of high-quality and regular dental care in preventing major oral and physical health problems and delivering cost savings to state Medicaid budgets. Mary Fliss, deputy of Clinical Strategy and Operations at Washington’s State Health Care Authority, reviewed her state’s Oral Health Connections Pilot Project. The project, recently authorized by the state legislature, will track how providing enhanced dental benefits to adult Medicaid clients in three counties impacts access to dental care, health outcomes, and medical costs. The project will specifically target individuals with diabetes — because of the links between periodontal health and chronic conditions — and pregnant women because improved periodontal health also benefits overall health.
Dentists who treat those two populations will receive enhanced reimbursement for periodontal treatment of Medicaid beneficiaries. The project is funded by the Arcora Foundation and state general funds. The state will seek federal approval for the project through a Medicaid state plan amendment.
One critical element of the project will be increased coordination between medical and dental providers. A referral tool, DentistLink, will provide a collaborative approach to documenting patient information and facilitating patient referrals and scheduling appointments.
California is also making strides toward medical-dental collaboration. Alani Jackson, chief of the Medi-Cal Dental Services Division within the California Department of Health Care Services, spoke about Local Dental Pilot Programs (LDPPs) that are testing new types of collaboration. The LDPPs are a component of the state’s Dental Transformation Initiative, which was authorized by a Medicaid 1115 waiver. Many of the LDPPs train primary care providers to conduct dental assessments to look for oral health risk factors and to administer basic preventive dental care like fluoride varnish.
For example, the LDPP run by the California Rural Indian Health Board places an oral health coordinator into primary care settings to complete dental decay risk assessments. By placing coordinators in primary care settings or in other venues such as after-school programs, California’s LDPPs are meeting people where they already are to improve access.
Another innovator takes a reverse approach by placing a physical health care provider in dental offices. Maria Dolce, associate professor at Stony Brook University School of Nursing, described the Nurse Practitioner and Dentist (NPD) Model for Primary Care, implemented by the Harvard School of Dental Medicine in partnership with Northeastern University School of Nursing. The NPD model places a nurse practitioner in a dental setting to act as a gateway to comprehensive care and to deliver primary care.
The program ensures that patients receive an annual wellness visit in combination with a dental visit for an integrated approach to care. The wellness visit is conducted by the nurse practitioner and includes a check on health and mental health risk factors as well as a review of a patient’s current health care providers.
These nurse practitioners already have the training to carry out these assessments in primary care offices – but under this program they conduct them in dental office settings. This unique model provides a personalized and patient-centric approach at potentially lower costs. To maximize resources, states considering this model could review their nurse practitioner scope-of-practice regulations to, for example, allow nurse practitioners to practice independently of physicians if they are not currently permitted under existing regulations.
Preliminary results suggest the NPD model is effective in improving overall health and managing chronic conditions. Because the wellness visit takes place in the dentist’s office, both dental and medical preventive services are provided.
The NPD model also addresses another critical theme raised during the session: how to secure long-term funding for these initiatives. Emphasis on the cost-saving benefits of these prevention initiatives could be key to moving them forward, as state policymakers contend with making these innovative practices, which emphasize cross-sector collaboration and prevention, a sustained program under Medicaid.
To learn more about strategies to incorporate oral health into medical care for chronic conditions, read State Strategies to Incorporate Oral Health into Medicaid Payment and Delivery Models for People with Chronic Medical Conditions. Both the report and this conference session were supported by the DentaQuest Foundation.
The first few years of life are critical to a child’s development, setting the foundation for success in school and overall health and well-being later in life. Recent research proves that providing early, skilled behavioral and mental health interventions in venues where young children and their families live and play is highly effective at improving wellness and reading scores, and in decreasing grade retention in early elementary school.
Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health), an initiative of the Substance Abuse and Mental Health Services Administration (SAMHSA), has helped state and local partners to promote the wellness of children from birth to age eight and to support pediatricians, child care providers, teachers and home visitors to identify and address behavioral issues before problems become severe.
To accomplish this, states and local programs funded by Project LAUNCH are implementing a range of strategies, including early childhood mental health consultation and integration of behavioral health services into pediatric primary care settings. The National Academy for State Health Policy (NASHP) explored these Project LAUNCH strategies and the impact they have had on children, families, and providers in two new issues briefs – The Use of Mental Health Consultation in Home Visiting and Early Care and Education Settings and The Integration of Behavioral Health into Pediatric Primary Care Settings – with support from SAMHSA under a sub-contract with NORC at the University of Chicago. The reports offer valuable insights into the challenges and successes of the Project LAUNCH grantees that states can use to strengthen their own child-serving systems.
Providing Mental Health Consultation Where Children Play and Learn
The places where young children and their families live, play, and learn provide important opportunities and venues to promote healthy social-emotional development and to intervene early when problems arise. Too often, child care providers, preschool teachers, home visiting program staff, and others who work with young children and their families are not trained to foster social-emotional development and may be ill-equipped to manage behavioral health issues when they arise. Early childhood mental health consultation (ECMHC) fosters a team approach by pairing a mental health consultant with professionals in child-serving settings to strengthen their knowledge of and build their capacity to support the social-emotional and behavioral health of children. Typical ECMHC supports include teaching behavior management strategies, creating behavior support plans for individual children in collaboration with families and child care staff, and facilitating linkages to mental health professionals.
State and local Project LAUNCH grantees were able to demonstrate that ECMHC had a positive impact on children and their families, and the providers who serve them. They found that:
- ECMHC services sharply reduced the number of children held back in the second grade and improved second grade reading scores.
- ECMHC services helped early childhood education and home visiting staff better identify children with social-emotional and behavioral challenges and provide support to these children and their families.
- The longer child care and home visiting providers were supported by ECMHC, the greater the gains for both children and programs.
Integrating Behavioral Health into Pediatric Primary Care Settings
Researchers found that the primary health care office was another key venue for supporting children’s social-emotional and behavioral health. Primary care providers have regular contact with young children and families and are often trusted by the family, making them well-positioned to proactively support social-emotional development and detect the early onset of behavioral health issues. However, primary care providers often:
- Lack training in the use of standardized screening tools;
- Have too little time to conduct additional screenings during appointments; and
- Are not always able to receive reimbursement for the full spectrum of behavioral health services required to meet a child’s needs.
Additionally, the physical and behavioral health systems in the United States have traditionally been highly fragmented, forcing families to navigate multiple systems in order to obtain appropriate care.
Behavioral health integration in pediatric primary care settings refers to a model of care where a practice team of primary care and behavioral health clinicians work in concert to provide a systematic, cost-effective, coordinated, and patient- and family-centered approach to care. While behavioral health integration can take a variety of forms, it ultimately is designed to equip primary care providers with the knowledge and skills needed to:
- Support children’s social, emotional, and behavioral health;
- Detect issues and intervene early; and
- Enhance coordination and collaboration among providers.
Project LAUNCH grantees implemented a variety of strategies to achieve greater integration of behavioral health services into pediatric primary care settings. The key integration strategies included:
- Training primary care providers in the routine use of developmental and social-emotional screenings;
- Establishing enhanced referral and care coordination systems;
- Providing parenting education and support groups within primary care settings; and
- Embedding an infant and early childhood mental health specialist in primary care settings.
Evaluations of the Project LAUNCH grantees found these efforts increased early screenings and referrals; boosted patient, family, and provider satisfaction levels; and improved children’s social-emotional functioning.
The work of the Project LAUNCH grantees clearly reinforces the role ECMHC and behavioral health integration can play in promoting healthy child development, supporting the whole family, and improving long-term outcomes. Implementing ECMHC across child-serving settings and integrating behavioral health services into primary care practices were significant undertakings by the Project LAUNCH grantees, and they faced numerous challenges in launching and expanding these initiatives.
For example, grantees had to obtain buy-in and commitments from providers, and cultivate acceptance and engagement among families. These initiatives also required a significant amount of resources, including time, funding, and staff capacity, and many grantees continue to grapple with how to sustain and expand them. However, the grantees demonstrated the positive impact that comprehensive, integrated, and coordinated systems can have on children, their families, and providers, and they offer valuable lessons for other states.
Walkabout Medical Homes with Mary Takach: A 10-month Study of Australia
What can states with large frontier areas such as Alaska, Texas, Montana, and Arizona learn from how Australia organizes and supports primary care delivery in its vast outback?
What do publicly financed community-based teams, networks, and organizations found in states including Vermont, North Carolina, Oregon, and Colorado have in common with the Australia government’s four-year experiment in financing and organizing local primary health care organizations nation-wide?
What lessons can states such as Massachusetts, Rhode Island, and Pennsylvania share with the Australian government on how to evolve primary care provider payments from fee for service (FFS) (yes, Australia general practitioners also get paid FFS) to blended payment models that include capitation and shared savings to better support access to medical homes?
States seeking to promote better coordination of patient care, either within Medicaid or through participation in multi-payer initiatives, will run into long-standing challenges to delivering care and promoting health in rural areas. Rural areas often experience disparities in access to care, health status, and available infrastructure relative to their urban counterparts. This brief draws from health initiatives undertaken in Alabama, Colorado, Montana, New Mexico, North Carolina, and Vermont to identify common policy considerations and action steps for coordinating care in rural areas. The brief was supported by the Robert Wood Johnson Foundation’s State Health and Value Strategies.
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Through the Infrastructure for Maintaining Primary Care Transformation (IMPaCT) initiative, North Carolina launched two learning collaboratives to enhance its existing infrastructure for primary care practice support. North Carolina is one of four lead IMPaCT states that have expanded, evaluated, and shared their efforts to transform primary care practices. This issue brief summarizes key strategies, results and lessons from North Carolina¹s IMPaCT learning collaboratives, which focused on regional leadership and care transitions.
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As states and providers move away from siloed health care systems and toward integrated systems of care, care coordination has become a key area of focus. Through the Assuring Better Child Health and Development (ABCD) III initiative, Arkansas, Illinois, Minnesota, Oklahoma and Oregon piloted and evaluated strategies to improve care coordination among primary care providers and community service providers serving Medicaid-eligible children, aged birth to three with or at risk of developmental delays. This report describes states’ evaluation methods, summarizes the results, and highlights lessons learned about evaluating care coordination.
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Care coordination is a focal point of health care delivery reform initiatives across the country, yet there has been limited progress in measuring it, particularly for children and between primary medical care and community service providers. How can states and providers begin to measure this crucial element of care? Join speakers from CMS, NASHP, and two states (Oklahoma and Minnesota) that participated in the Assuring Better Child Health and Development (ABCD) III Initiative for a national webcast to address this question. Speakers will set the national context for pediatric care coordination measurement, highlighting relevant CMS activity, and share care coordination measurement strategies, results, and lessons learned from ABCD III. Although ABCD III focused on improving care coordination for children ages birth to three, the information shared will be relevant for measuring care coordination among other populations.
- Carrie Hanlon, MA, Program Manager, National Academy for State Health Policy
- Glenace Edwall, PhD, PsyD, Director, Children’s Mental Health Division, Minnesota Department of Human Services
- Laura McGuinn, MD, Associate Professor of Pediatrics, Child Study Center, University of Oklahoma Health Sciences Center
- Karen Llanos, MBA, Technical Director, Division of Quality, Evaluation, and Health Outcomes, Center for Medicaid and CHIP Services, Centers for Medicare & Medicaid Services
NASHP is pleased to present a selection of state-oriented health services research from AcademyHealth’s 2013 Annual Research Meeting. Millions of Americans will become newly eligible for health insurance coverage in 2014 through Medicaid expansions or through the health insurance exchanges. It is likely that many of these newly insured individuals will have a host of untreated medical and behavioral health needs, which could put a strain on states’ health system capacity. Health services research can help states understand this population and their needs. This session will feature research that focuses on predicting the health status and unmet health needs of this population and the potential implications for state health policymakers.