Supporting HIV care through education and innovation

Oral Health Training Manual: Lessons Learned

Oral Health Training Manual: Lessons Learned

December 2013
Author:
IHIP
IHIP HRSA HIV/AIDS Bureau

A dentist works on a patientThe SPNS Oral Health Initiative allowed grantees to build or expand oral health care programs to serve their patients, and to test new models of care in an effort to identify innovative ways to do a better job of serving not only their own patients, but all PLWHA. The lessons learned from their SPNS projects are shared below to encourage implementation of best practices. They include the following:

  • Considerations for getting started with establishing an oral health care program, including securing partnerships, financing, and staffing and management,
  • The value of dental case management,
  • Tips on integrating medical and oral care,
  • Addressing patients’ geographic isolation and transportation needs, and
  • Pros and cons of the organizational models used by SPNS Oral Health Initiative grantees.

New to Oral Health or Need a Refresher?

See the glossary in Module 4 in the corresponding IHIP curriculum to brush up on key oral health terminology.

Getting Started

Embarking on an oral health program requires careful evaluation of available resources. Oral Health Initiative grantees performed needs assessments in advance of launching their SPNS projects that took into consideration the human resources, equipment and office space, marketing, and finances needed to execute their proposed projects successfully. Creating partnerships, establishing high standards for staffing and management, and ensuring sufficient financing were important
foundational activities that paved the road for successful and sustainable oral health programs, as discussed below.

Creating Partnerships

Many SPNS Oral Health Initiative grantees developed partnerships with other organizations to complement and supplement their services, as well as to help bring people into care through shared marketing resources and networks. In fact, those grantees that developed collaborative relationships with other providers offered higher levels of dental service on a whole than those that did not. (To revisit definitions for different levels of oral health care, see here). The types of partnerships explored by grantees ranged from collaboration with teaching institutions to partnerships with other HIV and/or community health organizations.

Collaboration itself can present challenges as well. It requires careful coordination and flexibility for all partners involved. SPNS grantees have shared the following lessons learned from the process of creating such partnerships:

  • A partnership, like any business relationship, is built on trust and mutual accountability. Providers should carefully define each partner’s responsibilities in a written agreement or contract. This written document should be revisited if disputes or misunderstandings arise regarding each partner’s agreed-upon contribution to the partnership.
  • Consider involving Ryan White Planning Councils or consortia in early discussions to provide guidance.
  • Learn from others. Talk to other local or national HIV organizations providing oral health services and share lessons learned.
  • Introduce partners to dental/medical case managers and dental/medical professionals. Encourage the parties to discuss and address questions around expectations and processes.

Staffing and Management

Health care is a “people profession,” and thus it comes as no surprise that human resources are as vital for a successful oral health program as they are for any health program. Ensuring the staffing of nonjudgmental, culturally competent oral health professionals, particularly in areas with high HIV stigma, is critically important. Some Oral Health Initiative grantees encountered challenges in recruiting staff at their sites. These included overcoming stigma and discomfort working with PLWHA, high turnover rates, and lack of education around the unique needs of PLWHA. “There’s still great stigma and fear [of PLWHA] in the dental profession,” shares Dr. Howell Strauss of the AIDS Care Group (ACG) in Chester, PA. Nancy Young, administrator of the SPNS Oral Health Initiative grant at SHRT, agrees. “In the first year of the grant, we struggled to find someone who was comfortable working with HIV-positive people.”

Another challenge for staffing is the growing number of dental health professional shortage areas (HPSAs)— commonly called “dental deserts”—in the United States. These are areas that have a disproportionately low number of practicing dentists, based on a dentist to population ratio of 1:5,000 or more people per dentist. As of January 2013, HRSA estimates that there are currently approximately 4,600 dental HPSAs.13 (To identify dental shortage areas across the country, please visit www.hrsa.gov/shortage/find.html).

These dental deserts are not due to a shortage of U.S.- based dentists overall. In fact, the Bureau of Labor Statistics reports that the number of dentists is expected to grow by 21 percent from 2010 to 2020, faster than the average for all occupations.14 Rather, dental shortage areas arise, in part, because of financial disincentives for dentists to set up practice in impoverished or rural areas. Dentists often graduate from dental school with significant debt and are much more likely to set up practice in areas that are more heavily populated and lower in poverty, increasing the likelihood that they will treat higher profit-margin patients.

Dental deserts are partly why SPNS grantees in rural settings were more likely to develop comprehensive training programs for dental residents and hygienists. Training provided not only a means of strengthening the number of dental providers in the region but, at the same time, helped reduce stigma and fear of working with PLWHA.

Once a provider has addressed key staffing and training concerns and has a solid oral health team in place, the next step is providing the necessary management and reporting structure between the oral health care team and the broader clinic team. This can be accomplished by creating a set of procedures that are documented and that all stakeholders have reviewed and approved. These procedures can be especially critical in cases where low managerial supervision is provided, such as in a satellite clinic.

One grantee addressed this challenge by transferring existing staff from its primary clinic to work at its satellite clinic and, in turn, hiring new help at the primary clinic. This ensured that those working at the satellite clinic were already fully familiar with the grantee’s policies and reporting structure, while giving new staff a chance to acclimate to their new roles in a more controlled setting.

Definitions for Levels of Care

Services that are underlined are services that are not included in the level of care immediately below the level being described.

  • Comprehensive Care: Nearly all dental services, including endodontics and fixed prosthodontics.
  • Intermediate Care: Diagnostic care; preventive care; restorative care, excluding crowns; and periodontal care, including surgery, oral surgery, removable prosthodontics and adjunctive services (emergency care, consultations, night guards, etc.).
  • Basic Care: Diagnostic services; preventive services; restorative care, excluding crowns; and periodontal care, excluding periodontal surgery and adjunctive services.

Source: Tobias CR; Fox, JE, Bachman SS, Bednarsh H, Reznik DA, Abel S, on behalf of the Evaluation Center on HIV and Oral Health (ECHO). Expanding Access to Care for People Living with HIV/AIDS: Service Utilization and Costs. May 2012.

Financing Oral Health Care

Navigating through policies related to payment for oral health care services is difficult. It is important for oral health and medical staff to understand the ins and outs of the funding options available for financing an oral health program for PLWHA.

Dental insurance is not as common in the private sector as medical insurance. The number of adults without dental coverage is three times as high as the number of adults without health insurance coverage.15 In fact, more than 100 million Americans do not see a dentist because they can’t afford it.16 In some cases, State Medicaid programs for low-income and disabled individuals are able to fund dental coverage for PLWHA, but the level of coverage can vary widely—and may even be nonexistent in some States. Unfortunately, the number of States with no or reduced Medicaid dental coverage may be increasing, as dental coverage is often one of the first services to be eliminated in State budget cuts.

The Ryan White HIV/AIDS Program also has provided funding for dental care for uninsured and underinsured HIV-positive patients, as a core component of comprehensive HIV/AIDS clinical care. Parts A, B, C, D, and F of the Program all may cover dental care as part of their service mix. (To learn more about the different Parts of the Ryan White HIV/AIDS Program, please visit http://hab.hrsa.gov/abouthab/aboutprogram.html).

Alternatives to Federal funding options should also be explored. Some grantees had success accessing private foundation funding for components of their programs, such as their dental case management, or by utilizing a sliding fee scale for patient services. Other grantees recruited patients with private insurance to their practices, helping to counterbalance the cost of HIV patients who cannot afford oral health care. (To learn more about the impact of this funding approach on project sustainability, please Program Sustainability).

The Affordable Care Act is expected to expand health insurance nationally, but will not require insurers to offer adult dental coverage as an essential health benefit.17 As such, there remains a need for Ryan White providers to offer this care to PLWHA. In order to understand what it will cost to expand oral health services for PLWHA, administrators need to know:

  • How many new people need care,
  • What services should be covered (basic care, intermediate care, comprehensive care, or all of the above),
  • How much providers should be paid, and
  • Funds available to pay for care.

The data displayed in the table below was collected by the SPNS Oral Health Initiative grantees over a 2-year period, capturing costs for services provided to 1,053 individuals and across 3 different fee schedules. During that short time, significant improvements in health and reductions in cost per person were realized. In fact, the cost of the care delivered in the second year dropped by more than two-thirds across fee schedules.

Average Costs of Services Per Person for 1st and 2nd Years of Treatment

 Average Price/
Person
Very LowMediumHigh
Comprehensive CareYear 1$603.31$1,271.32$1,829.13
 Year 2$231.67$393.02$546.44
 Difference
Year 1 – Year 2
$371.64$878.30$1,282.69
Intermediate CareYear 1$383.24$965.44$1,435.09
 Year 2$104.83$237.02$349.42
 Difference
Year 1 – Year 2
$278.41$728.42$1,085.67
Basic CareYear 1$216.99$541.16$833.52
 Year 2$55.88$126.19$191.89
 Difference
Year 1 – Year 2
$161.11$414.97$641.63

Source: Evaluation Center for HIV and Oral Health, BU School of Public Health, Health & Disability Working Group. Expanding Access to Dental Care for People Living with HIV/AIDS: Service Utilization and Costs. P. 6–7. Available at: http://echo.hdwg.org.

Dental Case Management

“I can’t see how a dental practice right now could function without a case manager.”

— Patient at Harbor Health, SPNS grantee, Provincetown, MA

While dental case management (DCM) can take different forms depending on patient needs and clinic resources, at its core it shares many similarities with HIV clinical case management, albeit with a priority placed on engaging and retaining patients in dental care as a component of an HIV/AIDS treatment plan. As with HIV clinical case management, DCM qualifies as a HRSA core medical service.

Out of 15 grantees, 9 employed a dental case manager or patient navigator to coordinate patient care. All of the dental case managers involved with the Oral Health Initiative provided some level of patient education, and were even instrumental in educating other providers involved with providing HIV care and services about the importance of oral health care for their patients. Dental case managers also handled a considerable amount of logistics for their patients, scheduling and making sure patients had a way to get to their appointments, and referring them to HIV case management, medical care, and support services.

Duties of a Good Dental Case Manager

Preparing staff for dental case management is not unlike preparing staff for medical case management. The same traits that distinguish a good medical case manager—attention to detail, strong communication skills, and ability to gain patients’ trust—are the same traits evident in a strong dental case manager.

When Lucy Wright was appointed the AIDS Dental Case Manager for the SPNS Oral Health Initiative at the Native American Health Center in San Francisco, she prepared herself for her new role by speaking with and shadowing the medical case managers in her organization and in other organizations. She paid attention to the kind of notes the case managers would take and how they engaged patients to come into the clinic for various reasons. “I wanted to get a better understanding of how patients are coming in for their appointments, what the labs look like, and what I’d need to look for to keep patients current with their labs—the CD4 and viral load values.”

The CDC has identified six tasks that should form the foundation of HIV case management. These include:

  1. Client identification, outreach, and engagement,
  2. Medical and psychosocial assessment of need,
  3. Development of a service plan or care plan,
  4. Implementation of the care plan by linking with service delivery systems,
  5. Monitoring of service delivery and reassessment of needs, and
  6. Advocacy on behalf of the client (including creating, obtaining, or brokering needed client resources).18

While case management skills are a must for a dental case manager, a formal background in dental care is definitely an asset. Wright is trained as a dental hygienist, and her background was an advantage for her in communicating effectively with the dental staff. It also helped her explain in detail the procedures that patients would undergo, clearly addressing any of their fears or questions to put them at ease. To learn more about skills and experience that benefit a dental case manager, see the job description detailed in Module 6 of the IHIP curriculum that complements this training manual.

One of the most valuable roles that a case manager can perform is to serve as a teacher that patients feel comfortable approaching without fear of judgment. SPNS Oral Health Initiative grantees found that patients were often afraid to ask questions of their dentist. “They’re scared to ask questions because they don’t want to feel like they are asking a stupid question,” explains Wright. “I wanted them to feel comfortable to ask me any question that they felt was necessary so I often took care to explain dental treatment plans to the patients—a lot of hand-holding.”

In some cases, Wright’s handholding for patients was literal. “Some of my patients had a very strong fear of going to the dentist. Sometimes I would sit next to them during an operation so they had support when they were getting a numbing shot or a tooth extracted.” One patient at Harbor Health reinforced the importance of Wright’s kind of empathetic care: “When you are in pain, [the dental case manager is] someone who understands that you are in pain and they kind of guide you along, you know.”

Patients are not the only ones benefitting from dental case managers. Providers have seen a marked increase in clinic efficiency and coordination with other service providers with the addition of dental case managers on staff. “Our case manager was a patient of ours for years,” says Strauss. “He knew the ins and outs and many of the procedures, so he was familiar with the dental terminology.”

ACG’s dental case manager was responsible for all patient intake and Institutional Review Board consent forms, thus reducing the paperwork burden for ACG clinicians. The dental case manager also worked with all the other case management agencies in 16 counties across Pennsylvania to arrange appointments for patients, and even drove patients to their appointments when transportation was a challenge. “He knew every single client who was serviced—knew where they lived and their families—and we served close to 500 in this project,” remarks Strauss.

Some grantees chose to provide some form of dental care coordination during the SPNS demonstration period, despite lacking a dedicated dental case manager. In these cases, grantees often chose to use an existing HIV case manager to perform dental care coordination. This usually involved the dental staff contacting a patient’s HIV case manager whenever a patient required referrals to specialty care or needed help navigating available dental benefits. This practice was most common among the ASOs and university- or hospital-affiliated programs.19 This approach can be a cost-effective way of maximizing existing resources when funding prohibits hiring and/or training a dedicated dental case manager, although special scrutiny should be given to the workload burden this may place on existing HIV case managers.

Even though HIV case managers who assume some dental case management duties will presumably already have training and experience around the principles of case management, it’s nevertheless important to ensure that they receive additional training around the unique oral health needs of PLWHA. This will enable them to communicate more clearly with oral health providers as well as their patients, and be better prepared to link their patients to the right types of oral health care and services. This IHIP training manual and the other related IHIP oral health training materials provide a solid initial orientation to these issues for HIV case managers.

Integrating Medical and Dental Care

Just as a patient cannot be truly healthy without a healthy mouth, dental providers can’t be truly successful without a healthy relationship with HIV medical care providers and case managers. Colocated medical and dental services can improve patient referrals to oral health care, as well as make it easier for patients to receive medical and dental care in one visit. This can be especially attractive when patients are traveling long distances for care.

Physically locating dental and medical care in one place, however, does not mean that integration will be seamless. To improve team communication and cohesiveness, AIDS Resource Center of Wisconsin (ARCW) used structured activities to ensure that medical and dental providers educated each other and coordinated care on behalf of individual patients at its Green Bay clinic. At staff meetings, the dentists presented the importance of oral health care to the medical providers. In turn, the medical providers explained HIV medications and their effects to the dentists. ARCW even had weekly integrated case conferences and a monthly review of patient medical and dental needs.

Data Management

When integrating medical and dental care, providers must inevitably share data about their patients, and this requires careful consideration of data management requirements and adherence to established privacy policies, whether institutional or Federal such as the Health Information Portability and Accountability Act of 1996 (commonly known as HIPAA). This can be especially challenging when working with providers—whether in a partner organization, or even within a different division of the same organization—that may be using different systems to make appointments and track patient data.

At Montefiore Medical Center in New York City, the initial integration of dental care and medical care data systems was somewhat problematic. “The dental appointment system was different from the medical system—different installation, different access,” shares Paul Meissner, health planner and program administrator at Montefiore. Adding to the complication was the fact that the system was largely a paper system as opposed to an electronic record system. But that changed. “Over the timeframe of the SPNS grant, we went to an electronic record system, and it has been a very positive shift. It’s made a huge difference in allowing our dental patient navigators to be able to communicate with doctors more effectively, and both patient navigators and doctors like it,” adds Meissner.

Addressing Geographic Isolation and Transportation Needs

Transportation is a key material need that can be a significant barrier to HIV care, as well as oral health care. The availability—or absence—of transportation can be the difference between making it to an appointment and not making it. Transportation becomes even more of a concern in areas where dental providers are few and far between, such as in rural areas, or when patients are otherwise geographically isolated from care.

SPNS grantees used a variety of approaches to address the challenges of transportation. Some programs arranged carpools or scheduled Medicaid-financed transportation. Some of the grantees’ dental case managers even drove vans that transported patients to and from clinic visits, which provided uninterrupted time to discuss both HIVand oral health-related issues. Other grantees introduced expanded hours in the evening or on the weekend for PLWHA, recognizing that one barrier to care was that clinic hours were during patients’ working hours.

Some grantees served broad geographic areas that spanned hundreds of square miles and included many counties. Some of their patients traveled up to 5 to 8 hours for care, and the programs provided reimbursement for gas. Considering the time and distance involved in getting patients to the dental clinic, both medical and dental services were scheduled on the same day to reduce the amount of dental visits and travel.

Several grantees provided transportation themselves, using a van to pick up patients and bring them into care. To address the inconvenience to patients of spending hours in a van and waiting for other patients to finish their appointments, some grantees provided meals or snacks for patients, and created comfortable waiting rooms where people could use a computer and the Internet.

A few grantee programs that offered direct patient transportation underestimated the demand it would place on the program in terms of expenses for vehicle maintenance and gas, particularly as gas prices skyrocketed during the grant period. For example, one grantee found that its van traveled tens of thousands of miles in the first year, and thus it would likely need to be replaced after a second or third year, and it still could not accommodate all their transportation needs. Providers may find that reimbursing or offering vouchers to patients for mileage, gas, or train tickets is a practical way of reducing a patient’s burden of traveling that does not require the clinic to have a vehicle to transport patients directly.

Mobile Dental Units

Four grantees chose to address geographic isolation and/or transportation challenges for their patients through the use of mobile dental units. These grantees designed, purchased, and implemented mobile dental units that ranged in cost from $144,000 for a one-chair unit to $330,000 for a unit with two dental chairs.

Launching a mobile dental program requires a high degree of planning and preparation. Providers interested in developing a mobile dental program will need to address regulatory and safety issues; medical record access, storage, and privacy concerns; scheduling and staffing issues; access to parking and permits; and be prepared for mechanical and maintenance issues with both the dental equipment and van. In fact, all of the Oral Health Initiative grantees built in specific days for van maintenance.

Consider This: Tips for Establishing a Satellite Clinic

Satellite clinics can provide significant benefits to patient care and overall clinic efficiency, but establishing them requires thoughtful preparation. Providers considering a satellite clinic should consider the following lessons learned by Oral Health Initiative grantees:

  1. Start small. Most of the grantees that set up satellite clinics did so after less resource-intensive approaches to expanding care were tried first. For example, one grantee leased dental treatment space at a local hospital before establishing its satellite clinic. Another site brought in portable dental equipment to provide oral exams and minor care at its drop-in homeless shelter before opening its satellite clinic.
  2. Don’t underestimate the time or resources needed. All grantees experienced some delays in the startup of their programs as a result of anticipated and unanticipated regulatory requirements, construction needs, or other challenges. Plan and budget for delays in your business plan for the clinic.
  3. Communication is key. “Build it and they will come” is unlikely to prove a successful strategy for building a satellite clinic patient base. First and foremost, ensure that all staff members, case managers in particular, are aware of the new clinic and can proactively identify and refer patients who would benefit most from the new location. All patients should learn about the clinic; word of mouth is a powerful tool for raising awareness. Staff should also be able to address any questions that may arise about the satellite clinic’s services and be able to answer these questions for patients and other stakeholders. Traditional marketing methods—such as radio announcements, flyers, social media announcements, or a dedicated satellite clinic Web page on your home Web site—can also be used to get the word out about the clinic.

Clinic Models

Satellite Clinics

Five programs—four in rural communities and one in an urban area—built satellite clinics to expand oral health access in their service areas. Grantees chose different approaches to launching their satellite clinics, including leasing treatment space from a local hospital and repurposing an existing office. In general, however, these satellite clinics enabled the SPNS grantees to enroll large numbers of new patients, and all were sustained beyond the life of the grant. Some grantees even utilized their satellite clinics to help serve a broader patient population not limited to PLWHA. (The benefits of this more inclusive approach are discussed further in the “Program Sustainability” section.) Their success is a testament to the benefits of employing this organizational model to expand care, despite any inherent challenges.

Fee-for-Service Dental Reimbursement

Despite making oral health care more accessible for many people, a satellite clinic does not guarantee that all patients will have improved access to care. One rural grantee found that, even with the addition of their satellite clinic, some of their patients who lived in very rural areas were still traveling up to 7 hours for care. To reduce their patients’ travel time, private dentists and dental clinics in some of the outlying rural areas of the State were contracted to provide services on a fee-for-service basis. This fee-for-service model can be an effective way to expand care to PLWHA in hard-to-reach locations, as long as provisions are taken to ensure that the providers who are contracted are culturally competent and trained in the special oral health needs of PLWHA.

Leasing Private Dental Space

Leasing dental space can be a viable option for providers, whether they are considering it as a bridge to a satellite clinic or as a stand-alone measure for increasing access to oral health care for PLWHA. Providers considering this approach to providing or expanding oral health care services should research the implications the location of the leased space may have on billing options, as well as carefully estimate any expected increase in patients that may arise from the increased convenience of the location, and ensure enough resources are in place to continue to treat patients in a timely and effective manner.

Partnerships with Teaching Institutions

Two of the biggest barriers to care for PLWHA are the lack of oral health providers trained and willing to treat PLWHA, and the lack of funding to hire oral health staff. Partnerships with teaching institutions are an excellent way to address both of these issues directly. Working with dental students also offers the opportunity to reduce the stigma associated with HIV, paving the way for a generation of dental providers that is more sensitive to the unique needs of PLWHA and more open to treating them in a sensitive, culturally competent manner.

The grantees that developed either formal or informal partnerships with dental schools or dental programs in their communities all have been able to sustain their programs beyond the life of the SPNS grant, in part, because of their fruitful partnerships with these teaching institutions. Providers interested in collaborating with dental teaching programs will need to delineate clearly the program elements for which each partner is accountable. This can include providing clinical space and equipment, program management and evaluation, dental case management, transportation, and finances.

Despite the benefits that dental students can provide, grantees found that it was important for interested students to undergo an interview process just like any other staff hire. For one grantee, the interview process for the students included writing essays about why they wanted to work with PLWHA and why they wanted the extra clinic experience. “We wanted to make sure they were doing it because they have a passion to treat people with HIV,” stressed the administrator of the organization’s Oral Health Initiative grant.

Patient Education

“Once you build that trust with a patient, they will always come back to care.”

— Lucy Wright, patient navigator, Native American Treatment Center, San Francisco, CA

Offering patient education was one of the factors most highly correlated with patient retention among SPNS Oral Health Initiative grantees. Providers can have a strong influence on patient education and oral health literacy.

Compassion is at the core of what drives effective patient education. There are simple things a dental case manager or patient navigator can do to demonstrate compassion and facilitate patient education.

SPNS grantees found that listening closely to patient stories and concerns, as well as their fears about dental work, was invaluable in helping to address questions and alleviate uncertainties. “I think listening was key,” says Wright. “Some patients don’t have anybody else to turn to, talk to, or provide companionship. Just being able to have somebody hear them out was a wonderful experience for them.”

Fear and anxiety around dental care is a big barrier to care for PLWHA that can often be effectively addressed by patient education. This anxiety was especially prominent among homeless individuals and immigrant populations who had limited experience with dental care. At several urban programs, dental case managers recruited patients directly by discussing dental services at a dropin center or clinic setting, allaying patient fears about dental care, and offering to accompany patients to their first dental visit. They also helped explain what would happen and what new patients could expect when they came in for their visits.

For some patients treated as part of the Oral Health Initiative, a visit to the dentist was their first ever, and thus, step-by-step guidance on what to expect was all the more critical to allay their fears. “Many of our patients had never been to a dentist and their parents had never been to the dentist,” shares Young. “This was their heritage, no dental care.”

Others had gone without care for long periods of time or received only episodic emergency care. In fact, 20 percent of Oral Health Initiative patients had not received any dental care in the previous five years or longer. Fourteen percent of the patients who came into care at one of the programs were there only once and did not return.

All of the grantees provided some level of patient education about the patients’ individual oral health treatment plans, the connection between HIV and oral health, and beneficial oral hygiene practices. Several programs took extra steps to engage patients in care, and encourage them to return for follow up, and establish a dental home.

Many grantees drafted patient education materials to address the concerns, questions, and barriers to oral health care discussed by patients. When preparing education materials, providers should make sure that their messages are understood by their target audiences by taking into consideration their optimal reading levels and preferred languages. For example, one grantee developed patient education materials in both Spanish and English, and hired bilingual staff to review the materials with individual patients.

Patient education can be approached in many ways. Some grantees educated patients on a one-on-one basis, in which a dental assistant or hygienist provided chairside education to patients around ideal oral health practices. At other grantees, patient education was provided in a group setting. Patient videos and demonstration materials were created for use in patient waiting rooms, and while patients were waiting to be seen for care the dental case manager engaged them in group discussions about good oral health practices.

Even with patient education, however, some patients will still not care for their teeth properly, once initial oral pain and infection are alleviated. Months later, this can result in patients returning to their dental hygiene clinic with new but preventable oral health problems. To overcome this hurdle, providers can use consumer focus groups to identify and test new patient education messages and methods.

Motivational interviewing can also be instrumental in inspiring patients to change their behaviors and helping to direct provider-patient education efforts. Motivational interviewing is defined as a “collaborative, person-centered form of guiding to elicit and strengthen motivation for change.”20 Because of its proven effectiveness in driving behavior change, ECHO offered motivational interviewing training for Oral Health Initiative grantees, with very positive feedback. “Motivational interviewing training really helped our dental hygienist get people to reduce smoking and dipping, which is high in Texas; increase flossing; and reduce sugar intake,” says Young. “It made a big difference.” (To learn more about motivational interviewing and to access motivational interviewing training tools, please see Module 8 in the corresponding curriculum).

Peer Involvement

Peers can be powerful influencers of behavior in PLWHA, and are well positioned to educate PLWHA about the importance of oral health care. Peers may be able to gain a patient’s trust more readily than a provider might, and they can utilize this relationship to help reduce patient fears of dental care and to share their own personal positive experiences with oral health care. They can also play important support roles in getting patients into and retained in care by helping to:

  • Provide transportation to and from appointments,
  • Connect patients with other social services,
  • Accompany patients to dental visits, and
  • Remind patients of appointments.

To learn more about peer-patient education and access related training tools, please see Module 9 of the corresponding curriculum.

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