Interprofessional value-based health care: Nurse practitioner-dentist model

1 Introduction

The United States (US) spends nearly twice as much as the average Organisation for Economic Co-operation and Development country, yet reports the highest chronic disease burden, highest number of hospitalizations from preventable causes, lowest life expectancy, and utilizes the most expensive technologies among these nations.¹ These challenges within the US health system are not new. In 2006, Porter and Teisberg proposed a value-based health care (VBHC) model that would address these issues. Value is defined as the quotient of “quality” and “cost” where value is the care delivered to the patient, quality is the experience of the patient as well as the objective output, and cost is the sum of direct and indirect costs involved in caring for the patient.² Subsequently, the Triple Aim posited that there needs to be an improvement in the experience of care, improvement in overall population health, and reduction of cost of health care.³ Value-based medical care systems are moving forward with the implementation and evaluation of VBHC models and aspire to the Triple Aim. Dentistry has been slower to adopt this framework; perhaps because process measures often substitute for quality metrics, and patient satisfaction data often is collected in lieu of patient experience data. As dentistry shifts toward person-centered, evidence-based care, however, integrating a value-based approach will facilitate achieving the Triple Aim. Included in this approach is the integration of oral health as an essential component of overall general health,^{4, 5} with an emphasis on the linkages between oral health and systemic health, wellness, and quality of life.^6-8

An interprofessional, person-centered approach integrating oral health and preventive primary care services was piloted in 2015 by Harvard School of Dental Medicine (HSDM). Investigators created and implemented the Nurse Practitioner-Dentist Model for Primary Care (NPD Model) within the Harvard Dental Center's (HDC) Teaching Practices. Patient workflow processes were revised and tested. For example, the revised workflow for screening new patients (Table 1) includes a NP referral process. Notably, the NPD Model shifted the focus of care from provider-centered to person-centered care.⁹ A step-by-step guide was developed for implementing the NPD Model in US dental schools.¹⁰

To support interprofessional practice in the predoctoral dental curriculum, nurse practitioner and dental students completed self-directed online modules, interprofessional didactic learning sessions, and faculty-supervised clinical rotations to develop competencies in collaborative practice and integrated care.⁹ The interprofessional practice approach emphasized whole-person care, oral-systemic health, chronic disease management, prevention, and wellness. Principles of VBHC informed the development, implementation, and evaluation of the NPD Model. By evaluating experience and outcomes, this model looked to improve the quality of care delivered to each patient, thus improving value for the served population.

The NPD Model sought to improve the value of care for older adults living with chronic health conditions, particularly diabetes and hypertension. These patients often have lower socioeconomic status and lower education status, and are more likely to experience multiple comorbidities and worse overall outcomes.¹¹ The study was designed to test an innovative care model in chronic disease management within a dental setting. Adherence and tracking have been shown to prevent direct costs that are incurred by the progression of diseases, while also inhibiting acute events associated with chronic diseases.¹² By integrating oral health and management of comorbidities of systemic diseases, the NPD Model focuses on promoting chronic disease management and preventing further acute events associated with these diseases, thus improving value of care delivered.⁹

The purpose of this study was to evaluate the effectiveness of the NPD Model as an integrated, interprofessional VBHC approach in oral health.

2 Methods

The NPD Model was implemented at the HDC Teaching Practices, an academic dental center located in Boston, Massachusetts. The HDC provides dental care to a patient base of more than 50,000 patient visits annually, approximately 17 percent of which are older adults. The HDC offers comprehensive dental care provided by third- and fourth-year predoctoral dental students and advanced graduate dentists. The HDC is staffed by dental hygienists, dental assistants, faculty dentists, administrative support staff and managers, and sterilization technicians. There are 42 dental chairs, an adapted medical-dental electronic health record,¹³ full-service sterilization center, and multiple radiology stations. A full range of dental care services are provided including dental hygiene, endodontics, oral diagnosis, oral surgery, orthodontics, periodontics, radiology, and restorative dentistry.

The study was approved by the HSDM Institutional Review Board (Protocol #15-4000; expedited review). Our research employed a nonexperimental study design and was informed by the Rainbow Model of Integrated Care, a comprehensive conceptual framework that integrates multiple dimensions of integrated care and primary care.¹⁴ The Rainbow Model presents a conceptualization of integrated care at the micro- (clinical), meso- (professional and organization), and macro- (system) levels. We focused our study at the micro-level of clinical integration, that is, person-centered care at the individual level; and adopted the Rainbow Model's definition of clinical integrated care: “The coordination of person-focused care in a single process across time, place, and discipline.”^14(p.7)

A pretest/post-test design was used to evaluate clinical patient outcomes for a convenience cohort of HDC Medicare beneficiaries aged 65 years and older with a reported diagnosis of hypertension and/or type 2 diabetes. Patients received a recruitment and prescreening telephone call from the nurse practitioner (NP) prior to their scheduled dental appointment, or an informational email message with a link to an eligibility screening tool. Patients with renal failure, current hemodialysis treatment, or diminished cognitive functioning were excluded from the study.

Monthly wellness visits (intervention) were conducted by the NP over a 6-month study period. Visits focused on prevention, health promotion, and chronic disease self-management. Core components of the wellness visit process are outlined in Table 2. The annual wellness visit (AWV), which includes a personalized prevention plan, is a reimbursable preventive service covered by Medicare.¹⁵ For patient convenience, monthly wellness visits were coordinated with scheduled dental treatment appointments. Weekly telephone calls were also instituted to monitor and follow up on the health status of study participants.

Clinical outcome measures included systolic/diastolic blood pressure (BP), weight, body mass index (BMI), hemoglobin A1c (HbA1c), advanced care planning status, and self-confidence rating. Outcome measures were determined based on a subset of nationally recognized HEDIS® measures.¹⁶ Operational measures were BP < 140/90 for controlled hypertension and HbA1c < 8.0 percent for controlled diabetes.

For each of the outcome measures, pre- and postintervention scores were tested to determine if there were significant decreases in the biomedical measures and increases in the patient self-confidence and advanced care planning. Data were analyzed using SPSS statistical software (SPSS V23, IBM Corporation, 2015). For all variables, with the exception of advanced care planning, paired t-tests were computed between the two time frames to appropriately determine whether or not the mean difference between observations was zero. Test of proportions was computed comparing pre- versus postintervention advanced care planning assessing the proportion of change in “Yes” responses from pre- to postintervention. Changes in weight from pre- to postintervention were calculated and subsequently categorized into percent change over time. For all tests, a P-value of ≤0.05 was used to denote statistical significance.

3 Results

Thirty-one HDC patients (mean age = 71.45, SD = 4.65, range 65-82) participated in wellness visits over the study period. Five (16 percent) participants completed two or three visits, thirteen (42 percent) completed four or five visits, and thirteen (42 percent) participants completed six visits. Selected participant demographics and baseline characteristics are displayed in Table 3. Positive and significant changes in the pre- versus postintervention measures for nearly all clinical outcomes were found (Table 4). Patients' systolic BP decreased postintervention as well as weight, BMI, and HbA1c. Results suggested significant positive change in patients' self-assessment of confidence to meet health goals, as well as positive increase in the proportion of patients who had advanced care planning postintervention. Overarching health goals addressed diet, exercise, weight loss, mindfulness, and sleep.

4 Discussion

Study findings support the NPD Model as an effective interprofessional practice approach aligned with the Triple Aim goal to improve patient and population health outcomes, and to advance VBHC in oral health. Significant clinical improvements in health outcome measures were achieved. Contributing factors included a focus on prevention, health promotion, chronic care self- management, and interprofessional collaborative practice. Overall, the combination of these factors indicates an increase in quality of care delivered by the NPD model, and therefore increased value to the patient. We assert that strategies to improve patient experience of care related to trust, cultural competence, health literacy, and patient-provider communication will positively influence the effectiveness of the NPD Model.¹⁷ To further evaluate the effectiveness of the NPD Model as a VBHC approach, our next steps will include data analyses evaluating oral health/dental quality outcomes and cost/financial indicators. We hypothesize that chronic disease management in the dental center can decrease cost to the overall healthcare system by tracking patients and consistently checking biometric data, which has been seen to diminish the risk factors for acute events.

We recognize several limitations of this research which may curb the generalizability of the findings. This was a single-site study of an academic dental center located in an urban setting. Potential limitations related to analysis of clinical outcomes included the short, 6-month study period, small convenience cohort size, and predominantly white, non-Hispanic, male study participants. Despite these shortcomings, results demonstrated clinical improvements in biometric health measures and medical-dental care planning for older adults. Study limitations were outweighed by use of the Rainbow Model as a theoretical model to guide the evaluation of integrated care. Aligned with the Rainbow Model, study findings support the intersectorial partnership between dentistry and nursing to deliver integrated, person-centered care.¹⁴ Last, we demonstrated the feasibility of implementing an interprofessional practice model within an academic dental setting.

Although there was an improvement in clinical outcomes, missing from this analysis has been the impact on costs. Measurement of value depends on integrating cost accounting into the analysis.¹⁸ Because labor costs are expensive, and are often increased by acute events, the NPD Model should minimize these by simplifying treatments^{11, 18} However, this study was a grant-funded demonstration project, designed to study the impact of integration on care delivery and health outcomes; cost and potential revenue measurement were not fully studied. VBHC pushes stringent measures of cost and quality in order to improve delivered value.¹⁸ Because quality outcomes in this study were consistently improved for chronic disease management, it can be posited that positive value was delivered to patients. Phase two of the project will incorporate an analysis of costs and potential revenues to further our understanding of the overall value delivered to patients. We recognize the importance of health care providers' work life and satisfaction. Future studies will be designed to assess nursing and dental provider perceptions and satisfaction in the context of the NPD Model and integrated care.

Educating patients about the model and its potential is critical. Patients may not understand associations between their oral and general health and therefore may not immediately understand the value of integrating the nurse practitioners into the teaching practice. If patients do not see value in this integration and do not understand the quality delivered during each visit, they may be less willing to extend their time in the dental chair, which would lead to lower uptake of the NPD referral services.¹⁹ However, a person-centered care model which values the time of the patient may strive to close gaps in care “in one stop.” For example, in Kaiser Permanente's medical-dental integration model, a visit to the dentist may represent an opportunity for a mammogram or routine vaccinations, elongating a visit but saving a trip.²⁰ Shifting to this type of person-centered care may increase the value of services from the patient's perspective, but will require increased communication and coordination among providers and between providers and patients.²⁰ Our current delivery system is not designed to promote this type of communication and integration, which is the foundation of team-based care.

Structural factors in the healthcare delivery system may impede the implementation of the VBHC model to its full potential. One such factor is the lack of integrated electronic health records across dentistry and primary care.²¹ Integrated health records would allow for better coordinated care and tracking of biometric progress data. The benefits of such a system would increase convenience and efficiency to the patient, enhancing patient experience, and thus imparting greater value to the patient.²² For example, Kaiser Permanente has demonstrated success in increasing quality, improving patient experience, closing care gaps, and increasing access to care.²⁰ An integrated electronic medical and dental record system also would facilitate billing. Adopting this model in the context of the existing oral health payment structure remains a large barrier to implementation, as most dental practices would not have the systems in place to bill for medical visits provided by nurse practitioners. Without a means to financially support the nursing services, dental practitioners may not have the margins to provide these services. Future studies demonstrating value in terms of tangible gains for oral healthcare providers may facilitate utilization of this model.

Alternative payments systems, such as accountable care organizations (ACOs) which share risk based on health outcomes, may provide a means for expediting VBHC in dentistry.²³ Presently, very few ACOs include dental care in their risk arrangements. Those that do tend to rely on process metrics such as numbers of patients referred to a dentist rather than metrics that examine changes in health status or patient experience. Thus, a major milestone to facilitate adoption of such a payment system in oral health is a uniform set of oral health outcome metrics that could be used to reliably measure quality. Recently, a collaborative study between the International Consortium for Health Outcome Measures (ICHOM) and the World Dental Federation (FDI) developed a standardized minimum set of oral health outcome measures for adult oral health.²⁴ Once the instrument is validated, it can be implemented globally. This can further tie into value measurements for patients on the oral health side, further integrating both dental and medical outcomes.

In 2011, through the Affordable Care Act, Medicare initiated the AWV to promote personalized prevention services and health risk assessments for beneficiaries.¹⁵ Notably, adoption of the AWV has been relatively slow and variable, with lower rates found in primary care practices caring for underserved populations.²⁵ Our study findings demonstrated the feasibility of conducting the AWV for older adults in a dental practice setting. To increase adoption of the AWV, policy makers should encourage utilization within dental offices and support a Medicare incentive model for dental practices.

In conclusion, the NPD Model is an early prototype for promoting interprofessional practice and VBHC in oral health. The dental office is a feasible and acceptable care setting to address whole-person care focused on wellness, health promotion, disease prevention, and self-management of chronic health conditions. Moreover, the dental office can serve as a gateway or bridge to comprehensive health care.