Section 3: Profiles and Audio from the Field

Features

Student Training With Public Health Focus. Students shadow an Infectious Disease specialist, assist with both primary and specialty dental services, and complete a public health project. Integration of Medical and Dental Care Within a Community Health Center. Combining primary care and dental care provides opportunities for interdisciplinary clinician consultation and improved patient retention in care. Improving Patient Outcomes Via a Dental Liaison. A Dental Liaison helps address appointment no-shows by follow-up with patients and coordination of providers.

Partners

Boston University Goldman School of Dental Medicine Holyoke Health Center

Massachusetts
Boston University, Goldman School of Dental Medicine

Urban Community Health Center Enhances HIV Dental Care

Holyoke, Massachusetts in western Massachusetts has the State’s highest rate of increase in HIV transmission cases, when measured in terms of cases that occurred from within the local area. Since cases predominate from within the area’s low income communities, it made sense to deliver dental services at the area’s major provider of primary care: the Holyoke Health Center, the largest federally-qualified health center (FQHC) in the region. For over 10 years, Holyoke Health Center has received Ryan White Part C funds for primary and specialty care HIV services. Holyoke also operates a state-of-the-art HIV dental clinic.

Holyoke Health Center works with the lead agency in this Partnership, Boston University’s dental school, which has a strong track record in training students through community-based dental education across the state.

Services: Dental Liaison Enhances System of Care

Holyoke Health Center serves an urban, impoverished and largely Hispanic/ Puerto Rican population and provides an array of primary care services out of a large health center site located in a refurbished downtown building complex. All project staff members are bilingual in English and Spanish and live in the community. Because of Ryan White funded dental care, many patients are getting their first-ever opportunity to have oral health integrated within their overall HIV and primary care. That translates into improved coordination of services, integrated care and improved outcomes. This is complemented by more immediate physician-to-dentist consultations on lab values and drug contraindications as well as case management support to help patients stay in care across various disciplines in the center.

Primary and specialty dental care is provided on-site at Holyoke Health Center. The dental school/Holyoke partnership is solidified via a formal Memorandum of Agreement. It articulates: identified responsibilities, vision and mission, as well as each partner’s role in achieving the program goals, the relationship between various departments and programs, and lines of communication between the partners. The latter is in the form of phone and email contact between the Ryan White project director at Boston University and Holyoke staff and team meetings, which occur about once per month.

Connections to care have been further bolstered through the establishment of a Dental Liaison position. Based at the Holyoke dental clinic, she is the point of contact for all HIV Team members, dental staff and sites throughout the Western Massachusetts Partnership area. The Dental Liaison ensures that primary care doctors refer their HIV patients for dental care through outreach and ongoing education.

Holyoke is not without its challenges in delivering oral services. The missed appointment rate is around 45 percent for new HIV-infected patients and 25-30 percent for other dental patients. Although it is challenging at times to begin care, once patients have started, the program has a completion of treatment rate of nearly 100 percent. The most common factors contributing to missed appointments by the HIV oral health program’s patients are illness, incarceration, homelessness, and substance addiction relapse. Steps to reduce broken appointments include reducing wait time for appointments, counseling of repeat no-shows, and reminder calls and cards. Additional techniques include enhanced integration of the HIV Team to make care more seamless and establishment of a personal relationship between the Dental Liaison and clients.

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.

Patient Education and Involvement: Technology, Satisfaction Surveys

Patient education occurs via dialogue between patients and providers and focuses on improving attitudes about oral health care. Technology plays a large supporting role in Holyoke’s patient education. CAESY software is used, which can be programmed in response to specific patient needs (e.g., oral hygiene instruction). Flat screen monitors are located in all dental operatories along with patient handouts. The software allows patients to access educational materials of their choosing while waiting for providers.

Oral health pamphlets and posters are provided to patients and cover such topics as the importance of oral health care for those infected with HIV, what to expect during an oral health exam, and the importance of follow-up care.

And what do patients think? Patient satisfaction surveys report that the care they receive is excellent and their improved oral health has dramatically improved their lives. Anecdotal observations add some understanding to these numbers. Said one patient: “They take care of my fear.” Another indicated: “They re-check the meds I am taking.” While patients indicate some challenges, such as transportation time and lack of student providers during the summer, there is interest in a Consumer Advisory Panel to provide input to clinic operations as well as a willingness to guide the clinic with outreach efforts.

Provider Education and Training: University Committed to Community Outreach

Boston University’s School of Dental Medicine is the source of student training and education for Holyoke and 24 other sites across the State. Their commitment to community-based health is evident. Several high-level community outreach positions exist at the school, providing voices of leadership that help promote the University’s 50-plus community-based programs, including Ryan White dental services.

Dental students complete a 10-week rotation at Holyoke and live in the area in the University’s apartment complex. Training includes the following:

• Students review three CDs on oral health management of HIV-infected patients and then shadow an Infectious Disease specialist one morning.
• This experience is then translated into clinical care delivery, under the direction of the Holyoke staff dentist, who holds a faculty appointment at the University. While most dental care is primary oral health, students also provide specialty services under the direction of an oral surgeon, periodontist, and endodontist.

In addition to the clinical experience, students must complete a public health project that addresses a need of the HIV community served by Holyoke. At the end of their rotation, the students write a report, including a reflection of their experience in conducting the public health project. Some examples of student projects include: creation and implementation of a patient satisfaction survey, and creation of a slide-based patient educational presentation regarding the importance of oral health for individuals with HIV that can be used chair side in the primary care clinic or with the patient’s HIV case manager. Both tools have been used to improve integration of HIV primary and dental care.