IMPROVING THE DENTAL CLINIC SHOW RATE FOR PATIENTS REFERRED BY STAR HEALTH CENTER
SUNY Downstate Hospital STAR Health Center

Project Background

Project Name: Improving the Dental Clinic show rate for patients referred by STAR Health Center

HIV Caseload: 824

Project Description: A 1997, DOH review of state-wide dental care data revealed poor compliance with dental care standards among persons living with HIV/AIDS. The aggregate data indicated that 32.6% of patients had a dental referral within one-year, as required by NYSDOH HIVQUAL standards. Moreover, only 24.1% had a documented exam completed in the same period. This trend was also evident at STAR Health Center (SHC), where a 1999 review of charts demonstrated a 71% compliance rate with annual dental referral (N=45). However, only 29% of patients had a dental exam documented in the medical record. The need to improve quality of care related to dental services spurred the development of an on-site dental clinic that would increase access to dental care. The next step involved development of strategies to increase the percentage of clients being referred for, and receiving dental care, which was addressed by the following quality improvement project.

Rationale for Selections: In August of 1999 the STAR Health Center initiated the first on-site dental services for all STAR Health center patients with cooperation from the pre-existing dental services at SUNY Downstate Hospital. SHC received Ryan White Title III supplemental funding to pay for one dentist to provide services for 3 sessions per week. The Department of Dental Services would be paid per session, rather than per patient. The first STAR Health Center patient was seen August of 1999.

Between August 1999 and June 2000, the utilization of dental services among SHC patients remained consistently low. The target established for number of dental encounters was 18 per week. Between August and December 1999, the average number of dental encounters was 17 per month. In the first six-months of 2000, the average number of dental encounters reached 35. Nonetheless, the number of dental encounters remained approximately 50% below target. In an effort to improve the use of dental services, we developed a quality improvement initiative for 2000/2001.

There should be special mention that participation in the IHI HIV/AIDS Collaborative helped establish the structure and process for this project and has been carried over to additional quality improvement projects.

Team Members:

• Jack DeHovitz MD, Director of the HIV Center for Women and Children
• Barbara O’Sullivan NP
• Alexa Kazim MPA, Clinic Manager
• Kristina Brown RPA-C, Quality Improvement Coordinator
• David Warren MD, SHC Medical Director
• Grace Abraham RN, SHC Head Nurse

Success Story

Improvement Goal: 75% of STAR Health Center patients will keep their scheduled dental appointment.

Methodology: On a monthly basis, SHC tracked the rate of kept dental appointments among SHC patients referred to dental services. To facilitate the implementation of this initiative, we narrowed the population of focus to the patients on the panels of three clinicians.

Indicator: Show rate percentage = number of patients seen in dental clinic divided by the number of patients w/a scheduled dental appt x 100

Accurate tracking is done via a two-step process:

STEP 1.) A list is faxed indicating SHC patients with a scheduled appointment for the next dental session by the dental administrative staff to the SHC Head Nurse the day before each SHC-designated session. This list indicates the total number of patients with a scheduled dental appointment. (DENOMINATOR)

STEP 2.) A list is faxed indicating SHC patients that kept their scheduled dental appointment by the dental administrative staff to the STAR HC Head Nurse after a session is completed. This list indicates the number of patients seen in the dental clinic. (NUMERATOR)

Changes Tested:

• Tested and initiated a new appointment system process: SHC medical providers give all SHC patients a dental referral at least once annually, nursing picks up the referral when completing clinician orders and discharge, and schedules the patient for the next available dental appointment. Patient leaves the SHC with an appointment for the dental clinic and is given an appointment reminder card.
• Tested and initiated reminder phone calls to all SHC patients scheduled to be seen in dental clinic: the day before the SHC-designated dental clinic, a list of SHC patients are faxed to the SHC Head Nurse, who then makes reminder phone calls to patients making them aware of their scheduled dental visit. (This had the greatest impact on improving the show rate).
• Tested and initiated the use of “CLIMACS” the preexisting SHC electronic medical record system, to improve the accuracy and speed of monitoring monthly dental show rate. The Head Nurse entered scheduled dental appointment under CLIMACS appointment system, as well as whether the patient kept or broke the appointment based on the faxed lists that were received regularly.

Other factors that helped improve the show rate:

• Flyers were used in the SHC to promote the availability of dental services and the importance of good dental health.

Results: Click here to view the chart: Dental Show Rate by Month for “POF”only (Adobe PDF)
http://hivguidelines.org/public_html/center/quality-of-care/qoc_success_stories/submissions/pdf/suny_downstate_ch1.pdf

The above chart represents the initial data collection that started July 2000 and continued through October 2001.

Data was collected month to month with an average number of patients being referred to dental services equaling 30.

*Tracking of data was limited to the population of focus (POF)-three specified providers’ panel of patients.

Click here to view: Dental Show Rate of all SHC Patients by Month (Adobe PDF)
http://hivguidelines.org/public_html/center/quality-of-care/qoc_success_stories/submissions/pdf/suny_downstate_ch2.pdf

The above charts represents that the second data collection process that is currently ongoing.

This started April 2001 and will continue indefinitely. It is important to note that the GOAL has increased to 100% dental show rate.

This was phased in on April 1, 2001 and includes all of the STAR Health Center’s clients with an average number of patients referred on a monthly basis to dental services equaling 40.

Summary

Lessons Learned:

• A mechanism for the sharing of service goals, on-going monitoring of service goals, and strategies and barriers to achieving these goals, needs to be in place early on to promote staff participation and success in meeting targets.
• Improved access alone may not always be the answer to improvement in utilization. Patient education is required to increase patient awareness about not only availability, but also the importance of oral health, especially as it relates to their HIV/AIDS primary care.
• Persons serving patients living with HIV/AIDS need to be informed about disease prevention and transmission. Familiarity on the part of the dental staff with how to reduce/respond to occupational exposure will increase employee comfort with treating patients that are known to be seropositive.

Next Steps: In 2002, SHC will monitor and improve the dental show rate as part of its continuous quality improvement program. Oral health is an important component in the clinical management of patients living with HIV/AIDS. Thus, it is essential that we continue to promote oral health among SHC patients.

The goal of increasing the number of SHC patients referred to dental services poses a challenge in that so many patients refuse dental services. A large number of patients report being fearful of going to the dentist. Fear of pain is a common thread among the patients that refuse dental services. The SHC will seek to develop an education campaign that: (1) emphasizes the importance of maintaining good oral health; and (2) educates patients about pain management.

Through close tracking of the number of patients referred for dental services, SHC will be better able to improve the number of patients that have a completed dental exam. On a monthly basis, the Quality Assurance Committee will review the number of patients that were eligible for a dental referral and compare it to the number that were actually referred. By monitoring compliance with dental referrals by clinician, the SHC will be able to reduce variation in referrals and increase the total number of dental referrals.

Finally, the SHC will share utilization target and achievement information routinely with dental services so as to jointly develop plans for maximizing the opportunities to provide dental care to patients.

For more information, please contact:

Kristina Brown RPA-C
Quality Improvement Coordinator
Submission Date: March 20, 2002
kristina_brown@netmail.hscbklyn.edu

SUNY Downstate Hospital
STAR Health Center
450 Clarkson Ave. Box 1240
Brooklyn, New York, 11203
(718) 270-2842 (phone)
(718) 270-2298 (fax)