Integrating Oral Health and Primary Care

Integrating Oral Health and Primary Care

Dental Clinics of North America, 2016-10-01, Volume 60, Issue 4, Pages 951-968, Copyright © 2016

This article describes federal programs, initiatives, and partnerships that have the demonstrated potential to initiate and institutionalize interprofessional practice that includes oral health providers as integral to the provider team. A discussion of landmark documents and reports, the role of legislation and statutory authority, and the influence of federal program priorities towards a national movement to increase access to care to bridge the chasms between the medical health care system, dental delivery system, and oral health is presented.

Key points

  • United States federal programs, initiatives, and partnerships have taken action to initiate and institutionalize interprofessional practice.

  • Federal activities recognize oral health providers as integral to the provider team.

  • Landmark documents and reports, legislation and statutory authority, and the influence of federal program priorities contribute towards a national movement to increase access to care to bridge the chasms between the medical health care system, dental delivery system, and oral health.

Introduction

Oral health, as a critical component of health, is embedded in the World Health Organization’s 1948 broadened definition, “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Even so, nearly 70 years have passed and oral health, dental education, and dental care delivery remain disconnected and separate from the larger medical system of care. This disconnect and view of the mouth as separate from the body is perpetuated by segmented models of care and delivery and payment systems that have not substantially integrated oral health in overall health. A 1972 Institute of Medicine (IOM) report echoed that “linkages are inadequate between existing models of health delivery and the educational institutions charged with developing the manpower for these systems.” The report presents the basic argument for interprofessional teams (and integration) in the ambulatory care environment in which the emphasis is on the patient and outcomes of care rather than “on professions, their techniques, or the process of care.” With significant disparities in oral health among segments of the population and multifactorial challenges in accessing care, it is in the primary care environment, in particular, that there is an urgent need for the deployment of effective health care teams. Through differing administrations, budget cycles, and economic cycles, the federal government has taken the lead on key issues, such as health promotion and access to care, that affect the nation.

Periodic efforts to move oral health and dental care delivery into the mainstream of health care, and to reunite the mouth with the body in efforts to achieve overall health, have met with mixed results. In Oral health in America: a report of the Surgeon General , then Secretary of the Department of Health and Human Services (DHHS), Donna Shalala, stated that oral health is integral to general health because “you cannot be healthy without oral health.” She was reflecting the nation’s struggle to achieve a systems-level change to implement true integration of oral health and primary care in a consistent and sustainable manner.

This article describes federal programs, initiatives, and partnerships that have the demonstrated potential to initiate and institutionalize interprofessional practice, which includes agreement that oral health providers are integral to the provider team. A discussion of landmark documents and reports, the role of legislation and statutory authority, and the influence of federal program priorities towards a national movement to increase access to care and bridge the chasms separating the medical health care system, the dental delivery system, and oral health is presented.

In 2000, in the first Surgeon General’s report on oral health, David Satcher wrote, “There are opportunities for all health professions, individuals, and communities to work together to improve health.” Furthermore, this report explicitly states that a principal component of a national oral health plan (NOHP) is an effective health infrastructure that meets the oral health needs of all Americans and integrates oral health effectively into overall health. The DHHS recently took a monumental step forward by promoting an NOHP and publishing the Oral Health Strategic Framework, 2014–2017 ( Framework ) that “builds upon and outlines a strategic alignment of HHS operating and staff divisions’ resources, programs, and leadership commitments to improve oral health with activities of other federal partners.”

The recent realignment of federal priorities and programs that recognize the importance and value of integrating oral health and primary care has ignited renewed interest in innovative approaches to continued progress in improving the nation’s oral health.

Historical perspective and the role of federal programs

Throughout history there have been notable occasions when federal policies and programs have made a substantial impact on the health care system in an effort to improve the health of the nation. One example is the 1965 passage of Medicaid and Medicare that today represents the nation’s main public health insurance programs for the low-income populations and Americans aged 65 years and older, respectively. The sweeping transformation of the health care system created by these programs continues today.

In the same year, Coggeshall submitted a report to the Association of American Medical Colleges. Although the health care system then was quite different from today, there was awareness and foresight that “the expanding role of government in the health field has been manifesting itself in a growing number of ways and with increasing resources and emphasis in recent years. This can be expected to continue to expand.” The Coggeshall Report provided a series of recommendations to the Association of American Medical Colleges that included the need to “maintain productive relationships with government.” Nearly 50 years lapsed before efforts to further transform health care delivery resulted in the passage and implementation of the Affordable Care Act (ACA) in 2010.

Partnering with Foundations or Nonprofits

Federal government programs have finite budgets for discretionary programs. Funds availability depends on the specific agency and congressional authorizations and appropriations for that fiscal year (FY). The amount of federal funding is directed by statute or legislation and must be used for specified purposes. Although grants to institutions and states are sometimes used for pilot or demonstration projects, in some circumstances the available federal funding level is insufficient to create permanent widespread change across workforce development education and practice delivery systems. Over the past decade, more and more public-private partnerships between government and nongovernment entities have emerged, such as foundations and nonprofit organizations, in efforts to leverage resources more efficiently and effectively to drive the transformation of health professions education and practice toward a more integrated approach with the goal of improving health outcomes.

An interprofessional education and integrated practice paradigm is not new, although previous efforts did not gain enough momentum to create a fully integrated national network with national visibility, influence, and acceptance. In the late 1980s, Pew Charitable Trusts and the Rockefeller Foundation funded 6 universities as part of their Health of the Public national program. One institution, Columbia University, focused on incorporating public health education in the dental, medical, and nursing school curricula by establishing an interdisciplinary clinical curriculum workgroup and a summer Institute in Clinical Public Health for entering dental, medical, and bachelor-degree nursing students.

Since then, spurred by the release of the 2000 Surgeon General’s Report, increased attention and progress has been made towards incorporating oral health into overall health. Studies have continued to be published that associate oral diseases and conditions with chronic illnesses. A growing number of dental, medical, nursing, and physician assistant education programs, and licensing and credentialing examinations, have begun to emphasize the oral-systemic connection. A summary of the 3-day workshop on the US Oral Health Workforce in the Coming Decade was published in 2009. Several relevant conclusions are displayed in Box 1 .

Box 1
Selected conclusions from the US Oral Health Workforce in the coming decade workshop summary
From IOM (Institute of Medicine). The U.S. oral health workforce in the coming decade: workshop summary. Washington, DC: The National Academies Press; 2009; with permission.

  • Interdisciplinary training of all students is required to bridge the gap between medicine and dentistry.

  • The scopes of practice of all health care professionals need to be maximized to improve access to oral health services in rural areas.

  • Integration with the nondental workforce allows for evolution toward true oral health, with dental professionals being an integral part of maintaining the systemic health of their patients.

  • More models are needed for the interdisciplinary education and training of health professions students.

  • Policies need to come into alignment with practice, such as the development and implementation of clinical practice guidelines.

In February 2011, the Health Resources and Services Administration (HRSA) convened a conference with the Josiah Macy Jr Foundation, the Robert Wood Johnson Foundation, the American Board of Internal Medicine Foundation, and the Interprofessional Education Collaborative (IPEC), to engage a diverse group of leaders in the development of competencies for interprofessional education (IPE) and practice, including dentistry. The final conference report with the IPEC competencies was released May 10, 2011.

Collaborations across a spectrum of funding entities have emerged to promote oral health integration in primary care and reconnect oral health and overall health. In 2012, the DentaQuest Foundation, the Washington Dental Service Foundation, the Highmark Foundation, and the Robert Wood Johnson Foundation provided funding to convene a group of grant makers, researchers, and practitioners to discuss issues related to integrating oral health and primary care. This group published an issue brief titled, Returning the Mouth to the Body: Integrating Oral Health & Primary Care . The brief makes a strong practical clinical case for integration. It proposes that “by sharing information, providing basic diagnostic services, and consulting each other in a systematic and sustained manner, dental and medical professionals in integrated practice arrangements would have a far better chance of identifying disease precursors and underlying conditions in keeping with a patient-centered model of care. Integration can also raise patients’ awareness of the importance of oral health, potentially aiding them in taking advantage of dental services sooner rather than later.”

In 2015, the February-March newsletter from the Commonwealth Fund on Integrating Oral Health into Primary Care acknowledged that integration is starting to occur through “new approaches to training for both dental and primary care providers, promotion of team-based care, and development of medical, rather than surgical, treatments for oral health problems.” The newsletter cites 2 IOM reports from 2011 funded by DHHS and HRSA.

The Institute of Medicine

The IOM is a component of the Academies of Sciences, Engineering, and Medicine that was recently renamed the Health and Medicine Division to emphasize a wider range of health matters while building on the rich history of the IOM’s previous work. For decades, the federal government has provided substantial support for IOM workshops, conferences, and reports on a variety of topics. The result of the IOM’s efforts has fundamentally shifted the landscape to facilitate system-wide change. A similar effect has been seen with federal reports, programs, and initiatives that promote an integrated approach to the delivery of health care and training of health professionals.

A few of the most relevant IOM reports regarding interprofessional practice and oral health integration in primary care are presented here. These IOM efforts were supported at least in part by federal government entities. Specific and relevant federal reports, programs and initiative will be described later.

  • In 1972, the IOM held a conference with leaders from allied health, dentistry, medicine, nursing, and pharmacy on the Interrelationships of Educational Programs for Health Professionals to inform national discussions about interprofessional education. The conference resulted in the report “Educating for the Health Team.”

  • The 2001 IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century , recommended that an interdisciplinary summit be held to “reform health professions education to enhance patient care quality and safety.” In response and with support from 2 federal agencies in the DHHS (HRSA and AHRQ) and 2 nonprofit organizations (ABIM Foundation and the California Healthcare Foundation) a summit was held to enhance health care quality in the United States.

  • The resulting 2003 report, Health Professions Education: A Bridge to Quality , underscores the importance of recognizing each profession’s essential contribution to not only the educational system and training of health professionals but also the practice environment and interfacing systems in which care is provided. The report focuses on “integrating a core set of competencies—patient-centered care, interdisciplinary teams, evidence-based practice, quality improvement and informatics—into health professions education.” Education and practice-based competencies and the federal policies and investments that spur the development of the health workforce must meet the needs of patients, communities and society overall, and the requirements of a changing or evolving health system. Recognizing the role, influence, and capability of the federal government to drive health professions systems change, this 2003 IOM report included 10 recommendations of which 5 were specifically directed to federal entities ( Table 1 ).

    Table 1
    Selected Institute of Medicine recommendations to federal agencies
    From Greiner AC, Knebel E, editors. Health professions education: a bridge to quality. Washington, DC: Institute of Medicine of the National Academies of Science, National Academies; 2003. Available at: http://www.nap.edu/catalog/10681.html . Accessed April 8, 2016; with permission.
    Recommendation 1 DHHS and leading foundations should support an interdisciplinary effort focused on developing a common language, with the ultimate aim of achieving consensus across the health professions on a core set of competencies that includes patient-centered care, interdisciplinary teams, evidence-based practice, quality improvement, and informatics.
    Recommendation 2 DHHS should provide a forum and support for a series of meetings involving the spectrum of oversight organizations across and within the disciplines. Participants in these meetings would be charged with developing strategies for incorporating a core set of competencies into oversight activities, based on definitions shared across the professions. These meetings would actively solicit the input of health professions associations and the education community.
    Recommendation 7 Through Medicare demonstration projects, the Centers for Medicare and Medicaid Services should take the lead in funding experiments that will enable and create incentives for health professionals to integrate interdisciplinary approaches into educational or practice settings, with the goal of providing a training ground for students and clinicians that incorporates the 5 core competencies.
    Recommendation 8 Agency for Healthcare Research and Quality and private foundations should support ongoing research projects addressing the 5 core competencies and their association with individual and population health, as well as research related to the link between the competencies and evidence-based education. Such projects should involve researchers across 2 or more disciplines.
    Recommendation 9 AHRQ should work with a representative group of health care leaders to develop measures reflecting the core set of competencies, set national goals for improvement, and issue a report to the public evaluating progress toward these goals. AHRQ should issue the first report, focused on clinical educational institutions, in 2005 and produce annual reports thereafter.

Landmark publications and reports

Landmark documents have established the foundation for understanding of the relationship between oral and systemic health, the prevalence of dental diseases in the population, barriers to access to care, the adequacy of the dental workforce, and health disparities of certain subpopulations in the United States. Federal agencies have provided funding to develop these documents, establish national priorities, take strategic actions, and implement policies to accelerate the translation of ideas into practice. For example, the aforementioned Surgeon General’s report on oral health, addressed the importance of building a science and evidence base to improve oral health, building the infrastructure to address oral health, removing barriers to oral health services, and developing public-private partnerships to address disparities in oral health. Oral health is essential to overall general health and well-being; however, the Healthy People 2020 national oral health objectives illustrate that many challenges identified 16 years ago have not been adequately addressed.

Federal Initiatives

Over the past 6 years, there have been significant federal investments and efforts to move the needle on improving oral health access to care and integrating oral health and primary care. In 2010, leadership from DHHS and HRSA announced the Oral Health Initiative 2010 (OHI2010), which renewed the DHHS commitment to work with national and state partners and continue building on the recommendations set forth in the 2000 Surgeon General’s Report on Oral Health and A National Call to Action to Promote Oral Health. The key message of the OHI2010 is that oral health is integral to overall health. This initiative used a systems-approach to create and finance programs to

  • Emphasize oral health promotion and disease prevention

  • Increase access to care

  • Enhance oral health workforce

  • Eliminate oral health disparities.

The OHI2010 featured 9 activities to maximize the impact of federal programs on the oral health of the nation. One of the highlighted activities was the development of 2 landmark IOM reports that have been widely studied, cited extensively, and have served as the impetus for actions federal agencies have taken and those planned. With the strategic priority to advance oral health for underserved populations, HRSA commissioned the IOM to assess current oral health and the oral health care system and make recommendations to DHHS to improve the oral health of the nation, especially for vulnerable and underserved Americans. In April and July of 2011, 2 significant oral health reports were published: Advancing Oral Health in America and Improving Access to Oral Health Care for Vulnerable and Underserved Populations .

These IOM reports are cornerstones in the conversation about access to care and have created new benchmarks for oral health in America, almost 2 decades after the release of the Surgeon General’s report on oral health.

The first of these 2011 reports assesses the current oral health care delivery system and explores ways to promote use of preventive oral health interventions and improve oral health literacy. The second report focuses on issues of access to oral health care for underserved and vulnerable populations. Each report contains recommendations for action, including the development of core competencies for health care professionals in oral health care. Specific recommendations related to interprofessional collaboration and integrating oral health and primary care practice are shown in Boxes 2 and 3 .

Box 2
Advancing oral health in America recommendation to increase the oral health workforce
From IOM (Institute of Medicine). Advancing oral health in America. Washington, DC: The National Academies Press; 2011; with permission.

  • Recommendation 4: DHHS should invest in workforce innovations to improve oral health that focuses on:

    • Core competency development, education, and training, to allow for the use of all health care professionals in oral health care

    • Interprofessional, team-based approaches to the prevention and treatment of oral diseases

    • Best use of new and existing oral health care professionals

    • Increasing the diversity and improving the cultural competence of the workforce providing oral health care.

Box 3
Improving access to oral health care for vulnerable and underserved populations recommendations on oral health competencies for health professionals
From IOM (Institute of Medicine), NRC (National Research Council). Improving access to oral health care for vulnerable and underserved populations. Washington, DC: The National Academies Press; 2011; with permission.

  • Recommendation 1a: The HRSA should convene key stakeholders from both the private and public sectors to develop a core set of competencies for health care professionals

  • Recommendation 1b: Following the development of a core set of oral health competencies for nondental health care professionals

    • Accrediting bodies for undergraduate and graduate-level nondental health care professional education programs should integrate these core competencies into their requirements for accreditation

    • All certification and maintenance of certification for health care professionals should include demonstration of competence in oral health care as a criterion.

HRSA, in response to these IOM recommendations, developed the Integration of Oral Health and Primary Care Practice (IOHPCP) initiative to expand the oral health clinical competency of primary care clinicians and to integrate oral health and primary care practice. The initiative was founded on 3 inter-related components:

  • Develop oral health domains and associated core clinical competencies

  • Use a systems approach to identify and prioritize the elements that affect the adoption of oral health competencies by primary care clinicians

  • Characterize foundational elements for successful implementation strategies that translate into primary care practice.

As part of the IOHPCP initiative, HRSA invited a diverse cross-section of individuals from the public and private sectors to participate alongside HRSA staff in facilitated discussions. The initial meeting focused on an essential set of Interprofessional Oral Health Core Clinical Competencies (IPOHCCC or IPOHC 3 ) ( Table 2 ) for nondental primary care providers. The second meeting used a systems approach and process that revealed complexities and interdependent relationships that are critical to successful integration in the practice setting. The systems analysis uncovered 12 cross-cutting systems ( Fig. 1 ) at the environment-organization level that are involved in the implementation of clinical oral health competencies for primary care providers. During the third meeting, presentations followed by facilitated discussions about strategies and approaches for implementing IPOHC were framed around the importance of 3 essential systems, with communication as an overarching requirement ( Fig. 2 ).

Table 2
Interprofessional oral health core clinical domains
Data from U.S. Department of Health and Human Services. Integration of oral health and primary care practice. Rockville (MD): U.S. Department of Health and Human Services, Health Resources and Services Administration; 2014. Available at: http://www.hrsa.gov/publichealth/clinical/oralhealth/primarycare/integrationoforalhealth.pdf . Accessed March 29, 2016; with permission.
Domains
Risk Assessment Identifies factors that impact oral health and overall health.
Oral Health Evaluation Integrates subjective and objective findings based on completion of a focused oral health history, risk assessment, and performance of clinical oral screening.
Preventive Intervention Recognizes options and strategies to address oral health needs identified by a comprehensive risk assessment and health evaluation.
Communication and Education Targets individuals and groups regarding the relationship between oral and systemic health, risk factors for oral health disorders, effect of nutrition on oral health, and preventive measures appropriate to mitigate risk on both individual and population levels.
Interprofessional Collaborative Practice Shares responsibility and collaboration among health care professionals in the care of patients and populations with, or at risk of, oral disorders to assure optimal health outcomes.
Systems approach analysis for 12 cross-cutting systems in interprofessional oral health core competencies.
Fig. 1
Systems approach analysis for 12 cross-cutting systems in interprofessional oral health core competencies.
Critical systems for successful implementation of interprofessional oral health competencies.
Fig. 2
Critical systems for successful implementation of interprofessional oral health competencies.

HRSA synthesized recommendations ( Box 4 ) to support core competency adoption by primary care clinicians and to promote the integration of oral health and primary care practice. The IOHPCP report and its recommendations serve as guiding principles and provide a framework for the design of a competency-based, interprofessional practice model to integrate oral health and primary care.

Box 4
HRSA integration of oral health and primary care report recommendations
From U.S. Department of Health and Human Services. Integration of oral health and primary care practice. Rockville (MD): U.S. Department of Health and Human Services, Health Resources and Services Administration; 2014. Available at: http://www.hrsa.gov/publichealth/clinical/oralhealth/primarycare/integrationoforalhealth.pdf . Accessed December 23, 2015; with permission.

  • 1.

    Apply oral health core clinical competencies within primary care practices to increase oral health care access for safety net populations in the United States.

    • a.

      Clinicians should incorporate the oral health core clinical competencies in patient care.

    • b.

      Health care professional education and training, as well as continuing education curricula, should incorporate the oral health core clinical competencies.

    • c.

      Accreditation and certification bodies should integrate the oral health core clinical competencies into primary care practitioner standards.

  • 2.

    Develop infrastructure that is interoperable, accessible across clinical settings, and enhances adoption of the oral health core clinical competencies. The defined, essential elements of the oral health core clinical competencies should be used to inform decision-making and measure health outcomes. Health care systems should

    • a.

      Establish technological infrastructure to support and facilitate referrals, knowledge exchange, and a follow up with clinicians to improve health outcomes.

    • b.

      Identify and support executive level champions to enhance communications and prioritize incorporation of the oral health core clinical competencies into primary care practice.

    • c.

      Engage and educate consumers about oral health in primary care as an expected standard of interprofessional practice.

    • d.

      Evaluate effectiveness of the application of the oral health core clinical competencies by assessing patient satisfaction and health outcomes.

    • e.

      Use common language, interoperable electronic health records, and interprofessional collaboration in patient-centered medical and health homes to facilitate high quality accessible oral health care.

  • 3.

    Modify payment policies to efficiently address costs of implementing oral health competencies and provide incentives to health care systems and practitioners.

    • a.

      Include or enhance public and private health care payment for oral health care throughout the lifespan.

    • b.

      Use safety net settings to pilot payment methodologies that lower dental care costs.

    • c.

      Build partnerships and coalitions that educate policy makers and the public about the benefit of integrating oral health care and primary care.

  • 4.

    Execute programs to develop and evaluate implementation strategies of the oral health core clinical competencies into primary care practice.

    • a.

      Implement pilot projects to identify innovative and promising practices that inform and support the broader implementation of the oral health core clinical competencies.

    • b.

      Develop demonstration projects to validate and replicate the oral health core clinical competencies implementation.

    • c.

      Evaluate implementation of the oral health core clinical competencies by clinicians and the systems in which they practice.

    • d.

      Assess the cost-effectiveness and efficiency of implementing the oral health core clinical competencies in primary care practice.

HRSA’s commitment to improving access to quality dental care by integrating oral health has not been limited to the release of the IOHPCP report. HRSA also funded a pilot project to demonstrate the validity of the IPOHC and potential implementation strategies for primary care practice at 3 health centers. The results are available as A User’s Guide for Implementation of Interprofessional Oral Health Core Clinical Competencies . Dental and medical education and training program priorities and funding opportunities reflect recognition of the importance of oral health and primary care integration. In FY 2015, HRSA grants for predoctoral dental and primary care medical training programs included a focus on enhancing training to support integration of oral health within the broader health care delivery system and models of training for integrated oral health and medicine or primary care.

Public-private partnerships and building on a foundation

Additional examples of areas of investment and collaboration aimed at maximizing opportunities to improve oral health for the persons with and without access to dental care are include in this section. The IOHPCP initiative has served as a national call to action and has contributed to the increased interest and focus on integrating oral health and primary care by federal and nonfederal entities alike. Many integration efforts across health professions are underway and it seems that a tipping point for gaining momentum has been reached. Cross-cutting efforts by entities such as nonprofits, foundations, insurers, and federal programs have been leveraging resources and building on programmatic successes and increased collaboration. Recently, a Qualis Health White Paper, Oral health: an essential component of primary care , describes the “complementary roles of primary care and dentistry in addressing oral disease, and describes the benefits of providing preventive oral health care in the primary care setting.” The paper outlines an “ Oral health delivery framework ” that “delineates the activities for which a primary care team can take accountability to protect and promote oral health.” The influence and impact of the federal government’s efforts to drive change is exemplified in the Qualis effort because their framework was built on the HRSA IOHPCP initiative and report.

In addition, the thirteenth annual report to the Secretary of the DHHS and the Congress of the United States from the Advisory Committee on Interdisciplinary, Community-Based Linkages emphasized, “Interprofessional education and collaborative practice can play an important role in improving patient care quality, satisfaction, safety, and efficiency. Health professions training, continuing education, continuing professional development, faculty development, and community-based training need to change to provide healthcare professionals, educators, and students with the collaborative care tools needed to improve the health of populations.”

Educational Resources for Clinicians, Academics, and Researchers

  • HRSA contracted with the American Academy of Pediatrics to develop a Web-based oral health module for pediatricians. The information is also available as an electronic document that may be used as the basis to educate primary care providers working with children. The content can be used to increase knowledge and integration of oral health preventive interventions into systems of care.

  • HRSA funded the Association of American Medical Colleges to build oral health training capacity in medical education (MedEdPortal) with the aim to advance physician understanding of the oral-systemic impact on overall health and to prepare clinicians to provide comprehensive coordinated care.

  • HRSA convened an expert workgroup to promote integrated health care and interprofessional collaboration and published Oral health care during pregnancy: a national consensus statement–summary of an expert workgroup meeting to shape the practices of both medical and dental professionals serving pregnant women. In addition, a valuable user-friendly resource document was developed for dental professionals, medical or prenatal care providers, and patients regarding dental care and pharmacologic considerations during pregnancy. Clinicians will find this a useful tool in caring for pregnant women in the dental setting. (See related information, Farmer-Dixon C, Thompson M, Young D, et al: Interprofessional Collaborative Practice (IPC): An Oral Health Paradigm for Women , in this issue.)

  • HRSA established a National Center for Interprofessional Practice and Education at the University of Minnesota. The interprofessional coordinating center provides an infrastructure for leadership, expertise, and support to enhance the coordination and capacity-building of interprofessional education and collaborative practice among health professions.

  • HRSA conducted interviews, convened expert panel meetings, and commissioned a report on women’s health curricula across health professions to identify actionable strategies and develop a dissemination plan to increase the awareness of women’s health education needs. The report includes details and resources leading to increased integration of women’s health content and interprofessional collaboration. Additional information and an in-depth discussion (see Farmer-Dixon C, Thompson M, Young D, et al: Interprofessional Collaborative Practice (IPC): An Oral Health Paradigm for Women , in this issue.)

Federal programs that promote oral health integration and interprofessional collaboration

The previously mentioned DHHS Framework articulates the vision of DHHS and other federal partners to increase the public’s understanding that oral health is integral to overall health. By leveraging public and private sector partnerships to achieve better oral health and overall health for all populations across the lifespan, Framework provides the roadmap for engaging and resolving ongoing disparities in oral health.

Organized around 5 overarching goals: (1) integrate oral health and primary health care, (2) prevent disease and promote oral health, (3) increase access to oral health care and eliminate disparities, (4) increase the dissemination of oral health information and improve health literacy, and (5) advance oral health in public policy and research, Framework illustrates the commitment across multiple federal entities to “serve as the catalyst for moving a national oral health agenda forward.” These goals provide the foundation for development, execution, and evaluation of implementation strategies and actions that federal agencies and partners alike may use to address the nation’s oral health and workforce needs.

In addition to DHHS and federal partners’ recognition of the importance of oral health integration and interprofessional collaboration, a HRSA strategic priority is the integration of oral health and primary care. As a follow up to the OHI2010 , the agency has continued to lead efforts to increase access to quality care for vulnerable and underserved populations by investing in activities that promote oral health integration and improve access for early detection and preventive interventions by expanding the oral health clinical competency of primary care clinicians. HRSA has undertaken multiple activities designed to accelerate the integration of oral health and primary care at the level of training and education and the practice interface.

Training and Education Grant Programs

Beginning in the early 1980s, recognition of aging trends in the US population coupled with research indicating insufficient training of health care professionals in geriatrics led to the development of the Veterans Affairs (VA) Geriatric Dental Fellowships the and DHHS HRSA Geriatric Education Centers (GEC) grant program. The VA fellowships were analogous to the Geriatric Medical Fellowships and represented a partnership between a VA Medical Center and a university. The HRSA “Geriatrics Education Centers funded health professions schools [including dentistry] to provide interprofessional/interdisciplinary education and training to health professions students, faculty, and practitioners in the diagnosis, treatment, and prevention of disease, disability, and other health problems of older adults.” The VA geriatric fellowship program continued for about 10 years while the HRSA programs persisted. The GEC and other similar HRSA programs have evolved over the decades with renewed efforts to integrate geriatrics with primary care with an emphasis on increasing the knowledge and skills of the primary care workforce to care for older adults as the focus of the new Geriatrics Workforce Enhancement Program (GWEP). The GWEP, established in 2015, resulted from the consolidation 4 geriatric education programs, including the GEC; Geriatric Training for Physicians, Dentists, and Behavioral/Mental Health Providers; Comprehensive Geriatric Education Program; and Geriatric Academic Career Award. For further insight into IPE and interprofessional collaborative practice [IPCP] with geriatrics (see Kaufman LB, Henshaw MM, Brown BP, et al: Oral Health and Interprofessional Collaborative Practice: Examples of the TEAM Approach to Geriatric Care , in this issue.)

With the enactment of the ACA in October 2010, HRSA oral health training programs were expanded and continue to provide funding to universities and institutions for predoctoral and postdoctoral training, faculty development, faculty loan repayment, and grants to states to support oral health workforce activities to improve oral health by increasing the number of and improving the quality of well-trained primary oral health care providers working in underserved areas. In 2015, the grant programs were updated to reflect the growing importance of interprofessional education and collaboration in support of IPCP. For example, the Pre-doctoral Training in General, Pediatric, and Public Health Dentistry and Dental Hygiene grant program includes a focus on “Enhancing training to support integration of oral health within the broader health care delivery system to improve access to oral health care for vulnerable, underserved, or rural communities.”

Additional leverage to promote interprofessional training and practice was implemented in the 2015 postdoctoral grant program. Institutions receiving HRSA grants are required to develop or enhance integrated health care delivery systems that serve as training sites for postdoctoral dental trainees, including partnerships with primary care delivery organizations and other community-based organizations. HRSA oral health program support spans the continuum from training and education to practice. Ten states received funding for activities in a new focus area, “Integrating oral and primary care medical delivery systems for underserved communities” under the Grants to Support Oral Health Workforce Activities program. In addition to grant programs administered with funds directed for oral health, many other health professional grant programs have encouraged interprofessional education and practice, thereby magnifying the oral health footprint supported by HRSA funds. Examples include

  • HRSA GWEP (see previous discussion of the history of this program and geriatric training supported by the VA).

  • HRSA funding to Area Health Education Centers nationwide to enhance “access to high quality, culturally competent health care through academic-community partnerships to ultimately improve the distribution, diversity, and supply of the primary care health professions workforce who serve in rural and underserved health care delivery sites.”

AHEC programs and centers along with state and local partners

  • Promote interprofessional education and collaborative teams to improve quality of care

  • Recruit and train students from minority and disadvantaged backgrounds into health careers

  • Place health professions students in community-based clinical practice settings, with a focus on primary care

  • Facilitate continuing education resources and programs for health professionals, particularly in rural and underserved areas.

HRSA also funds Advanced Nursing Education Grants that “support projects that develop and test innovative academic-practice partnership models for clinical training.” Several grants have been made for training-based collaborations between schools of dentistry and nursing. Examples include

  • Enhanced oral-systemic IPE and IPCP through collaboration between the University at Buffalo Schools of Nursing and Dental Medicine to develop innovative IPE experiences and new IPCP teams that include dental and advanced practice registered nurse (APRN) students and faculty.

  • Teaching Oral-Systemic Health is an interprofessional initiative of New York University (NYU) College of Nursing, to engage APRN students, together with medical students from NYU School of Medicine and dental students from NYU College of Dentistry in simulation learning with standardized patients and virtual patient cases. Note: this HRSA funded program is discussed in detail (see Gordon S, Donoff RB: Problems and Solutions for Interprofessional Education in North American Dental Schools , in this issue.)

  • The Academic Unit-Primary Care Training and Enhancement grant program focuses on academic units that integrate oral health and primary care models, such as increasing oral health core clinical competencies for primary care trainees, training in integrated or virtually integrated oral health and primary care practices, and new interprofessional education models for integrated oral health and primary care; in particular, on models that support the training of providers in advanced roles. The academic unit must understand the challenges, limitations, and levels of a fully integrated model and understand and disseminate how training programs can promote and achieve successful integration.

Clinical Practice Investments

Agencies such as HRSA, the Federal Bureau of Prisons, Office of Minority Health, and the Indian Health Service foster activities that promote interprofessional collaboration. Examples of federal activities that have implications for clinical care are presented in the DHHS Framework under the Goal 1 strategy, “Create programs and support innovation using a systems change approach that facilitates a unified patient-centered health home.” Furthermore, a Qualis paper on the patient-centered medical home (PCMH) states that, “embracing comprehensive care, the PCMH model provides the perfect environment for strengthening access to oral health care, improving provider and patient understanding of oral health, and providing the needed oral health care screening, preventive and restorative services that are essential to optimal health status.” The PCMH or health home provides a conceptual platform in which IPCP can be actualized to maximize health outcomes for individuals and populations.

Over the past several years, HRSA Health Center Program has made substantial investments in new service delivery sites, expansion of existing health centers, and school-based health centers. In FY 2014, nearly 300 HRSA Health Center grantees expanded oral health services. An additional FY2016 commitment of $156 million was made specifically for oral health expansion of 420 existing health centers to increase access to oral health care services and improve oral health outcomes for Health Center Program patients. Health centers are required to provide “all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established written arrangements and referrals” and, therefore, provide the opportunity to integrate oral health and primary care practice and capitalize on interprofessional collaboration.

Federal program initiatives and investments may serve to facilitate systems change and demonstrate value and the opportunity for quality improvement with improved health outcomes attainable through a truly integrated model of care. The HRSA Health Center Program promotes formalized PCMH recognition, which “includes an emphasis on care coordination, patient self-management, and ongoing quality improvement in all areas including oral health.” As of June 2015, 61% of health centers had achieved National Committee for Quality Assurance PCMH recognition, “the most widely-used way to transform primary care practices into medical homes” and 96% of health centers use electronic health records, including the electronic dental records.

The IOHPCP Report’s Recommendation 2 (see Box 4 ) accentuates the importance of interoperable and accessible health care systems infrastructure that “use common language, interoperable electronic health records, and interprofessional collaboration in patient-centered medical and health homes to facilitate high quality accessible oral health care.” Furthermore, oral health integration in a PCMH environment has the imperative for funders to “support integration/interface of health center electronic dental and medical records systems [with the understanding that] bi-directional sharing of dental and medical records will allow the care teams in both services to better address the needs of their patient population(s) and enable fully coordinated care.”

The important take-away message is that dental and other health professional students and recent graduates increasingly have training and practice experience working collaboratively across health disciplines. Through community-based clinical experiences, targeted training programs such as those previously discussed, and increasing exposure to interprofessional faculty, graduates of health professional programs will be more comfortable working in mixed or diverse practice environments, will have the familiarity and knowledge of the roles of other clinicians, and be able to work together to assure overall health of the patients they serve. In addition, the increase in availability of patient-centered interprofessional practice settings that use integrated electronic health records provides the opportunity to facilitate the provision of quality competent care and improved health outcomes through prevention, early detection and treatment, and increased patient education to maintain health.

Summary

For more than 50 years, experts have weighed in on the benefits of integrated collaborative care and the challenges of translating interprofessional training and education into sustainable, disseminated clinical practice models. Numerous workshops, conferences, and published reports have examined the issues and recognized the important role of the federal government in supporting health professional’s training and educational programs; as well as health care delivery for vulnerable population groups, especially those who are underserved, geographically isolated, poor or disadvantaged, and those with special needs.

The United States federal government has taken the lead on key issues that affect the nation, such as health promotion and access to care. It serves as an essential partner working collaboratively with states and local governments, academic institutions, professional organizations, health care providers, and nonfederal entities in efforts to improve the quality of health care and overall health across the lifespan. The historical and present day perspective presented in this article shows that the federal government’s programs, initiatives, and public-private partnerships play a critical role to influence, incentivize, initiate, and institutionalize interprofessional practice in which oral health providers are an integral part of the patient-centered provider team. The federal government has provided support for innovation, infrastructure expansion, clinical services delivery, and policy development to drive systems change. As a result, great progress has been made in establishing and promoting integrated training experiences for interprofessional health professional students, residents, and practicing clinicians to integrate oral health and primary care while endorsing a patient-centered interprofessional approach dedicated to improving health outcomes.

Disclosure Statement: The views expressed in this article are solely the opinions of the author and do not necessarily reflect the official policies of the US Department of Health and Human Services or the Health Resources and Services Administration, nor does mention of the department or agency names imply endorsement by the US government.

References

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Integrating Oral Health and Primary Care CAPT Renée W. Joskow DDS, MPH, FAGD, FACD Dental Clinics of North America, 2016-10-01, Volume 60, Issue 4, Pages 951-968, Copyright © 2016 This article describes federal programs, initiatives, and partnerships that have the demonstrated potential to initiate and institutionalize interprofessional practice that includes oral health providers as integral to the provider team. A discussion of landmark documents and reports, the role of legislation and statutory authority, and the influence of federal program priorities towards a national movement to increase access to care to bridge the chasms between the medical health care system, dental delivery system, and oral health is presented. Key points United States federal programs, initiatives, and partnerships have taken action to initiate and institutionalize interprofessional practice. Federal activities recognize oral health providers as integral to the provider team. Landmark documents and reports, legislation and statutory authority, and the influence of federal program priorities contribute towards a national movement to increase access to care to bridge the chasms between the medical health care system, dental delivery system, and oral health. Introduction Oral health, as a critical component of health, is embedded in the World Health Organization’s 1948 broadened definition, “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Even so, nearly 70 years have passed and oral health, dental education, and dental care delivery remain disconnected and separate from the larger medical system of care. This disconnect and view of the mouth as separate from the body is perpetuated by segmented models of care and delivery and payment systems that have not substantially integrated oral health in overall health. A 1972 Institute of Medicine (IOM) report echoed that “linkages are inadequate between existing models of health delivery and the educational institutions charged with developing the manpower for these systems.” The report presents the basic argument for interprofessional teams (and integration) in the ambulatory care environment in which the emphasis is on the patient and outcomes of care rather than “on professions, their techniques, or the process of care.” With significant disparities in oral health among segments of the population and multifactorial challenges in accessing care, it is in the primary care environment, in particular, that there is an urgent need for the deployment of effective health care teams. Through differing administrations, budget cycles, and economic cycles, the federal government has taken the lead on key issues, such as health promotion and access to care, that affect the nation. Periodic efforts to move oral health and dental care delivery into the mainstream of health care, and to reunite the mouth with the body in efforts to achieve overall health, have met with mixed results. In Oral health in America: a report of the Surgeon General , then Secretary of the Department of Health and Human Services (DHHS), Donna Shalala, stated that oral health is integral to general health because “you cannot be healthy without oral health.” She was reflecting the nation’s struggle to achieve a systems-level change to implement true integration of oral health and primary care in a consistent and sustainable manner. This article describes federal programs, initiatives, and partnerships that have the demonstrated potential to initiate and institutionalize interprofessional practice, which includes agreement that oral health providers are integral to the provider team. A discussion of landmark documents and reports, the role of legislation and statutory authority, and the influence of federal program priorities towards a national movement to increase access to care and bridge the chasms separating the medical health care system, the dental delivery system, and oral health is presented. In 2000, in the first Surgeon General’s report on oral health, David Satcher wrote, “There are opportunities for all health professions, individuals, and communities to work together to improve health.” Furthermore, this report explicitly states that a principal component of a national oral health plan (NOHP) is an effective health infrastructure that meets the oral health needs of all Americans and integrates oral health effectively into overall health. The DHHS recently took a monumental step forward by promoting an NOHP and publishing the Oral Health Strategic Framework, 2014–2017 ( Framework ) that “builds upon and outlines a strategic alignment of HHS operating and staff divisions’ resources, programs, and leadership commitments to improve oral health with activities of other federal partners.” The recent realignment of federal priorities and programs that recognize the importance and value of integrating oral health and primary care has ignited renewed interest in innovative approaches to continued progress in improving the nation’s oral health. Historical perspective and the role of federal programs Throughout history there have been notable occasions when federal policies and programs have made a substantial impact on the health care system in an effort to improve the health of the nation. One example is the 1965 passage of Medicaid and Medicare that today represents the nation's main public health insurance programs for the low-income populations and Americans aged 65 years and older, respectively. The sweeping transformation of the health care system created by these programs continues today. In the same year, Coggeshall submitted a report to the Association of American Medical Colleges. Although the health care system then was quite different from today, there was awareness and foresight that “the expanding role of government in the health field has been manifesting itself in a growing number of ways and with increasing resources and emphasis in recent years. This can be expected to continue to expand.” The Coggeshall Report provided a series of recommendations to the Association of American Medical Colleges that included the need to “maintain productive relationships with government.” Nearly 50 years lapsed before efforts to further transform health care delivery resulted in the passage and implementation of the Affordable Care Act (ACA) in 2010. Partnering with Foundations or Nonprofits Federal government programs have finite budgets for discretionary programs. Funds availability depends on the specific agency and congressional authorizations and appropriations for that fiscal year (FY). The amount of federal funding is directed by statute or legislation and must be used for specified purposes. Although grants to institutions and states are sometimes used for pilot or demonstration projects, in some circumstances the available federal funding level is insufficient to create permanent widespread change across workforce development education and practice delivery systems. Over the past decade, more and more public-private partnerships between government and nongovernment entities have emerged, such as foundations and nonprofit organizations, in efforts to leverage resources more efficiently and effectively to drive the transformation of health professions education and practice toward a more integrated approach with the goal of improving health outcomes. An interprofessional education and integrated practice paradigm is not new, although previous efforts did not gain enough momentum to create a fully integrated national network with national visibility, influence, and acceptance. In the late 1980s, Pew Charitable Trusts and the Rockefeller Foundation funded 6 universities as part of their Health of the Public national program. One institution, Columbia University, focused on incorporating public health education in the dental, medical, and nursing school curricula by establishing an interdisciplinary clinical curriculum workgroup and a summer Institute in Clinical Public Health for entering dental, medical, and bachelor-degree nursing students. Since then, spurred by the release of the 2000 Surgeon General’s Report, increased attention and progress has been made towards incorporating oral health into overall health. Studies have continued to be published that associate oral diseases and conditions with chronic illnesses. A growing number of dental, medical, nursing, and physician assistant education programs, and licensing and credentialing examinations, have begun to emphasize the oral-systemic connection. A summary of the 3-day workshop on the US Oral Health Workforce in the Coming Decade was published in 2009. Several relevant conclusions are displayed in Box 1 . Box 1 Selected conclusions from the US Oral Health Workforce in the coming decade workshop summary From IOM (Institute of Medicine). The U.S. oral health workforce in the coming decade: workshop summary. Washington, DC: The National Academies Press; 2009; with permission. Interdisciplinary training of all students is required to bridge the gap between medicine and dentistry. The scopes of practice of all health care professionals need to be maximized to improve access to oral health services in rural areas. Integration with the nondental workforce allows for evolution toward true oral health, with dental professionals being an integral part of maintaining the systemic health of their patients. More models are needed for the interdisciplinary education and training of health professions students. Policies need to come into alignment with practice, such as the development and implementation of clinical practice guidelines. In February 2011, the Health Resources and Services Administration (HRSA) convened a conference with the Josiah Macy Jr Foundation, the Robert Wood Johnson Foundation, the American Board of Internal Medicine Foundation, and the Interprofessional Education Collaborative (IPEC), to engage a diverse group of leaders in the development of competencies for interprofessional education (IPE) and practice, including dentistry. The final conference report with the IPEC competencies was released May 10, 2011. Collaborations across a spectrum of funding entities have emerged to promote oral health integration in primary care and reconnect oral health and overall health. In 2012, the DentaQuest Foundation, the Washington Dental Service Foundation, the Highmark Foundation, and the Robert Wood Johnson Foundation provided funding to convene a group of grant makers, researchers, and practitioners to discuss issues related to integrating oral health and primary care. This group published an issue brief titled, Returning the Mouth to the Body: Integrating Oral Health & Primary Care . The brief makes a strong practical clinical case for integration. It proposes that “by sharing information, providing basic diagnostic services, and consulting each other in a systematic and sustained manner, dental and medical professionals in integrated practice arrangements would have a far better chance of identifying disease precursors and underlying conditions in keeping with a patient-centered model of care. Integration can also raise patients’ awareness of the importance of oral health, potentially aiding them in taking advantage of dental services sooner rather than later.” In 2015, the February-March newsletter from the Commonwealth Fund on Integrating Oral Health into Primary Care acknowledged that integration is starting to occur through “new approaches to training for both dental and primary care providers, promotion of team-based care, and development of medical, rather than surgical, treatments for oral health problems.” The newsletter cites 2 IOM reports from 2011 funded by DHHS and HRSA. The Institute of Medicine The IOM is a component of the Academies of Sciences, Engineering, and Medicine that was recently renamed the Health and Medicine Division to emphasize a wider range of health matters while building on the rich history of the IOM’s previous work. For decades, the federal government has provided substantial support for IOM workshops, conferences, and reports on a variety of topics. The result of the IOM’s efforts has fundamentally shifted the landscape to facilitate system-wide change. A similar effect has been seen with federal reports, programs, and initiatives that promote an integrated approach to the delivery of health care and training of health professionals. A few of the most relevant IOM reports regarding interprofessional practice and oral health integration in primary care are presented here. These IOM efforts were supported at least in part by federal government entities. Specific and relevant federal reports, programs and initiative will be described later. In 1972, the IOM held a conference with leaders from allied health, dentistry, medicine, nursing, and pharmacy on the Interrelationships of Educational Programs for Health Professionals to inform national discussions about interprofessional education. The conference resulted in the report “Educating for the Health Team.” The 2001 IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century , recommended that an interdisciplinary summit be held to “reform health professions education to enhance patient care quality and safety.” In response and with support from 2 federal agencies in the DHHS (HRSA and AHRQ) and 2 nonprofit organizations (ABIM Foundation and the California Healthcare Foundation) a summit was held to enhance health care quality in the United States. The resulting 2003 report, Health Professions Education: A Bridge to Quality , underscores the importance of recognizing each profession’s essential contribution to not only the educational system and training of health professionals but also the practice environment and interfacing systems in which care is provided. The report focuses on “integrating a core set of competencies—patient-centered care, interdisciplinary teams, evidence-based practice, quality improvement and informatics—into health professions education.” Education and practice-based competencies and the federal policies and investments that spur the development of the health workforce must meet the needs of patients, communities and society overall, and the requirements of a changing or evolving health system. Recognizing the role, influence, and capability of the federal government to drive health professions systems change, this 2003 IOM report included 10 recommendations of which 5 were specifically directed to federal entities ( Table 1 ). Table 1 Selected Institute of Medicine recommendations to federal agencies From Greiner AC, Knebel E, editors. Health professions education: a bridge to quality. Washington, DC: Institute of Medicine of the National Academies of Science, National Academies; 2003. Available at: http://www.nap.edu/catalog/10681.html . Accessed April 8, 2016; with permission. Recommendation 1 DHHS and leading foundations should support an interdisciplinary effort focused on developing a common language, with the ultimate aim of achieving consensus across the health professions on a core set of competencies that includes patient-centered care, interdisciplinary teams, evidence-based practice, quality improvement, and informatics. Recommendation 2 DHHS should provide a forum and support for a series of meetings involving the spectrum of oversight organizations across and within the disciplines. Participants in these meetings would be charged with developing strategies for incorporating a core set of competencies into oversight activities, based on definitions shared across the professions. These meetings would actively solicit the input of health professions associations and the education community. Recommendation 7 Through Medicare demonstration projects, the Centers for Medicare and Medicaid Services should take the lead in funding experiments that will enable and create incentives for health professionals to integrate interdisciplinary approaches into educational or practice settings, with the goal of providing a training ground for students and clinicians that incorporates the 5 core competencies. Recommendation 8 Agency for Healthcare Research and Quality and private foundations should support ongoing research projects addressing the 5 core competencies and their association with individual and population health, as well as research related to the link between the competencies and evidence-based education. Such projects should involve researchers across 2 or more disciplines. Recommendation 9 AHRQ should work with a representative group of health care leaders to develop measures reflecting the core set of competencies, set national goals for improvement, and issue a report to the public evaluating progress toward these goals. AHRQ should issue the first report, focused on clinical educational institutions, in 2005 and produce annual reports thereafter. Landmark publications and reports Landmark documents have established the foundation for understanding of the relationship between oral and systemic health, the prevalence of dental diseases in the population, barriers to access to care, the adequacy of the dental workforce, and health disparities of certain subpopulations in the United States. Federal agencies have provided funding to develop these documents, establish national priorities, take strategic actions, and implement policies to accelerate the translation of ideas into practice. For example, the aforementioned Surgeon General’s report on oral health, addressed the importance of building a science and evidence base to improve oral health, building the infrastructure to address oral health, removing barriers to oral health services, and developing public-private partnerships to address disparities in oral health. Oral health is essential to overall general health and well-being; however, the Healthy People 2020 national oral health objectives illustrate that many challenges identified 16 years ago have not been adequately addressed. Federal Initiatives Over the past 6 years, there have been significant federal investments and efforts to move the needle on improving oral health access to care and integrating oral health and primary care. In 2010, leadership from DHHS and HRSA announced the Oral Health Initiative 2010 (OHI2010), which renewed the DHHS commitment to work with national and state partners and continue building on the recommendations set forth in the 2000 Surgeon General’s Report on Oral Health and A National Call to Action to Promote Oral Health. The key message of the OHI2010 is that oral health is integral to overall health. This initiative used a systems-approach to create and finance programs to Emphasize oral health promotion and disease prevention Increase access to care Enhance oral health workforce Eliminate oral health disparities. The OHI2010 featured 9 activities to maximize the impact of federal programs on the oral health of the nation. One of the highlighted activities was the development of 2 landmark IOM reports that have been widely studied, cited extensively, and have served as the impetus for actions federal agencies have taken and those planned. With the strategic priority to advance oral health for underserved populations, HRSA commissioned the IOM to assess current oral health and the oral health care system and make recommendations to DHHS to improve the oral health of the nation, especially for vulnerable and underserved Americans. In April and July of 2011, 2 significant oral health reports were published: Advancing Oral Health in America and Improving Access to Oral Health Care for Vulnerable and Underserved Populations . These IOM reports are cornerstones in the conversation about access to care and have created new benchmarks for oral health in America, almost 2 decades after the release of the Surgeon General’s report on oral health. The first of these 2011 reports assesses the current oral health care delivery system and explores ways to promote use of preventive oral health interventions and improve oral health literacy. The second report focuses on issues of access to oral health care for underserved and vulnerable populations. Each report contains recommendations for action, including the development of core competencies for health care professionals in oral health care. Specific recommendations related to interprofessional collaboration and integrating oral health and primary care practice are shown in Boxes 2 and 3 . Box 2 Advancing oral health in America recommendation to increase the oral health workforce From IOM (Institute of Medicine). Advancing oral health in America. Washington, DC: The National Academies Press; 2011; with permission. Recommendation 4: DHHS should invest in workforce innovations to improve oral health that focuses on: ○ Core competency development, education, and training, to allow for the use of all health care professionals in oral health care ○ Interprofessional, team-based approaches to the prevention and treatment of oral diseases ○ Best use of new and existing oral health care professionals ○ Increasing the diversity and improving the cultural competence of the workforce providing oral health care. Box 3 Improving access to oral health care for vulnerable and underserved populations recommendations on oral health competencies for health professionals From IOM (Institute of Medicine), NRC (National Research Council). Improving access to oral health care for vulnerable and underserved populations. Washington, DC: The National Academies Press; 2011; with permission. Recommendation 1a: The HRSA should convene key stakeholders from both the private and public sectors to develop a core set of competencies for health care professionals Recommendation 1b: Following the development of a core set of oral health competencies for nondental health care professionals ○ Accrediting bodies for undergraduate and graduate-level nondental health care professional education programs should integrate these core competencies into their requirements for accreditation ○ All certification and maintenance of certification for health care professionals should include demonstration of competence in oral health care as a criterion. HRSA, in response to these IOM recommendations, developed the Integration of Oral Health and Primary Care Practice (IOHPCP) initiative to expand the oral health clinical competency of primary care clinicians and to integrate oral health and primary care practice. The initiative was founded on 3 inter-related components: Develop oral health domains and associated core clinical competencies Use a systems approach to identify and prioritize the elements that affect the adoption of oral health competencies by primary care clinicians Characterize foundational elements for successful implementation strategies that translate into primary care practice. As part of the IOHPCP initiative, HRSA invited a diverse cross-section of individuals from the public and private sectors to participate alongside HRSA staff in facilitated discussions. The initial meeting focused on an essential set of Interprofessional Oral Health Core Clinical Competencies (IPOHCCC or IPOHC 3 ) ( Table 2 ) for nondental primary care providers. The second meeting used a systems approach and process that revealed complexities and interdependent relationships that are critical to successful integration in the practice setting. The systems analysis uncovered 12 cross-cutting systems ( Fig. 1 ) at the environment-organization level that are involved in the implementation of clinical oral health competencies for primary care providers. During the third meeting, presentations followed by facilitated discussions about strategies and approaches for implementing IPOHC were framed around the importance of 3 essential systems, with communication as an overarching requirement ( Fig. 2 ). Table 2 Interprofessional oral health core clinical domains Data from U.S. Department of Health and Human Services. Integration of oral health and primary care practice. Rockville (MD): U.S. Department of Health and Human Services, Health Resources and Services Administration; 2014. Available at: http://www.hrsa.gov/publichealth/clinical/oralhealth/primarycare/integrationoforalhealth.pdf . Accessed March 29, 2016; with permission. Domains Risk Assessment Identifies factors that impact oral health and overall health. Oral Health Evaluation Integrates subjective and objective findings based on completion of a focused oral health history, risk assessment, and performance of clinical oral screening. Preventive Intervention Recognizes options and strategies to address oral health needs identified by a comprehensive risk assessment and health evaluation. Communication and Education Targets individuals and groups regarding the relationship between oral and systemic health, risk factors for oral health disorders, effect of nutrition on oral health, and preventive measures appropriate to mitigate risk on both individual and population levels. Interprofessional Collaborative Practice Shares responsibility and collaboration among health care professionals in the care of patients and populations with, or at risk of, oral disorders to assure optimal health outcomes. Fig. 1 Systems approach analysis for 12 cross-cutting systems in interprofessional oral health core competencies. Fig. 2 Critical systems for successful implementation of interprofessional oral health competencies. HRSA synthesized recommendations ( Box 4 ) to support core competency adoption by primary care clinicians and to promote the integration of oral health and primary care practice. The IOHPCP report and its recommendations serve as guiding principles and provide a framework for the design of a competency-based, interprofessional practice model to integrate oral health and primary care. Box 4 HRSA integration of oral health and primary care report recommendations From U.S. Department of Health and Human Services. Integration of oral health and primary care practice. Rockville (MD): U.S. Department of Health and Human Services, Health Resources and Services Administration; 2014. Available at: http://www.hrsa.gov/publichealth/clinical/oralhealth/primarycare/integrationoforalhealth.pdf . Accessed December 23, 2015; with permission. 1. Apply oral health core clinical competencies within primary care practices to increase oral health care access for safety net populations in the United States. a. Clinicians should incorporate the oral health core clinical competencies in patient care. b. Health care professional education and training, as well as continuing education curricula, should incorporate the oral health core clinical competencies. c. Accreditation and certification bodies should integrate the oral health core clinical competencies into primary care practitioner standards. 2. Develop infrastructure that is interoperable, accessible across clinical settings, and enhances adoption of the oral health core clinical competencies. The defined, essential elements of the oral health core clinical competencies should be used to inform decision-making and measure health outcomes. Health care systems should a. Establish technological infrastructure to support and facilitate referrals, knowledge exchange, and a follow up with clinicians to improve health outcomes. b. Identify and support executive level champions to enhance communications and prioritize incorporation of the oral health core clinical competencies into primary care practice. c. Engage and educate consumers about oral health in primary care as an expected standard of interprofessional practice. d. Evaluate effectiveness of the application of the oral health core clinical competencies by assessing patient satisfaction and health outcomes. e. Use common language, interoperable electronic health records, and interprofessional collaboration in patient-centered medical and health homes to facilitate high quality accessible oral health care. 3. Modify payment policies to efficiently address costs of implementing oral health competencies and provide incentives to health care systems and practitioners. a. Include or enhance public and private health care payment for oral health care throughout the lifespan. b. Use safety net settings to pilot payment methodologies that lower dental care costs. c. Build partnerships and coalitions that educate policy makers and the public about the benefit of integrating oral health care and primary care. 4. Execute programs to develop and evaluate implementation strategies of the oral health core clinical competencies into primary care practice. a. Implement pilot projects to identify innovative and promising practices that inform and support the broader implementation of the oral health core clinical competencies. b. Develop demonstration projects to validate and replicate the oral health core clinical competencies implementation. c. Evaluate implementation of the oral health core clinical competencies by clinicians and the systems in which they practice. d. Assess the cost-effectiveness and efficiency of implementing the oral health core clinical competencies in primary care practice. HRSA's commitment to improving access to quality dental care by integrating oral health has not been limited to the release of the IOHPCP report. HRSA also funded a pilot project to demonstrate the validity of the IPOHC and potential implementation strategies for primary care practice at 3 health centers. The results are available as A User’s Guide for Implementation of Interprofessional Oral Health Core Clinical Competencies . Dental and medical education and training program priorities and funding opportunities reflect recognition of the importance of oral health and primary care integration. In FY 2015, HRSA grants for predoctoral dental and primary care medical training programs included a focus on enhancing training to support integration of oral health within the broader health care delivery system and models of training for integrated oral health and medicine or primary care. Public-private partnerships and building on a foundation Additional examples of areas of investment and collaboration aimed at maximizing opportunities to improve oral health for the persons with and without access to dental care are include in this section. The IOHPCP initiative has served as a national call to action and has contributed to the increased interest and focus on integrating oral health and primary care by federal and nonfederal entities alike. Many integration efforts across health professions are underway and it seems that a tipping point for gaining momentum has been reached. Cross-cutting efforts by entities such as nonprofits, foundations, insurers, and federal programs have been leveraging resources and building on programmatic successes and increased collaboration. Recently, a Qualis Health White Paper, Oral health: an essential component of primary care , describes the “complementary roles of primary care and dentistry in addressing oral disease, and describes the benefits of providing preventive oral health care in the primary care setting.” The paper outlines an “ Oral health delivery framework ” that “delineates the activities for which a primary care team can take accountability to protect and promote oral health.” The influence and impact of the federal government’s efforts to drive change is exemplified in the Qualis effort because their framework was built on the HRSA IOHPCP initiative and report. In addition, the thirteenth annual report to the Secretary of the DHHS and the Congress of the United States from the Advisory Committee on Interdisciplinary, Community-Based Linkages emphasized, “Interprofessional education and collaborative practice can play an important role in improving patient care quality, satisfaction, safety, and efficiency. Health professions training, continuing education, continuing professional development, faculty development, and community-based training need to change to provide healthcare professionals, educators, and students with the collaborative care tools needed to improve the health of populations.” Educational Resources for Clinicians, Academics, and Researchers HRSA contracted with the American Academy of Pediatrics to develop a Web-based oral health module for pediatricians. The information is also available as an electronic document that may be used as the basis to educate primary care providers working with children. The content can be used to increase knowledge and integration of oral health preventive interventions into systems of care. HRSA funded the Association of American Medical Colleges to build oral health training capacity in medical education (MedEdPortal) with the aim to advance physician understanding of the oral-systemic impact on overall health and to prepare clinicians to provide comprehensive coordinated care. HRSA convened an expert workgroup to promote integrated health care and interprofessional collaboration and published Oral health care during pregnancy: a national consensus statement–summary of an expert workgroup meeting to shape the practices of both medical and dental professionals serving pregnant women. In addition, a valuable user-friendly resource document was developed for dental professionals, medical or prenatal care providers, and patients regarding dental care and pharmacologic considerations during pregnancy. Clinicians will find this a useful tool in caring for pregnant women in the dental setting. (See related information, Farmer-Dixon C, Thompson M, Young D, et al: Interprofessional Collaborative Practice (IPC): An Oral Health Paradigm for Women , in this issue.) HRSA established a National Center for Interprofessional Practice and Education at the University of Minnesota. The interprofessional coordinating center provides an infrastructure for leadership, expertise, and support to enhance the coordination and capacity-building of interprofessional education and collaborative practice among health professions. HRSA conducted interviews, convened expert panel meetings, and commissioned a report on women’s health curricula across health professions to identify actionable strategies and develop a dissemination plan to increase the awareness of women’s health education needs. The report includes details and resources leading to increased integration of women’s health content and interprofessional collaboration. Additional information and an in-depth discussion (see Farmer-Dixon C, Thompson M, Young D, et al: Interprofessional Collaborative Practice (IPC): An Oral Health Paradigm for Women , in this issue.) Federal programs that promote oral health integration and interprofessional collaboration The previously mentioned DHHS Framework articulates the vision of DHHS and other federal partners to increase the public’s understanding that oral health is integral to overall health. By leveraging public and private sector partnerships to achieve better oral health and overall health for all populations across the lifespan, Framework provides the roadmap for engaging and resolving ongoing disparities in oral health. Organized around 5 overarching goals: (1) integrate oral health and primary health care, (2) prevent disease and promote oral health, (3) increase access to oral health care and eliminate disparities, (4) increase the dissemination of oral health information and improve health literacy, and (5) advance oral health in public policy and research, Framework illustrates the commitment across multiple federal entities to “serve as the catalyst for moving a national oral health agenda forward.” These goals provide the foundation for development, execution, and evaluation of implementation strategies and actions that federal agencies and partners alike may use to address the nation’s oral health and workforce needs. In addition to DHHS and federal partners’ recognition of the importance of oral health integration and interprofessional collaboration, a HRSA strategic priority is the integration of oral health and primary care. As a follow up to the OHI2010 , the agency has continued to lead efforts to increase access to quality care for vulnerable and underserved populations by investing in activities that promote oral health integration and improve access for early detection and preventive interventions by expanding the oral health clinical competency of primary care clinicians. HRSA has undertaken multiple activities designed to accelerate the integration of oral health and primary care at the level of training and education and the practice interface. Training and Education Grant Programs Beginning in the early 1980s, recognition of aging trends in the US population coupled with research indicating insufficient training of health care professionals in geriatrics led to the development of the Veterans Affairs (VA) Geriatric Dental Fellowships the and DHHS HRSA Geriatric Education Centers (GEC) grant program. The VA fellowships were analogous to the Geriatric Medical Fellowships and represented a partnership between a VA Medical Center and a university. The HRSA “Geriatrics Education Centers funded health professions schools [including dentistry] to provide interprofessional/interdisciplinary education and training to health professions students, faculty, and practitioners in the diagnosis, treatment, and prevention of disease, disability, and other health problems of older adults.” The VA geriatric fellowship program continued for about 10 years while the HRSA programs persisted. The GEC and other similar HRSA programs have evolved over the decades with renewed efforts to integrate geriatrics with primary care with an emphasis on increasing the knowledge and skills of the primary care workforce to care for older adults as the focus of the new Geriatrics Workforce Enhancement Program (GWEP). The GWEP, established in 2015, resulted from the consolidation 4 geriatric education programs, including the GEC; Geriatric Training for Physicians, Dentists, and Behavioral/Mental Health Providers; Comprehensive Geriatric Education Program; and Geriatric Academic Career Award. For further insight into IPE and interprofessional collaborative practice [IPCP] with geriatrics (see Kaufman LB, Henshaw MM, Brown BP, et al: Oral Health and Interprofessional Collaborative Practice: Examples of the TEAM Approach to Geriatric Care , in this issue.) With the enactment of the ACA in October 2010, HRSA oral health training programs were expanded and continue to provide funding to universities and institutions for predoctoral and postdoctoral training, faculty development, faculty loan repayment, and grants to states to support oral health workforce activities to improve oral health by increasing the number of and improving the quality of well-trained primary oral health care providers working in underserved areas. In 2015, the grant programs were updated to reflect the growing importance of interprofessional education and collaboration in support of IPCP. For example, the Pre-doctoral Training in General, Pediatric, and Public Health Dentistry and Dental Hygiene grant program includes a focus on “Enhancing training to support integration of oral health within the broader health care delivery system to improve access to oral health care for vulnerable, underserved, or rural communities.” Additional leverage to promote interprofessional training and practice was implemented in the 2015 postdoctoral grant program. Institutions receiving HRSA grants are required to develop or enhance integrated health care delivery systems that serve as training sites for postdoctoral dental trainees, including partnerships with primary care delivery organizations and other community-based organizations. HRSA oral health program support spans the continuum from training and education to practice. Ten states received funding for activities in a new focus area, “Integrating oral and primary care medical delivery systems for underserved communities” under the Grants to Support Oral Health Workforce Activities program. In addition to grant programs administered with funds directed for oral health, many other health professional grant programs have encouraged interprofessional education and practice, thereby magnifying the oral health footprint supported by HRSA funds. Examples include HRSA GWEP (see previous discussion of the history of this program and geriatric training supported by the VA). HRSA funding to Area Health Education Centers nationwide to enhance “access to high quality, culturally competent health care through academic-community partnerships to ultimately improve the distribution, diversity, and supply of the primary care health professions workforce who serve in rural and underserved health care delivery sites.” AHEC programs and centers along with state and local partners Promote interprofessional education and collaborative teams to improve quality of care Recruit and train students from minority and disadvantaged backgrounds into health careers Place health professions students in community-based clinical practice settings, with a focus on primary care Facilitate continuing education resources and programs for health professionals, particularly in rural and underserved areas. HRSA also funds Advanced Nursing Education Grants that “support projects that develop and test innovative academic-practice partnership models for clinical training.” Several grants have been made for training-based collaborations between schools of dentistry and nursing. Examples include Enhanced oral-systemic IPE and IPCP through collaboration between the University at Buffalo Schools of Nursing and Dental Medicine to develop innovative IPE experiences and new IPCP teams that include dental and advanced practice registered nurse (APRN) students and faculty. Teaching Oral-Systemic Health is an interprofessional initiative of New York University (NYU) College of Nursing, to engage APRN students, together with medical students from NYU School of Medicine and dental students from NYU College of Dentistry in simulation learning with standardized patients and virtual patient cases. Note: this HRSA funded program is discussed in detail (see Gordon S, Donoff RB: Problems and Solutions for Interprofessional Education in North American Dental Schools , in this issue.) The Academic Unit-Primary Care Training and Enhancement grant program focuses on academic units that integrate oral health and primary care models, such as increasing oral health core clinical competencies for primary care trainees, training in integrated or virtually integrated oral health and primary care practices, and new interprofessional education models for integrated oral health and primary care; in particular, on models that support the training of providers in advanced roles. The academic unit must understand the challenges, limitations, and levels of a fully integrated model and understand and disseminate how training programs can promote and achieve successful integration. Clinical Practice Investments Agencies such as HRSA, the Federal Bureau of Prisons, Office of Minority Health, and the Indian Health Service foster activities that promote interprofessional collaboration. Examples of federal activities that have implications for clinical care are presented in the DHHS Framework under the Goal 1 strategy, “Create programs and support innovation using a systems change approach that facilitates a unified patient-centered health home.” Furthermore, a Qualis paper on the patient-centered medical home (PCMH) states that, “embracing comprehensive care, the PCMH model provides the perfect environment for strengthening access to oral health care, improving provider and patient understanding of oral health, and providing the needed oral health care screening, preventive and restorative services that are essential to optimal health status.” The PCMH or health home provides a conceptual platform in which IPCP can be actualized to maximize health outcomes for individuals and populations. Over the past several years, HRSA Health Center Program has made substantial investments in new service delivery sites, expansion of existing health centers, and school-based health centers. In FY 2014, nearly 300 HRSA Health Center grantees expanded oral health services. An additional FY2016 commitment of $156 million was made specifically for oral health expansion of 420 existing health centers to increase access to oral health care services and improve oral health outcomes for Health Center Program patients. Health centers are required to provide “all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established written arrangements and referrals” and, therefore, provide the opportunity to integrate oral health and primary care practice and capitalize on interprofessional collaboration. Federal program initiatives and investments may serve to facilitate systems change and demonstrate value and the opportunity for quality improvement with improved health outcomes attainable through a truly integrated model of care. The HRSA Health Center Program promotes formalized PCMH recognition, which “includes an emphasis on care coordination, patient self-management, and ongoing quality improvement in all areas including oral health.” As of June 2015, 61% of health centers had achieved National Committee for Quality Assurance PCMH recognition, “the most widely-used way to transform primary care practices into medical homes” and 96% of health centers use electronic health records, including the electronic dental records. The IOHPCP Report’s Recommendation 2 (see Box 4 ) accentuates the importance of interoperable and accessible health care systems infrastructure that “use common language, interoperable electronic health records, and interprofessional collaboration in patient-centered medical and health homes to facilitate high quality accessible oral health care.” Furthermore, oral health integration in a PCMH environment has the imperative for funders to “support integration/interface of health center electronic dental and medical records systems [with the understanding that] bi-directional sharing of dental and medical records will allow the care teams in both services to better address the needs of their patient population(s) and enable fully coordinated care.” The important take-away message is that dental and other health professional students and recent graduates increasingly have training and practice experience working collaboratively across health disciplines. Through community-based clinical experiences, targeted training programs such as those previously discussed, and increasing exposure to interprofessional faculty, graduates of health professional programs will be more comfortable working in mixed or diverse practice environments, will have the familiarity and knowledge of the roles of other clinicians, and be able to work together to assure overall health of the patients they serve. In addition, the increase in availability of patient-centered interprofessional practice settings that use integrated electronic health records provides the opportunity to facilitate the provision of quality competent care and improved health outcomes through prevention, early detection and treatment, and increased patient education to maintain health. Summary For more than 50 years, experts have weighed in on the benefits of integrated collaborative care and the challenges of translating interprofessional training and education into sustainable, disseminated clinical practice models. Numerous workshops, conferences, and published reports have examined the issues and recognized the important role of the federal government in supporting health professional’s training and educational programs; as well as health care delivery for vulnerable population groups, especially those who are underserved, geographically isolated, poor or disadvantaged, and those with special needs. The United States federal government has taken the lead on key issues that affect the nation, such as health promotion and access to care. It serves as an essential partner working collaboratively with states and local governments, academic institutions, professional organizations, health care providers, and nonfederal entities in efforts to improve the quality of health care and overall health across the lifespan. The historical and present day perspective presented in this article shows that the federal government’s programs, initiatives, and public-private partnerships play a critical role to influence, incentivize, initiate, and institutionalize interprofessional practice in which oral health providers are an integral part of the patient-centered provider team. The federal government has provided support for innovation, infrastructure expansion, clinical services delivery, and policy development to drive systems change. As a result, great progress has been made in establishing and promoting integrated training experiences for interprofessional health professional students, residents, and practicing clinicians to integrate oral health and primary care while endorsing a patient-centered interprofessional approach dedicated to improving health outcomes. Disclosure Statement: The views expressed in this article are solely the opinions of the author and do not necessarily reflect the official policies of the US Department of Health and Human Services or the Health Resources and Services Administration, nor does mention of the department or agency names imply endorsement by the US government. References 1. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference. New York, June 19-22, 1946. 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