Multi-Level Interventions to Reduce Oral Health Disparities among Adults in Primary Care Settings

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PROJECT SUMMARY/ABSTRACT Northeast Ohio has one of the highest rates of oral diseases (caries, periodontitis) and poor dental attendance among low-income older adults. Professional organizations and the IOM recommend integration of oral health (OH) activities into primary care for adults in order to reduce medical costs. But, published literature indicates a lack of outcomes data to assemble an effective medical-dental integration. Impeding integration are also factors such as lack of an electronic health record (EHR) based oral health (OH) assessment and referral, and inadequate OH education and training for medical providers. Our survey data indicate that the majority of providers would like OH facts to be communicated at primary care visits (PCV) but lack education and resources. There are misperceptions about oral diseases among older adults that prevent regular dental attendance. The proposed multi-level interventions will address factors that impede OH integration, and subsequently improve self-regulatory behaviors in adults. The interventions are: Practice (medical assistants, nurses): EHR systems based changes to ask, advise, assess, connect (AAAC). Provider (physician/nurse practitioner): improve knowledge and skills using Common-Sense Model of Self-Regulation (CSM) theory based education and skills training to communicate OH facts and reinforce importance of dental visits. A cluster-randomized clinical trial is proposed to test implementation (practice) and behavioral (provider) intervention to address self-regulation and increase dental attendance among low-income adults aged ≥55 years. The primary aims are: 1) UG3, Conduct qualitative work with stakeholders and practices; system-based changes in EHR; and pilot-test the interventions in 2 practices. UH3, randomize 8 practices to two arms to investigate the efficacy of a EHR based strategy at the practice level to ask [OH risk assessment], advise [going to dentist], assess [willingness for referral], connect [eReferral and/or resources] together with provider CSM theory-based education and skills to communicate OH facts versus provider alone (standard or usual oral health care) to increase dental attendance (primary outcome); and improve OH quality of life, oral hygiene behavior, and biometric measures of health (secondary outcomes). Secondary aims (UH3) are to explore: the delivery and documentation of AAAC implementation strategy; and to investigate causal pathways that affect the outcomes. The sample includes 209 providers and medical staff, and 800 Medicaid-enrolled adults. Data analysis (UG3) will utilize a mixed method design for qualitative and descriptive statistics for quantitative data. Data collection (UH3) will follow the RE-AIM framework: adults (outcome data from Medicaid claims, questionnaires, EHR); provider, practice (questionnaires); provider, practice (process measures: reach, fidelity, adoption, maintenance from audits). A generalized estimating equations approach will be used to assess effects of multi-level interventions on dental attendance and other outcomes, while accounting for clustering within practice. Mediation methods will determine if intervention effects occur through hypothesized mediators. A sustainable OH care model is proposed for primary care clinicians.