Midwest Network for Oral Health Integration (MNOHI)
Overview
MNOHI was one of three projects in the Networks for Oral Health Integration (NOHI) Within the MCH Safety Net. The purpose of NOHI was to improve access to and utilization of comprehensive, high-quality oral health care for pregnant women, infants, and children at high risk for oral disease. The projects were awarded funding from the Maternal and Child Health Bureau for a 5-year period (2019–2024) to develop, implement, and evaluate models of care. The MNOHI project focused on improving access to and use of comprehensive, high-quality oral health care for children ages 6–11 who received health care in selected community health centers (CHCs) throughout Illinois, Iowa, Michigan, and Ohio.
Partners
MNOHI consisted of the Michigan Primary Care Association (lead) working in partnership with the Illinois Primary Health Care Association, the Iowa Primary Care Association, and the Ohio Association of Community Health Centers (OACHC). The National Network for Oral Health Access (NNOHA) provided technical assistance (TA) on outreach and educational activities. The Michigan Department of Health and Human Services, the Michigan Oral Health Coalition, and Oral Health Ohio partnered with MNOHI on policy activities. The Michigan Public Health Institute conducted an evaluation of the MNOHI project.
Approach
MNOHI state coordinators (one from each of the four primary care associations (PCAs)) worked with 34 participating CHCs to develop, implement, evaluate, and improve models of care for integrating oral health care into primary care for children ages 6–11.
Settings
MNOHI applied the following criteria for CHC recruitment and selection:
- CHC leadership has a vision for integrating oral health care into primary care.
- CHC leadership agrees to participate fully in the 5-year project, or for cohorts that start later, to participate for the remaining project period.
- CHC serves children ages 6–11.
- CHC offers primary care and oral health care (co-located care preferred).
- CHC has experience with QI projects.
- CHC uses health information technology (HIT) for patient and clinical data.
- CHC leadership identifies champions (care integration, HIT, QI).
- CHC is in a geographically diverse location.
Models of Care
The MNOHI models of care incorporated the five domains of the interprofessional oral health core clinical competencies:
- Risk assessment
- Evaluation
- Preventive interventions (e.g., fluoride varnish application, dental sealant application)
- Communication with and education of health providers and parents and other caregivers
- Interprofessional collaborative practice
An important element of the MNOHI models of care was the incorporation of a community health worker (CHW) or care coordinator into the primary care team to conduct outreach to parents and other caregivers and offer them education, help make appointments for patients referred for oral health care, and provide support to help ensure that patients keep their appointments.
Strategies to Help Sustain Models of Care in CHCs: Lessons Learned
The 34 participating CHCs incorporated documentation of preventive oral health care during well-child visits in their electronic medical record (EMR), a main focus of the MNOHI project. MNOHI worked with NNOHA to reduce the burden of oral health training for primary care providers by condensing training modules. MNOHI required that participating CHCs add oral health outreach duties to job descriptions.
Core Function Activities
Data, Analysis, and Evaluation
MNOHI state coordinators worked with participating CHCs to develop structured data fields in the EMR to document preventive oral health care provided to patients. CHCs received funding to assist with EMR enhancement. MNOHI created a CHW tracking form to capture care-coordination activities and gauge the impact of CHWs’ efforts on closing referral loops. MNOHI built a data dashboard to enable visualization of progress across participating CHCs in all four states. MNOHI used qualitative and quantitative data to track, assess, and report outcomes resulting from project activities. It also tracked and assessed policy and systems changes to provide data for the oral health core clinical competencies.
Outreach and Education
MNOHI used Smiles for Life: A National Oral Health Curriculum modules to train primary care providers and staff. To supplement the curriculum, NNOHA developed a module specific to MNOHI’s target population. In response to feedback from participating CHCs, NNOHA condensed the Smiles for Life modules and the NNOHA module to accommodate those whose schedules precluded their completing the training modules. During quarterly calls with participating CHCs and CHWs, MNOHI provided opportunities for peer learning, and NNOHA offered training, as needed.
Policy and Practice
MNOHI state coordinators and partners conducted environmental scans to gather information about factors that could impact the integration of oral health care into primary care at the state level. The scans included questions about scope of practice of primary care providers and oral health providers, Medicaid billing and payment, and policies and regulations that impact the oral health of children ages 6–11. See Midwest Network for Oral Health Integration (MNOHI): Environmental Scan 2023 Chartbook for environmental scan results. State coordinators and partners used information from the environmental scans to raise awareness about needed system changes (e.g., reimbursement for CHW and care-coordination activities, increasing the upper age limit for which health providers can be reimbursed for applying fluoride varnish to children’s teeth).
Impact of COVID-19 and Workforce Shortages
The COVID-19 pandemic significantly impacted health behaviors and health care use for children ages 6–11 who were receiving care in CHCs in the MNOHI states. As COVID-19 infection rates fluctuated in the MNOHI states, CHCs shifted staff responsibilities to focus on testing and vaccination, making it challenging to engage project champions and delaying project timelines. Troubleshooting was often necessary to make adjustments in response to these disruptions. Participating CHCs continued to experience workforce shortages and staff turnover. In Michigan, participating CHC dental clinics continued to struggle to recruit dentists, dental hygienists, and dental assistants. In response, CHCs prioritized primary care referrals by saving designated appointment times in the dental clinic schedule for children referred by primary care to limit their wait time for a dental appointment. Facing similar challenges in Iowa, CHCs considered this option, and the Iowa state coordinator encouraged the primary care team to collaborate with the dental team to determine the best way to address pediatric primary care referrals. In response to health care provider burnout and staff shortages in Illinois, CHCs adjusted their workflows and gave CHWs more responsibility for oral health education and follow-up to help the primary care team. OACHC provided TA to its CHCs, which, like CHCs in other MNOHI states, also faced workforce shortages and explored options to address the problem.
Resources
- Midwest Network for Oral Health Integration: Project profile, project video and handout
- Azara DRVS (Data Reporting and Visualization System) Dental Measures (2021)
- Community Health Worker and Care Coordination: Best Practices (2022)
- Community Health Workers for Integrated Care Coordination (2022)
- Midwest Network for Oral Health Integration (MNOHI): Environmental Scan 2023 Chartbook (2023)
- Oral Health Risk Assessment, Children Ages 6–11 (2020)
- Participating Community Health Center Needs Assessment (2020)
- Patient Satisfaction Survey (2022)
- Prospective Community Health Center Readiness Assessment (2020)
- Training Modules
- Condensed Smiles for Life Modules 2 and 6 (2022)
- Instructions for Accessing the Modules (rev. ed.) (2022)
- Oral Health in the Well Child Visit (2020)
Project Contact
- Project director: Amber Desgranges, M.P.H., C.E.D. Michigan Primary Care Association
- Project manager: Lindsay Sailor, B.S. Michigan Primary Care Association
See Midwest Network for Oral Health Integration (MNOHI): Project Profile—Update 2024 for more information about the MNOHI project.