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

Delivery of Oral Health Services at Medical Visits through 3 Medical Dental Integration Models

INTRODUCTION

The Rocky Mountain Network of Oral Health is 1 of 3 regional projects funded by the Health Resources and Services Administration (2019 to 2024) focusing on caries prevention through medical-dental integration (MDI) in community health centers (CHCs). MDI models included provision of preventive oral health services (POHS) at medical visits by the medical team (model 1), by integrated dental hygienists (DHs; model 2), or a hybrid of these models (model 3). The overarching aim is to evaluate the effectiveness of these models on 3 objectives: (1) ≥50% receive POHS, (2) ≥75% with high caries risk receives dental referral, and (3) ≥30% of parents/caregivers set an oral health goal for the child.

METHODS

Primary care association practice facilitators (PFs) recruited 22 CHCs to participate from Arizona, Colorado, Montana, and Wyoming. CHCs completed oral health needs assessments prior to participating. PFs coached CHCs using an MDI change package. CHCs submitted monthly and 6-mo, aggregated, deidentified population metrics for children aged 0 to 40 mo receiving well-child care visits. Monthly CHC-specific reports were used by PFs with teams in continuous quality improvement activities. POHS delivery trends over time were assessed using a linear mixed model, adjusting for number of eligible patients during each 6-mo reporting period.

RESULTS

Participating CHCs were urban (55%), rural (36%), and frontier (8%). Twelve (55%) had co-located dental clinics. Ten CHCs implemented model 1, 5 implemented model 2, and 7 implemented model 3. From September 2020 to August 2023, CHCs reported providing 91,604 POHS to eligible children. After adjustment, there was significant improvement over time for all objectives: objective 1: F(5, 90) = 4.66, P = 0.0008; objective 2: F(5, 90) = 2.99, P = 0.0151; objective 3: F(5, 90) = 4.56, P = 0.0009.

CONCLUSIONS

The implementation of 3 MDI models across 22 CHCs in 4 states resulted in a meaningful increase in POHS delivery. POHS delivery by both medical and embedded DHs was associated with the most substantial increase in POHS delivery.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by medical and dental providers when deciding which approach they wish to use when planning the delivery of preventive oral health services at medical visits.

Toward a Comprehensive Model of Medical-Dental-Behavioral Integration

INTRODUCTION

Existing models of medical-dental integration, as well as those from behavioral health care integrated with primary medical treatment, provide a basis for a truly synthesized and expanded model incorporating medical, dental, and behavioral components. Such a comprehensive model allows for collaborative health care serving patients seamlessly without disciplinary silos, promoting optimal whole-person health. This innovative approach is consistent with recent developments in the behavioral and social oral health sciences that include an imperative for their full inclusion in dental health care, research, and education.

METHODS

Existing models of medical-dental integration are described, along with current models from integrated primary medical and behavioral health care. Using these existing approaches as a basis, a new multilevel model is proposed to include social and cultural determinants of health.

RESULTS

Contemporary approaches to providing health care across disciplines include referral to a geographically separate entity, co-location of services, and integrated, side-by-side care. Integration of electronic health records and interoperability are necessary (but not sufficient) factors that affect transdisciplinary health care. Effective communication among health care providers and the need for interprofessional education, comprehensive training, and ongoing cross-disciplinary consultation also are noted as crucial factors in truly collaborative care. Evidence for existing models varies greatly depending on the target population and type of services provided.

CONCLUSIONS

A fully integrated, transdisciplinary model of health care is possible, theoretically and practically. Combining aspects of extant integrated models and extending them provides opportunity for a greater focus on systemic factors and more emphasis on prevention. Consistent with this new model, medical and dental home concepts can be expanded to that of a person-centered health care home that includes interprofessional practice. This transdisciplinary approach contributes to greater health equity given the multilevel approach. Multidirectional integration of diverse disciplines representing the various realms of medicine, dentistry, and behavioral health care is essential for optimal health of all.

KNOWLEDGE TRANSFER STATEMENT

This article can be used by clinicians, scientists, administrators, and policy makers in developing and implementing integrated systems of care that provide for patients' medical, dental, and behavioral health needs.

The Patient-Centered Dental Home: A Framework for Quality Measurement, Improvement, and Integration

OBJECTIVE

This study completed the development of a standardized patient-centered dental home (PCDH) framework to align and integrate with the patient-centered medical home. This study identified measure concepts and specific measures and standards to complete the 4-level measurement framework to implement and evaluate a PCDH. This study built on prior model development, which identified the PCDH definition and characteristics and the components nested within those characteristics.

METHODS

An environmental scan identified existing oral health care quality measure concepts, measures, and standards for rating by the project's National Advisory Committee (NAC). A modified Delphi process, adapted from the RAND appropriateness method, was used to obtain structured feedback from the NAC. NAC members rated measure concepts on importance and, subsequently, specific measures and standards on feasibility, validity, and actionability using a 1 to 9 rating scale. Criteria for model inclusion were based on median ratings and rating dispersion. Open-ended comments were elicited to inform model inclusion as well as identify additional concepts.

RESULTS

We identified more than 500 existing oral health care measures and standards. A structured process was used to identify a subset that best aligned with a PCDH for rating by the NAC. Four Delphi rounds were completed, with 2 rounds to rate measure concepts and 2 rounds to rate measures and standards. NAC quantitative ratings and qualitative comments resulted in a total of 61 measure concepts and 47 measures and standards retained for inclusion in the framework.

CONCLUSIONS

The NAC ratings of measure concepts, and specific measures and standards nested within those concepts, completed the 4-level PCDH measurement framework. The resulting framework allows for the development and implementation of core measure sets to identify and evaluate a PCDH, facilitating quality improvement and dental-medical integration.

KNOWLEDGE TRANSFER STATEMENT

Clinicians, payers, health care systems, and policy makers can use the results of this study to guide and assess implementation of the various components of a patient-centered dental home and to support dental-medical integration.