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Section 3: Profiles and Audio from the Field
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Features
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- 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.
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Partners
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- Louisiana State University School of Dentistry
- Tulane University CD4 Clinic
- Central Louisiana AIDS Support Services
- Central Louisiana Area Health and Education Center
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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.
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