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Consortium for Oral Health Systems Integration and Improvement

Rocky Mountain Network of Oral Health (RoMoNOH)

 

Overview

2024 NOHI RoMoNOH profile
Read project profile for more information about RoMoNOH.

RoMoNOH 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 RoMoNOH project focused on primary prevention of dental caries in infants and children from birth to age 40 months and pregnant women who were receiving health care in participating community health centers (CHCs) throughout Arizona, Colorado, Montana, and Wyoming.

Partners

NOHI RomoNOH presentation
View the project presentation video and handout from the final NOHI learning collaborative meeting.

RoMoNOH consisted of the Denver Health Office of Research (lead) working in partnership with the University of Colorado Department of Family Medicine, the American Academy of Pediatrics (AAP), the Colorado Department of Public Health and Environment (CDPHE), the National Network for Oral Health Access (NNOHA), and primary care associations (PCAs) in Arizona, Colorado, Montana, and Wyoming.

Approach

RoMoNOH developed and implemented a change package to support the integration of oral health clinical competencies into primary care in 34 CHCs. PCA practice-transformation coaches worked with participating CHCs in their state to develop, implement, and validate RoMoNOH’s models of care using the change package to guide activities.

Settings

RoMoNOH applied the following criteria for CHC recruitment and selection:

  • Provides infant and child care and/or perinatal care (those with a large population of infants and young children are prioritized).
  • Is located in a health professional shortage area.
  • Has insufficient on-site and/or community-based oral health care for infants, young children, and pregnant women.

Models of Care

RoMoNOH supported CHCs in the establishment of several models of care depending on the oral health needs of the population, capacity of the CHC to manage these needs and the state’s policies and regulations on the provision of preventive oral health care (e.g., scope of practice of medical and oral health providers, Medicaid reimbursement). All models featured a variety of services that addressed the five interprofessional oral health core clinical competencies for integrating oral health care into primary care (i.e., risk assessment, evaluation, preventive interventions, communication and education, interprofessional collaborative practice) and referrals to oral health providers. The models included delivery of preventive oral health services by medical team members, by dental hygienists embedded in the medical team, or a hybrid of these two models. In all models, referrals to a dental home included coordinated referrals from the primary care providers and/or dental hygienists to off-site oral health providers and/or co-located oral health providers depending on the oral health needs and availability of dental services within the CHC and community.

Strategies to Help Sustain Models of Care in CHCs: Lessons Learned

CHCs with the most success in implementing their models of care were driven by strong leadership support and primary care provider and staff buy-in, dedicated time to work on implementing their model, and reliable monthly metrics to guide their continuous-quality-improvement activities and provide care to a population with substantial oral health needs. These drivers supported the CHCs’ success at attaining project objectives and earning their benchmark payments. PCA coaches provided support and held CHCs accountable for making ongoing changes and improvements to their models of care.

RoMoNOH worked with the CHCs to sustain the provision of preventive oral health care at medical visits by:

  • Operationalizing changes to electronic health records.
  • Incorporating oral health training into employee onboarding training.
  • Establishing standard policies and procedures for providing preventive oral health care at medical visits.
  • Hiring and retaining dental hygienists embedded in CHC medical teams (in CHCs that implemented this model).

PCA coaches developed training manuals and other materials as resources to sustain their support of CHCs with incorporating preventive oral health services into primary care visits.

Core Function Activities

Data, Analysis, and Evaluation

RoMoNOH leadership from the Denver Health Office of Research and the University of Colorado Department of Family Medicine, in collaboration with the PCA coaches, worked with participating CHCs to optimize their electronic medical record and electronic dental record and processes for documenting provision of preventive oral health care. Participating CHCs submitted monthly aggregated data into the Shared Practices Learning Improvement Tool (SPLIT) and RoMoNOH created monthly feedback reports, which coaches used in their continuous-quality-improvement activities with CHCs. SPLIT was also used for collecting and tracking coaching field notes, which provided coaching updates on the implementation of the project’s change package and attainment of the change package’s drivers, which include data-driven improvement, engaged leadership, engaged providers and staff, devoted time, team-based care: role assignment and adoption, and team based-care: workflows.

RoMoNOH implemented the Practical, Robust Implementation and Sustainability Model, a multilevel, mixed-method evaluation tool, to frame its evaluation. The evaluation included pre/post primary care provider and oral health provider surveys, pre/post key informant interviews of health care leaders and implementation teams, parent/caregiver surveys, and a cost-benefit analysis utilizing Medicaid claims data to estimate the return-on-investment of providing preventive oral health services at primary care visits to young children to reduce expenditures for caries-related treatments.

Outreach and Education

RoMoNOH, with assistance from its outreach and education partners, CDPHE and NNOHA, developed a five-module eLearning course to train primary care providers on delivery of preventive oral health care. The modules incorporated the five oral health core clinical competencies and include

  • Module 1: Introduction | Interprofessional Collaborative Practice
  • Module 2: Caries Risk Assessment | Oral Evaluation | Preventive Interventions
  • Module 3: Communication and Education | Patient Engagement
  • Module 4: Interprofessional Collaborative Practice | Dental Referral
  • Module 5: Perinatal Oral Health

RoMoNOH developed coaching tools to train nonclinical staff on integrating oral health care into primary care. RoMoNOH also developed an enhanced parent and caregiver engagement activity using AAP’s Brush Book Bed program to motivate primary care providers to discuss oral health and oral hygiene practices with parents and other caregivers and encourage them to set and meet oral health goals for their children.

Policy and Practice

RoMoNOH, with assistance from AAP, its policy and practice partner, conducted environmental scans in Arizona, Colorado, Montana, and Wyoming to gather information about the scope of practice for primary care providers and oral health providers, Medicaid payment for preventive oral health care, and policies and regulations that impact the target population’s oral health. See Rocky Mountain Network of Oral Health (RoMoNOH): Environmental Scan 2023 Chartbook for environmental scan results and see executive summaries of the 2023 environmental scan results: Arizona, Colorado, Montana, Wyoming. RoMoNOH used the information to gain knowledge about state-level barriers and opportunities for integrating oral health care into primary care. RoMoNOH also used the information to raise awareness among key stakeholders in each state about policies that provide opportunities for or create barriers to promotion of oral health and delivery of preventive oral health care to the target population.

Impact of COVID-19

The COVID-19 pandemic significantly impacted health behaviors and health care use for all NOHI projects. CHCs had to dedicate time and effort to managing new challenges during the global health emergency, which took them away from RoMoNOH activities. In some CHCs, IT and data staff ’s time shifted from developing processes for collecting and reporting data for RoMoNOH to emergent COVID-19 needs, which resulted in RoMoNOH project delays. In response, RoMoNOH adjusted timelines for assigned tasks, moved meetings and coaching sessions to an online platform when necessary, and provided additional support when needed. Patients continued to come to CHCs for well-child visits and immunizations, and these visits were leveraged for same-day integrated oral health care visits.

Resources

Project Contact

    Project director: Patricia Braun, M.D., M.P.H. Denver Health and Hospital Authority

    Project manager: Cherith Flowerday, C.R.A. Denver Health and Hospital Authority

See Rocky Mountain Network for Oral Health Integration (RoMoNOH): Project Profile—Update 2024 for more information about the RoMoNOH project.