January 2004

ACKNOWLEDGMENTS

This booklet would not have been possible without the participation of many people at community-based organizations, hospitals, dental schools and community health centers who lent their time and expertise during the preparation of this document. In particular we wish to acknowledge the generous assistance from individuals at the following organizations:

Albany Medical Center
David Drohan, DDS

Bronx Lebanon Hospital Center
Paul Gates, DDS; Cheryl Stolarski, DMD; Iris Santiago

Brooklyn Hospital Center, The PATH Center
Dan Sendzik; Leonard Berkowitz, MD; Harry Dym, DDS

Columbia University School of Dental and Oral Surgery
Georgina Zabos, DDS; Sandra Burkett, DDS

Erie County Medical Center
Stuart Fischman, DMD

Harlem United Community AIDS Center, Inc.
Patrick J. McGovern

Joseph P. Addabbo Jr. Family Health Center
Rosa Rodriguez

Montefiore Medical Center
Barry Zingman, MD; Judy Schrager, RN; Jorge Rodriguez, MPA; Joan Grcevic, DDS; Lila Nikkah, DDS; Fleur Wheeler, RDH

Saint Barnabas Hospital
Dara Rosenberg, DDS

State University of New York Stony Brook School of Dental Medicine
Barbara Berentsen, RDH; Fred Ferguson, DDS; Sharon Nachman, MD

Westchester Medical Center
Peter De Lisi, DDS; Giovanni Boiano, DDS; Anthony Alessi, DMD; Rosanne Scallion, Elfreda Darrien, Keri Gallagher-Tone

Woodhull Medical and Mental Health Center
Sheldon Stachel, DDS; Peter Sherman, DDS; Yusaf Afacan, MD; Maria Pineiro

Photographic Credits:
Dr. Victor Badner, Kimberly L. Collins, Dr. Peter Delisi, Dr. David Drohan, Jennie B. Epstein, and Dr. Olapeju Simoyan

Special thanks to Dr. Victor Badner, the principal consultant, and Dr. Olepeju Simoyan for their active participation in this project.

INTRODUCTION

The purpose of this booklet is to provide health care practitioners and administrators with practical advice for initiating and maintaining a high standard of HIV oral health care for their patients.

The HIV/AIDS epidemic continues to pose enormous challenges in the United States, both for the communities most affected, and for the health care professionals who serve these communities. Highly active antiretroviral therapy has made HIV/AIDS a chronic, manageable disease.¹ Inadequate oral health care, however, can undermine the success of treatment by exacerbating existing medical conditions, compromising adherence to an antiretroviral treatment regimen, and diminishing quality of life.

Oral disease occurs disproportionately among individuals from low socioeconomic levels and among those who are most vulnerable because of poor general health.² Most reported cases of HIV occur in communities where levels of oral health care utilization are among the lowest in the nation. This is associated with lack of access to care and lower education levels.³ Improving oral health within these communities will require changes at a number of levels. Medical care providers will require a better understanding of the relationship between oral disease and general health, and patients living with HIV will need to better appreciate the importance of oral health in general health and well being.

This booklet offers guidance to individuals and health care organizations that currently provide or are planning to initiate oral health care services for people with HIV/AIDS. The best practices included in this booklet reflect creative solutions to the challenges that arise in providing quality oral health care, ranging from attracting and retaining patients in care to approaching oral health care delivery in a multidisciplinary manner. These best practices have been compiled from a series of face-to-face and telephone interviews with clinicians and administrators working in hospitals and community health centers across New York State.

This booklet is divided into several sections:

The Importance of Oral Health: This section explains why oral health care is a critical component of high quality HIV primary care. Key recommendations developed by the New York State Department of Health AIDS Institute regarding routine oral health care for HIV-infected patients are included.

Best Practices with Case Studies: This second section describes practices that have been demonstrated to be effective in improving oral health care delivery at facilities across New York State. Best practice topics include increasing patient knowledge and access to information, improving access to dental services, improving patient outreach, encouraging patients to schedule and keep their appointments, facilitating information management, and utilizing staff resources effectively. The accompanying cases describe in greater detail strategies that different institutions have utilized to overcome barriers.

Quality Improvement: This section includes examples of quality improvement activities that institutions may adopt to attract greater numbers of HIV-infected clients into dental care.

Resources and Tools: Resources and training information to assist sites in delivering high quality oral health care are presented within this section.

We hope the insights and perspectives included here will inspire readers to develop new programs or to improve existing services within their settings. The response of those who use this manual will assist us in improving how we promote quality of care. Please address any comments or suggestions to:

Oral Health Policy Liaison
HIV Guidelines Program
Office of the Medial Director,
AIDS Institute, New York State Department of Health
5 Penn Plaza, New York, NY 10001
or use the “Contact Us” link at www.hivguidelines.org.

Bruce D. Agins, MD, MPH
Medical Director
AIDS Institute
New York State Department of Health

Stephen N. Abel, DDS, MS
Oral Health Policy Liaison
AIDS Institute
New York State Department of Health

I. THE IMPORTANCE OF HEALTH FOR HIV-INFECTED PATIENTS

Oral health is integral to general health. Good oral health care is especially important for people living with HIV/AIDS for the following reasons:

• Oral manifestations are common in people with HIV infection. By some estimates, more than ninety percent of HIV-infected patients will have at least one HIV-related oral manifestation in the course of their disease.⁴
• Oral lesions may herald decline in immune function. For example, untreated HIV-infected patients with oral candidiasis have been shown to progress to an AIDS diagnosis within a two-year period.⁵
• Controlling a focal infection within the oral cavity may eliminate adverse consequences such as systemic infections.
• Poorly functioning dentition can adversely affect quality of life. For example, oral pain or discomfort may cause patients to avoid eating resulting in weight loss, which may be especially distressing for HIV-infected patients concerned about wasting.
• Oral pain and difficulty in swallowing (dysphagia) can be unrecognized barriers to successful treatment adherence, illustrating the importance of close coordination between the oral health and medical teams.

II. BEST PRACTICES IN ORAL HEALTH CARE

The oral health care providers and administrators interviewed for this booklet have identified best practices in the provision of oral health care for people living with HIV/AIDS which include:

• Increasing patient knowledge through education
• Increasing access to oral health care
• Improving information management
• Utilizing a multidisciplinary approach to oral health care

Best practices are summarized and are followed by one or more detailed examples from a specific facility illustrating model practices. Not all examples will apply to every facility. However, the best practices outlined below represent a menu of options that can be tried, and when appropriate, adapted for your facility.

Increasing Patient Knowledge Through Education

Empowering patients with knowledge is associated with adherence to a variety of medical recommendations, including those for HIV. Providers should ensure that each patient has the information needed for reasoned decision-making.⁷ The following are examples of educational efforts that some facilities use to enhance patients’ understanding about the importance of oral health:

• Develop simple fact sheets at a range of literacy levels and in languages used by your patient population which emphasize:
  • The importance of oral health care for those infected with HIV,
  • What to expect during an oral health exam; and
  • The importance of follow-up care

• Make oral care brochures in multiple languages available to illustrate techniques on self-examination, flossing and brushing.
• Turn dental and clinic waiting rooms into “education rooms” by playing educational videotapes that promote oral health care.
• Create a lending library of oral health-oriented education videos that clients may take home and watch. These resources are available from dental professional organizations such as the American Dental Association.
• Provide critical prevention messages at the onset of therapy. Empower patients to prevent disease recurrence by combining professional care with good self-care. This includes training patients to check their mouths for any changes such as the development of red or white areas. Use models, brochures, drawings, and diagrams to visually reinforce messages. Additionally, teach patients how to reduce the incidence of caries through oral hygiene techniques and dietary intake. Hygienists can distribute toothbrushes and floss, instruct patients on their proper use and assist them in developing strategies to incorporate self-care into daily routines.

See Section IV for resources related to patient education and access to information.

Focus on Patient Education:

Westchester Medical Center

Westchester Medical Center has developed a multidisciplinary, focused program that offers both inpatient and outpatient care. This AIDS Care Center serves Westchester County and the six surrounding counties of the Mid-Hudson region. Westchester’s dental program, established in 1992, is an integral component of the AIDS Care Center, offering comprehensive and emergency dental treatment to over 300 HIV-infected clients annually.

Westchester’s dental program prides itself on conducting extensive education programs for HIV-infected persons. The following are key components of program activities:

Patient Education Materials

Patients seen in the dental department are educated about the signs and symptoms of infections associated with HIV and what can be done to maintain oral health through diet and oral hygiene. A patient education brochure entitled “A Guide to Dental Care for the HIV-Infected” was developed by staff members and is an especially useful resource for this purpose (see Section IV, Printed Resources for Health Professionals and Consumers).

Community Patient Education

The dental staff provides oral health education sessions at many community-based social service agencies throughout the Hudson Valley region. Through question and answer sessions, clients build a better understanding of the importance of oral health in their general health. Subsequently, many schedule dental appointments at Westchester Medical Center. Additionally, Westchester Medical Center invites groups of people with HIV from local community-based organizations to the Center for HIV education updates. The dental director reviews the dental brochure with them and encourages participants to schedule appointments for oral health care.

Improving Access to Dental Care

There are a number of practices that facilities can implement to improve access to oral health care. Methods for achieving greater access include:

• choice of treatment site location
• flexibility when scheduling appointments
• co-location of oral health services with medical or other services
• networks of community-based dentists
• satellite clinics in convenient locations
• family-centered service models
• transportation/escort services and childcare

All of the approaches described in the best practice case studies involve responding to the unique needs of the community served, from methadone maintenance treatment clients to residents of rural communities. These sites made efforts to bring oral health care to the communities they serve.

Access to safe, appropriate oral health services is of particular concern for children who are HIV-infected. Pediatric dentists or services should be made available to these children either on site or through referral. Because providing dental care to children presents unique challenges, those facilities not able to do so on site should develop a network of linkages within their community of pediatric dentists able to offer this care. Offering transportation and/or escort services for dental appointments may be especially effective in ensuring that HIV-infected children receive appropriate dental care.

The following suggestions come from several oral health care programs that have made efforts to increase access to care for their HIV-infected patients:

• Ensure that all HIV primary care team members and their patients can find and access nearby dental facilities when oral health services are not available on site. Utilization of oral health services has been shown to increase when patients can access care near their homes. The New York State Department of Health has published an HIV oral health directory of sites funded to provide oral health care to patients with HIV disease (see Section IV, HIV Oral Health Resource Directory).
• Offer transportation or fares to and from oral health services, or provide case management escorts to and from appointments. A Metrocard or the encouragement of a case manager can be helpful in getting a patient to visit the dentist.
• Make oral health care available at times that are convenient for the population served, such as early mornings, evenings, weekends, or at times when patients are coming to the clinic for medical care. Build time into the dental program’s schedule for walk-in appointments.
• Use reminder tools to help patients remember appointments. Examples include associating appointments with certain milestones or times of the year, sending reminder letters, which should be available in multiple languages, or making confirmation phone calls prior to the appointment.
• Offer safe and appropriate childcare either on-site or through a local community- based organization. This issue is of particular concern to single parents. Clinics that provide childcare when HIV-infected parents are undergoing treatment can eliminate a major barrier to making dental appointments and receiving care.
• Train front-desk staff to be sensitive to the needs of the patient, including asking patients for their scheduling preferences and appropriately handling HIV-related information. Facilities should provide training on HIV confidentiality issues to all staff members.
• Allow patients to choose their place of treatment among the various sites at a facility, if multiple sites exist. Patients may, for example, choose a mainstream clinic or a location that is designed exclusively for the care of HIV-infected patients.

A Model of Convenience to Care for Patients and Their Families:
Woodhull Medical and Mental Health Center, Paul Paroski Center

The Woodhull Medical Center has been providing care to people living with HIV since the early 1980s. Woodhull’s team approach to HIV care includes physicians, dentists, pediatricians, nurses, social workers and community liaisons all working together to administer high quality treatment.

In 1993, four dental treatment rooms within the general dental clinic were set aside for the care of HIV patients. Initially, all dental services were located separately from the general medical clinic. It soon became apparent that many dental patients were dissatisfied with the inconvenience of having to leave the HIV Center to access dental care and with the insensitivity towards their HIV status displayed by some staff of the dental clinic. Woodhull addressed these and other patient concerns in the following ways:

Choice of locations

In 1994, concerns from patients and providers resulted in the establishment of a second dental service which was physically integrated into the HIV program. Currently, this integrated HIV facility provides over 1,200 oral health visits annually. HIV/AIDS patients are now able to obtain oral health care either at the general dental clinic or in the smaller, integrated HIV care facility.

Fast-tracking appointments

To streamline the process of making appointments, HIV patients who prefer the general dental clinic are given appointments more quickly than the general population. Not only are emergency cases seen on a same-day basis, but Woodhull’s electronic referral and communication lines are so well established that non-emergent dental care can often be obtained on the same day.

Family-focused services

To further reduce barriers to care, Woodhull has also eliminated the inconvenience of separate treatment sites for the family members of HIV/AIDS patients. Family members are welcome to receive care in the HIV clinic. The family-friendly Center also provides a playroom for clients’ children with puzzles, coloring books, toys and furniture appropriate for different age groups.

In many aspects of its daily operation, Woodhull Medical Center stands as a model of patient- and family-centered care for HIV-infected patients and their families.

Bringing Care into the Neighborhoods:
Montefiore Medical Center, Community Dentistry Division

Montefiore Medical Center (MMC) is located in a community in the Bronx that has one of the highest incidence rates of HIV infection in New York State. Access to dental care in the Bronx is especially limited, with several localities designated as Federally Qualified Dental Health Professional Shortage Areas. Montefiore has developed one of the largest dental departments in New York State, providing oral health care to HIV-infected patients in multiple locations including: hospital-based dental facilities, HIV-focused integrated dental/medical facilities, community-based drug treatment programs, homeless shelters and community health centers. To increase access to dental care, Montefiore has established dental services within a broad network of community-based organizations and offers appointments at times which are convenient for the target population.

For some patients, one obstacle to accessing dental care is an ongoing concern that they will be discriminated against or denied appropriate care at facilities not specifically dedicated to the care of HIV-infected individuals. The dental program at MMC’s Infectious Disease clinic addresses this concern by integrating its services with those of the HIV medical team. Patients’ familiarity with team members and scheduling personnel, and the use of patient service representatives to escort patients to and from dental appointments, increases patients’ use of dental services at this facility.

Initially, Montefiore provided community-based facilities, such as shelters, drug treatment centers and nursing homes, with opportunities to work together in the design of HIV primary care/oral health programs that matched the needs of their client base. Designing successful programs required collaboration between the health care team from an academic medical center and the administration of community-based agencies.

Unique to these programs is the availability of Montefiore oral health staff during hours that are convenient to the populations served by the community agencies. For instance, the dental program that is located within a methadone maintenance program opens early to provide morning dental appointments when the clients arrive for their daily methadone. At the dental facility that has been established within a homeless shelter, access to care is available in the early evening hours when clients arrive.

All aspects of preventive, restorative and prosthodontic care, along with simple extractions, are performed at each of the satellite facilities, while parenteral sedation for the many apprehensive patients and for those undergoing more complex procedures is performed at the local Montefiore dental clinics.

Montefiore successfully brings oral health to the hard-to-reach populations within the Bronx by:

• Co-locating services throughout the community
• Meeting the scheduling needs of the clients
• Offering integrated dental services in the medical clinic for patients most comfortable receiving care in that setting

Developing Community Partnerships:
We Care – Columbia University School of Dental and Oral Surgery

Established in 1999, Columbia University’s We Care program offers preventive and early intervention dental services at four community-based HIV/AIDS medical programs in Manhattan, effectively bringing dental care to the people it serves. A mobile dental team provides direct dental services on-site to the following affiliated community-based organizations:

• Women and Children Care Center (Babette’s Place), which provides medical and supportive services for women with HIV/AIDS and their children.
• Harlem United Community AIDS Center, Inc., which offers medical and supportive day treatment services to adults with problems including homelessness and substance abuse.
• Safe House, a residential program, which provides a temporary home, supportive services and medical referrals to homeless adolescents with HIV/AIDS.
• Project Renewal, a non-profit provider of homeless services.

The oral health care team of We Care consists of a dental school faculty attending, a dental fellow and a dental assistant. Portable equipment is stored at the various sites and is used in spaces that are shared with other medical specialties. Storage space is provided on-site for bulk materials and supplies; sterilization of equipment is performed at the Columbia University School of Oral and Dental Surgery.

We Care staff actively recruit patients in the waiting rooms and communal areas of the community-based organizations where it offers services. Additionally, the dentists promote their program to all staff and health providers within the agencies.

Once a client elects to become a dental patient, the following services are offered:

1. Education about appropriate oral health self-care
2. Distribution of toothbrushes, toothpaste and floss
3. Periodic oral examinations
4. Early intervention and preventive care services (i.e. sealants, fluoride treatments, interim restorations)
5. Follow-up appointments in local dental clinics for comprehensive dental services such as restorative and prosthodontic care.

The rise in the number of patients who have accessed dental care services through the We Care program speaks to its success. Prior to the establishment of the program in 1999, only 15% of the clients at these participating agencies had an annual dental visit. Presently, the percentage is over 50%. Thus, through developing close partnerships with community agencies, Columbia University has effectively promoted and improved the oral health of Manhattan’s underserved populations.

Bringing Oral Health Care to a Rural Setting:
Albany Medical Center and the Mid-Hudson Care Center

The Albany Medical Center (AMC) serves the dental needs of many HIV patients in the northeast region of New York State. Current strategies to improve access at this site include the establishment of an HIV satellite clinic for rural consumers, co-location of dental and medical services, and close collaboration between the academic and community-based facilities.

AMC provides services at its rural satellite clinic, the Mid-Hudson Care Center in Kingston, New York, 55 miles from Albany Medical Center. Because no major health care institutions are located in the area surrounding Kingston, AMC elected to establish HIV medical and oral health care services at this community site. All patients seen by the medical team at Mid-Hudson Care Center are referred to the dental service for treatment.

The Mid-Hudson site provides dental care on a limited basis (three Mondays per month), requiring close coordination with the parent institution in Albany. While routine preventive, restorative, and prosthetic dental services are provided in Kingston, more complicated procedures are referred to Albany. When a patient is referred to AMC for treatment, the same treatment team from Mid-Hudson provides the care at AMC, retaining the advantage of interpersonal relationships that have been established. In these cases, the dentist transports the dental charts from the Mid-Hudson site to Albany, assuring seamless provision of care.

The relationship between Albany Medical Center and the Mid-Hudson Care Center is a model dental partnership between an urban and a rural region. As the incidence of HIV disease continues to rise in rural settings, successful models of delivering HIV care in these and other hard-to-reach communities become increasingly important.

Focus on Pediatric Oral Health Care:
State University of New York at Stony Brook Dental School

The State University of New York at Stony Brook Dental School (SUNY Stony Brook) has a long history of providing services to HIV-infected patients on Long Island in New York State. Since 1990 SUNY Stony Brook has been addressing the oral health care needs of HIV-infected pediatric patients through a Ryan White-funded dental program.

As a response to the high number of pediatric HIV operating room procedures for extensive oral rehabilitation in the 1990′s, the dental program shifted its focus. SUNY Stony Brook’s mission now focuses on prevention, recognizing that HIV-infected children are particularly susceptible to caries, in part as a result of taking sugar-based medications. Furthermore, the dental program, originally located within the University Hospital Center, was moved to the Dental School to offer greater comfort and confidentiality to young patients and their families and caregivers.

Stony Brook’s pediatric dental program plays an active role in improving access to pediatric oral health care throughout Long Island. Not only does the program coordinator arrange appointments and facilitate the children’s visits, but often arrangements are made for transportation and/or escort services free of charge. Through effective teamwork among primary medical care providers, social workers, maternal/child health workers and dentists, HIV-infected children treated within SUNY Stony Brook receive routine outpatient dental care.

Managing Information to Improve Care

Thorough, accurate and definitive documentation ensures the effectiveness of an oral health program and facilitates monitoring quality of care. The following strategies facilitate the use of information to provide continuity of care:

• Forms completed by patients should be written at a reading level that is appropriate for the population. Medical history, release of information and informed consent forms should be available in multiple languages. Documentation of all forms signed by patients should be maintained within the patient file. (Copies of release of information and other HIV-related forms can be accessed through the New York State Department of Health AIDS Institute website’s Order Form)
• The dental chart should contain all necessary information relevant to a patient’s oral care. Pertinent information includes:
  • Medical history
  • Dental history
  • Identification of chief complaint

Documentation in the record should be arranged in a manner that provides quick access to key information and lends itself to easy review by third parties.

• Implement a system to document dental and medical communication. Dental visit and consultation reports rarely make their way into medical charts. Some programs have overcome this barrier to effective communication by implementing carbonless medical record inserts and consultation forms that can readily be placed in the medical and dental charts.
• Revise the medical chart and progress notes to include an oral health referral section. This has been implemented by several facilities as part of quality improvement activities.

Following are two examples of well-designed dental and medical forms. The dental treatment plan form used by St. Barnabas Hospital in the Bronx has a particularly functional layout. The medical annual examination flow chart used by Brooklyn Hospital Center effectively integrates oral health care into routine health maintenance documentation.

Medical annual examination flow chart used by Brooklyn Hospital Center (Acrobat PDF)

Dental treatment plan form used by St. Barnabas Hospital (Acrobat PDF)

Multidisciplinary Models of Care

Strong collaboration between oral health practitioners, medical providers and social service support staff is critical in order to achieve optimal health care outcomes. Practices utilized by clinics throughout New York State follow.

• Increase the percentage of patients referred for annual oral health care to 90%.
• Increase the percentage of referred patients receiving oral health care to 75%.

Organize a Quality Improvement (QI) Team

A multidisciplinary QI team was formed consisting of:

Chief of ID Medicine
PATH Director
Senior Staff Nurse
Operations Manager
Chief of Oral Surgery
Dental Residents

Clarify the Existing Process

The QI Team reviewed how patients were being assessed for oral health needs and how and where they were being referred for exams.

Understand the Process Variations

Through brainstorming, the QI Team identified the process variations—where the process of referral and receiving care required improvement. Barriers included the following:

• House staff serving in the PATH Clinic lacked adequate orientation on the importance of oral health care for HIV-infected patients.
• For most PATH patients, oral health services were not available near their homes.
• Documentation of oral health care was not easily visible in the medical record.

Select Improvement Measures

Based upon the above analysis, the QI Team selected and implemented four interventions. They were:

• Incorporate an oral health segment into the orientation for house staff rotating onto PATH. Information was added to the orientation packet and to the presentation given monthly to the residents by the Director of Clinical Services.
• Use a rubber stamp to highlight dental notes in the medical record so providers and reviewers could locate the information readily.
• Recruit a dental hygienist for the PATH Clinic to perform oral health screenings on-site.
• Create an HIV Dental Clinic at the Caledonian campus location thereby providing dental services closer to many patients’ homes.

Results

These interventions resulted in a significant improvement in the percentage of patients referred for oral health care and the percentage that actually received services, as the following graphs illustrate.

patientsreferred.jpg

patientsreceiving.jpg

By September 30, 2002, 88% of patients received an annual oral health referral. Of those, 100% had received services.

Conclusions

• A coordinated, multidisciplinary team approach can improve oral health care delivery for HIV-infected patients.
• Incorporating a dental clinic into the HIV program setting improves access and the likelihood that patients will accept oral health services. Co-locating a dental provider in the medical clinic to perform triages also promotes the acceptance of dental services by patients.
• For teaching institutions, orientation of house staff is a critical link in ensuring that patients receive oral health services.

A Comprehensive Approach to Increasing the Number of Patients Receiving Dental Care:
Nassau University Medical Center

Background

The Nassau University Medical Center (NUMC) is part of a 1,500 bed health care system that includes a 615-bed tertiary care teaching hospital, an 889-bed skilled nursing facility, a 40-bed correctional center infirmary and six community health centers. HIV outpatient services are provided at the NUMC Designated AIDS Center and at three community health centers (Freeport, Hempstead, and New Cassel-Westbury).

Methodology and Improvement Goals

In 1998, a random review of 50 HIV outpatient clinic charts documented that only 12% of patients were referred for dental services, and only 4% received dental services within the past year. NUMC AIDS Program staff decided to develop a quality improvement project to increase the percentage of patients referred for dental care to 60% and increase the percentage of patients receiving dental examinations to 20%.

Quality Improvement (QI) Team:

A multidisciplinary team was created to oversee this project. The members included the:

• Medical Director of HIV Outpatient Services

Clarifying the Existing Process and Selecting Improvement Measures

The QI team reviewed the current mechanism for dental referrals and identified the following problems:

• Clinic staff was unaware of the importance of oral care as a component of comprehensive HIV care.
• Providers and patients were unaware of the dental resources within the community.
• The progress note had no specific area to document discussion of dental services.

After reviewing the current process and identifying barriers experienced by providers and patients, the following measures were initiated:

Results

dentalreferral.jpg

The Dental Improvement Project resulted in a significant increase in documentation of the number of patients being referred for dental services and receiving dental services. The initial rate of referral for annual dental examination has increased from 12% to 95%. This improvement has been sustained over several years. In 2002, 70% of patients at NUMC received a dental examination, up from 4% since 1998.

Conclusions

A QI approach to identifying and eliminating barriers to care was successful in increasing the number of patients receiving dental services. These improvements were achieved through:

• staff and patient education
• identification of dental resources
• improving the medical record and
• implementing a multidisciplinary approach to assure that patients with HIV receive routine oral care.

References

1. Hogg RS, Rhone SA, Yip B, et al. On viral load-driven antiviral therapy. AIDS 1998;12:279-284.

2. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

3. Marcus M, Freed JR, Coulter ID, et al. On unmet need for oral treatment among HIV-positive medical patients. Am J Public Health 2000;90:1059-1063.

4. McCarthy, GM. Host factors associated with HIV-related oral candidiasis. A review. Oral Surg Oral Med Oral Pathol 1992;73:181-186.

5. Nielson H, et. al. Oral candidiasis and immune status of HIV-infected patients. J Oral Pathol (med), Mar 1994, 23(3) p 140-143.

6. AIDS Institute, New York State Department of Health. “Oral Health Care for People with HIV Infection—HIV Clinical Guidelines for the Primary Care Practitioner.” December 2001.

7. Weiss L, et al. HIV-related knowledge and adherence to HAART. AIDS Care 2003;15:673-679.

8. AIDS Institute, New York State Department of Health. “Pediatric and Adolescent HIV Guidelines – Chapter 16. HIV Clinical Guidelines for the Primary Care Practitioner.” December 2002.

IV. RESOURCES AND TOOLS

The information presented in this section is intended to provide clinicians and administrators with additional resources for:

• Locating clinical education and professional development related to oral health and HIV
• Obtaining printed educational materials for themselves and their patients
• Utilizing on-line resources for more in-depth information on oral health care in the HIV-infected population
• Securing financial assistance available to facilities and consumers to cover oral health services
• Identifying facilities offering dental care in communities throughout New York State to increase patients’ access to an oral health provider

Local, Regional and Statewide Training Resources for Health Professionals

New York State Department of Health AIDS Institute:
The HIV Clinical Education Initiative (CEI)

http://www.nyhealth.gov/nysdoh/aids/clinician.htm

The CEI was established to expand HIV clinical expertise among clinical providers within a wide range of community-based settings by providing on-site training. The CEI also provides phone consultations on clinical management and post-exposure prophylaxis. For information and to contact one of the nearest CEI Centers in New York State, call The New York State Department of Health AIDS Institute, Office of the Medical Director, (518) 473-8815.

New York State Department of Health AIDS Institute:
The Nicholas A. Rango HIV Clinical Scholars Program

The Nicholas A. Rango HIV Clinical Scholars Program is a fellowship-type program designed for physicians, physician assistants, nurse practitioners and dentists who are seeking hands on training in HIV clinical care and the public health aspects of the epidemic. The program strives to recruit clinicians who have the skills and commitment to provide leadership in the rapidly changing field of HIV medicine. Oral health is an integral component of the curriculum for all HIV Clinical scholars. The oral health-training component of this program is based out of Bronx-Lebanon Hospital Center. For further information, contact the Nicholas A. Rango HIV Clinical Scholars Program at the New York State Department of Health AIDS Institute, Office of the Medical Director, (518) 473-8815.

The New York/New Jersey AIDS Education and Training Centers (AETC) Program

www.nynjaetc.org

The NY/NJ AETC program assists health care professionals to provide high quality services and care to persons with HIV. The NY/NJ AETC is capable of designing a training program tailored to the needs of an institution or the geographic region it serves. To discuss training needs call the NY/NJ AETC program at Columbia University at (212) 305-8291.

The Westchester Medical Center’s Annual HIV Dental Conference

This conference has trained hundreds of dentists, dental hygienists and dental assistants on the principles of oral health management for persons with HIV. For additional information call the AIDS Care Center at Westchester Medical Center, (914) 493-7700.

Printed Resources for Health Professionals and Consumers

1. For Health Professionals

New York State Department of Health AIDS Institute: Oral Health Care for People with HIV Infection. HIV Clinical Guidelines for the Primary Care Practitioner

www.hivguidelines.org

These clinical guidelines are intended to assist in providing all members of the primary health care team with important clinical information regarding oral health. This publication can be downloaded at the website. Requests for sample copies and order forms for clinical guidelines and other educational materials are available by phone at (518) 474-9866 in Albany or (212) 268-6164 in NYC or by e-mail at hivpubs@health.state.ny.us. Publication #9450, 2001.

New York City Department of Health HIV Resource Library

www.nyc.gov/html/doh/html/ah/ah.shtml
This library was established by the New York City Department of Health, Bureau of HIV Program Services, in order to provide current and comprehensive HIV-related information to health care providers in the New York City area, staff and clients of publicly funded community-based organizations, and the general public. The collection consists of books, periodicals, a videotape collection and special information packets. The library is located at 225 Broadway, 23 Floor, New York, NY 10007. To register for courses, call (212) 693-0774 between 10 am and 4 pm Monday to Friday.

Dental Alliance for AIDS/HIV Care:
Principles of Oral Health Management for the HIV/AIDS Patient

www.aidsetc.org/pdf/curricula/Princ_Oral_Health_HIV.pdf

This consensus monograph was developed by nationally and internationally recognized leaders in the dental community who are on the front lines of HIV clinical care and social support issues.

To order call (888) 275-4772 and request inventory code #HAB 00230 or download.

Academy of Oral Medicine: Clinician’s Guide to the HIV-Infected Patient

http://aaom.com

This monograph, developed by the Academy of Oral Medicine (AAOM), includes information on HIV epidemiology, pathogenesis, oral manifestations and treatment planning for patients with HIV disease.

Order forms are available online.

New York State Department of Health AIDS Institute: Oral Health is Important. A Guide for Caregivers of Children with HIV Infection

This easy-to-read pamphlet provides useful oral health education for caregivers of children with HIV. Requests for sample copies of this and other educational materials are available by phone at (518) 474-9866 in Albany or (212) 268-6164 in NYC or by e-mail at hivpubs@health.state.ny.us. Publication # 9290, February 2001.

Westchester County Medical Center AIDS Management Program:
A Guide to Dental Care for the HIV-Infected

This consumer brochure provides guidance on self-examination for oral lesions along with daily oral hygiene techniques. A copy of this brochure may be requested by phone from the Ryan White Dental Clinic at Westchester Medical Center at (914) 493-7785.

Web-Based Resources for Health Professionals

New York State Department of Health AIDS Institute

www.hivguidelines.org

This website has been developed as a central, on-line resource that equips clinicians and administrators who provide services to people with HIV infection with current, state-of-the-art tools to ensure delivery of the highest quality HIV clinical care. These tools include clinical guidelines, prevention guidelines, examples of best practices and quality improvement information and software.

The AIDS Education and Training Centers (AETC) National Resource Center

www.aidsetc.org

The National Resource Center is a web-based HIV/AIDS training resource that supports the training needs of the regional AETCs through coordination of HIV/AIDS training materials, rapid dissemination of late-breaking advances in treatment and changes in treatment guidelines, along with critical review of available patient education materials.

HIVDENT

www.hivdent.org

This coalition of health care professionals is committed to assuring access to high quality oral health care services for people living with HIV disease. This site disseminates state-of–the-art treatment information and includes extensive information on the oral aspects of HIV disease.

American Dental Association

www.ada.org

This website provides information on practice management, government issues and scientific affairs as they relate to HIV disease and oral health. Additional resources for patients and consumers include informational videos and brochures on oral health.

Dental Alliance for AIDS/HIV Care

www.critpath.org/daac

This association of dental health care workers and other concerned professionals was organized to provide improved clinical oral care for patients with HIV disease.

AIDSinfo

www.aidsinfo.nih.gov

A service of the U.S. Department of Health and Human Services, AIDSinfo is a central resource for current information on federally and privately funded clinical trials for AIDS patients and others infected with HIV. As the main dissemination point for federally approved HIV treatment and prevention guidelines, AIDSinfo provides information about current treatment regimens for HIV infection and AIDS-related illnesses.

Centers for Disease Control and Prevention (CDC)

www.cdc.gov

CDC serves as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and education activities designed to improve the health of the people of the United States. The CDC website has extensive information related to HIV/AIDS disease, treatment and prevention.

Financial Resources for Institutions Providing Dental Care

New York State HIV Uninsured Care Programs: ADAP and ADAP Plus

The New York State Department of Health AIDS Institute has established the HIV Uninsured Care Programs to provide access to medical services and medications for eligible New York State residents with HIV/AIDS. The ADAP formulary consists of more than 400 medications for HIV-related illnesses. ADAP Plus covers a full range of HIV primary care outpatient services including oral health treatment.

For information regarding client and facility eligibility contact:

New York State Department of Health
HIV Uninsured Care Programs
(518) 459-1641 or (800) 542-2437

Department of Health & Human Services
Health Resources and Services Administration
HIV/AIDS Bureau

• Dental Reimbursement Program of the Ryan White CARE Act

This program provides grants to accredited dental schools, postdoctoral dental education programs and dental hygiene education programs to help cover the uncompensated costs of providing oral health services to patients with HIV infection.

• Community Dental Partnership Program of the Ryan White CARE Act

This newly established program provides support to dental and dental hygiene schools to partner with community-based organizations. The goals of the program are to provide oral health services to people with HIV in rural and urban unserved and underserved areas, and to train additional numbers of dental providers to deliver quality oral health care to people with HIV disease.

For information on the Dental Reimbursement Program or the Community Dental Partnership Program contact:

Division of Community-Based Programs
HIV/AIDS Bureau
Parklawn Building, Room 7A-30
5600 Fishers Lane
Rockville, MD 20857
(301) 443-0493

HIV Oral Health Resource Directory

This directory, organized by borough in New York City and by region in New York State, is intended for use as a referral tool for providers and individuals seeking oral health services for HIV-infected patients. Among the many reported reasons why people with HIV do not access dental care is the fact providers and consumers are unaware of sites that offer oral health services. Through this directory, individuals may find venues for care previously unknown to them and providers may become more knowledgeable of oral health referral sites in their regions.

Every attempt has been made to list facilities that receive funding through the Ryan White Care Act. It may be necessary to contact the site prior to the patient’s arrival in order to determine the intake policy of the facility. Within New York City, it may be helpful to look at sites in several boroughs since some sites serve clients from neighboring localities.