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Abstract
The aims of this study were to evaluate the feasibility of an interprofessional education and collaborative practice model (IECPM) developed by the School of Dentistry (SOD) and College of Pharmacy (COP) for the University of Minnesota dental clinics and to report results of the needs assessment using specific primary care metrics and medication histories gathered through use of the model in 2015–16. Planning focused on establishing a workflow to implement the IECPM by the SOD and COP. The interprofessional team that provided patient care for the study consisted of 50 dental students, ten dental therapy students, one pharmacy student, one pharmacy resident, one faculty pharmacist, one dental assistant, one faculty dental hygienist, and two dentists. The team selected 190 patients in the SOD clinic for the study based on the inclusion criteria: patients with two or more chronic medical conditions who were taking medications. The 190 patients received a comprehensive dental exam, review of social and medical history, and medication therapy management assessment by the interprofessional team. Specific core primary care metrics (blood pressure, pulse, tobacco use, and diabetes status) and identification of drug therapy problems (DTPs) were monitored and/or screened for during the dental visit. The results showed that the IECPM helped identify that this cohort of patients presented with chronic conditions: 64% had hypertension, 34% had diabetes, and 10.5% reported smoking cigarettes. Several DTPs were identified, of which “needs additional drug therapy” was the most common. This cohort was taking multiple medications (2–34 per patient) to address a variety of medical conditions. The study concluded that the IECPM with the SOD and COP helped address a primary care need that often goes unmet in dental clinics.
- dental education
- interprofessional education
- pharmacy education
- interprofessional practice
- collaborative practice
- dentistry
- pharmacy
- medication history
Poor oral health status has been associated with undesirable population-based health outcomes in patients with a variety of chronic diseases, including diabetes, hypertension, cardiovascular disease, tobacco use, and obesity.1,2 Frequently, patients with poorly managed chronic conditions such as diabetes are more likely to have an increased level of severity of periodontal disease.3,4 Nationally, the diagnosis of adults with diabetes has quadrupled from 5.5 million to 21.3 million over the past 32 years.5 Similar to other states, chronic disease conditions are prevalent in Minnesota, with diabetes occurring in 6.4% of adults, hypertension occurring in 21.6% of adults, and tobacco use occurring in 16.7% of adults.6 According to the Centers for Disease Control and Prevention (CDC), oral disease and many of the most common chronic medical conditions, such as heart disease, diabetes, and obesity, are preventable and would benefit from early identification and intervention.7
A number of patients with multiple chronic diseases live in underserved communities. For underserved populations, comprehensive primary health care and oral health care remain elusive. To help provide care for these patients, the University of Minnesota School of Dentistry provides oral health care services at a range of clinics, including the school’s Comprehensive Care Clinics, and through several innovative outreach programs providing services to underserved populations and a large, diverse, metropolitan and rural patient population. The Comprehensive Care Clinics are both a primary and tertiary oral health care center that accepts Medical Assistance (Minnesota’s Medicaid program). Because a significant number of patients seen by dentists do not have a medical home, implementing models of care that provide an opportunity to reach patients who would otherwise be outside the reach of the health care delivery system should be explored. Teaching dental providers to function as part of the primary care team with members of the larger health care delivery system could assist patients in receiving more consistent and coordinated health care. Dental students could benefit greatly by understanding the important role they could play in their patients’ general health.
The establishment of new collaborative models of care could provide a mechanism for identification and development of early intervention for some common chronic conditions in a dental setting. While dental providers typically collect and review medical information, they are generally viewing this information through the prism of how it could affect oral health treatment. Oral health care professionals provide care focusing on both oral and overall health conditions, but this care is frequently provided with limited interaction with other health care professionals in a clinical setting. Working in an interprofessional environment could help broaden the perspective of the dentist to look at the patient’s health more globally. Furthermore, the comprehensive needs of patients today exceed the skills and knowledge of any one health care professional.8 Exploring how oral health care providers could work in an interprofessional education and collaborative practice model (IECPM) could create an opportunity for screening or monitoring for unmet primary care needs. By working with other health professionals in the dental clinic who are able to make primary care interventions and acting as a liaison between the patient and the patient’s primary care team, dental providers could play an active role in primary care.
Formicola et al. noted that collaboration among health professionals might be driven by the need to provide better care for our aging population and those patients who have complex health needs.9 Their study reported in 2012 that 63% of dental schools in the U.S. and Canada were involved in interprofessional education (IPE) experiences with medical schools, but fewer of the IPE experiences were with other health professions schools. An IECPM between pharmacy and dentistry, while untraditional, could create opportunities to identify or screen for primary care metrics through a process in which both the individual and wider community needs for the diverse population of patients seen in dental clinics can be assessed. Clinical primary metrics are information about patients in a cohort that can be used to aid in tracking outcomes. Some of these metrics that could be monitored include assessing blood pressure, medication adherence, tobacco status, etc. of each patient, which could be incorporated into the dental visit. Incorporating pharmacy in the clinics could add value by monitoring medication issues impacting the dental patient in real time. For example, xerostomia is often medication-related, and pharmacists may be able to suggest therapeutic alternatives to alleviate or eliminate adverse effects. The aims of this study were to evaluate the feasibility of an IECPM developed by the School of Dentistry and College of Pharmacy for the University of Minnesota dental clinics and to report results of the needs assessment using specific primary care metrics and medication histories gathered through use of this model.
Methods
This study was deemed exempt from oversight by the University of Minnesota Institutional Review Board (1602E84702). This project was a feasibility study to design an IECPM partnership between the University of Minnesota School of Dentistry (SOD) and College of Pharmacy (COP) while conducting a needs assessment. The planning for the project commenced with three faculty members (associate dean for clinical affairs at the SOD and the directors of interprofessional education for the SOD and COP), who designed and implemented the clinic model. Subsequently, the three principal investigators submitted the project for vetting and approval to the National Center for Interprofessional Practice and Education as a Nexus Innovator Network (NIN) site. The NIN is a national effort to standardize interprofessional practice and education research in clinical settings and to systematically evaluate the impact of health professions collaboration on patient outcomes. The project was approved as an NIN site.
The Team Care Clinic (TCC) at the SOD was identified as the site for initial study implementation. The TCC was designed originally as a model for intraprofessional care that would give dental, dental hygiene, and dental therapy students experiences in functioning as a team in a flexible delivery system that utilizes a team approach in addressing the patient’s needs. All SOD students have a clinical rotation in the TCC during their clinical training. Integration of the interprofessional model in the TCC provides an opportunity for SOD students to gain clinical skills in both intraprofessional care with their SOD peers in this group practice setting and interprofessional collaboration working with members of another profession.
The clinical collaborative team that provided patient care consisted of students and faculty members from dentistry, dental hygiene, and dental therapy and a resident, student, and faculty member from the COP as well as staff dental assistants in the TCC. To determine a workflow for integrating pharmacy into the TCC, we employed a second-year pharmacy resident to help establish our clinical process and utilized a faculty member from the COP who could also provide clinical and educational services on alternate clinic days with the resident. A pharmacy student was added to the team later in the fall. As members of the interprofessional team, the pharmacy resident and pharmacy faculty member were given training in the dental school’s electronic health record (EHR; axiUm, Exan Group, Coquitlam, BC, Canada) and given access to the EHR to document their findings and gain access to the same vital health and oral health information for care planning as SOD members of the interprofessional team.
Two methods were used to identify patients that met our selection criteria for examination by the interprofessional team in the TCC; the criteria were patients with two or more chronic medical conditions who were taking medications. When patients presented for care in the TCC, a pharmacy team member or oral health care team member identified prospective study participants as follows. First, for patients who completed a medical history prior to their appointment, a pharmacy team member reviewed the EHR. Based on that review, the team determined whether the patient was a candidate for further evaluation by the interprofessional team, and then the patient was examined by the team at the patient’s appointment. Second, for patients who did not have a medical history prior to their appointment, the medical history information was added to the EHR and reviewed at the beginning of the appointment by a dental team member with a pharmacy team member present to determine whether the patient was a candidate for further evaluation by the interprofessional team. In addition, a team huddle at the beginning of the clinic session provided an opportunity for both pharmacy and dental team members to communicate about which patients presenting on a given day would be examined by the interprofessional team.
Patients visiting the TCC between August 2015 and May 2016 were identified and examined by the interprofessional team. During the appointment, patients received a comprehensive dental exam, review of their social history, review of their medical history, and a medication therapy management (MTM) assessment. Once the team reviewed the information gathered during the visit, its members formulated a collaborative care plan that was presented to the patient jointly by the team. Separate visits were scheduled for dental treatment, MTM, and/or follow-up visits based on the findings. When elevated blood pressure was detected, the measurement was repeated; if it was still elevated, this information was discussed with the patient. Both this information and the patient’s self-reported management of diabetes were included in the letter sent to the primary care provider by the pharmacy team member. If a drug therapy problem and/or medical concern was identified, the pharmacy team members acted as the communication hub between the interprofessional team and the patient’s primary care provider. The communication of information to the primary care provider was a letter that was either mailed or given to the patient to present to his or her provider at the next appointment.
As part of the needs assessment, we a priori identified important metrics used in primary care settings such as blood pressure, pulse, tobacco use, diabetes status, cardiovascular status, immunization status, and potential drug therapy problems (DTPs) for assessment. The information technology director provided the principal investigator (GBM), who was blinded to all clinical care, with de-identified patient information from axiUm for patients seen by the interprofessional team during the study period for analysis. In addition, the de-identified information included patients’ age and list of medications they reported taking.
During the second year of the project, three additional pharmacists joined the project to provide their expertise in reviewing de-identified MTM data. The principal investigator designed a calibration process to evaluate de-identified MTM information recorded in axiUm, utilizing these three pharmacists who were blinded to all clinical activity during the observation period from August 2015 to May 2016. Two pharmacists were assigned to independently review the pharmacy note per patient to identify and categorize DTPs documented in the EHR during the observation period. DTPs were identified and categorized systematically following principles outlined in the third edition of Pharmaceutical Care Practice: The Patient-Centered Approach to Medication Management.10 These principles are listed in Table 1. After the independent review and categorization of the DTPs by two pharmacists, the principal investigator reviewed their findings for discrepancies between the two. If a discrepancy was identified, the two evaluating pharmacists were asked to discuss the discrepancies until a consensus was reached regarding both the number and category of DTPs. The data were descriptively analyzed.
Categories of drug therapy problems
Results
During the observation period, the interprofessional team that provided patient care in the TCC consisted of 50 dental students, ten dental therapy students, one pharmacy student, one pharmacy resident, one faculty pharmacist, one dental assistant, one faculty dental hygienist, and two faculty dentists. The team selected 190 patients for examination: 87 females and 103 males (Table 2). The age of the patients ranged from 23 to 93 years with an average age of 66. A total of 68% of the patients identified were ≥60 years of age.
Characteristics of patients in study (N=190), by female and male cohorts
Early in the project we had to establish a standardized process for documentation of the primary care metrics to allow the technical staff to prepare de-identified reports from axiUm. Changes to our axiUm EHR were necessary for this process. The key modifications to the axiUm record were providing a designated area to add the pharmacy note, MTM codes for billing, entry of patient primary care provider information, a place to add current vaccination history, a designated area to record blood pressure, a drop-down menu to record diabetes history, and addition of a place for follow-up questions if the patient gave a positive response to history of tobacco use. These changes were all completed during the study period with the exception of the vaccination history.
Our assessment showed that 62% of the patients in this population reported having hypertension, 34% reported having diabetes, and 10.5% reported smoking cigarettes. The number of medications taken by the cohort per patient ranged from one to 34. The seven most common medications used by this patient population (Figure 1) were consistent with medications used to manage hypertension and diabetes. The majority of the patients were taking four or more medications. Although several other medical conditions were identified in this population, a review of the medical history was focused on the specific primary care metrics hypertension, diabetes, and tobacco use. For example, several patients were also taking opioids, antidepressants, and medications for neuropathy that are commonly associated with xerostomia, but for the purposes of our needs assessment we recorded only the top seven common medications used by the cohort.
Top seven most common drugs taken by patients in study (N=190)
ACE=angiotensin-converting enzyme; ARB=angiotensin II receptor blocker
An assessment for potential medication issues was completed, and DTPs were identified. Based on the review process established for identification of DTPs, the pharmacist used the seven categories of DTPs shown in Figure 1. In this cohort, 153 DTPs were identified based on the de-identified axiUm data (Table 3). A noteworthy finding was that the most common DTP was “needs additional drug therapy.” Adverse drug reaction was the next most common DTP.
Drug therapy problems (DTPs) identified among patients in study, by number and percentage of total who had a DTP (N=153)
Discussion
According to the World Health Organization, interprofessional collaborative practice occurs when multiple health workers from different professions work together with patients and their caregivers to deliver high-quality care.11 Our study included pharmacy students, a pharmacy resident, and a pharmacist on a dental team.
Many patients seek oral health care because of an acute need, but may not interact with the health care system at large in a consistent manner. Health professionals in non-primary care sites, such as dental clinics, can be utilized to identify or screen such patients to assist in early diagnosis and become a key component in improving overall health and oral health. A survey of dentists by Greenberg et al. reported in 2010 that those practitioners were willing to include screening as a part of their daily practice.12 But even if willingness exists, the limits of the dental visit structure and which activities are reimbursed in a tight financial model could place significant burden on the dental team, which affects implementation. In our study, the TCC setting provided a distinctive opportunity to help screen and identify patients who have chronic medical conditions during a dental visit using the expertise of SOD and COP members. The co-investigators were also able to complete a systematic method of identifying unmet health care needs for this cohort of patients by using specific primary care metrics.
Many patients with chronic disease may be using multiple medications to manage a wide array of medical conditions.13 Different health professionals in separate clinical settings (e.g., primary care provider’s office, specialty care provider’s office, emergency department, urgent care center) often prescribe these medications. This practice can lead to fragmented, redundant, and less effective care for those needing a more focused integrated approach to chronic disease state management. In addition, patients diagnosed with chronic conditions like diabetes and hypertension are often those who struggle with medication adherence.14 Disease management may be negatively impacted and medication non-adherence increased, which is prevalent among U.S. patients in general. However, studies have found that patients with chronic diseases, such as diabetes, cardiovascular disease, and hypertension, exhibited improved outcomes with consistent management of their condition.15,16
In our study, utilizing pharmacists on our dental team led to identification of DTPs, such as medication non-adherence, that could help improve patient care. According to Cipolle et al., the term “DTP” can refer to “any undesirable event experienced by a patient that involves, or is suspected to involve, drug therapy and that interferes with achieving the desired goals of therapy.”10 Using this definition, pharmacy practitioners at the University of Minnesota began practicing pharmaceutical care in 1994 and employed these principles as they provided patient care. A study found that the work of these practitioners demonstrated pharmacists’ value with their ability to identify and resolve drug therapy problems in 42% of their patients during their first visit.17 That study also found that adding a pharmacist to the care team reduced adverse drug events. Other health care providers generally focus on a specific type of drug therapy, sometimes only for a short period of time. However, pharmacists are trained to consider all medications throughout all areas of patient care.
With use of a collaborative model in our study, oral health care professionals and pharmacists working together in a dental setting facilitated a safer and more effective means to provide comprehensive care. Our dental providers were made aware of potential DTPs that can occur for chronic disease patients and how to work with a pharmacist in the TCC to facilitate care coordination. While we know of at least one other example of co-located pharmacy and dental services (at Creighton University), to our knowledge our model is the only example of integrating a pharmacist into a dental school clinic, with the dual purpose of creating an interprofessional experience and conducting a needs assessment using primary metrics care as a component of the clinic activities.
The definition of primary care, according to the American Association of Family Physicians (AAFP), is “health promotion, disease prevention, health maintenance, and treatment of acute and chronic illness in a variety of health care settings.”18 The AAFP also notes that non-physician providers can be a part of the collaborative team. Because of the large number of patients with chronic disease presenting to a dental clinic, the dental team is uniquely positioned to intervene as members of the primary care team. In our study, in the TCC we identified patients with hypertension, diabetes, and risk factors like smoking in order to provide them with both comprehensive dental care and screening with MTM assessment. Although our school’s curricula provide training for members of the dental team to recognize primary care concerns among their patients, they often do not have the resources to adequately address them. Designation of this time-consuming role to a pharmacist on the team can provide an important primary care communication hub and help patients obtain consistent primary care services. This role is frequently one that pharmacists play in other non-dental clinic settings that can play a role in increasing patient safety.
In this study, we examined patients with chronic diseases who were taking multiple medications. By taking an interprofessional team approach, we identified 153 DTPs that had not been previously identified by the patients’ primary care providers. This discovery would not have occurred with the traditional dental clinic delivery model. Patients in the study were taking an average of four or more medications, and the most common DTP noted was “needs additional drug therapy” (30.7% of participants). This is an important finding because it indicates a condition that is not being treated or being inadequately treated, which requires the patient’s primary care provider to assess.
This study found that integrating a pharmacist into the dental team was feasible and that patients’ primary care needs were effectively monitored and communicated to their primary care providers so that appropriate care could be provided. Some educational benefits for this interprofessional model were also observed for both oral health care team members and pharmacy team members. In the TCC setting, it was important to create a standardized process for data entry in the EHR and analysis of data as well as to create consistent clinical interactions for team members. Establishing a standardized process for pharmacy data entry and adding the pharmacy note to the EHR addressed one of the major obstacles facing health care providers, which is not having access to a common EHR. Also, as part of the screening process, dental and pharmacy team members gained experience working together to identify patients with multiple chronic conditions with polypharmacy. This process allowed all team members to learn how another profession assesses a patient’s health status and to observe and discuss those components of the exam and interview that are relevant to each profession as well as where their scopes of practice intersect. Dental team members were made aware of the need to refer patients for an MTM assessment while utilizing their skills in evaluating their patients’ pharmacotherapeutics. They also benefited by observing the pharmacist on the team identifying medication combinations that could be used to trigger communication with a pharmacist or primary care provider. Pharmacy team members benefited as well from working in the dental clinic as it provided an additional option to provide patient care in a clinic other than a medical setting. Additionally, it provided an opportunity for the pharmacy team members to learn more about oral health, which is minimally covered in the pharmacy curriculum, and about interprofessional collaboration with oral health care providers.19
A limitation of this study was that it took place at only one dental school, so its findings may not be generalizable to students at other schools. Another limitation is that, during the first year of the project, we determined that we needed to make changes to the interprofessional team make-up. Specifically, we needed additional pharmacists to help sustain the model and to provide expertise to evaluate data from the MTM assessment and, moving forward, to provide consistent coverage since the pharmacy resident would be completing the residency program. A calibration process was thus established so that all pharmacy team members use a common chart note and common standards in analyzing the data. We also determined that, to involve more pharmacy students in the model, the timing for the rotation needed to coincide with all other COP rotations.
This project is now in the second year of implementation. Assessment for program expansion, responding to lessons learned, and financial resources required to sustain the clinical pharmacist team member will be of paramount importance. Initially, a resident was employed as the clinical pharmacist team member from the COP, with the goal that the medical billing would subsidize the personnel cost. However, reimbursement was lower than expected for a variety of reasons, including determining the optimal process for engaging primary care providers in non-university locations. Reimbursement mechanisms have not caught up with innovative collaborative efforts such as these. A recent British Dental Journal article about the need for integrating dentistry and pharmacy stated, “In anticipation of the validation of the efficacy and cost efficiency of such initiatives, health regulators, educators, commissioners, and other funders of dental services should be acting now to put in place arrangements to facilitate and encourage such collaborative working.”20 It became apparent to us that the financial resources were not in place to hire a full-time pharmacist. Therefore, our solution was to incorporate three pharmacists from the COP to divided clinical coverage during each week in the second year of the project. This practice allowed for flexible project time allotted to each pharmacist that was used as his or her clinic time, but it meant establishing a standardized process for screening and documentation of primary care and medication issues. We need to continue to evaluate this process. In the future, we will continue to assess barriers, refine the model, and review the strategy for integration of multiple pharmacists to find the most sustainable financial model and identify real costs associated with this interprofessional effort.
This project can be used to inform future curricular revisions in both the dental and pharmacy programs and to better prepare students for a dental-pharmacy collaboration while on clinical rotation and after graduation. We also hope to add objective assessment measures to determine knowledge gain through the use of pre- and posttests for dental and pharmacy students and potential use of other interprofessional tools to assess progress towards competence.
Conclusion
In this feasibility study, we determined that an IECPM with the SOD and COP could be designed and implemented in a clinic setting that could help address an existing primary care need that often goes unmet in a dental clinic setting. In a short period of time with only a small subset of the dental clinic population, a significant number of medical and medication issues were identified. Pharmacy and oral health professionals worked together to expand their roles in primary health care, which underscores the need for an intentional connection between the dental clinic setting and primary care using an interprofessional model.
Acknowledgments
We would like to thank Ms. Jaime Wascalus and Ms. Alexandra Paffrath.
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