7

Reflections on the Workshop

In the final session of the workshop, the members of the roundtable identified key themes that they had heard over the course of the day and reflected on these themes and on the implications of integrating oral health care and general health care.

THE PROSPECTS FOR AND BARRIERS TO INTEGRATION

Catina O’Leary, president and chief executive officer of Health Literacy Media, started the discussion by commending the authors of the commissioned paper (see Chapter 2) and the systems approach to thinking about integration. A challenge, she added, is to create systems in which people who have different kinds and levels of training can work together for the benefit of the patient. That requires asking patients what matters to them and what is important, which is where health literacy is important.

Johanna Martinez, graduate medical education director of diversity and health equity at Northwell Health, praised Yarbrough’s definition of oral health (see Chapter 6): “Oral health is multifaceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow, and convey a range of emotions through facial expressions with confidence and without pain, discomfort, and disease of the craniofacial complex.” The definition emphasizes that oral health, like health in general, is multifaceted, and that maintaining health likewise requires a multifaceted approach.

Vanessa Simonds, assistant professor of community health at Montana State University, observed that the importance of dental health to overall health makes a powerful case for integration. Both economic analyses and

personal stories of how oral health affects eating, speaking, or getting a job can help make this point. She also noted that one effective way to reach a community and to be a change agent is to work with children, which is another place where developing health literacy can be critical.

Steven Rush, director of health literacy innovations at UnitedHealth Group, emphasized the business case for oral health literacy and the integration of oral health and general health. He recounted an experience at UnitedHealth Group in which a group of professionals considered how the system handles back pain, with the result that benefits were changed so that people could go to spine specialists first with little or no copay or co-insurance. “Focus on the business case,” he recommended. “Figure out how to present that to decision leaders in the states and in the health care industry.”

Nicole Holland, assistant professor and director of health communication, education, and promotion at the Tufts University School of Dental Medicine, rephrased the idea of dental and general health care being responsible for integration to their being accountable for integration. “It’s not just responsibility,” she said. “It’s more the accountability of all the providers in going back to why are we in this. Because we do know the majority of dental diseases are preventable, but the disease burden is still so high. When we think about whose responsibility it is, we need to think about that critically.”

Lindsey Robinson, California Dental Association, noted that the dental profession has an ambivalent relationship with medicine. The majority of dentists are still running small businesses, and it is very difficult to be part of large governmental programs like Medicare or Medicaid when running a small business. “That’s where integration will help overcome those barriers and perhaps make some dentists more willing and able to participate,” she said. In addition, for dentists to be able to provide an expanded level of care, states need to be more open to expanding scopes of practice so that existing practitioners are able to do the functions they were trained to do.

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, noted that the incompatibility of medical records between the dental and general health systems means that it will not be possible to use big data to answer questions that have not been answered before. For instance, the general health system is now merging genetic analyses with disease processes, responses to medication, side effects, and familial patterns to determine the interactions of genetics with systemic health. If both oral health and behavioral health are left out of this process, prevalent and prominent correlations will not be found. “If we don’t solve this problem in both situations, behavioral health and oral health, we’re

going to leave big gaps in the ability to understand phenotypic-genotypic correlations.”

Suzanne Bakken, alumna professor of nursing and professor of biomedical informatics at Columbia University, also said she was interested in how the Marshfield Clinic was integrating medical and dental records to the extent of being able to do data mining on the combined data. On this issue, Gayle Mathe, director of community health policy and programs at the California Dental Association, stated that medical records are commercial products for the most part for which integration is not a high priority. Getting the Health Resources and Services Administration (HRSA) or some other organization to fund work on an integrated record that would be widely disseminated would “make a huge difference.”

Terri Ann Parnell, principal and founder of Health Literacy Partners, appreciated the structure of the meeting in returning to the themes of health literacy and integration. She commented that issues such as additional health professional education, the consistency of definitions, practicing to the full scope of practice, breaking down silos, innovative technology, telemedicine, and looking at measures of health all relate to those two central themes.

PROFESSIONAL BURNOUT AS A FACTOR IN INTEGRATION

Smith pointed out that the medical profession has never had a higher burnout rate in history than it does today. “We may well lose a generation of practitioners, and the highest burnout rate is in primary care physicians.” He worried it was unrealistic that primary care physicians would be able to assume some of the tasks described at the workshop. Primary care must be delivered by a team, he said, and everyone on the team must be able to do the maximum that they are allowed to do by virtue of their education. Primary care physicians therefore should be responsible for tasks that require the complexity of training they received in medical school and residency. “I’d like to know a little bit more about teeth when I look in the mouth—that would be a positive thing. But the idea of doing structured oral health screenings is not going to be part of that physician’s job. It just can’t be.”

Christopher Trudeau, associate professor of medical humanities at the University of Arkansas for Medical Sciences and associate professor of law at the William H. Bowen School of Law at the University of Arkansas at Little Rock, agreed that the comments about primary care physicians being overburdened resonated with him. “How do we create a coordinated care model that works in all areas?” For example, the idea that anyone with training can apply fluoride varnish was a revelation. Embracing more of that kind of innovation can help reduce disparities in a more integrated system.

Integrated and health-literate practices will help achieve what is coming to be known as the quadruple aim, said Bernard Rosof, chief executive officer of the Quality in Health Care Advisory Group, and professor of medicine in the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell:

• Enhancing the patient experience
• Improving population health
• Reducing costs
• Improving the work life of health care providers, including clinicians and staff

The integration of oral and general health through greater health literacy can help achieve these aims while focusing on the concept of value in terms of cost effectiveness versus outcomes, Rosof said.

THE NEED TO ADDRESS SOCIAL DETERMINANTS

Michael McKee, assistant professor of family medicine at the University of Michigan Medical School, expressed surprise at how many ways oral health affects people. As such, oral health disparities raise the basic issue of people’s right to health care. As with general health, oral health has many haves and have-nots. This is the case not only for vulnerable populations but for other populations, such as those in health systems of different sizes. If integration occurs only in large government programs and health care corporations, many people will be missed. All of these observations argue for a global health insurance system, he said, that encompasses both dental and medical care. Keeping the two separate is “onerous, inefficient, and unfortunate for many people in our country.”

Jennifer Dillaha, medical director for immunizations and medical advisor for health literacy and communication at the Arkansas Department of Health, emphasized the importance of the social determinants of health. She noted that addressing these in a health-literate way can do much to promote the integration of health. Martinez, too, mentioned the need to address social determinants, “because if not, it’s all for nothing.”

Robinson emphasized the need to reach out to populations that are not served by large health care organizations and provide them with care in community-based settings “where the kids are, where the families are.” This idea appealed as well to Terry Davis, professor of medicine and pediatrics at Louisiana State University Health Sciences Center, who praised the idea of bringing oral health care to where children are and having this care delivered by a wide variety of professionals.

THE ROLE OF HEALTH LITERACY

Linda Harris, director of the Division of Health Communication and e-Health Team in the Office of Disease Prevention and Health Promotion at the U.S. Department of Health and Human Services, emphasized the value of the workshop in clarifying how the entire health care system can become more navigable through enhanced health literacy. She thought that a Medicare pilot project or demonstration project could help vulnerable people use the health care system in a way that leaves them more informed, “which is essential for having a value-based care system.”

Amanda Wilson, head of the National Network Coordinating Office at the National Library of Medicine, pointed to the critical role that health literacy can play in dealing with the “tsunami” of change posed by integration. However, the task of using literacy to advance integration is daunting, she added. The complexity of both dental care and medical care is not worked to the benefit of the patient. In that respect, team-based care is probably the most promising way forward.

Wilson also pointed to the need for dentistry and not just primary care to change. An integrated system with a global budget and vertical integration can help drive these changes.

Lori Hall, director of health literacy, Global Medical Strategy and Operations, for Eli Lilly and Company, talked about meeting patients where they are. “The missing piece for the evolution of this discussion is to talk with patients.” She also recommended leveraging what is known about the role that health literacy plays in general health and about the factors that influence nonadherence in patients to better understand why patients do not adhere to a healthy dental health regime. Finally, she recommended involving representatives from the target audiences in research and in the planning, implementation, dissemination, and evaluation of information regarding their oral health.

Mathe reemphasized the point about engaging across the social services, where oral health literacy practices are fundamental to success, especially given the relatively small influence of clinical services on most people’s health. Following the money is a useful guide. “When the medical payers see the benefit and feel the benefit, the needle will start to move. And because it hasn’t moved as much as it could, that’s where I’d be focusing research.” For example, if a demonstration project in Medicare could focus on people with diabetes and prove how much money is being saved, the demonstrated return on investment could drive change.

HEALTH LITERACY AND COMMUNICATION

Holland emphasized the influence of the language used within health care. For example, within dentistry, and within her specialty of facial pain,

“the terminology is all over the place.” People do not know what TMJ (temporomandibular joint) or TMD (temporomandibular joint disorder) means. Doing research on some of the basic questions involved in communication information “would certainly lift both oral health and general health.”

Davis, too, noted that, like medicine, dental health is full of jargon. People spoke repeatedly at the workshop about caries and periodontal disease, but most people think of these as cavities and gum disease. Many people continue to have low levels of health literacy, she pointed out, which requires that communications be understandable, not just that those levels of literacy be raised. “Sometimes I feel like I need help with forms in the dental office,” she said.

Gemirald Daus, public health analyst with HRSA’s Office of Health Equity, agreed that being able to speak clearly with each other would help integration. Even the phrase “oral health” is not exactly plain language, Daus noted. The definition of oral health discussed at the workshop could help with this.

Dillaha pointed out that health care providers struggle with communications between and within primary care centers. Health literacy can be a lever to put pressure on the system to integrate physical, behavioral, and oral health.

Olayinka Shiyanbola, assistant professor in the Division of Social and Administrative Sciences at the University of Wisconsin–Madison School of Pharmacy, mentioned a family member who ended up in the hospital because of a dental issue and emphasized the opportunity to communicate health information when a patient is in a dental chair. It would be an opportunity for a patient to learn about periodontal disease or even the proper way to floss. “Even if it’s just that little piece where we start enhancing health literacy and bringing forth health literacy principles, it would go a long way.”

EDUCATION AS A DRIVER OF INTEGRATION

With regard to education, McKee emphasized the pipeline issue and the need for dentistry to attract a very diverse range of students and faculty members. In particular, more needs to be done for people who want to return to their communities, he said. Martinez also called attention to the importance of the educational pipeline in building human capacity, doing research, and changing systems.

Bakken mentioned the simulation training across professional students taking place at Columbia as part of an effort to promote integration. She also noted that Columbia has a nurse who is jointly appointed in the School of Dentistry, which makes interprofessional education easier.

HAVING AN OPPORTUNITY TO EXPLORE INTEGRATION

Holland thanked the roundtable and the National Academies for holding the workshop, saying that her students at the Tufts University School of Dental Medicine were “excited that oral health has been elevated to this level.” Robinson similarly expressed her thankfulness to the National Academies and to the roundtable for organizing and holding a workshop on the subject of oral health. She also thanked the past director of the roundtable, Lyla Hernandez, who retired the summer before the workshop but was instrumental in moving it forward.

Finally, Robinson mentioned again the power of stories, such as the story of Deamonte Driver’s death, to move policy. “His death was a reflection of a system’s failure,” she said. It helped create champions who can remove barriers, “whatever they may be: economic, policy, educational, health literacy, or oral health literacy.”

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