Jack DeHovitz, MD, Director of the HIV Center for Women and Children
Barbara O'Sullivan, NP
Alexa Kazim, MPA, Clinic Manager
Kristina Brown, RPA-C, Quality Improvement Coordinator
David Warren MD, SHC Medical Director
Grace Abraham RN, SHC Head Nurse

% of kept dental appointments among patients referred to dental services

Background

At the State University of New York (SUNY) Downstate Hospital's STAR Health Center (SHC), a 1999 chart review showed that although 71% of patients received an annual referral for dental care, only 29% of patients actually had a dental exam documented in their medical records.

We had previously developed an on-site dental clinic to increase access to dental care and set a target for the number of dental encounters: 18 per week. By the first six months of 2000, the average number of dental encounters reached 35 per month, but remained approximately 50% below target.

As a result of these findings, we began the improvement project described here (participation in IHI's HIV/AIDS Collaboratives helped establish the structure and process for this project, which has carried over to additional quality improvement projects).

Over the course of the improvement project, we implemented a number of changes to help us track and analyze data, improve kept-appointment rates, and increase patient awareness of the importance of regular dental care.

Data Collection:

• Collected data monthly.
  • To facilitate the implementation of this initiative, we narrowed the population of focus to the patients on the panels of three clinicians.
• Implemented a two-phase data collection process:

1. Dental administrative staff faxes a list to the STAR Health Center Head Nurse the day before each SHC-designated clinic session, indicating SHC patients with a scheduled appointment. This list indicates the total number of patients with a scheduled dental appointment.
2. Dental administrative staff faxes a list to the SHC Head Nurse after each session is completed, indicating SHC patients who kept their scheduled dental appointment. This list indicates the number of patients seen in the dental clinic.

Data Tracking:

• Tested and initiated the use of "CLIMACS" the preexisting SHC electronic medical record system, to improve accuracy and speed in monitoring monthly dental show rate.
• Head Nurse enters scheduled dental appointments into the CLIMACS appointment system, also indicating whether the patient kept or broke the appointment, based on lists faxed by the dental clinic administrative staff.

Referral and Reminder Process:

• Tested and initiated a new appointment system process:
  • SHC medical providers give all SHC patients a dental referral at least once annually.
  • Nursing picks up the referral when completing clinician orders and discharge, and schedules the patient for the next available dental appointment.
  • Patient leaves the SHC with an appointment for the dental clinic and is given an appointment reminder card.
• Tested and initiated reminder phone calls to all SHC patients scheduled to be seen in the dental clinic:
  • SHC Head Nurse makes reminder phone calls to patients, using the list faxed by dental administrative staff . (This had the greatest impact on improving the show rate).

Patient Education

• Distributed flyers in the SHC to promote the availability of dental services and the importance of good dental health.

Lessons Learned:

• A mechanism must be in place from the start to promote staff participation and improve success in meeting targets, via the following:
  • Sharing of service goals
  • Ongoing monitoring of service goals
  • Sharing of strategies for achieving these goals (and barriers in meeting them)

• Improving access without increased patient education may not improve utilization. Patient education increases patient awareness about availability and the importance of oral health, especially as it relates to their HIV/AIDS primary care.

• Persons serving patients living with HIV/AIDS must be informed about disease prevention and transmission. Dental staff familiarity with protocol for reducing/responding to occupational exposure to HIV will increase employee comfort in treating patients known to be seropositive.

Next Steps:

• Continue to monitor and improve the dental show rate as part of our continuous quality improvement program.

• Seek to develop an education campaign that both emphasizes the importance of maintaining good oral health and educates patients about pain management.
  • (Many patients refuse dental services. A large number of patients report being fearful of going to the dentist. Fear of pain is a common thread among the patients that refuse dental services.)

• Track the number of patients referred for dental services, (this will make SHC better able to improve the number of patients that have a completed dental exam.)
  • On a monthly basis, the Quality Assurance Committee will review the number of patients that were eligible for a dental referral and compare it to the number that were actually referred.
  • Monitor compliance with dental referrals by clinician  , the SHC will be able to reduce variation in referrals and increase the total number of dental referrals.

• Share utilization target and achievement information routinely with dental services so as to jointly develop plans to maximize opportunities to provide dental care to patients.

Kristina Brown RPA-C
Quality Improvement Coordinator

Kristina_brown@netmail.hscbklyn.edu