Oral Disease Prevention Model in Long Term Care: WHO Systems Thinking Framework

项目摘要 目前，有150万老年人生活在长期护理设施中，而且这一数字还在增加。他们的 对牙齿护理的需求也在增长，因为现在几乎70%的老年人都有牙齿。虽然牙科 龋齿和牙周病是可以预防的，96%的65岁以上的成年人有龋齿 根据经验，至少有20%的人患有未经治疗的蛀牙，68%的人患有牙周病。两个条件 是由多种药物、合并症和虚弱加速的动态过程的结果。 虽然没有关于长期护理（LTC）居民口腔健康状况的全国性数据， 队列研究一致表明，LTC居民的口腔健康状况比 居住在社区的老年人。面对健康状况下降和人口减少的负担， 独立，LTC中的老年人不太可能获得牙科护理，更有可能开发新的 蛀牙和牙周病恶化，因此预防护理是至关重要的。然而，大多数研究在口腔 健康和LTC的重点是接受恢复性治疗的护理途径，但存在重大障碍， 限制LTC居民获得这种护理的能力。另外，还有一个重点是照顾 助理执行口腔卫生护理（OHC），而在实践中，他们往往没有提供足够的培训 也没时间提供OHC这是进一步复杂的事实，即居民的LTC正在经历 独立性下降，脆弱性增加。考虑到LTC环境的复杂性， 疾病管理的方法也不可能减少新的龋齿和牙周骨丢失， 由此产生的负担。为了解决这一复杂性，该项目将使用健康协同设计工具箱 与世卫组织卫生系统思维框架合作，共同设计系统干预措施， 龋齿和牙周病。这项调查将寻求了解居民的经验， 工作人员作为发展预防性口腔保健综合模式的起点。最初 将通过回顾性临床审计和一系列 焦点小组。然后，一个由利益相关者组成的设计团队将与调查人员合作，共同设计干预措施 在系统内的多个代理和进程上工作。可能的例子包括，临床医生 评估龋齿风险并开具预防药物处方，为内部药房配备口腔卫生设备 助手和电子病历提示启动口腔健康转介某些医疗诊断。仿真建模， 基于系统映射数据，将通过使用不同的 预防机制和不同的疾病模式。一个外部咨询小组将提供反馈意见 定性数据和系统干预协议。如果被证明是有效的，这种模式有可能 为公共政策提供信息，并减少美国150万LTC居民所经历的口腔健康不公平现象。

PROJECT SUMMARY Currently, 1.5 million older adults live in Long Term Care (LTC) facilities and that number is increasing. Their need for dental care is also growing since almost 70% of older adults are now dentate. Even though dental caries and periodontal disease are preventable, 96% of dentate adults over age 65 years have caries experience, at least 20% are living with untreated decay and 68% have periodontal disease. Both conditions are the result of dynamic processes which are accelerated by polypharmacy, comorbidities, and frailty. Although there is no national data regarding the oral health status of long-term care (LTC) residents, small cohort studies consistently document that LTC residents have substantially worse oral health than the population of community-dwelling elders. Faced with the burden of declining health and diminished independence, older adults in LTC are less likely to access dental care and more likely to develop new cavities and worsening periodontal disease, hence preventive care is vital. However, most research in oral health and LTC has focused on care-pathways for receiving restorative treatment, but significant barriers exist which limit LTC residents’ ability to access this care. Alternatively, there is a focus on having care assistants perform oral hygiene care (OHC), when in practice they are often not provided adequate training or time to offer the OHC. This is further complicated by the fact that the residents of LTC are experiencing diminishing independence and increasing frailty. Given the complexity of the LTC setting, a siloed biomedical approach to disease management is also unlikely to reduce new dental caries and periodontal bone loss and the resultant burden. To address this complexity, this project will use the Health Co-design toolbox together with the WHO Health Systems thinking framework to co-design a system intervention to reduce the increment of caries and periodontal disease. This investigation will seek to understand the experiences of residents and staff as a starting point for developing a comprehensive model of preventive oral health care. Initially, the current system supporting oral health in LTC will be mapped through a retrospective clinical audit and a series of focus groups. Then, a design team of stakeholders will work with investigators to co-design an intervention that works on multiple agents and processes within the system. Possible examples include, clinicians assessing caries risk and prescribing preventive agents, equipping in-house dispensaries with oral hygiene aides, and EMRs prompts to initiate oral health referrals for certain medical diagnosis. Simulation Modelling, based on system mapping data, will conceptualize the effects of the intervention by using different mechanism of prevention and different patterns of disease. An external advisory panel will provide feedback on qualitative data and the system intervention protocol. If proven effective, this model has the potential to inform public policy and reduce the oral health inequities experienced by 1.5 million LTC residents in the U.S.