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Abstract
Models and systems of the dental care delivery system are changing. Solo practice is no longer the only alternative for graduating dentists. Over half of recent graduates are employees, and more than ever before, dentists are practicing in groups. This trend is expected to increase over the next 25 years. This article examines various models of dental care delivery, explains why it is important to practice in integrated medical-dental teams, and defines person-centered care, contrasting it with patient-centered care. Systems of care in which teams are currently practicing integrated oral health care delivery are described, along with speculation on the future of person-centered care and the team approach. Critical steps in the education of dental and other health care professionals and the development of clinical models of care in moving forward are considered. This article was written as part of the project “Advancing Dental Education in the 21st Century.”
- dental health services
- dental education
- health care systems
- dental care delivery
- interprofessional practice
- person-centered care
- patient-centered care
- electronic health record
In 1993, former U.S. Surgeon General C. Everett Koop suggested that “You’re not healthy without good oral health.”1 The Institute of Medicine (IOM) conducted landmark studies in 2009 and 2010 that detailed the state of the nation’s oral health and developed recommendations for reducing disparities.2,3 The intent of these IOM studies was to improve access to oral health care for the nation and, in particular, persons who are vulnerable and underserved.
Among the findings in these IOM reports were that oral health is an essential component of overall health and that significant improvements have been made in access to care and reducing dental caries and tooth loss over the last six decades.2,3 However, vulnerable populations, defined by the IOM as children, adolescents, homeless, low-income, and poor persons, rural populations, pregnant women and mothers, underserved elderly, persons with special needs, and underserved minority populations, have less frequent access and more prevalent and severe disease than the population at large. The reports suggested that vulnerable or underserved groups are that way due to costs and finances, insurance (or not), place of residence, health status, age, personal characteristics, functional or developmental status, ability to communicate effectively, and presence of chronic illness or disability. The first report recommended that the U.S. Department of Health and Human Services (HHS) take the following actions to improve the oral health of the underserved: 1) integrate oral health in planning, programming, policies, and research in all HHS programs/agencies; 2) promote and monitor evidence-based prevention (clinical and community-based) and counseling across the life span; 3) develop and disseminate oral health literacy and education information aimed at individuals, communities, and health care professionals; 4) invest in workplace innovations to improve oral health; 5) explore new delivery and payment models in Medicare, Medicaid, and CHIP to improve access, quality, and coverage of oral health care across the life span; 6) advance science and improve oral health through research; and 7) report annually on the progress.2
Under recommendation four, the IOM report specified the development of core competencies and the employment of diverse, culturally competent interprofessional teams that include both new and existing professionals functioning at the top of their licenses to improve oral health.2 Subsequently, the Commission on Dental Accreditation (CODA) developed and adopted a new standard on interprofessional education in its predoctoral dental education standards. CODA Standard 2.19 states that “graduates must be competent in communicating and collaborating with other members of the health care team to facilitate the provision of health care.”4 The intent of the standard is that “students should understand the roles of members of the health care team and have educational experiences, particularly clinical experiences that involve working with other health care professional students and practitioners. Students should have educational experiences in which they coordinate patient care within the health care system relevant to dentistry.”
The purpose of this article is to define person-centered care, examine why it is important to practice in integrated medical-dental teams, describe systems of care in which teams are currently practicing integrated oral health care delivery, speculate on the future of person-centered care and the team approach, and describe critical steps in the education of professionals and development of clinical models of care as we move forward. This article was written as part of the project “Advancing Dental Education in the 21st Century.”
Why Teams?
Health care today is fragmented and costly. An individual need only be a patient in a health care system to understand why integrated medical-dental team-based care is important. Time is spent by all patients repeating the same information to every health care provider, so they can easily understand the value of a unified chart that is well organized, complete, and usable by all team members. Current systems combine paper and electronic versions that rarely talk to one another. The National Quality Forum’s triple aim for improving health care focuses on improving the experience, lowering the cost of care, and improving outcomes.5 To improve the experience, patients should be cared for by the same providers who know, respect, and work well with the patient and each other. It helps when all providers have access to the same comprehensive electronic information system, so the care received meets the IOM standards of quality: safe, timely, efficient, effective, equitable, and patient-centered.6
In the 18th century, Voltaire wrote, “Doctors are men [and women] who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing.”7 Presumably, conditions have improved since Voltaire’s time, but the IOM in 2001 still felt the need to emphasize that an important aspect of quality is patient-centeredness.6 Health care of the future must focus first on the patient as a person and then as a patient. Knowing our patients as people is critical to optimize communication and outcomes. Person-centered care, defined in the IOM report as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions,” is a hallmark of quality care. The term “person-centered care” is now preferred over the more widely used “patient-centered care” because it takes into account “the entirety of a person’s needs and preferences, beyond just the clinical or medical.”8
Interprofessional Practice Integrating Care Delivery
The current state of oral health care delivery contains scant integration. At the same time, the distribution of dentists surveys conducted by the American Dental Association (ADA) Health Policy Institute found a reduction in the proportion of dentists who were private practice owners from 91.0% in 1991 to 84.8% in 2012 and a reduction of the proportion of dentists who were solo practitioners from 67.0% in 1991 to 57.5% in 2012.9,10 Few dental practices are integrated with other health care providers. Although dentists may refer patients back and forth to, for example, the internists, orthopedists, nutritionists, or psychiatrists down the hall or across the street, little to no information is shared either formally or informally. Certainly, health care records, histories, list of medications, allergies, and family or social history are not shared and thus must be duplicated.
There are, however, several examples of systems of care with full integration including all medical and dental records. Some are “best in class” organizations that focus on the whole person and share electronic information that increases efficiency and reduces duplication of efforts. Notable examples are the U.S. Department of Veterans Affairs (VA), Kaiser Permanente (Permanente Dental Associates), HealthPartners, PACE programs, and some Federally Qualified Health Centers (FQHCs).
Department of Veterans Affairs
The VA operates one of the largest integrated health care systems in the world and the largest in America. Born of the promise made by President Abraham Lincoln in his second inaugural address—“Let us strive on to finish the work we are in, to bind up the Nation’s wounds, to care for him who shall have borne the battle and for his widow and his children”—the Veterans Health Administration consists of over 1,700 sites of care, serving 8.76 million veterans each year.11,12 VA Dental Services serve a steadily increasing patient population, averaging 3.42% growth each year over the last nine years. In fiscal year 2014, oral health care services were provided to 457,016 veterans, resulting in a total of 1,595,567 visits during the year in 138 dental facilities operated across the country and in Puerto Rico.13
VA Dental Services are fully integrated with the VA health care system. Dental records are part of the integrated medical records. The electronic health records include a cover sheet with all diagnoses, medications, allergies, and alerts. Medication and laboratory orders are entered electronically and are visible to all health professionals. Laboratory results and progress notes are readily available. Referrals between providers are made regularly and enhanced by patient care teams in units focused on the special needs of vulnerable patients, including frail, chronically ill (medical and psychiatric), and homeless veterans. The organization and recording of care in the electronic health record facilitate improvements in quality and efficiency and research on clinical effectiveness and health services.11–23 Currently, risk assessments for oral problems including dental caries, periodontal diseases, and dental caries are under development. Patient-specific reports on risk are now available to patients from their providers. Reports include educational materials on why the veterans are at risk and what they can personally do to decrease their risk for each oral disease, all from existing data in the unified electronic (including dental) record.
Permanente Dental Associates
Permanente Dental Associates, P.C. (PDA), is a professional corporation owned, governed, and managed by shareholder dentists.24 PDA has contracted exclusively with the Kaiser Foundation Health Plan since 1974 to jointly operate and manage the Kaiser Permanente dental program in the northwest United States. This partnership has remained operationally and financially successful for over 40 years. PDA’s history demonstrates a commitment to quality and an evidence-based philosophy of total health in an evolving landscape in dentistry.
Being embedded in a large health care system and sharing a common electronic health record provide a distinctive opportunity for PDA dentists to expand an oral health care focus to the overall health of their patients.25,26 PDA dentists capitalize on the integrated relationship within Kaiser Permanente to notify its members of “care gaps” via the Patient Support Tool (PST) in the electronic record, “HealthConnect.” The PST is a personalized report that notifies patients of both overdue and pending routine medical screenings and vaccinations. When screenings or immunizations are overdue, they are identified as a care gap. The dental care team encourages patients to schedule preventive care or to visit adjacent or nearby Kaiser Medical Facilities to close care gaps the same day. An overwhelming adoption of the PST by PDA dentists regularly keeps dental medicine in the top three of 37 Kaiser Permanente departments for patient touch points. Family medicine and internal medicine have the greatest number of patient encounters, but dental medicine maintains access to medically stable patients during spans of time when they may not otherwise require medical attention. Early research shows improvements in several Healthcare Effectiveness Data and Information Set quality measures for patients who receive both medical and dental care with Kaiser Permanente.27
PDA is committed to an evidence-based care philosophy as defined by the ADA, operationalizing evidence-based care to focus on four areas: scientific evidence, patient preferences or values, clinical/patient circumstances, and the experience and judgment of the dentist.28 Application of evidence-based principles for the patients most in need of intervention includes such examples as “Fluoride: % of moderate/high risk caries patients” and “Sealant rates for select age groups.”
While improved health outcomes are a compelling value proposition for an integrated medical-dental partnership, the dentist-patient relationship remains foundational in dentistry. Patients are paired with a dentist of record to receive care over the long term. Patient satisfaction with the care they receive is monitored by surveys administered by Press Ganey. “Top box” scores (“very good” only) assess patient satisfaction with the dentist’s concern for comfort, time between call and being seen, overall satisfaction, likelihood of recommending the dentist, and the concern for overall health by dentists and care teams.
Recruitment and retention of clinical dental professionals are key to maintaining PDA’s standard of comprehensive care. By investing in dentists who share PDA’s vision of becoming the practice of choice for patients, retirement is the prevailing cause of turnover for PDA dentists. PDA uses compensation incentives that promote the evidence-based care philosophy and integrated care model, recognizing and rewarding dentists for their contributions to total health.
HealthPartners
Founded in 1957, HealthPartners is the nation’s largest consumer-governed medical and dental collaborative organization.29 Based in Minnesota, HealthPartners includes a medical group and comprehensive medical plan, a dental group, and dental plan. Also part of the HealthPartners family is a pharmacy; an expansive, multiple hospital system including a Level I trauma center; health promotion; and an independent HealthPartners Institute for Education and Research.
Berwick et al. referred to the organizational “integrator” as one who “accepts responsibility for … at least five components: partnership with individuals and families, redesign of primary care, population health management, financial management, and macro system integration.”5 The HealthPartners family of companies employs this approach and has made efforts to improve the quality of care delivery by enacting a multifaceted definition and approach.
HealthPartners Dental Group (HPDG) pursues a vision of the highest quality in health care provision, affordability, and patient experience (Triple Aim) and has established innovative programs and initiatives in line with quality aims. HPDG consists of 24 HealthPartners dental clinics across the seven-county greater Twin Cities metropolitan area, creating an “internal” group practice clinic structure of 75 interdisciplinary multi-specialty dentists and serving more than 125,000 patients. In addition, throughout the broader community of the upper Midwest, more than 2,500 dentists participate in the HealthPartners Preferred Provider Organization network and practice in Minnesota, Wisconsin, North Dakota, South Dakota, and Iowa.29
HPDG’s value comes from being part of a large multi-dimensional integrated system of care. HPDG operates as a “group practice” in which providers have the autonomy to act on their own, relative to diagnosis and treatment planning. The group relies on a common philosophy of care and a shared agenda regarding the approach to care in a systematic manner. HPDG also functions as a research institute, with active involvement in research including practical, chair-side research conducted through the National Dental Practice-Based Research Network.28 Participation in research gives HPDG providers an opportunity to better understand how to define and deliver quality care. As a dental plan, HPDG measures all aspects of care provided and strives to integrate subsequent learning into creative plan designs and innovative ways to finance care.
HPDG’s non-clinician leadership partners with its team of clinicians, with a goal of allowing clinicians to perform at their best. In a highly complex world of compliance with regulators and payment systems, HPDG management systems support the delivery of care and maximize efficiency. HPDG has non-clinical as well as clinical leaders who partner in overseeing all aspects of the practice, allowing the direct providers to focus on patients and their needs. This support allows individuals to deliver their best care and assign responsibilities relative to management expertise in order to maximize overall outcomes.
A systems-based (integrated) approach is both afforded and demanded by a large-group, multi-clinic system. A resulting responsibility of this orientation is to continuously evaluate the systems and to establish performance metrics that ensure high-quality care. Evidence-based decision making has been an underpinning value in the development of HealthPartners’ care delivery agenda. Responsiveness to authoritative guidelines is expected of clinicians. HealthPartners makes its guidelines publicly available and continues to update them based on current best evidence.30 Annual performance evaluation in the dental group adheres to this principle. Clinical metrics pulled from a well-established, comprehensive electronic dental record system allow for administrative reporting that informs dentists’ compliance with regular risk assessment and preventive intervention, as well as appropriate and consistent treatment planning and recordkeeping. Subjective evaluation rounds out the performance evaluation with specific attention devoted to other equally critical competencies: patient communication, responsiveness, flexibility, respectful workplace attitudes and behaviors, positive participation in work-related activities, and an opportunity to participate in research.
Quality control in HealthPartners dental clinics is a formalized process that involves ongoing random chart audits. HealthPartners dentists, dental hygienists, and dental therapists participate in chart review. New providers may, in their first month of employment, be asked to review the charts of a more senior colleague. The process is participatory and equitable, meant not to be punitive but to establish expectations for all that are fair, reasonable, and useful in ensuring and improving quality. Findings from chart audits are organized and evaluated and are reviewed quarterly by a Quality Assurance Committee of approximately eight representative dentists and dental hygienists. All dentists in the group rotate through the committee, allowing for not only the opportunity to provide input but also full comprehension of the process.
For 15 years, HealthPartners has used an electronic record system and captured diagnostic codes with all diagnoses. With its large patient base, HPDG strives to be a learning organization and to continuously evaluate and improve quality of care. Partnering is key, both within and beyond the integrated system. HPDG has been involved with the Dental Quality Alliance since its inception and is firmly committed to the development of nationally agreed upon and certified metrics of measuring quality in dental care. Currently, HPDG measures compliance with its care guidelines and links that to dentists’ compensation. For example, by using the diagnostic coding system, dentists identify early enamel carious lesions and are able to implement early, non-surgical management of incipient carious lesions. Coupled with a firm belief in risk assessment and the electronic record, HPDG has the ability to follow and monitor the entire spectrum of care from diagnosis through management of diagnoses.
Affordability is integral to the Triple Aim and is essential as the three goals are simultaneously managed. Recently, HPDG has improved its ability to measure the total cost-of-care (TCOC) within its care system along with the TCOC of its network provider groups. That analysis produced an affirmation that not only can the Dental Group deliver positive health outcomes, but it can do so at a significantly more affordable rate than elsewhere. Integration is key to HPDG’s success in the context of the evolving complexity of dental care in this country. Management complexity has increased due to regulation, payment, and compliance issues. HPDG’s group practice model addresses these challenges by allowing clinicians to focus on what they do best: deliver care consistent with the Triple Aim.
Federally Qualified Health Centers
FQHCs are another model of integrated medical and dental care. In fiscal year 2007, FQHCs comprised a vast safety net: over 9,000 sites provided care to over 24 million persons.31,32 The main purpose of the national FQHC program is to provide primary care services in underserved urban and rural communities. FQHCs include safety net providers such as community health centers, public housing centers, outpatient health programs funded by the Indian Health Service, and programs serving migrants and the homeless. An entity qualifies as an FQHC if it receives a grant under Section 330 of the Public Health Service (PHS) Act; receives funding from a grant under a contract with the recipient of a grant and meets the requirements to receive a grant under Section 330 of the PHS Act; or is not receiving a grant under Section 330 of the PHS Act but is determined by the secretary of HHS to meet the requirements for receiving such a grant (an FQHC look-alike) based on the recommendation of the Health Resources and Services Administration (HRSA).
Many FQHCs (but not all) integrate dental programs into the interdisciplinary care provided. Dental care may be integrated with pediatric and OB-GYN programs and internal medicine clinics serving patients with a multitude of chronic diseases (e.g., hypertension, arthritis, cardiovascular diseases, COPD, asthma, and diabetes), offering many opportunities for care integration.
Program for All-Inclusive Care for the Elderly
The Affordable Care Act introduced the concept of Affordable Care Organizations (ACOs), defined as “a mechanism to increase and sustain care quality, better manage chronic conditions, and control expenditures.”33 One form of ACO is the Program for All-Inclusive Care for the Elderly (PACE) model, which is a “national system of long-term care that provides community-based managed care for the frail elderly.” PACE programs have advantages when compared with traditional long-term care: PACE programs are person-centered, focus on the integration of resources needed to support elders’ access to health and personal care, and provide support for elders living in the community. Most of the care is provided in the community rather than in hospitals and nursing homes.
The central goal of the PACE model of care is to make it possible for very frail and disabled persons to delay or avoid placement in a nursing home.33 Eligibility for PACE services requires certification that the needs of the individual are at the nursing home level of care. PACE operates within a capitated reimbursement system: risk-adjusted Medicare and Medicaid funds (based on a blend of NH and HCBS rates) for each participant are pooled to support the care of the population. This care is costly, with monthly rates in the $5,000 range in Denver in 2015. Approximately two-thirds of the funds come from Medicaid. Programs invest heavily in community care and reduce the very expensive use of inpatient hospital and nursing home care. Capitated payments offer flexibility; thus, PACE programs are able to offer the optimal level and mix of services to each participant, consistent with the constraints of available funding.
PACE programs are proactive rather than reactive, meaning that they promote a preventive approach that emphasizes early detection of problems and a collaborative team approach involving caregivers and social services to provide cost-effective, home-based, person-centered care for frail elders. An example of a successful PACE program is the Denver InnovAge organization.33 The InnovAge Dental Program is fully integrated into the PACE system. All PACE participants are eligible for dental care, and dental care is covered in the monthly PMPM capitation payment to InnovAge from Medicare and Medicaid (if qualified). This funding system creates an incentive for dental and other health care providers to provide high-quality oral health care with a prevention focus. Approximately 80% of PACE participants are seen at the outpatient sites. Most of the remainder, due to frailty and cognitive problems, have oral assessments and limited prosthodontic or palliative care treatment completed at their nursing homes. PACE enrollees are typically scheduled for a dental exam on admission to the program and after their medical-psychosocial workups (usually within 60 days). After treatment completion, enrollees are scheduled at intervals of one year or less (depending on needs).
University of Colorado fourth-year dental students spend time with PACE on an extramural assignment.34 The program involves students in care: they provide all types of diagnostic, restorative, and prosthodontic (mostly removable) care if capable of doing so. A detailed evaluation of each student’s competence is provided by the dental school prior to his or her start in the PACE clinic. Faculty members observe students closely as they begin to provide care and then modify their role appropriately. PACE has an in-house oral surgeon who provides most of the extractions. There is a daily interdisciplinary meeting at all sites with the full team of providers. All the dental students attend at least one of these hour-long meetings and then debrief afterwards with their dental faculty preceptors. Most of their interdisciplinary clinical exposure is via direct conversations with other providers (physicians, nurses, pharmacists, etc.) to best manage the oral problems they are asked to address, but also by reading, processing, and applying the information in the patient’s electronic health record.
Geriatricians and nurses are trained by the PACE dentists to do their own oral assessments and evaluations. On many occasions, while a patient is being evaluated by the physicians or nurses, dental personnel are asked to walk over to the treatment room and do a hands-on evaluation of a patient they are seeing or something they wondered about. The program also trains paid and family caregivers in basic oral hygiene care. This training is often done when the caregivers are present at the clinic. Dental staff demonstrate oral hygiene techniques and inform the caregivers of other important ways they can help. In addition, sometimes a telephone call is made to instruct caregivers or emphasize what is working and what may need improvement. Finally, if the participant lives in a nursing home and is not receiving adequate oral hygiene assistance, the dentist can write a physician’s order requiring daily effective hygiene assistance, providing the additional impetus to motivate staff. Also, staff members often provide fluoride varnishes and prescription fluoride toothpastes.
Apple Tree Dental
An integrated, collaborative practice is Apple Tree Dental, a nonprofit group dental practice founded in 1985 to address the unmet dental needs of frail elders living in the Twin Cities region.35 Apple Tree’s mission is to improve the oral health of all people, including people with special access needs who face barriers to care. Its multidisciplinary team delivers education, prevention, and restorative dental services to vulnerable populations using a hub-and-spoke model in which Centers for Dental Health support the year-round delivery of care at more than 130 partnering community sites using new workforce models, telehealth, and mobile dental delivery systems. Apple Tree Dental’s Innovations Center works to help transform the health care system locally and nationally.
Apple Tree operates eight Centers for Dental Health in Minnesota and California, as well as robust On-Site Care Programs operated in partnerships with teachers in schools and Head Start centers, mental health professionals in primary care settings, behavioral specialists in group homes and work settings, nurses and physicians in long-term care and assisted living centers, caregivers of veterans, and other health, education, and social services professionals. In 2015, Apple Tree’s staff provided preventive care and comprehensive treatment valued at more than $27 million to more than 32,000 individual patients and delivered more than 94,000 dental visits. Nationally recognized for its approach to integrating dental care as part of overall health and well-being, Apple Tree most recently opened its San Mateo, CA, center after completing a collaborative needs assessment and business planning effort funded by the Peninsula Health Care District in California. The San Mateo center was designed to create a sustainable dental program to address gaps in the availability of geriatric and special care dentistry services in the area.
A customized electronic record system was created by Apple Tree in 1985, and since then, longitudinal oral health records that include diagnostic codes have been in place. This distinctive database includes comprehensive information for tens of thousands of institutionalized elders. Today, Apple Tree’s cloud-based electronic record system is entering into Phase II meaningful use and links all eight centers with on-site teams operating in Minnesota and California.
Person-Centered Care and Health Care Homes
There are many opportunities to extend oral health care to people with disabilities using community-based approaches. Providing dental care in community settings such as adult day health care, residential care, and elders housing is an area for future growth. Given barriers of mobility and transportation, providing care in settings where disabled persons and elders already live and congregate is important and worth investigating.
With these needs in mind, what should health care look like in 2040? Optimal integrated delivery systems for overall health care will take a person-centered approach to the health care home. Health care homes will combine population- and practice-based approaches, resulting in greater integration of a public health approach to dental practice. Electronic dental records will be integrated with records for overall health care treatment. Collaborative approaches will be used both within and outside the traditional dental team. A prime component of future practices will be that oral health professionals (dentists, dental hygienists, dental therapists, and community health navigators) will work at the top of their licenses and coordinate with nurses, physicians, pharmacists, therapists, and social workers to improve patient care.
Rubin and Edelstein described three models of the extent of medical-dental care integration.36 The first model is a siloed model, in which dental care is totally separate from medical care. They suggest that, in the siloed conceptualization, dental care practices would over time aggregate or consolidate into virtual or de facto groups. They posit that this model would develop into corporate or commercial health and payment systems. The second model is an overlapped model that envisions dental care as primary care in its own right. In this model, dental care becomes a component of the patient-centered medical home, supervising dental care and screening for medical problems. The third model is a fully integrated model, with dentistry serving as a specialty service in a patient-centered medical home and dental specialty care analogous to subspecialty medical care. Payment in this system is similar to that in any other specialty service.
The Qualis Health Approach is based on the premise that the dental community is essential but insufficient to meet the oral health needs of the population.37 This brief, structured approach engages members of the primary health care team in identifying and referring people who need care. It uses the ASK-LOOK-DECIDE-ACT-DOCUMENT approach within the scope of primary care. ASK refers to asking patients about oral disease symptoms and/or use of care. Providers then LOOK for signs of oral disease and DECIDE on the most appropriate response (referral, nothing, or other interventions). ACT refers to the delivery of preventive interventions, such as motivational interviewing, nutritional counselling, and application of fluoride. Finally, the provider DOCUMENTS the process, intervention, and plans for follow-up.
What must dental education do now to prepare practitioners for 2040? Interprofessional education is key to working on teams. Competencies in inter-professional education have been developed in four domains: values and ethics, roles and responsibilities, interprofessional communication, and teams and teamwork.38
Conclusion
Health care of the future will be both person-and population-based and will emphasize keeping people healthy rather than treating diseases. Oral health promotion and prevention will be emphasized at the individual and population levels. Oral health literacy is key to a person-centered approach that involves health care providers’ communicating effectively with their patients about shared goals of care, what prevention is effective, and when, where, and from whom to seek care. Oral health is a fundamental human need and integral to overall health. Only by partnering with our patients and other providers can we achieve this common goal.
Footnotes
Disclosure
Dr. Jones’s work is funded by the U.S. Department of Veterans Affairs and the Santa Fe Group.
Editor’s Disclosure
This article is published in an online-only supplement to the Journal of Dental Education as part of a special project that was conducted independently of the American Dental Education Association (ADEA). Manuscripts for this supplement were reviewed by the project’s directors and the coordinators of the project’s sections and were assessed for general content and formatting by the editorial staff. Any opinions expressed are those of the authors and do not necessarily represent the Journal of Dental Education or ADEA.
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