Section 3: Profiles and Audio from the Field

Features

Sharing Medical Charts Electronically. An electronic medical records system was developed under HRSA SPNS funding to ease provider access to client information. Representation on the Louisiana Governors Commission on HIV/AIDS. Involvement raised the Partnership’s visibility as an expert and service partner. Hiring a Program Coordinator. This staffer has experience working with the area’s clients and agencies. Reducing No-Shows. Various techniques lowered the no-show rate: confirmation of contact information, identification of conflicting appointments with other providers, coordination by case managers, and reminder calls and mailings.

Partners

Louisiana State University School of Dentistry Tulane University CD4 Clinic Central Louisiana AIDS Support Services Central Louisiana Area Health and Education Center

Louisiana
Louisiana State University, School of Dentistry

Overcoming a Hurricane

A dedicated staff, enthusiastic students, and a client population anxious for services are certainly crucial—and probably underappreciated—elements for success in a clinic. Each is reportedly in place at Louisiana’s Ryan White-funded outpatient clinic-centered dental project. But these factors are just part of the story that makes this program work—really, to persevere—in the face of many challenges.

Think Hurricane Katrina to get a sense for what Louisiana State University’s (LSU) dental project faced in getting back up and running. The Dental School was seriously damaged and evacuated to Baton Rouge, 80 miles north of New Orleans. The General Practice residency program lost its home base of Charity Hospital in New Orleans, forcing a move from their 26 chair clinic to one chair in a MASH tent in a parking lot and, in a later upgrade, of sorts, to a six chair “clinic” in an abandoned department store. They survived and are serving a rural eight parish region of Northern Louisiana.

Despite dealing with all these challenges, the Dental Partnership not only continued but the no-show rate has declined dramatically—from 51 percent in early 2006 to about 17 percent in late 2007. A number of techniques were used to great effect: confirmation of contact information, identification of conflicting appointments with other providers, coordination by case managers, and reminder calls and mailings.

Among the factors that helped LSU re-establish and improve services were the many partner agencies that helped bring dental services to the area’s clients and increased visibility about the Dental Partnership through representation on the Louisiana Governors Commission on HIV/AIDS. This helped with disseminating information about the Partnership’s Ryan White dental services, greater agency involvement in service delivery and referrals via various Ryan White consortia throughout the State, and an increased role for the Partnership as a source of expertise, such as involvement in a Statewide Continuous Quality Improvement committee. Also helpful was the hiring of a program coordinator with a strong history working with the area’s client population and service agencies.

Services: Networking, Addressing No-Shows

In the LSU Dental Partnership, extensive communications help facilitate delivery of care and referral of patients to other services. Their referral system works in both directions, in getting clients to both dental care and medical care. Communication methods sound routine but they work and include phone, letters/consult requests outlining medical information needed from medical providers, and sharing of clinical information. Most notably, providers share medical charts via electronic medical records, which are accessed via the Statewide CLIQ and Lab Tracker data systems.

The electronic medical records system was developed under funding from Ryan White’s SPNS, or Special Projects of National Significance—specifically, a funding initiative on health information technology. This system allows the dental clinic to print out a patient’s most recent medical progress notes, medications, and diagnosis codes and have them ready for dental residents to consult prior to treatment.

The focus on electronic records has been particularly helpful following the evacuation of patients from southern Louisiana to the central part of the State. All patients presenting to the dental clinic have their latest medical progress notes, medications, and diagnosis codes printed out for dental residents to consult prior to treatment.

The program promotes its services by communicating with HIV medical providers co-located in their building. Increasing efforts are underway to broaden outreach in the community via presentations to outside dentists on HIV oral health care that help frame the program as a resource to other health care providers in the community.

Outreach is also conducted to inform clients about services. The Partnership is now represented at testing and counseling events and has participated in three health fairs since 2006. The project coordinator developed a health fair in June 2008 where Jeannie White (mother of Ryan White) spoke. In 2007-2008, outreach to Latinos, adolescents and local drug rehabilitation programs was implemented.

For current clients, a number of appointment support efforts are in place to address no-shows:

• The staff regularly checks for conflicts with appointments at other health care clinics and confirms telephone numbers and addresses at each visit. The appointments are coordinated with medical care providers.
• Appointments for dental services can be made by other agencies as part of the referral process.
• Appointments are coordinated through case managers. Patients also discuss their next appointment with the scheduler after completing their current dental appointments.
• Patients are called/mailed reminders during the month of their recall date. Appointment failure is tracked in the program’s database. The most common reason for broken appointments is “low dental IQ,” in the words of the project, which is seen in a common belief among patients that they do not need to come to their next appointment if they have no acute complaints.

The eight parishes included in this initiative cover 7,000 square miles, making transportation pivotal to the success of the program. Vouchers for gas are provided to all patients with access to a car. For patients living within Rapides Parish, the only parish with public transportation, bus coupons are available.

Broken appointments can result in treatment being primarily episodic and problem oriented. At a consumer meeting, clients said they were unaware they were getting appointment cards. The cards/letters say “GPR” appointment, not “dental appointment,” which many clients did not recognize as a dental appointment. Clients also reported allegiance to the ancillary staff but not to the dentist as they rarely see the same provider more than once. The dramatic decrease in no-show rates during 2007 is attributed to having only one dental resident in the clinic, allowing for the development of better rapport between client and provider.

Patient Education and Involvement: Focus Groups, Smoking Cessation

In Louisiana, patients have expressed appreciation for the privacy they get from being able to go upstairs to the dental clinic to check-in, thus bypassing the first floor check-in used by other patients.

LSU has faced some difficulty raising awareness about the importance of non-urgent oral health care. Strategies to increase utilization have included:

• Raising community awareness of oral health care through patient education methods such as oral health instruction, nutritional counseling, risk minimization and prevention.
• Oral health information sheets and brochures that are provided to patients.
• A smoking cessation program. All patients presenting for care in the dental clinic are asked about tobacco use and smokers are provided with smoking cessation literature. In addition smokers are asked if they wish to access the State Tobacco Cessation Initiative, where further education (individual and group sessions) and medications are provided.

Provider Recruitment and Retention

Multiple efforts are made to involve more dentists in HIV care:

• The program coordinator and case manager participated in a summer service learning institute sponsored by Community Campus Partnerships for Health, the Ryan White TA provider for Dental Partnerships.
• The program’s principal investigator and hygienist are involved in delivering continued education courses to dental, medical, and allied health care providers. Community dental providers are provided an annual update of HIV and infectious diseases in the dental office, in conjunction with the Central Louisiana Dental Association. In addition, local providers who express interest in treating patients from this project receive more in-depth information (e.g., evaluating the HIV patient in the dental office, local counseling and testing resources, post exposure prophylaxis).
• Community dentists providing care to patients are provided with an “in house” education that targets the whole office. Feedback from these seminars has helped improve lines of communication between the Partnership site and private offices as well as greater understanding of the HIV-positive client by the entire dental staff.
• Education to local medical providers occurs twice yearly at lunch time seminars and includes topics on oral manifestations of HIV and treating dental emergencies in the medical office.