Promoting Oral Health in Primary Care - Closing the Dental Referral Loop

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics (AAP) recommends collaboration with dentists and early dental referral as an essential component of oral health care for young children. The objective of this project was to increase dental referrals by implementing a structured referral process for young children at highest risk for caries. METHODS. A quality gap was identified showing a low percentage of 1-3 year old children with an established dental care provider. Process measure of identifying and documenting a primary dentist was tracked. Families of children without a dentist were provided with updated lists of community dentists at well child visits. Following the well child visit, a report of absolute high risk (AHR) patients was generated. Based on the AAP Oral Health Assessment Tool, children were identified as being at AHR for caries if they had evidence of early caries or had a primary caregiver with untreated caries. Outreach by a dedicated administrative assistant via phone, mail and electronic portal was done for 3-4 months following the appointment to encourage families to schedule a dental visit. Multiple PDSAs adjusting method of outreach, timing of calls, and dedicated callback number were informally implemented to facilitate communication. Feedback on barriers to making or keeping the dental appointment was solicited. A referral form was faxed to the dental office around the time of the scheduled visit with a request to confirm and communicate pertinent findings back to the provider. RESULTS: Documentation of existing dentist remained steady at ∼30% (23.8-32.6%), although this was higher in AHR patients. Between Sept 2017 and February 2018, 148 1-3 year olds at AHR were identified. Seventy-eight (52%) of these children did not have a dental provider. Twenty six (33%) of this subset of patients eventually had a dental appointment scheduled. Thirteen (16.6 %) patients completed a dental visit, 8 (10.2%) visits are pending, and 5 patients did not keep their appointment. Of the 13 patients seen, 6 (46%) had completed referral forms returned by the dentist. Parents cited insurance coverage, unaffordable co-pays, transportation, lack of access to preferred dentist, patient age, and competing priorities as barriers to making or keeping dental appointments. CONCLUSIONS: The use of a dedicated staff member can facilitate the completion of community dental referral for young children at AHR for caries, but the process is labor intensive. Significant barriers exist to making and keeping appointments after the family leaves the clinic. Exploring these barriers during the clinic visit with the help of ancillary services such as case management may be necessary. This subset of patients may benefit from alternate models of care such as co-location of dental health personnel in the primary care setting. Opportunities for improvement in physician-dentist collaboration should be explored.