3

Systems Thinking, Integration, and Health Literacy as a Catalyst¹

The first panel was designed to foster discussion at a “high, systems level” of the link between integration and health literacy, explained moderator Dushanka Kleinman, principal associate dean, associate dean for research, and professor in the School of Public Health at the University of Maryland, College Park. Four panelists with a wealth of experience in oral health engaged in this systems thinking—Kathryn Atchison, professor at the University of California, Los Angeles (UCLA), School of Dentistry, and in the UCLA Fielding School of Public Health (whose earlier presentation was summarized in Chapter 2); Anita Glicken, associate dean and professor emerita at the University of Colorado School of Medicine and executive director of the National Interprofessional Initiative on Oral Health; Ronald Inge, chief operations officer, chief dental officer, and vice president of professional services for Delta Dental Plan of Missouri; and George Taylor, associate dean of diversity and inclusion and professor in the Department of Preventive and Restorative Dental Sciences at the University

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¹ This chapter is based on presentations by Kathryn Atchison, professor at the University of California, Los Angeles (UCLA), School of Dentistry, and in the UCLA Fielding School of Public Health; Anita Glicken, associate dean and professor emerita at the University of Colorado School of Medicine and executive director of the National Interprofessional Initiative on Oral Health; Ronald Inge, chief operations officer, chief dental officer, and vice president of professional services for Delta Dental Plan of Missouri; and George Taylor, associate dean of diversity and inclusion and professor in the Department of Preventive and Restorative Dental Sciences at the University of California, San Francisco, School of Dentistry. Their statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

of California, San Francisco, School of Dentistry. The question-and-answer session following their presentations provided workshop participants with an opportunity to pose questions that would shape further discussions over the course of the day.

The panelists were asked to address the following questions:

1. From your perspective, what do you see as a new path forward toward integrating oral health with general medicine using health literacy as a catalyst?
2. Integration of health care delivery has to happen across multiple systems; given the systemic barriers and facilitators, what role can health literacy play to support integration?

INTEGRATING ORAL HEALTH WITH GENERAL MEDICINE

Taylor approached the issue of integration from the perspective of the systems that create and disseminate knowledge. Despite the scientific evidence linking oral health and general or systemic health, awareness of this evidence is limited. Statements such as “I didn’t know that diabetes has an impact on oral health” are heard from many health care professionals, Taylor pointed out. Without greater awareness, efforts to integrate oral and systemic health in primary care will continue to falter.

A specific example of the lack of awareness involves the link between periodontal health and pregnancy, Taylor continued. Evidence is emerging regarding a two-way relationship between gestational diabetes mellitus (GDM) and periodontitis whereby GDM adversely affects periodontal health and periodontitis may have an adverse effect on GDM and maternal outcomes (Borgnakke et al., 2017). Furthermore, more broadly for people with type 2 diabetes, meta-analyses and systematic reviews support the idea that glycemic control is significantly improved in individuals with diabetes by receiving nonsurgical periodontal therapy and periodontitis is associated with complications of diabetes (Borgnakke et al., 2017). Using that evidence as a basis and motivation for integration could enhance programs directed toward pregnant women, Taylor observed. Additional evidence supports an association between oral health and atherosclerotic cardiovascular diseases, though that evidence is weaker than for GDM and type 2 diabetes.

Another specific example involves the geriatric population in long-term care facilities. An emerging evidence base suggests that poor oral health and factors related to oral hygiene may increase the risk for aspiration pneumonia among the elderly, which is a major adverse outcome in long-term care facilities (Liu et al., 2018).

In response to a question on the economic and overall benefits to be derived from integration, Atchison noted that pediatric dentistry has more

evidence than other areas of dentistry. In particular, the provision of oral health care before the age of 42 months can prevent devastating early childhood caries, which, if not treated, can require hospital treatment for a child. Atchison added that she was not aware of studies that followed children who received routine preventive oral health services over time to track future oral and general health care costs and savings. The need for a more comprehensive inclusion of oral health in overall health care for children is reflected in statewide health survey findings, professional oral and general health care guidelines, organizational policy statements, and recommendations from the U.S. Preventive Services Task Force and Bright Futures. “The leadership is on board for doing this, and I think that it is well ingrained in both pediatric dentists and pediatricians,” Atchison said.

Lindsey Robinson from the California Dental Association suggested developing a prospective study to determine if dental services offered to patients would reduce the cost of managing chronic disease, especially in terms of hospitalizations and the use of pharmaceuticals. Such a study could also examine whether greater health literacy improves patients’ ability to take better care of themselves and could inform the design of health care systems to ensure that such messages are provided consistently.

INTERPROFESSIONAL COLLABORATION

“Systems change is never easy,” said Glicken, “but it is particularly difficult when we do not have a shared vision of where it is we want to go.” She advocated increasing the health literacy not just of patients but of providers, payers, and others associated with oral health care and medicine to help create such a vision.

In 2007, newspapers across the country carried the story of 12-year-old Deamonte Driver, who died from the effects of an untreated tooth abscess due to dental caries. At the time, a physician, nurse, physician assistant, or pharmacist might have read the story and thought, “What a shame. Too bad they couldn’t find a dentist,” Glicken observed. A decade later, redefining the problem through the lens of an integrated care delivery system has made those health care providers and others an important part of the solution.

In 2009, Glicken was part of a group of innovative health leaders from medicine and dentistry who worked together with the goal of eradicating dental disease. They started from the hypothesis that integrating oral health care into the primary care practice of multiple providers (physicians, nurses, physician assistants, etc.) would create a paradigm shift that would lead to a different approach to oral health care. “We knew that this paradigm shift of putting the mouth back in the body was not going to be easy,” she said. “It was going to challenge our values and many of our basic assumptions…. But we thought we could create a new standard.”

The next year saw the launch of the National Interprofessional Initiative on Oral Health, which was organized around four key strategies: (1) cultivating leadership, (2) facilitating interprofessional learning and agreement, (3) developing and supporting tools and resources that bridge cultures and create a shared knowledge base and vocabulary across the health professions, and (4) working with health, medical, and dental professional organizations to try to align strategies and create actionable strategies for change. The initiative sought to create shared ownership of oral health so that the members of different professions could work together interprofessionally.

Oral health literacy has been a key lever in this work, Glicken said. It has helped to grow and change the oral health workforce. It has been preparing professionals for a paradigm shift from treatment to prevention, from individual care to population health, and from a fragmented delivery system to more integrated practice models that care not just for the mouth but for the whole person and for all people.

Kleinman pointed out that the 2000 Surgeon General’s report on oral health had a similarly broad message (HHS, 2000). It focused on oral health, not just on dentistry, and one of its key messages was that promoting oral health required everyone to be involved, from individuals and caregivers at home to medical and dental health care providers to entire systems.

DESIGNING DELIVERY SYSTEMS

Integration has to go in both directions, said Inge. The message that “oral health can help on the medical side” is often repeated. But dentists have resisted integration, Inge observed. “We still have instances, too frequently, that dentists will refuse to treat a woman who is pregnant for fear of potential liabilities. To me, that is a disservice to those patients.”

Inge, who works mostly with benefit designs, is part of the Delta Dental group of companies, which is responsible for the dental care benefits of more than 75 million people in the United States. It has emphasized the relationship between oral health and systemic health, but it has not been able to implement that relationship in delivery models on a large scale. While the system may provide extra benefits for a pregnant woman or someone who is diabetic, not enough information or knowledge is being disseminated as to why those benefits exist.

The challenge is largely economic, he continued. Dental benefits in the United States are driven mostly by what employers are willing to pay for with their employees. For the situation to change, decision makers, such as human resources directors, need to be convinced to change benefit plans. For example, they would need to agree to integrate oral health into those areas of general health where it has been shown to be beneficial. Change

would then need to be integrated into the care protocols of both dentists and physicians so that they have a shared responsibility and possibly a shared reimbursement.

Inge observed that dentists often ask, “How do I get paid for doing this service? If I am not going to get paid for it, then I am less likely to do it.” Overcoming this resistance requires considering the economics of integration, he said, “because unfortunately, in this day and age, the economics are going to drive what services a patient receives and whether or not there is going to be collaboration between physicians and dentists.” Kleinman added that this is another area where the system is well positioned and needs to disseminate knowledge from one component of the delivery system to others about the potential health benefits that exist.

In response to a question from Atchison regarding what the process of a hypothetical integrated program between Delta Dental and Blue Cross might look like, Inge recounted that, about 15 years ago, Delta Dental of Minnesota and Blue Cross/Blue Shield of Minnesota implemented a pilot program that provided dentists with screening tools for diabetes. Based on the results of those screens, additional tailored services for the patient would be covered, so greater integration is possible. The challenge, he continued, is whether employers have the mindset to take care of their employees’ health as opposed to providing them with a dental benefit as an employment incentive. “There are individuals like myself who sit at every Delta Dental office and look to find ways to integrate oral health and overall health. It is in most of our mission statements. But because of our siloed position between dentistry and medicine, there is not a clear path forward,” Inge stated.

Inge also noted that the marketplace has facilitators entering with access to the medical plan, the disease management program, the dental plan, and dental providers, allowing for information to pass between the systems. However, a barrier is that the systems currently speak different languages. He said,

On this point, roundtable consultant Lawrence Smith, dean of the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell

and executive vice president and physician-in-chief of Northwell Health, observed that he has been a primary care physician for 42 years, yet “I have never seen a dental record of any patient I have ever cared for. I would not even know what they looked like. I doubt I could understand them if I read them.” Smith also asked about the differences in the insurance systems between dentistry and medicine, with medical insurance typically including a copay and deductible but dental insurance working very differently.

Inge agreed that a disparity exists between medical insurance and dental benefits. “You notice that I say ‘dental benefits’ and not ‘dental insurance,’ because that is the distinction.” After World War II, when wages were frozen, benefits became an additional incentive for employment, and dental benefits were developed not necessarily to influence an employee’s dental health but as an employment incentive. For example, Delta Dental, which was the first dental-only benefits company, started in Washington, California, and Hawaii and was for the children of longshoremen. That dental benefits plan still exists today, and it has 100 percent coverage, said Inge. “The reason for that is, if you do the actuarial analysis, only 3 to 5 percent of all people who have dental benefits actually exceed their maximum. So there is a governor there. Your out-of-pocket amount that you have to pay is the true governor of the the amount of services you will receive.”

The challenge today is to shift the focus from dental services to oral health services in the context of insurance, Inge observed, with insurance reserved for catastrophic costs. He warned that many dentists may be offended by the idea, but

GETTING PEOPLE TO WORK TOGETHER

Atchison said that, as a former private practitioner, educator, and residency director, she often wonders, “How do you get people, practitioners, to work together?” Professional office buildings often have dentists and physicians in the same building, but they rarely interact. Because the predominant form of practice for dentists is still private practice, and because they rarely come into contact with physicians through their practices, the problem needs to be approached at a systems level, she said. The leadership of the professions must say, “This is important that we all work together.”

Atchison recommended that all professional organizations open their continuing education programs to everyone. If the American Dental Association offered its Continuing Education Recognition Program not only to dentists and dental hygienists but to physicians and nurses, people would learn together. Sessions could even include opportunities for people to talk about what they learned and how they could operationalize this new understanding among professions.

On the topic of interprofessional collaboration, Rosof pointed out that when he was in the New York State Department of Health, dentistry was in the Department of Education, making it difficult to integrate changes based on guidelines that had been developed. “Integration has to occur at multiple levels, and clearly health literacy would help that.”

THE ROLE OF HEALTH LITERACY IN INTEGRATION

Inge pointed out that health literacy enables people to get outside their comfort zones. As an example, he cited the Delta Dental plans that are partnering with large employers and their pharmacy benefit providers to identify opioid abuse within their populations. The dental plans can then provide counseling to dentists and to their members about overcoming opioid abuse. This is one of many ways in which dentistry has an opportunity to be viewed as part of the larger health care system. “We are now, for the most part, very isolated to the mouth, when we know that there is so much more that we can communicate to our patients,” Inge said. In this way, dental benefits companies can go beyond what is traditional and explore opportunities to educate individuals about the links between oral health and overall health.

The value of health literacy extends across multiple dimensions, said Taylor, especially when, as Glicken pointed out, it is a two-way street between the consumers and the providers of health care (including health care payers and systems). Effective communication requires cultural humility and overcoming unconscious bias. Everyone brings assumptions to an encounter, regardless of the nature of that encounter. When a patient is meeting with a provider, signals emanate from dress, speech, grammar, and body language. With groups, relevant questions include who is paying attention, who is not paying attention, what language is used, and what kinds of questions are asked. Assumptions often will be immediate and automatic, and people need to pay attention to those assumptions and how they influence an encounter, Taylor said. These assumptions play a role in both achieving cultural competency and avoiding unconscious bias. The result can be “appropriate as well as culturally sensitive communications across the board.” As Kleinman emphasized, these considerations extend across organizational levels, influencing everything from facility design and signage in a building to the ways in which staff are trained.

Belonging is another important concept, Taylor pointed out. Many dentists do not feel that they belong to the broader health care system. Interprofessional education and interprofessional practice can build that sense of belonging while improving the health of patients and populations.

INVOLVING CONSUMERS IN THE DISCUSSION

Glicken agreed about the need to expand the discussion to consider the voice of the consumer. “If we look around at some of the changes that are happening—the advances in technology and immediate accessibility of information—we are on the verge of a paradigm shift, and potentially a tsunami,” she said. Health literacy can push that tsunami along, she said, while helping to produce a more consumer-oriented mindset. She recalled that in 1993, when she began teaching a course titled “Evidence-Based Medicine,” she tended to get pushback from students who said things like “Why should I learn this? Nobody else is doing it. That is someone else’s job.” Confronted with the same body of evidence, providers would say, “Are you questioning my clinical judgment? This is my area of expertise.” Policy makers and payers struggled to figure out how to integrate this new approach into paying for and managing care.

But just a few years later, students who were trained in evidence-based medicine were being praised for thinking in different ways about the practice of medicine. At the same time, patients were bringing to their providers information they saw on the Internet and asking how it applied to their situation. The same thing could happen with oral health, said Glicken. Patients need readily accessible and culturally sensitive information about their oral health. But across the health professions they also need providers and leaders who can help them figure out how to personalize that information and apply it to their own care. “I am hoping that oral health literacy is the tsunami of change that activates patients and moves us forward toward a more integrated care delivery system.”

Atchison suggested working to improve health literacy through insurance-based networks. For example, if people received information on topics such as cardiovascular disease, diabetes, and other chronic diseases when they signed up for insurance, including Medicaid, they could receive information that they need to have and are not necessarily going to get from their providers. She recounted the story of a colleague’s husband who wanted to have more periodontal cleanings because he had heart disease, was overweight, and had diabetes. He was told by his dentist that his insurance would pay for only two cleanings per year, though Atchison knew it would pay for three. When she wrote out the information and had him present it to his dentist, he was told that in his case insurance would pay for three cleanings. “The practice did not know. The practice did not offer it to him. We need to get information directly

to the patient … that they can use to get the care they need. That would be a health-literate message.”

QUESTIONS FOR DISCUSSION

At the end of the discussion session, Kleinman called for workshop participants to provide questions that could be addressed over the course of the day as well as by the panelists. These questions were provided:

• How can consumers promote the integration of care?
• How can payment systems be reformed to drive integration?
• How can evidence of the benefits of integration be generated?
• How can oral health be included in continuing medical education?
• How can better health literacy among providers and consumers enhance integration?
• Whose responsibility is it to communicate information to providers and consumers about the link between oral health and general health?
• How can the public health system contribute to integration?
• How can dentists be encouraged to pursue integration?
• How can the existing evidence for cost savings and better health as a consequence of integration be documented, communicated, and strengthened?

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