Administrative Challenges to the Integration of Oral Health With Primary Care: A SWOT Analysis of Health Care Executives at Federally Qualified Health Centers

SWOT analysis to reduce surgical center idleness and increase revenue in a hospital

OBJECTIVE

To reduce surgical center idleness by analyzing the competitive structure of the surgical center in a hospital, and thereby generate value in operations and increase hospital revenue.

METHODS

The study used qualitative and quantitative methods and an action research approach involving the surgical center leadership of a small private specialized hospital in southeastern Brazil. We used the Strengths, Weaknesses, Opportunities, and Threats or SWOT tool to analyze the competitive structure of the surgical center and then implemented interventions as proposed by the science of improvement method proposed by the Institute of Healthcare Improvement.

RESULTS

By applying the SWOT tool, we identified a concentration of surgeries in the specialty of Otolaryngology and the need to establish a health management system to reduce the idleness of the operating rooms. Based on subsequent intervention, procedures from other specialties were inserted that increased surgical production by 2.62X, reduced idleness by 67.84%, and increased revenue by over US$ 276,609.87 in 2018 compared to the previous year 2017.

CONCLUSION

Investing in quality, surgical schedule management, and inducting new surgeons to the clinical staff resulted in decreased surgical idleness, increased production, better uniformity in scheduling, and increased revenue, while costs remained below the linear trend, allowing for increased profits.

Using a participatory method to test a strategy supporting the implementation of a state policy on screening children for adverse childhood experiences (ACEs) in a Federally Qualified Health Center system: a stepped-wedge cluster randomized trial

BACKGROUND

Adverse childhood experiences (ACEs) are potentially traumatic events occurring before age 18, such as maltreatment or exposure to violence. ACE screening is increasingly recommended to prevent and address physical and mental health conditions associated with ACEs. To promote ACE screening uptake, the state of California issued the "ACEs Aware" policy that provides Medicaid reimbursement for ACE screening annually for child primary care visits. However, policy directives alone often do not translate into effective screening efforts and greater access to care. Few rigorous studies have developed and tested implementation strategies for ACE pediatric screening policies. This study will fill this gap by testing a multifaceted implementation strategy in partnership with a Federally Qualified Health Center (FQHC) system serving low-income families in Southern California to support the ACE Aware policy.

METHODS

We will use Implementation Mapping, with study process and consideration of determinants and mechanisms guided by the EPIS framework, to co-create and refine an implementation strategy. The proposed strategy is comprised of online training videos, a customized algorithm and use of technology to improve workflow efficiency, implementation training to internal FQHC personnel, clinic support and coaching, and written implementation protocols. A hybrid type 2, stepped-wedge cluster randomized trial design with five primary care clinics will test whether a multifaceted implementation strategy improves (a) fidelity to the ACE screening protocol, (b) reach defined as the proportion of eligible children screened for ACEs, and (c) the impact of the ACE policy on child-level mental health referrals and symptom outcomes. The study will use mixed methods with data to include electronic health records, surveys, and interviews with clinic personnel and caregivers.

DISCUSSION

This study is designed to increase the capacity of FQHCs' inner context to successfully implement an outer context-initiated ACE policy designed to benefit pediatric patients. It capitalizes on a rare opportunity to use a co-creation approach to develop, adapt, refine, and pilot test an implementation strategy to maximize the impact of a new state-wide policy intended to improve ACE assessment and subsequent care to improve child health, particularly those from underserved communities.

TRIAL REGISTRATION

Trial # NCT04916587  registered at ClinicalTrials.gov on June 4, 2021.

Assessment of Academic-Community Partnerships in Translational Research

OBJECTIVE

The Community Engagement Core (CEC) of the Center of Collaborative Research in Health Disparities focuses on developing and implementing strategies to increase academic-community collaborations and partnerships, enhance the recruitment and retention of study participants, disseminate research findings to a broader audience, and mitigate health disparities in Puerto Rico.

METHODS

In order to assess the current state of academic-community relationships and also collect ideas for their improvement, a strengths, weaknesses, opportunities, and threats (SWOT) analysis was conducted. Participants for the SWOT analysis activity were drawn from a pool of stakeholders at the University of Puerto Rico Medical Sciences Campus and a group of community representatives.

RESULTS

The areas identified by the group for the CEC to focus on were weaknesses such as 1) a lack of interaction and involvement with community leaders, 2) limited numbers of advocacy groups in several health areas, and 3) few research consortia. Opportunities identified included the possibilities of 1) creating alliances between academia and industry, municipalities, and community-based organizations, 2) advocating integration in research proposals, and 3) establishing a network of researchers and community leaders.

CONCLUSION

The SWOT analysis activity served to foster relationships with diverse community stakeholders and select members for a community advisory board to collaborate in developing educational activities for our researchers and communities. These findings will also help the CEC establish a strategic plan that should be able to supply a strong community-based participatory research approach that would help mitigate health disparities in Puerto Rico, as well as define the strategies to implement such recommendations.

A Framework to Foster Oral Health Literacy and Oral/General Health Integration

Science and technology advances have led to remarkable progress in understanding, managing, and preventing disease and promoting human health. This phenomenon has created new challenges for health literacy and the integration of oral and general health. We adapted the 2004 Institute of Medicine health literacy framework to highlight the intimate connection between oral health literacy and the successful integration of oral and general health. In doing so we acknowledge the roles of culture and society, educational systems and health systems as overlapping intervention points for effecting change. We believe personal and organizational health literacy not only have the power to meet the challenges of an ever- evolving society and environment, but are essential to achieving oral and general health integration. The new “Oral Health Literacy and Health Integration Framework” recognizes the complexity of efforts needed to achieve an equitable health system that includes oral health, while acknowledging that the partnership of health literacy with integration is critical. The Framework was designed to stimulate systems-thinking and systems-oriented approaches. Its interconnected structure is intended to inspire discussion, drive policy and practice actions and guide research and intervention development.

How Patient-Centered Medical Homes Integrate Dental Services Into Primary Care: A Scoping Review

Integrated care delivery is at the core of patient-centered medical homes (PCMHs). The extent of integration of dental services in PCMHs for adults is largely unknown. We first identified dental-medical integrating processes from the literature and then conducted a scoping review using PRISMA guidelines to evaluate their implementation among PCMHs. Processes were categorized into workforce, information-sharing, evidence-based care, and measuring and monitoring. After screening, 16 articles describing 21 PCMHs fulfilled the inclusion criteria. Overall, the implementation of integrating processes was limited. Less than half of the PCMHs reported processes for information exchange across medical and dental teams, referral tracking, and standardized protocols for oral health assessments by medical providers. Results highlight significant gaps in current implementation of adult dental integration in PCMHs, despite an increasing policy-level recognition of and support for dental-medical integration in primary care. Understanding and addressing associated barriers is important to achieve comprehensive patient-centered primary care.

Barriers and Facilitators to integrate Oral Health care for Older Adults in General (Basic) Care in East Netherlands. Part 2 Functional Integration

OBJECTIVE

to synthesise a framework of barriers and facilitators in the functional integration of oral health care (OHC) into general health care for frail older adults at macro (system), meso (organisation and interprofessional integration) and micro (clinical practice) levels.

BACKGROUND

Identification of these barriers and facilitators is expected to promote better and more appropriate care.

METHODS

For this qualitative study, comprising 41 participants, representatives of 10 different groups of (professional) care providers, and OHC receivers (home-dwelling and nursing-home patients) were interviewed. Transcripts of the in-depth, topic-guided interviews were thematically analysed. In a subsequent workshop with 52 stakeholders, results and interpretations were discussed and refined.

RESULTS

Two themes were identified: (1) compartmentalised care systems and (2) poor interprofessional and communication infrastructure. Barriers related to (1) included lack of integrative policies and compartmentalised healthcare education (macro level); poor embedding of OHC in care procedures, instruments and guidelines (meso level); and poor interprofessional skills (micro level). Barriers related to (2) included poor financial incentives for collaborative practices (macro level) and badly connected ICT systems (meso level). Identified facilitators included integration of an OHC professional into care teams, and interdisciplinary consultations (meso level); and integration of OHC in individual care plans (micro level).

CONCLUSION

In The Netherlands, OHC for older people is at best poorly integrated into general care practices. Barriers and facilitators are interconnected across macro-, meso- and micro levels and between normative and functional domains and are mainly related to compartmentalisation at all levels and to poor interprofessional and communication infrastructure.

Barriers and facilitators to integrate oral health care for older adults in general (basic) care in East Netherlands. Part 1: Normative integration

OBJECTIVE

to synthesise a framework of barriers and facilitators in the normative integration of oral health care (OHC) into general health care for frail older adults at macro (system), meso (organisation and interprofessional integration) and micro (clinical practice) levels.

BACKGROUND

Identification of these barriers and facilitators is expected to promote better and more appropriate care.

METHODS

For this qualitative study, comprising 41 participants, representatives of 10 different groups of (professional) care providers, and OHC receivers (home-dwelling, and nursing home patients) in East Netherlands were interviewed. Transcripts of the in-depth, topic-guided interviews were thematically analysed. In a subsequent workshop with 52 stakeholders, results and interpretations were discussed and refined.

RESULTS

Two main themes were identified: (1) a compartmentalised care culture in which OHC and general health care are seen as two separate realms, and (2) prioritisation, awareness and attitude regarding OHC integration. Subthemes such as low political attention (macro level); unclear responsibilities, hierarchical relations and the lack of vision of organisations (meso level); and poor awareness and low prioritisation by care providers and patients (micro level) were identified as potential barriers. Subthemes such as leadership (meso level), and the supportive personality of individual caregivers and ownership of patients (micro level) were identified as facilitators.

CONCLUSION

Barriers and facilitators in normative OHC integration in The Netherlands are interrelated and apparent at macro-, meso- and micro levels. They are mainly related to (a) a compartmentalised care culture, and (b) related low prioritisation, and poor awareness of and attitude towards (integration of) oral health (care).