The OHS Journey

1
The OHS Journey Year 1
2
Where weve been
Team
FGs
Lit.
Meet
Submit
OHS
3
Serving Seniors Challenges for Oral Health

• By 2041, the senior population will be 23 (1995
  only 12) - 80,000,000 more teeth to care for!
• Literature indicates many barriers to care
• Financial, access, attitudes beliefs,
  institutional, education, physiological
• Oral health is marginalized from publicly funded
  health care
• Oral health impacts overall health
  and quality of life

4
Purpose

• To determine the key components of a health
  services model, based on continuity of care,
  which will help improve access to oral health
  services for seniors.

5
Whats needed?

• A collaborative, integrated team approach
• Data
• Increased awareness of the issue
• Links to other research and initiatives

6
Nova Scotia Our Projects Playground

• High proportion of seniors 128,333 seniors (65)
  in NS 13.6 of total population
• Many seniors living in rural communities, at home
  and with poor socio-economic conditions
• Currently, outside of our project, there is no
  information on the oral health services, barriers
  and facilitators
• No publicly funded dental services for seniors

7
Objectives Year 1 (Data Collection/Planning)

• Develop a survey for seniors and DCP
• Develop 4 focus group guides
• Develop a research logic framework for the Best
  Practices
• Identify resources and experts to consult
• Develop a recruitment strategy and materials
• Begin organizing the Forum
• Develop a communication plan

MAWG
BPWG
RFCWG
8
Objectives Year 2 (Analysis/Model Dev./
Dissem.)

• Synthesize, design and prepare a final report and
  executive summary for the Focus Group findings
  and Best Practices Scan
• Design Forum process, recruitment strategy,
  funding, and develop materials/presentations
• Host Forum
• Assist with the development of proposals for
  future projects/initiatives
• Develop a oral health services model for Nova
  Scotia
• Disseminate project findings

Research
Forum Planning
Team
9
Products/Wins

• Intersectoral team, 20 working group meetings
• A comprehensive evaluation framework
• Communication Plan - 30 opportunities
• Facilitator training workshop
• Recruitment process and materials
• 2 surveys and 4 focus groups guides
• Survey and Focus Groups findings
• Framework for Best Practices Scan
• Over 266 literature references
• Detailed tracking of project progress

10
It takes a village to build a model
Seniors
Education
Government
Researchers
LTC facilities
Insurance
Researchers
Dentistry societies
11
Celebrating our Work
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Todays Agenda
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Challenge Today

• To receive an update of the OHS projects Year 1
  activities
• To share and discuss the research results we have
  to date
• Prepare recommendations and a plan for Year 2
  activities including the Forum and model
  development

14
Research Objectives

• Goal To determine the key components of a health
  services model, based on continuity of care,
  which will improve the oral health status of
  seniors?
• Seniors Oral Health Services Evaluation
• Survey, Focus Group Sessions, Key Informant
  Interviews
• Best Practices Scan
• Review of literature, program scan, policy scan,
  professional training scan, insurance scan,
  promotion prevention scan
• Oral Health Policy Forum
• Review OHS project findings, develop strategies,
  clarify sector roles

15

• Seniors Oral Health Services Evaluation

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Senior Focus Groups

• 7 focus groups
• Average attending 10
• Range 2-15

17
Dentists, Dental Hygienists and NursesFocus
Groups

• 6 concurrent focus group sessions (18 in total)
• Average attending
• DDS DH 7
• Nurses 4
• Range
• DDS DH 6-9
• Nurses 2-5

18

• Survey Findings

19
Profile of the Senior Participants

• 67 senior participants
• Most
• Female
• Living 21 years in their community
• Perceived oral health and general health to be
  good
• Partial or full dentures, only 73 had all their
  own teeth
• All but 3 of the seniors were able to care for
  their own teeth and/or dentures
• Slightly over half of the seniors visited a
  dentist, dental hygienist, or denturist in the
  last year
• Only 68 of the seniors have private dental
  insurance

20
Profile of Dentist and Dental Hygienist
Participants

• 41 dentists and 44 dental hygienists participants
• Most
• 41 years of age
• 11 years in practice
• 19 DDS and 22 DH had some form of geriatric
  training - either as a component of their degree
  or CE courses
• Seniors comprised less than 30 of their patient
  base
• Like the seniors, most of the care providers
  perceived their senior patients oral health and
  general health to be good
• All but 10 indicated that their dental offices
  were wheelchair accessible
• 26 DDS and 9 DH provide dental services to
  seniors outside of the traditional dental office
• 16 DDS and 5 DH in nursing homes
• 7 DDS in the hospital
• 4 DDS and 2 DH serve homebound seniors

21

• Focus Group Findings

22
Profile of Nurse Participants

• 21 nurses participated in the focus
  groups
• There were both general nurses
  and nurse supervisors and working
  in homecare, long-term care and
  hospitals.
• Majority indicated no existing dental care
  policies or procedures in work place.
• No formal or informal geriatric dental care
  training either during nursing training or
  through their place of employment

23
Question 1 What are the existing dental
services for seniors?
Key Findings - Services
Note Lack of services in rural areas
24
Key Findings - Barriers

• Question 2 What hinders seniors from accessing
  dental care (the barriers)?
• Financial (Rural)
• Lack of continuity LTCF
• Attitudes Beliefs, Practices (Rural/Communicatio
  n)

25
Key Findings - Enablers

• Question 3 What helps seniors access dental
  care (the enablers)?
• Supportive Measures
• Transportation
• Education/Awareness
• Initiatives Outside N.S.

26
Key Findings - Ideas

• Question 4What do you feel is needed to create
  a system of oral health care for seniors living
  in Nova Scotia?
• Universal dental coverage
• Mobile clinics/equipment
• Policies/standards
• Geriatric education/awareness
• Dental Coordinator

27

• The following is an example of storytelling

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An Overview of the Seniors Oral Health Services
Evaluation
Adventures in Smileyville

29
Welcome to Smileyville

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• Introduction

Gotta Research Played by Pam Magee
31
Our Representatives

Shirley A. Senior Played by Liz Tait
Ima Caregiver Played by Crystal Holly
Unida Scale Played by Jennifer Le
Dr. Phil Yourtooth Played by Steve Creaser
32
Profile of the Senior Participants

• 67 senior participants, 7 focus groups
• Most
• Female
• Living 21 years in their community
• Perceived oral health and general health to be
  good
• Partial or full dentures, only 73 had all their
  own teeth
• All but 3 of the seniors were able to care for
  their own teeth and/or dentures
• Slightly over half of the seniors visited a
  dentist, dental hygienist, or denturist in the
  last year
• Only 68 of the seniors have private dental
  insurance

Shirley A. Senior (Liz Tait) will be travelling
to Smileyville to speak on behalf of the senior
patricipants-
33
Profile of DDS and DH Participants

• 41 DDS and 44 DH participants
• Most - 41 years of age
• - 11 years in practice
• 19 DDS and 22 DH - some form of geriatric
  training (component of degree or CE courses)
• Seniors comprised lt 30 of patient base
• Most care providers perceived senior oral health
  and general health as good
• All but 10 indicated that their dental offices
  were wheelchair accessible
• 26 DDS and 9 DH provide services to seniors
  outside dental office
• 16 DDS and 5 DH in nursing homes
• 7 DDS in the hospital
• 4 DDS and 2 DH serve homebound

Dr. Phil Yourtooth (Steve Creaser) and Ms.Unida
Scale (Jen Le) will be travelling to Smileyville
to speak on behalf of the participants of their
sector
34
Profile of Nurse Participants

• 21 nurse participants in the focus groups, 6
  focus groups
• Nurse supervisors and general nurses working in
  homecare, long-term care and hospitals.
• Majority indicated no existing dental care
  policies or procedures
• in work place
• No formal or informal geriatric dental care
  training either during nursing training or
  through their place of employment

Ms. Ima Caregiver (Crystal Holly) will be
travelling to Smileyville to speak on behalf of
the nurse patricipants
35
The Round Table Begins
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Question 1.
What are the existing dental services for
seniors?
37
Key Point Recap Question 1
Note Lack of services in rural areas
38
Question 2.
What hinders seniors from accessing dental care
(the barriers)?
39
Key Point Recap Question 2

• Financial (Rural)
• Lack of continuity LTCF
• Attitudes Beliefs, Practices (Rural/Communicatio
  n)

40
Question 3.
What helps seniors access dental care (the
enablers)?
41
Key Point Recap Question 3

• Supportive Measures
• Transportation
• Education/Awareness
• Initiatives Outside N.S.

42
Question 4.
What do you feel is needed to create a system of
oral health care for seniors living in Nova
Scotia?
43
Key Point Recap Question 4

• Universal dental coverage
• Mobile clinics/equipment
• Policies/standards
• Geriatric education/awareness
• Dental Coordinator

44
Discussion Questions

• What key findings or issues stand out? What are
  the highlights?
• Do you feel that story-telling would be a useful
  tool for dissemination of these findings at the
  Forum? Ideas for improvement?

45
Recap of Focus Group Findings

• Services All / rural
• Barriers Financial, LTC facilities, attitudes,
  beliefs and practices
• Enablers Supportive measures, transportation,
  education / awareness
• Think Big Universal dental coverage, mobile
  units / equipment, policies / standards,
  geriatric education / awareness, dental
  coordinator

46

• Best Practices Scan

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BP Scan
Literature Review
Prevention Promotion Scan
Policy Scan
Program Scan
Professional Training Scan
Insurance Scan
48
Best Practices Analysis Scan of barriers and
facilitators in oral health services for
seniors. Critical analysis of experiences and
lessons learned in Canada and elsewhere.
Objectives
Conduct a review of the literature relating to
the Oral Health Care of Seniors.

• Conduct a scan for programs services at 3
  levels
• Seniors dental programs
•  Geriatric dental training programs
•  Seniors oral health promotion/prevention
  services

• Conduct a scan of existing policies that address
  seniors access to oral health care
• govt, insurance
• national, international

Progress
Comprehensive search of existing literature
completed
Oral Health Policy Scan initial stages of
search, on-going

• Seniors oral health program scan completed
•  Geriatric dental training scan completed
•  Promotion / prevention scan on-going

Next Steps
49
Literature Review
50
Key Findings

• 266 articles that address seniors oral health
  issues
• Disparities in Oral Health Care and Access
• Seniors Oral Health Status
• Oral Health and Quality of Life
• Oral Health and Medical Status
• Oral Health and Nutrition
• Barriers to Accessing Oral Health Care
• Seniors Barriers
• Care Providers Barriers
• System Barriers
• Long-term Care Facilities and Oral Health
• Oral Health Prevention/Promotion
• Geriatric Oral Health Education/Training
• Policy and Seniors Oral Health
• Recommendations and Future Directions

Attitudes, beliefs and practices
51
Policy Scan
52
What is a Policy?

• A policy is a broad direction or course of
  action that has been endorsed by a body with
  authority to both implement it and resource it.
• HEAL Policy and Initiatives Scan, 2003

53
Types of Policies

• Care/Access- Those which state the level of care
  one must receive, and also the level of access to
  which one is entitled
• Coverage- The policies which outline the coverage
  of dental care and treatment to which individuals
  are entitled
• Advocacy- The policies of authoritative bodies
  which advocate for better or changed Oral Health
  Policies

54
Profile of Policies (total 18)
Canada 7 3 Coverage 4 Care/Access
US 4 2 Advocacy 2 Care/Access
International 7 1 Advocacy 6 Coverage
55
Canadian Policies (total 7)
56
Policy- Canada
Policy Level Addressing
Veterans Health Care Regulation Federal Coverage
Non Insured Health Benefits Federal Coverage
Community Care Facility Act Provincial Care/Access
Extended Health Benefits for Seniors Provincial Coverage
Ontario Nursing Homes Act Provincial Care/Access
Long Term Care Facility Oral and Dental Care Program (Halton) Regional Care/Access
Health Care Insurance Plan Act Provincial Care/Access
57
Policy- International
Policy Location Level Addressing
Policy of Gov't of Australia Australia Federal Coverage
Securite sociale couverture maladie universelle France Federal Coverage
Social Security Germany Federal Coverage
Irish Legislation Ireland Federal Coverage
Medicare and Medicaid State operations manual US Federal Care/Access
North Carolina Senior Tar Heel Legislature US State Advocacy
Policy of American Public Health Association US Federal Advocacy
United States Medicaid and Medicare US Federal Care/Access
58
Key Findings

• Policies can be classified as governing
  care/access, coverage or advocacy
• There are relatively few policies directly
  mandating the Oral Health of Seniors
• There is also a lack of research or assessments
  of the few existing policies

59
Program Scan
60
What is a Program?

• Division of programs (better and promising)

61
Profile of Programs (total 58)
Canada 32
US 18
International 8
62
How did we select Better Programs

• Based upon
• 1. Theoretical and best practices literature
  findings from
• health prevention/promotion literature
• community development and capacity building
  literature
• 2. Discussions with senior oral health program
  directors (e.g. Apple Tree, Baycrest Geriatric
  Dental Program and Golden Care)

63
Key Indicators
Literature and Program findings used to help
determine better seniors oral health programs
using accessibility and sustainability as the
assessment markers
Sustainability
Accessibility
Funding OH initiatives Geriatric
Education Expansion Awareness On-going
evaluation Awareness Delivery Location
Public/Private Partnerships Duration
Transportation Open to seniors
64
Key findings

• Halton Dental Program (Ontario)
• Golden Care Dental Services (Ontario)
• Baycrest Centre for Geriatric Care (Ontario)
• Apple Tree Dental (US)
• Geriatric Dental Clinic, Yad Sarah (Isreal)

65
Insurance Scan
66
What is a Dental Insurance Plan?

• An agreement that guarantees the financial
  coverage of costs (partial or full) incurred as a
  result of receiving dental treatment
• Two kinds
• Private
• Public

67
Private Insurance
Company Dental Packages for Seniors Dental Packages for Seniors Evaluation Evaluation
Company Individual Group Program Needs Assess.
Liberty N/A
Green Shield Canada ? ? (none offered in NS) No ?
Standard Life N/A
Imperial N/A
Sun Life N/A
Maritime Life ? No No No
Great West Life ? ? (retiree packages) No No
Manulife ? No ? No
Canada Life Not willing to participate
Atlantic Blue Cross ? ? No
68
Public Insurance
Plan Coverage Population
NWT Extended Benefits Dental Plan Comprehensive 1000 max All seniors 60 and over
Yukon Comprehensive 1400 2 years max All seniors 65
Veteran Affairs Dental Plan Comprehensive 600 max All veterans 60 and older
NIHB Dental Plan Comprehensive All Status First Nations Metis
Denmark Public Health Dental Plan Comprehensive All residents
Finland Public Health Dental Plan Comprehensive 70 Coverage All residents
Norway Public Health Dental Plan Comprehensive Seniors (homebound and LTC) and children
Sweden National Dental Plan Comprehensive Seniors (homebound and LTC), partial for others
Germany National Dental Plan Partial coverage All residents
69
Key Findings

• Private If seniors come forward and ask for
  private insurance the insurance companies will
  develop a dental plan
• Public Not good enough just to have a system in
  place (e.g. NFLD childrens)
• Explore why not working attitude and beliefs of
  seniors, caregivers perception of need, dental
  community not raising awareness about the system

70
Prevention Promotion Scan
71
Prevention and Promotion Scan

• This scan is ongoing
• The three components of this scan are
• Basic Informational Resources
• Educational Tools
• Workshops
• Tool Kits
• Other educational aids
• Assessment tools developed

72
Professional Training Scan(DDS and DH)
73
DDS and DH Programs in North America
DH Programs (Cdn) Diploma 20 (1 private) Degree
4 (2 pending)
DDS Programs (Cdn) Undergraduate 10
DDS Programs (US) Undergraduate 53
DH Programs (US) Diploma 115 Degree 60
74
Key Findings DDS Programs

• Geriatric dental education is not universal in
  Canadian and US schools
• Need to develop universal geriatric educational
  standards
• Curriculums not changing to meet the needs of the
  population no major changes over the last decade
• Major barrier to inclusion/expansion of geriatric
  didactic and clinical components in curriculum,
  over crowded curriculum
• Lack of faculty members with an interest in or
  training in geriatrics

75
Geriatric Component in DDS Undergraduate Programs
76
Key Lessons Iowa University Geriatric Dental
Program

• Geriatrics
• multidisciplinary
• should be integrated into clinical departments
• Seniors require specific OH treatment
• Senior faculty member as director of geriatric
  courses
• Students should only provide care when equipped
  with the knowledge and skills
• Students need to gain clinical experience working
  with seniors
• Faculty need CE in geriatric dental care

77
Key Findings DH Programs

• Lack of standardized geriatric accreditation
  standards
• Differences between geriatric components offered
  in Diploma and Degree programs
• Lack of faculty trained in geriatric dentistry
• Overcrowded curriculum cited as the key barrier
  to the growth of geriatric curriculum within
  programs
• No major changes in geriatric components in
  curriculum over last decade

78
Geriatric component in DH curriculum
Curriculum requires Canada and USA N 210
Geriatric Component 187
Clinical Component 113
Specific Course 40
79
Average time allotted for geriatric didactic and
clinical components in dental hygiene programs









































80
Time Allotted to Geriatric Clinical Components
Dental Hygiene Programs
81
Key Findings DDS and DH Programs

• Similar barriers identified to lack of
  enhancement of geriatric dentistry components in
  curriculum
• Overcrowded curriculum
• Lack of faculty trained in geriatric
• Financial considerations
• Lack of standardized accreditation standards
• No major changes in geriatric components offered
  over last ten years

82
Lack of seniors oral health delivery programs
Lack of standardized geriatric accreditation
standards
Where are the gaps?
Lack of standardized accreditation assessment
tool
Lack of availability of services (transportation,
facilities, equipment)
Lack of a continuum of oral health care from one
setting to another (independent living,
homecare, long-term care, hospital)
83
Building a Model
Training
Research
Public
Private
Education
Funding
?
Policy
Services
84
Discussion Questions

• How can these findings be used in the development
  of a model?
• What is necessary to build the model
• During the Forum
• After the Forum
• Do we need new team members to help with
  strategic planning and model development?

85
Closing Remarks - Workplan

• Synthesize, design and prepare a final report and
  executive summary for the Focus Group findings
• Synthesize, design and prepare a final report and
  executive summary for the Best Practices Scan
• Design Forum process, recruitment strategy,
  funding, develop materials/presentations
• Host Forum
• Assist with the development of proposals for
  future projects/initiatives
• Develop a oral health services model for Nova
  Scotia
• Disseminate project findings

Research
Best Practices
Forum Planning
Team