Long-term needs of long-term care
Serving the oral healthcare needs of a growing number of long-term-care residents demands a new perspective on how - and where - dentistry can be performed.
Meet Big Beige. It houses a STATIM compact autoclave from SciCan and assorted supplies, and it’s just one component of Access Dental Care’s "operatory on wheels."
Asheboro, N.C.-based Access Dental is part of the "front line" of providers serving the oral healthcare needs of the frail elderly in long-term-care facilities. Others include Apple Tree Dental, Minneapolis, Minn.; Carolinas Mobile Dentistry, Charlotte, N.C.; and Outreach Dentistry, Lafayette, La. Theirs is not a new mission, but it is one that will probably grow more urgent in the years ahead, as the number of elderly Americans increases.
"Twenty years ago, the idea was, you could only receive quality care in a fixed dental office," says Bill Milner, DDS, MPH, president of Access Dental, which provides onsite dental services to the residents of 50 long-term-care facilities in North Carolina. "But our point is, you can provide the same quality of care to anybody with the amazing [mobile] technology we have in dentistry now." Big Beige is Exhibit No. 1. Others include Airbex Inc.’s handheld X-ray technologies and A-dec’s rolling equipment. "And with our software capabilities and the Internet, we can do almost anything the office does."
But even though the technology might exist, the fact is, dental care for long-term-care residents is "a giant hole in our delivery system," says Michael Helgeson, DDS, founder of Apple Tree, which since 1986 has provided mobile services to Minnesota long-term-care residents. And there are many, many reasons why that is the case.
The need
In the United States, nearly 2 million older adults reside in 16,100 nursing homes, according to Rita Jablonski, PhD, RN, CRNP, in a January 2010 article in The Annals of Long-Term Care, "Examining Oral Health in Nursing Home Residents and Overcoming Mouth Care-Resistive Behaviors." Ninety-one percent are 65 years of age or older, and 46 percent are over 85. The majority of these residents need some assistance with activities of daily living, including eating and, one can assume, mouth care.
Noting that just 19 percent of all nursing home residents received dental care in 1997, the Centers for Disease Control and Prevention, in its "Healthy People 2010" report, listed as one of its targets "to increase the proportion of long-term care residents who use the oral health care system each year."
"For many nursing home residents, substantial anecdotal evidence suggests that neither dental assessments nor subsequent treatments are being provided effectively," noted the CDC in its report.
The landscape
More than 92 percent of dentists provide care to the vulnerable elderly, that is, patients over age 65 with limited mobility or resources, or complex health status, according to the American Dental Association’s "2007 Oral Health Care of Vulnerable Elderly Patients Survey." Those dentists reported that an average 9 percent of their patients were vulnerable elderly. Other findings:
- Most dentists (98.3 percent) provide care in their offices, and 13.8 percent reported providing care in a nursing home or long-term-care facility.
- About one-quarter of these patients (24.9 percent) require dentists to consult with dental specialists, and more than a third (37.4 percent) require dentists to consult with physicians. The most common referral by dentists is for transportation services, with 39.5 percent of dentists reporting such a referral.
- Many dentists (68.5 percent) reported needing more information on managing patients with complex medical histories; managing xerostomia, or dry mouth (63.6 percent); managing dementia patients (49.1 percent); managing caries (48.7 percent); and developing home care plans for patients with functional or mental impairments (41.5 percent and 35.6 percent, respectively).
- Dentists surveyed also reported that more than half of vulnerable elderly patients (56.6 percent) were not covered by insurance, 57.4 percent of patients receive discounted care, and 14.3 percent receive free care.
- A third of dentists (33.5 percent) said vulnerable elderly have a problem obtaining dental care in their community. Among the barriers identified were the inability to pay for care (88.7 percent); lack of transportation (68.4 percent); inadequate financial support from local, state or federal programs (65.5 percent); lack of perceived need (61.5 percent); and not knowing where to go (51.3 percent).
In a recent study cited by Milner, 53 percent of nursing home administrators surveyed rated the oral health of their residents as fair to poor. An earlier study (from 2005) found that only 16 percent of nursing home residents got any oral care by the nursing assistants taking care of them. And for those who did, the average time spent by assistants brushing patients’ teeth was just over 16 seconds per resident.
What’s wrong
Poor oral health among long-term-residents frequently starts before they go to a nursing home, points out Milner.
"Unless they have an acute illness, they have been at home for awhile," continues Milner, speaking of many long-term-care residents. "During that time, they’ve been trying to meet a lot of their other healthcare needs. Dentistry is often lacking. They may have been visited by home healthcare aides or nurses. But we’ve seen oral health take a big hit. So you have five years of dental neglect leading up to the time we see them as patients in the long-term-care setting.
"By the time we see them, there’s gross decay, gum disease, fractured teeth, ill-fitting dentures...just general things any of us would see in our mouths if we had not been to a dentist in five years. Then, in the long-term-care setting, [the neglect] continues."
Ramifications of poor oral health
Poor oral health can place nursing home residents at risk for developing pneumonia, exhibiting poor glycemic control if already diabetic, and increasing cardiovascular disease, points out Jablonski.
"Unfortunately, what is most common [in long-term-care facilities] is the lack of a prevention-oriented program," says Helgeson. While it’s true that nursing homes must have a dentist of record, who acts either as a consultant or director, the fact is, that person too often plays a passive role. "They’ll get a call if there’s a problem, but there’s no oral health program," he says.
Ironically, as more older adults retain their teeth (as opposed to getting dentures), the resources for maintaining dental health are diminishing, says Jablonski. In the early 1980s, 54 percent of people age 65 or older had some natural teeth, she points out in her article. By 2002, that percentage had increased to 70 percent. The average number of teeth for all elderly people age 65 years and older in 2004 was 18.9 teeth.
"Now here come all of us baby boomers," says Milner. "We’ve been used to continuity of [dental] care all our lives. We have spent a lot of money on our mouths, and we’re not going to put up with facilities that don’t provide preventive care and routine restorative care. But what we see right now is an absolute disaster. Among people who have crowns and bridges, and all the advantages of preventive dentistry, there is a rapid decline within a year’s time [of substandard care]. Plus you’re working with folks who are not able to communicate all their dental needs."
"There is one thing we find commonly among people with significant cognitive impairments," says Helgeson. "When they have an untreated [oral] infection, they act out, they become behavior problems. Frequently they end up having falls, being restrained, getting antipsychotic medication. It costs a fortune. And it’s a horrible thing to do to someone -- to mask their suffering with drugs or restraints, when what they need is to have a tooth pulled or their mouth cleaned."
As many as one-third of older adults suffer from xerostomia, or dry mouth, which is exacerbated by the medications they take, notes Jablonski. The loss of saliva, with its antibacterial properties, results in increased bacteria in the mouth. Dryness also interferes with chewing and swallowing, and promotes plaque formation.
Plaque can serve as a source of colonizing respiratory pathogens, including pneumonia, and has even been linked to certain cardiovascular conditions, Jablonski points out. And once again, older adults are more at risk for plaque formation, possibly due to gingival recession, which exposes more tooth to the oral environment, and reduced salivary flow.
"Nobody can argue that having an infection-free mouth adds to one’s overall well-being, with the ability to chew and eat," says Helgeson. "But when people have an uncomfortable mouth, pretty soon they’re eating mush, and it becomes a downward spiral." Nutrition and overall health diminishes.
Money problems
The potential dangers of poor oral healthcare for elderly adults, especially long-term-care residents, are well-documented. And those dangers are stubborn. The reasons are simple to understand, though complicated to resolve:
- Money, or lack of it.
- Lack of training among dentists, dental staff and nursing staff on how to provide oral healthcare to the elderly.
- The difficult logistics of taking care of the elderly.
- Special characteristics of the elderly that can make delivery of care difficult, such as dementia.
The dollar dilemma for caregivers and patients is simple: Medicare doesn’t cover routine dental care - only care associated with medical conditions, such as oral cancer, or accidents that damage the mouth or jaw. Medicaid coverage is spotty. And in states where such coverage exists, it often fails to cover the dentist’s costs of providing care.
"People may enter the nursing home with private-pay, and they may have some Medicare coverage," explains Helgeson. "Then they go through the ‘spend-down,’ where the state liquidates their home and everything they’ve earned over their lifetime. They are then down to a few things they’re allowed to keep, and they become a Medicaid patient."
Medicaid guarantees coverage for dental care for children, but not always for adults. And in the last couple of years, given the economic downturn, states have become even stingier with funding. "The reimbursement paid is generally about half of what a normal fee would be for each service," says Helgeson.
"One thing I’m continuing to watch is the effect of state Medicaid plans" on dental care for adults, says Milner. "As states try to balance their budgets, we are very, very conscious of what’s going on at the state level."
A world without Medicaid would be a disaster for long-term-care residents, according to those with whom First Impressions spoke. "In our state [North Carolina], about 75 percent of people in skilled nursing facilities are Medicaid patients, and that mirrors [Access Dental’s] patient population," says Milner. "There are many, many people who have cashed out their life savings, have very few resources, and are still in need of dental services, but aren’t getting them."
Lack of training
A big challenge in caring for the elderly in nursing homes is lack of training on the part of dentists, hygienists, and the medical directors and nursing assistants in the nursing homes themselves.
"Here are [dental] practitioners getting calls from family members of patients they’ve been seeing for 30 years," says Milner. "Now their loved one is in a nursing home. This really becomes a challenge.
"Many practitioners walking into nursing homes don’t have the foggiest idea what to do. They’re looking at charts that are [many] times the size of the charts in their office, they’re looking at people who have altered states of health, and they lack the equipment to take care of them."
Inadequate daily oral care provided by caregivers in the long-term-care facility may be the most significant factor for poor oral health, says Jablonski. Nurses and physicians receive scant training on oral health, so it’s simply not on their radar, she says.
Without proper training on how to oversee a resident’s tooth-brushing activities, nurse assistants might confront what Jablonski and others refer to as "mouth-care-resistive behavior," such as biting. Resistance to care often increases as the resident’s dementia increases, she says. Such behavior leads to another downward spiral, as caregivers avoid such duties altogether.
Caregivers may also believe that if their tooth-brushing leads to bleeding gums, they’re hurting the resident, adds Milner. "All these things exacerbate the problems that have been going on [with the resident] previous to them checking in to the facility."
Complicated logistics
Simply getting long-term-care residents into a chair for treatment is a hassle, one with which many dentists are unable or unwilling to cope. Milner talks about different "levels" at which dentists can meet elderly patients who reside in long-term-care facilities - each with its own set of challenges.
The first level is the elderly patient who is brought to the dentist’s office, either by a family member or a nursing home van. "The office may need to adapt to getting the wheelchair into the operatory," says Milner. "This is where, just knowing how to do the simple things, like getting the patient transferred from the wheelchair into the chair, makes a huge difference." Dentists who traditionally avoid having patients’ family members or friends in the operatory may have to drop their misgivings. "Sometimes patients need someone to communicate for them, or to hold their hand," he says.
In the next level, the dentist and/or hygienist goes to the nursing home to do some simple cleaning and perhaps to prescribe preventive regimens for the staff members to follow. For more serious matters, such as a fractured crown, the patient may still have to be brought to the dentist’s office.
In the third level, the dentist packs portable equipment into his or her car or truck, and performs minor procedures in several nursing facilities.
In the fourth level - the level at which organizations such as Access Dental and Apple Tree operate - the dentist and his or her team work with medical equipment manufacturers to modify their equipment for transport in a van or truck. They call on dozens of nursing homes on a rotating basis, and they provide almost as many services as an office-based practice.
In the fifth level, the patient is combative or otherwise difficult to treat in the facility, so must be treated in an operating room under general anesthesia.
Apple Tree Dental
Helgeson - one of four founders of Apple Tree Dental - was a physics major in college. After graduation, he got a job as a dental assistant, driving a van and working with dentists who provided care to nursing home residents. "It was an experience that opened my eyes to what a huge unmet need there was, and that there wasn’t really a good solution to provide the care needed," says Helgeson, who is a member of the American Dental Association’s National Elder Care Advisory Committee. "It solidified my interest in dentistry, and it made me feel that we as a profession were not geared up educationally [to provide this type of care]. What’s more, the technology piece and the public-policy piece weren’t there either."
His grandfather had practiced dentistry in a small town in central Minnesota for 50 years. "The idea that my grandparents - or anyone’s grandparents - in their last 10 or 15 years of life would have [inadequate] mouth care really got to me. It’s been an ongoing mission of mine ever since."
He gave up physics and attended the University of Minnesota School of Dentistry. After that, he completed a two-year postgraduate program in geriatric dentistry in Minnesota. After serving as a United States Public Health Service dentist in St. Louis, Mo., he returned to Minneapolis in 1991 to serve as Apple Tree’s executive director.
Apple Tree has been serving the frail elderly and other special-needs patients since 1986. About a third of its patients are children; another third are young and middle-aged adults; and the rest are age 65 and older. "We have more than 100 active patients who are over 100 years old," he says.
Apple Tree has four programs around the state, and will open a fifth - in Fergus Falls - later this year. Its mobile program brings dental care to the long-term-care residents, in collaboration with nursing home administrators and medical directors.
"In the typical dental practice, the onus is on the patients to know when they need dental care, to have the money and the car to get there, and to be at the office within 15 minutes of the appointment time," says Helgeson. But that model doesn’t work with most elderly residents of long-term-care facilities.
Instead, Apple Tree acts as the dental director of the nursing homes with which it contracts. "It’s a very different concept from being a dentist in the community, waiting for people to show up."
When a resident is admitted into the facility, he or she is given an oral health assessment by an Apple Tree hygienist. The hygienist identifies residents with significant oral health problems, and they also create a daily oral healthcare plan for him or her. "That written daily oral care plan becomes part of the care plan orders, so people don’t fall through the cracks," says Helgeson. For residents with significant oral health problems, Apple Tree may facilitate a visit to their long-standing dentist in the community. "But a lot of times, they may not have seen their dentist for 15 years, and [he or she] may not be comfortable seeing them, because they have some chronic disease," says Helgeson.
Apple Tree provides onsite care for residents who either have no dentist, or whose dentist does not accept Medicaid patients, or who cannot travel to their dentist’s office. With five trucks, Apple Tree services more than 100 facilities statewide, on a regularly scheduled basis.
Each of Apple Tree’s trucks can be equipped with the equivalent of three operatories. The trucks pull up to the scheduled nursing home in the late afternoon, and set up shop in the facility’s activity room or other designated area.
Each Apple Tree truck can transport three mobile offices, says Helgeson. "We can do everything from check-ups to digital X-rays, all the way to oral surgery and periodontal procedures." (An exception is advanced sedation, which must be performed at one of Apple Tree’s community clinics.) At the end of the day (or, in the case of the largest homes, at the end of a two-day visit), technicians pick up the equipment and move to the next site on the schedule.
Ninety percent of Apple Tree’s funding comes from private pay, insurance or Medicaid. The remaining 10 percent comes from grants and philanthropic gifts.
"We wouldn’t be able to do what we do without help from the dental industry," he adds, citing A-dec, Patterson Dental and others.
Access Dental
Like Helgeson, Milner has long had an interest in dental care for the elderly, having begun a public health program to address the issue approximately 25 years ago through the North Carolina Dental Society. In 1997, he worked with Ford Grant, DMD - who was director of geriatric dentistry at Carolinas Medical Center in Charlotte, N.C. - to help start Carolinas Mobile Dentistry, a mobile outreach program modeled after Apple Tree Dental. Three years later, Milner started Access Dental, which, like Carolinas Mobile Dentistry, replicated the Apple Tree model.
Access Dentals’ team of 16 people use three trucks to provide diagnostic, preventive, restorative, surgical, denture-related and other procedures to people in need. "I’ve found that a 16-foot truck handles nicely in parking spaces," he says. Another plus is that pretty much anyone can drive it.
Since its founding in 2000, Access Dental has made about 50,000 visits and served 7,900 patients in the Piedmont area of North Carolina. Roughly 25 percent of those patients have intellectual or developmental disabilities. "So we’re not just doing all skilled nursing facilities," he says.
The Access Dental team sees an average of 18 patients a day. Typically, the organization has three operatories in use at the facility (usually an activity room or lunch room that’s not in use) - one for the dentist, a second for the hygienist, and a third (usually a wheelchair) for denture work. "A liaison - usually a nurse’s aide - meets us at the door of the facility and keeps patients flowing to us," says Milner. "What’s nice about our operation is, we don’t have any no-shows," he jokes.
"Our equipment works incredibly well," says Milner. "I don’t even have a sore back after working five days a week." Access Dental uses the Kodak SOFTDENT dental practice management system, and Milner looks forward to implementing a web-based system sometime in the future.
Solving the long-term-care dilemma
Experts agree that to solve the dilemma facing long-term-care dentistry - that is, a growing population of aging Americans and a diminishing number of resources to care for them - more money will be needed. That is the goal of the Special Care Dentistry Act. First introduced into the U.S. House of Representatives in 2005 and again considered for introduction in 2007, the first draft of the bill was authored by Greg Folse, DDS, the founder of Outreach Dentistry, a mobile dental care service for long-term-care residents in Louisiana.
If passed, the Act would appropriate more money for dental care for nursing-home residents. "Dental services would be provided by all states, and it would be heavily funded by the federal government," says Folse, who hopes the bill will be re-introduced into the House of Representatives later this year.
"It will take every doctor on every corner to effectively treat this population," he says. "Is that possible? Yes. Is it possible without any funding support from the government? The answer is, absolutely ‘no.’"
Selling such a bill to a cost-conscious Congress will be no easy task, he concedes. "That’s been something we’ve had to work to overcome," he says. The selling job comes in showing lawmakers that by treating this vulnerable adult population, dental and medical bills will actually decrease. "Currently half the nursing home patients I see have infected teeth," he says. Take away the infection and you take away corresponding health-related issues, he adds.
Money may be a sine qua non for providing dental care to long-term-care residents, but it isn’t the end of the story, according to those with whom First Impressions spoke. Awareness of the issue and education are the other two components.
"Dentists need to be encouraged...to think about how to care for the patients they’ve been seeing for 20 or 30 years," says Milner. What do they do when their elderly patients are no longer able to see them, or if the only way they can get around is in a wheelchair? "A person in a wheelchair can be perceived as someone who can’t be treated in the private practice setting," he says. Dentists need to be thinking how to make their offices geriatric-patient-friendly.
What’s more, dental students need to be trained on how to use mobile equipment, says Milner. "Typically, if a dental school has any special-care training, it’s in a fixed site in a dental school. But the population is in the community."
Indeed, says Milner, baby boomers may be the driving force to change dentists’ perspectives. They will demand oral care, even as they reside in a long-term-care facility.
"Dentistry has always been defined in a fixed office," he says. "Over the next 20 to 30 years, especially, dentists must meet the needs of those who are not able to access a fixed-office setting. Dentistry needs to meet long-term-care facilities halfway."
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