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What Primary Care Innovation Teaches Us About Oral Health Integration

Learning Objectives
1. Explain a new or unfamiliar viewpoint on a topic of ethical or professional conduct
2. Evaluate the usefulness of this information for his or her practice, teaching, or conduct
3. Decide whether and when to apply the new information to his or her practice, teaching, or conduct
1 Credit CME
Abstract

Integrating primary and oral health care is critical to improving population health and addressing health inequity exacerbated by the COVID-19 pandemic. Leaders of the patient-centered medical home (PCMH) movement focused on building consensus for the PCMH model among diverse stakeholders in order to enhance infrastructure investment, care innovation, and payment reforms that support access and equity. This article offers 5 lessons from the PCMH movement to inform primary and oral health care integration.

Patient-Centered Medical Homes

Consumers want primary care that is accessible, comprehensive, coordinated, and responsive to overall health and well-being and that integrates oral and behavioral services.1 However, despite the fact that comprehensive primary care improves population health and reduces inequity,24 this care is hard for patients to find because of siloed payment, insurance, and delivery streams. The COVID-19 pandemic has further weakened primary care and exacerbated inequity.5,6 Yet primary care innovators who have built momentum over the last decade might still help increase access to comprehensive care by creating patient-centered medical homes (PCMHs)7 that can connect silos. PCMHs offer advanced primary care models that do the following:

  • Quiz Ref IDStrengthen partnerships between primary care clinicians and patients

  • Deliver comprehensive services through team-based, proactive approaches

  • Leverage technology to track, target, and evaluate interventions

PCMHs have been widely adopted by commercial health plans, states, and federally qualified health centers (FQHCs). As of 2010, 44 states and the District of Columbia had passed 330 laws to support and incentivize medical homes.8 White and Twiddy reported in 2017 that 45% of family physicians practice in a PCMH,9 and the American Medical Association showed that 32% of physicians in 2018 participated in a medical home.10,11

Shortages and Need

The 2007 Joint Principles of the PCMH, which guided the development of this advanced primary care model, were updated in the 2017 Shared Principles of Primary Care12,13 (see Figure 1), now embraced by over 350 organizations.14Quiz Ref ID

Figure 1. Shared Principles of Primary Care
Adapted from Epperly T, Bechtel C, Sweeney R, et al.12

Each principle is germane to primary and oral health care integration. The principle of comprehensive and equitable care deserves particular attention here, since it encourages disease prevention and intervention strategies' inclusion of general medical, mental health, and oral health services, as well as social determinants of health, which are often overlooked and undervalued in siloed service delivery streams. In 2013, the Substance Abuse and Mental Health Services Administration-Health Resources and Services Administration Center for Integrated Health Solutions created a framework of 6 levels of integrated health care (see Figure 2).15,16

Figure 2. A Standard Framework for Levels of Integrated Health Care
Reproduced from Heath B, Wise Romero P, and Reynolds K.16

Models of care based on this framework included co-located dental hygienists or full-service dental clinics but didn't offer system-wide integration of whole-person care. Most ambulatory visits in the United States are to primary care clinicians,17 which is no wonder, since 61 million people live in dental health professional shortage areas (HPSA) and 124 million live in mental HPSAs.18

The following data suggest that primary care equipped to meet patients' needs holistically must offer a range of services (eg, screening, education, interventions, appropriate referrals) in general medicine, mental health, and oral health.

  • Quiz Ref IDDental caries is considered the most prevalent infectious disease on earth,19 and half of US adults aged 30 and older have periodontitis.20 Oral disease is associated with worse outcomes across multiple health conditions and organ systems, and chronic inflammation associated with periodontal disease is associated with diminished glycemic control among people with diabetes21 and increased risk of preterm birth.22

  • Seventy percent of primary care visits are for psychosocial concerns,23 and patients with physical or mental disability have higher rates of substance use disorder and serious mental illness.24 Patients with mental illness die 13 to 30 years earlier than members of the general population from treatable conditions.25 Conversely, people with physical illness or injury have higher rates of undetected mental illness.26,27

  • Up to 2.1 million emergency department visits each year are for nonurgent, preventable dental conditions28; 108 million people annually see a physician but not a dentist, and 27 million people annually see a dentist but not a physician.29

Five Lessons

General medical, mental health, and oral health care integration can be guided by 5 lessons from the adoption of PCMHs.

Lesson 1: compile evidence. Evidence offers exemplars of implementation successes and failures, which can enable articulation of shared values that spur engagement, motivate communication and consensus, and forge innovation in education, policy, advocacy, and research. In mental health, for example, the IMPACT study, published in 2002, provided evidence that late-life depression intervention in primary care settings reduced depressive symptoms relative to usual care,30 which led the National Council for Community Behavioral Healthcare to define mental health roles for PCMHs in 2009.31 In 2010, the Milbank Memorial Fund published Evolving Models of Behavioral Health Integration in Primary Care,32 which described how to nationally scale mental health integration to improve depression intervention outcomes,33,34 increase adherence,35 and support quality of life.36

A nascent evidence base for oral health integration is being formed from insurance claims data on positive outcomes for at-risk patients who received combined medical and dental care.34,38,39 Since 2009, the National Interprofessional Initiative on Oral Health (NIIOH) has convened diverse stakeholders to create a framework for integrating oral health care into primary care. NIIOH also participated in the US Health Resources and Services Administration's consensus process that defined core clinical oral health competencies for primary care clinicians.40 NIIOH continues to support Smiles for Life,41 a free online primary care oral health curriculum, and the Oral Health Delivery Framework,42,43 which offers sample workflows for stepwise, incremental integration of oral health into primary care (see Figure 3). The Primary Care Collaborative (PCC) also convened diverse leaders to reporton oral health care and primary care integration with a view to compiling and disseminating exemplar oral health integration models.44

Figure 3. Oral Health Delivery Framework
a Reproduced from Hummel J, Phillips KE, Holt B, Hayes C.43 Reprinted by permission of Jeffrey Hummel.

Lesson 2: Collaborate. Care delivery innovations affect a range of stakeholders (eg, payers, policymakers, clinicians) with competing interests. Inclusive co-creation of a shared vision of the future state of health care generates buy-in, and buy-in makes for easier implementation. The PCC's team-based advocacy efforts, for example, have generated widespread adoption of PCMHs by federal and state agencies and insurers.45 Together with the National Alliance of Healthcare Purchaser Coalitions and the Pacific Business Group on Health, the PCC released 7 new attributes of advanced primary care models that align shared principles, including mental health integration.46 Similar collaborative effort could be replicated for oral health integration.

Lesson 3: Reformboth service delivery and payment streams. Quiz Ref IDAlthough PCMHs have demonstrated some improvements in cost and quality, many experts believe that the model is underpowered because payment structures do not support team-based care.47 Primary care is still largely fee-for-service and makes up only 5% to 7% of total US health care spending,4850 so organizations' investment in primary care is low. More than 60% of primary care practices' revenue must come from prospective payments in order to substantially reform care delivery without fiscal loss.50 Reliance on fee-for-service hampers practices' capacity to offer comprehensive services via cross-disciplinary teams.52 To help practices with financial obstacles to integration, the AIMS Center for Advancing Integrated Mental Health Solutions53 offers resources (eg, bundled payment models, collaborative care codes) for managing fiscal demands of mental health integration. Texas, for example, began contracting with Medicaid to integrate services and reduce fragmented care.54 Reformers need examples of financially successful integration models to co-locate oral health and primary care in FQHCs and bundle benefits in some Taft-Hartley plans.55

Lesson 4: Motivateequity. Initially, the value proposition of PCMH focused more on cost than quality, but both are key to promoting equity, particularly as we emerge from the COVID-19 pandemic. Quiz Ref IDBefore the pandemic, one-third of US adults lacked dental insurance,56 and Americans with low incomes or without health insurance were less likely to have visited a dentist within a year.57,58 Before the pandemic, Black and Brown communities had lower rates of annual dental visits and higher rates of tooth decay and tooth loss.5961 The COVID-19 pandemic has likely worsened these outcomes, as many lost employer-sponsored insurance that included some coverage of dental services.6264

Lesson 5: Invest in metrics infrastructure. As with organizational transitions to PCMHs, infrastructure investments are prerequisites for integration. Most primary care electronic health record (EHR) systems lack oral health fields, which impedes interoperability, data and analytics collection, care coordination, and key performance indicator tracking and reporting needed to ensure value-based care and payment. Public and private insurers can help incentivize organizational investment in EHR architecture that enables innovation and integration. Of 1100 metrics endorsed by the National Quality Forum's Quality Positioning System, we identified 122 primary care metrics and 9 oral health metrics.65 A standardized and reliable measure of caries, for example, is essential to meaningful integration of oral health into primary care.

Next Steps

Equitable care of patients and communities requires integrating mental health and oral health into primary care. We envision comprehensive, patient-centered service delivery streams that prioritize prevention, value, and national scalability of standard-of-care exemplars that we all want and deserve.

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Credit Designation Statement:  The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to: 

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

1 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

1 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and

1 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Article Information

AMA Journal of Ethics

AMA J Ethics. 2022;24(1):E64-72.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

Conflict of Interest Disclosure: The author(s) had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.

Author Information:

  • Ann Claire Greiner, MCP is the president and chief executive officer of the Primary Care Collaborative, which defines and implements advocacy, research, and education agendas to promote comprehensive, team-based, and patient-centered primary care. She previously served as vice president of public affairs for the National Quality Forum and as deputy director at the National Academies of Medicine and in leadership roles within the National Committee for Quality Assurance and the American Board of Internal Medicine. She earned a master's degree in urban planning from the Massachusetts Institute of Technology; Anita Duhl Glicken, MSW is the executive director of the National Interprofessional Initiative on Oral Health as well as a professor and associate dean emerita at the University of Colorado Anschutz Medical Center in Aurora. She also serves as the chair of the Health Resources and Services Administration Advisory Committee on Training in Primary Care Medicine and Dentistry. A clinical social worker by training, her publications focus on innovative, transformative, collaborative education and service delivery models that motivate health equity.

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