Geriatric Dentistry: Care Delivery Systems

1
Geriatric Dentistry Care Delivery Systems

• Kenneth Shay, DDS, MS
• VA Office of Geriatrics and Extended Care

2
Geriatric Dentistry Care Delivery Systems

• Community (private settings)
• Dental school
• Aggregate day settings
• Home care
• Institutional settings
• Assisted living
• Nursing home
• Hospital

VA
3
Department of Veterans Affairs (VA)

• About 25,000,000 veterans
• 42gt65 yr
• 8 million enrolled 6M receive care from VA
• 56gt65 yr.
• VHA, VBA, NCA
• VHA is appropriated about 35B/yr
• About 220,000 employees
• Approximately 9,000 MDs14,000 nurse staff
• gt900 outpatient clinics
• 134 Hospitals (each with a dental clinic)

4
Department of Veterans Affairs (VA)(all data
are unofficial)

• 784 DDSs (includes 102 residents)
• 183 RDHs
• 991 DAs, CDAs
• 239 Lab technicians
• 381,000 unique patients treated in 2006 (includes
  about 35,000 fee patients)
• 2006 expenditures 351M (62M fee)
• budget submission was 419M
• 2008 budget submission 501M
• 2009 budget submission 551M

5
Priority levels regarding care and co-pay
obligations

• Standard vs Special and Limited benefits
• Dental is limited to
• 2 yr post-discharge
• 70 service-connected
• Service-related oral/dental trauma
• Former Prisoners of War
• Emergency care
• Participants in VA Vocational Rehab programs
• Inpatients (includes LTC) as resources allow
• Medically adjunct as resources allow

6
Geriatrics in VA

• 134 Nursing Home Care Units
• Average Daily Census (ADC) 10,500 and dropping
• Subacute, palliative, rehab, long-term
• Community Nursing Home Care
• ADC approximately 7,500 and stable
• State Veterans Homes
• State-administered
• ADC approximately 18,000 and climbing
• Life stay
• Non-institutional extended care
• Home-based primary care, respite, home hospice,
  adult day health care, homemaker/home health
  aide, skilled home care
• ADC approximately 26,000 and climbing

7
Geriatric Dentistry in VA--fantasies and
realities

• Everyone is eligible for dental care
• as resources permit
• Political pressures favoring recent dischargees
• Performance pressures favoring rapid turnover
• Personal pressures favoring particular case types
• Integration of medicine and dentistry
• Pressures to minimize medically adjunct
• Absence of an evidence base linked to treatment
• Dental inferiority complex
• Electronic health record

8
Geriatric Dentistry in VA--what might it be
telling us?

• Dentists like to treat who they like to treat
• (healthy people with clean mouths)
• Dentists like to do what they like to do
• (work on teeth
• sometimes on mouths
• less commonly on people
• And almost never, ever on teams)
• Supply and demand arent just capitalism
• (as long as there arent enough dentists, less
  desirable patients will be untreated)

9
Geriatric Dentistry Care Delivery Systems

• Kenneth Shay, DDS, MS
• VA Office of Geriatrics and Extended Care