6/24/2019 1 Hacking into the Teledentistry Trend – New Generation of Dentists Marisa Watanabe, DDS, MS Jenny Tjahjono, DMD David Kadar, DDS June 25, 2019 Region IX Clinical Excellence Conference 2019 Newport Beach, CA Outline of Today’s Presentation • Overview of Telehealth • Addressing the barriers of social determinants through different telehealth delivery modalities • Engaging the workforce and integrating into clinical teledentistry models • Introduction of Billing and Reimbursement • Discussion of varying state policies regarding telehealth and teledentistry • Explaining different reimbursement models based on Medicaid Dental and Federally Qualified Health Center (FQHC) prospective payment system rate • Federally Qualified Health Center Integration of Teledentistry • Integrating the Virtual Dental Home into an FQHC • Describing the best practices and challenges of the Virtual Dental Home in an FQHC environment Overview of Telehealth Marisa Watanabe, DDS, MS Associate Professor Assistant Dean for Community Patient Care Western University of Health Services, College of Dental Medicine
Transcript
6/24/2019
1
Hacking into the Teledentistry Trend –
New Generation of DentistsMarisa Watanabe, DDS, MS
Jenny Tjahjono, DMD
David Kadar, DDS
June 25, 2019
Region IX Clinical Excellence Conference 2019
Newport Beach, CA
Outline of Today’s Presentation• Overview of Telehealth
• Addressing the barriers of social determinants through different telehealth delivery modalities
• Engaging the workforce and integrating into clinical teledentistry models
• Introduction of Billing and Reimbursement• Discussion of varying state policies regarding telehealth and teledentistry• Explaining different reimbursement models based on Medicaid Dental and
Federally Qualified Health Center (FQHC) prospective payment system rate
• Federally Qualified Health Center Integration of Teledentistry• Integrating the Virtual Dental Home into an FQHC• Describing the best practices and challenges of the Virtual Dental Home in an
FQHC environment
Overview of Telehealth
Marisa Watanabe, DDS, MS
Associate Professor
Assistant Dean for Community Patient Care
Western University of Health Services, College of Dental Medicine
6/24/2019
2
Disclaimers
All rights reserved. This presentation is protected by copyright. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. To request permission, please contact the presenter at [email protected].
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under Grant Number D85HP30837 Predoctoral Pediatric Training in General Dentistry and Dental Hygiene for grant amount $1,499,999, with 0% match from nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
Learning objectives
Following the presentation, the audience will be able to:
• Describe the need for telehealth to address the social determinants in health disparities;
• Explain the difference between synchronous and asynchronous telehealth delivery systems;
• Develop a list of community partners to initiate a teledentistrymodel; and
• Integrate team members into the teledentistry model
I. Social Determinants and Integration of Telehealth
social determinants of health
—WORLD HEALTH ORGANIZATION1
8
HEALTH DISPARITIES AND NEED FOR CHANGE
Pediatrics
Geriatrics
Persons with Special
Health Care Needs
Rural
Inner-city
HPSA (DHPSA)
Dental Deserts
6/24/2019
4
What is telehealth?
“… the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.”
-- Health Resources and Service Administration (HRSA) of the U.S. Department of Health and Human Services2
Photo Credit WesternU Jeff Malet
Telehealth Applications3
• Synchronous: A live two-way videoconferencing linked through an audiovisual format
Connected electronic tools to record personal health and medical data in one location
• Mobile Health (mHealth):
Notifications through mobile devices to inform the public regarding healthcare and public health information
II. Telehealth Delivery Systems
6/24/2019
5
General Guidelines to Establishing a Telehealth Model
Target Population: Form partnerships and
affiliation agreements
Building trust and rapport with the
community
Decide on the telehealth application and
delivery system model
Create a well-trained and calibrated team
Continue to calibrate as new changes in policy,
certification of team members, and billing
Determine target population and location-Needs assessment and demographic analysis
• Grassroots and administrative levels
• Execute appropriate affiliation agreements (i.e. MOA or MOU)
• Continue to build and form partnerships to support initial infrastructure
Target Population: Form partnerships and affiliation agreements
School Name
Grade Levels
EnrollmentFRPMEligble
(K-12) (%)
Shirpser K-6 589 97.6
Cortada K-6 401 96.8
Potrero K-8 847 96.7
Wright K-8 749 96.5
Columbia K-8 846 95.4
Student Poverty Free or Reduced Price Meals (FRPM) 2018-2019 El Monte City School District Data4
Building trust and rapport with the community
Provide support in health screenings and community events
• Get involved in community meetings, events, and donations
• Build relationships with community health workers or promatoras, and health educators
• Provide at no-cost or pro bono health screening events
Foothill Family Services Health Fair 2018El Monte, CA
6/24/2019
6
Decide on the telehealth application and delivery system model
Assess social determinant barriers and budget for appropriate telehealth model
Mobile Dental HomeHub-and-Spoke
Virtual Dental Home
A main clinic and spoke that utilizes teams that may include a dentist at both sites
A spoke that uses allied dental personnel to refer back to the main hub with the dentist
A mobile clinic acts as the “hub” with teams gathering data at the spokes.
Create a well-trained and calibrated team
Your selected telehealth model will determine your team members
• Ability to work independently
• Attention to detail
• See the big picture
• Team-oriented
• Higher level of critical-thinking
Virtual Dental Home ITR ExaminationPomona, CA
Partnerships and affiliation agreementsContinue to calibrate as new changes in policy, certification of team members, and billing
“If you think in terms of a year, plant a seed; if in terms of ten years, plant trees; if in terms of 100 years, teach the people.” -- Confucius- Ever-changing needs at a systems level
• Acceptance of telehealth model by state and/or region
• Governing bodies of team members – changes in scope of practice
• Updates in billing and reimbursement rates at state and federal levels
6/24/2019
7
III. Example of Clinical Workforce Development in Teledentistry
Example: Hub-and-Spoke ModelMountain View School District in El Monte, CA (Spoke)
Future Workforce in Teledentistry Action: On-Site (Asynchronous Data Gathering)- Allied Dental Personnel (completion of data gathering only)
Dental students = Allied Dental Personnel
Example: Hub-and-Spoke ModelJeff Seymour Family Center Dental Clinic, El Monte, CA (Hub)
Future Workforce in Teledentistry Action: Off-Site (Asynchronous Data Analysis)- Dental Student Roles (completion of all treatment under faculty supervision)
- Dentist Roles (completion of all treatment and/or supervision of dental students)
6/24/2019
8
Key Takeaways• Telehealth is a delivery system to address the different social
determinants of health which are barriers to different populations;
• Through either a synchronous or asynchronous method, individuals are able to obtain health care and minimize the impact of transportation and costs;
• This model can be successful by building the trust and rapport with the community first; and
• Future healthcare workforce are applying different clinical teledentistry delivery systems, and will be a great value to those who are looking to expand their current practice model.
References
1. Social Determinants of Health. World Health Organization; 2019. https://www.who.int/social_determinants/sdh_definition/en/ . Accessed June 7, 2019.
2. Telehealth Programs. Health Resources & Services Administration; 2019. https://www.hrsa.gov/rural-health/telehealth/index.html . Accessed June 4, 2019.
3. Telemedicine and Telehealth. HealthIT.gov; 2017. https://www.healthit.gov/topic/health-it-initiatives/telemedicine-and-telehealth . Accessed June 4, 2019.
4. Student Poverty FRPM Data. California Department of Education; 2019. https://www.cde.ca.gov/ds/sd/sd/filessp.asp . Accessed June 4, 2019
Assistant Dean for Community Partnerships and Access to Care
Western University of Health Services, College of Dental Medicine
Disclaimers
All rights reserved. This presentation is protected by copyright. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. To request permission, please contact the presenter at [email protected].
• Paul Glassman, DDS, MA, MBA, Emeritus Professor, University of the Pacific School, Arthur A. Dugoni School of Dentistry
• David Campbell, DDS, Los Angeles Christian Health Center
• Luahna Ellner, RDHAP
• Randi Grifka, Henry Schein
• Bill Jackson, DDS, Mitali Hariawala, DMD, MS, Virtual Dental Care
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under Grant Number D85HP30837 Predoctoral Pediatric Training in General Dentistry and Dental Hygiene for grant amount $1,499,999, with 0% match from nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
Man Wai Ng and Zameera Fida, Dental Hygienist-Led Chronic Disease Management System to Control Early Childhood Caries. Journal of Evidence Based Dental Practice, 2016, 16:20-33.
Sealant
Interim Therapeutic Restoration
III. State Regulation and Reimbursement
6/24/2019
13
Let’s take a quick poll of the audience: Who do you think can bill for reimbursement in teledentistry?
A) Dentists
B) Hygienists
C) Both
Policies and Billing on Teledentistry
• Scope of practice regulations for dental auxiliary professionals differs between states
• Dental coverage differs between states
• Billing policies on teledentistry are varied widely, lacking or are unclear between states
• Check with the State Boards of Dentistry and Medicaid dental program on laws, regulations, and reimbursement for teledentistry
State Telehealth Laws and Reimbursement Policies by Center for Connected Health Policy
State Telehealth Laws and Reimbursement Policies Report. Sacramento, CA.: Center for Connected Health Policy; 2019. https://www.cchpca.org/telehealth-policy/state-telehealth-laws-and-reimbursement-policies-report. Accessed June 4, 2019.
• Expands definition of teledentistry to include an examination by a dentist
• Enables dental hygienists to place interim therapeutic restorations (ITR) upon successful completion of an ITR course but without taking expanded functions dental assistant (EFDA) training/exam
"Teledentistry" means the use of data transmitted through interactive audio, video or data communications for the purposes of examination, diagnosis, treatment planning, consultation and directing the delivery of treatment by dentists and dental providers in settings permissible under title 32, chapter 11 or specified in rules adopted by the board.
6/24/2019
16
Scope of Practice • Dental Therapists: Placing interim therapeutic restorations after
successful completion of a course completed at an institution accredited by the commission on dental accreditation of the American dental association
• Dental hygienist: Preventive services; placing interim therapeutic restorations after successful completion of a course completed at an institution accredited by the commission on dental accreditation of the American dental association
• Extended Function Dental Assistant (EFDA): An expanded function dental assistant may place interim therapeutic restorations under the general supervision and direction of a licensed dentist following a consultation conducted through teledentistry
Arizona Revised Statues. Arizona State Board of Dental Examiners. August 2, 2018.
Arizona Summary
•Live video (synchronous)
•Arizona Medicaid enrollees under the age of 21
• ITR can be performed by a dental therapist, a hygienist or an EFDA upon completion of a course under the general supervision and direction of a dentist
California
6/24/2019
17
California Assembly Bill 1174
• AB1174 passed in 2014
• Authorize a hygienist and a Registered Dental Assistant in Extended Functions (RDAEF) to perform radiograph decision-making and to place ITR upon completion of a course and under the general supervision and direction of a dentist through teledentistry
Example of Teledentistry Model: Virtual Dental Home (VDH)• Virtual Dental Home demonstrated at the Pacific Center for
Special Care at the University of the Pacific, Arthur A. DugoniSchool of Dentistry (Pacific)
• Registered dental hygienists in alternative practice (RDHAP), registered dental hygienists (RDH), and registered dental assistants in extended functions (RDAEF) can keep people healthy in community settings
Dr. Paul Glassman
6/24/2019
18
Scope of Practice
• Hygienist: Preventive services; place interim therapeutic restorations in public health settings using telehealth under the general supervision of a dentist
• Registered Dental Assistant in Extended Functions (RDAEF): Place interim therapeutic restorations in public health settings using telehealth under the general supervision of a dentist
California Business and Professions Code, Dental Practice Act. Dental Board of California. 2018
California Summary
•Live video (synchronous)
•Store-and-forward (asynchronous) – hub-and spoke including the VDH model
• ITR can be placed by a hygienist or an RDAEF upon completion of a course under the general supervision and direction of a dentist
Hawaii
6/24/2019
19
Hawaii Senate Bill 2395• SB 2395 passed in 2016
• Require the state’s Medicaid managed care and fee-for-service programs to cover services provided through telehealth
• Allow reimbursement for services provided through telehealth shall be equivalent to reimbursement for the same services provided via face-to-face contact between a health care provider and a patient
• Ensure that telehealth encompasses store and forward technologies, remote monitoring, live consultation, and mobile health
Teledentistry Pilot Program
Adopt the Virtual Dental Home (VDH) system developed by Pacific Center for Special Care at the University of the Pacific School of Dentistry Arthur A. Dugoni School of Dentistry
Dental hygienists utilize VDH to connect patients at Women, Infants and Children (WIC) centers, preschools, and schools with dentists.
Report to the Thirtieth Legislature. State of Hawaii, 2019. December 2018.
Hawaii Summary
•Live video (synchronous) & Store-and-forward (asynchronous)
•Adopted the Virtual Dental Home pilot program
•Hygienists do not place ITRs
6/24/2019
20
Nevada
Nevada Assembly Bill 292
• AB 292 passed in 2015
• Encourage and facilitate the provision of health care services through telehealth
• Ensure that services provided through telehealth are covered by policies of insurance to the same extent and in the same amount as though provided in person or by other means
UMC Hospital Emergency Room Pilot Program
University Medical Center (UMC) Hospital Emergency Department uses Liberty Dental Plan’s teledentistry software and consultants for consultation and case management of the non-traumatic dental conditions.
Program Activities and Updates 2019. Department of Health and Human Services, Nevada Division of Public
and Behavioral Health. May 2019.
6/24/2019
21
Nevada Summary
• Live video (synchronous) & Store-and-forward (asynchronous)
• No specific teledentistry law, policy, or regulations
• UMC Hospital Emergency Room Pilot Program using teledentistry software
Pacific Islands
CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=1169454
Substitute Bill 245 in Guam
• SB 245 passed in 2008
• Referred to as “The Telemedicine Act of 2008”
• Allow a licensed physician who resides outside of Guam to provide consultation through telemedicine
Department of Public Health and Social Services Northern Health Center in Dededo launched Guam’s first telemedicine program with Good Samaritan Hospital specialists in Los Angeles.
Losinio L. Telemedicine Program Launched. The Guam Daily Post. June 9, 2016.
The Compacts of Free Association Veterans Review Act
• A new bill introduced in April 2019
• A 3-year pilot to support telemedicine for veterans living in Palau, the Marshall Islands and Federated States of Micronesia
Wicklund E. Senate Eyes Telehealth to Help Pacific Island Veterans Access Care. mHealth Intelligence. April 30, 2019.
Summary slide of Pacific Islands
No specific teledentistry laws, policy, or regulations
Adopted from Teledentistry in Arizona Initial Development. Phoenix, AZ.: Arizona Department of Health Services Office of Oral Health; 2009.
6/24/2019
24
Key Takeaways
• Policies on teledentistry are varied widely between states;
• Certified and trained allied dental personnel perform state-approved teledentistry dental procedures which may include data gathering, radiograph decision-making, and/or prevention;
• Check with the State Boards of Dentistry and Medicaid dental program on laws, regulations, and reimbursement for teledentistry; and
• Opportunities for financial resources to sustain the teledentistry delivery model must go beyond grant funding for long-term success.
References• D9995 and D9996 – ADA Guide to Understanding and Documenting Teledentistry Events. American Dental Association; 2017.
https://www.ada.org/~/media/ADA/Publications/Files/D9995andD9996_ADAGuidetoUnderstandingandDocumentingTeledentistryEvents_v1_2017Jul17.pdf?la=en. Accessed June 4, 2019.
• State Telehealth Laws and Reimbursement Policies Report. Sacramento, CA.: Center for Connected Health Policy; 2019. https://www.cchpca.org/telehealth-policy/state-telehealth-laws-and-reimbursement-policies-report. Accessed June 4, 2019.
• Caffrey E, Tate AR, Cashion SW, et all. Are Your Kids Covered? Medicaid Coverage for the Essential Oral Health Benefits. Chicago IL. American Academy of pediatric Dentistry; 2017. https://www.aapd.org/assets/1/7/AreYourKidsCoveredfinal.pdf. Accessed June 4, 2019.
• Arizona Revised Statues. Arizona State Board of Dental Examiners. August 2, 2018.
• Lebsock J. Teledentistry. Arizona Health Care Cost Containment System. https://www.azahcccs.gov/AmericanIndians/Downloads/Consultations/Meetings/2015/91415TribalConsultationTeledentistry.pdf. Accessed June 4, 2018.
• Teledentistry in Arizona Initial Development. Phoenix, AZ.: Arizona Department of Health Services Office of Oral Health; 2009.
• Report to the Thirtieth Legislature. State of Hawaii Department of Health. 2019.
• Losinio L. Telemedicine Program Launched. The Guam Daily Post. June 9, 2016. https://www.postguam.com/news/local/telemedicine-program-launched/article_c9b4d502-2d62-11e6-96d8-934e206312a5.html. Accessed June 4, 2019.
• Wicklund E. Senate Eyes Telehealth to Help Pacific Island Veterans Access Care. mHealth Intelligence. April 30, 2019. https://mhealthintelligence.com/news/senate-eyes-telehealth-to-help-pacific-island-veterans-access-care. Accessed June 5, 2019.
THANK YOUNext up: FQHC Integration of Teledentistry
All rights reserved. This presentation is protected by copyright. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. To request permission, please contact the presenter at [email protected].
• Earlier Diagnosis and Intervention• Preventive Services to Greater
Population• Increased compliance with
appointments• Nearly 0% no show rate• Recall appointments can take place in
community• Dental resources are reserved for
patients needing restorative and advanced care in “brick and mortar” site
Additional Opportunities
• Integration into Primary Care Clinic• Opportunity to provide
diagnostic, preventative and other dental services at non-dental FQHC clinic sites.
Pearls, Best Practices, and Challenges
Challenge Establishment of affiliation agreements (i.e. MOUs) and Identification of Community Sites
• Fear of providing dental services at non-traditional community-based sites
• Lengthy process of MOUs
6/24/2019
31
Pearls, Best Practices, and Challenges
The FIRST (or almost first) thing to say when approaching a potential community partner:
NO SHOTS
NO BLOOD
Pearls, Best Practices, and Challenges
Consider School Screenings as a Gateway to the Virtual Dental Home
• Builds trust with school/site administration• School staff are already familiar with the
team• Identification of students that would benefit
from the VDH • Identification of students that need urgent
in office treatment
Pearls, Best Practices, and Challenges
Another challenge:What do we do during the summer when school is out?
• Plan ahead to be involved in summer school programs
• Identify year round early learning programs• Consider utilizing VDH team at a non-
dental Health Center site
6/24/2019
32
Pearls, Best Practices, and Challenges
To Be Determined: SUSTAINABILITY:• What is the path after the grants
supporting the program conclude?
• What alternate staffing models are being developed in the community?
• Change in State Reimbursement?
Teledentistry in FQHCs
• Items to Remember:• Teledentistry policy and reimbursement models vary by state to state
• Long term funding/sustainability—grant funding
• Scope of practice laws for allied dental personnel (Dental Hygienists and Dental Assistants) differ from state to state
• Billing Scope of Dental Hygienist
Key Takeaways
Teledentistry will and has been shown in the FQHC world to:
• Improve Access to Care for the Underserved through the VDH model;
• Build partnerships and teams that promote and provide Early Intervention and Prevention; and
• Change the way we practice in the future to address barriers of social determinants and continue to challenge oral health provider roles.
6/24/2019
33
References
1. Langelier M, Rodat C, Moore J. Case Studies of 6 Teledentistry Programs: Strategies to Increase Access to General and Specialty Dental Services. Rensselaer, NY: Oral Health Workforce Research Center, Center for Health Workforce Studies, School of Public Health, SUNY Albany; December 2016
THANK YOUNext up: Future for Teledentistry and Holistic Care
Future for Teledentistryand Holistic Care
Marisa Watanabe, DDS, MS
Associate Professor
Assistant Dean for Community Patient Care
Western University of Health Services, College of Dental Medicine
6/24/2019
34
Disclaimers
All rights reserved. This presentation is protected by copyright. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. To request permission, please contact the presenter at [email protected].
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under Grant Number D85HP30837 Predoctoral Pediatric Training in General Dentistry and Dental Hygiene for grant amount $1,499,999, with 0% match from nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
Future - Interprofessional Collaborative Practice and Telehealth Models?• Integration of dental team member in medical practice
• Collection of data (asynchronous and/or synchronous telehealth)
• Use of shared electronic health record systems for dentist analyses off-site to determine dental treatment
• Expansion of teledentistry into non-dental FQHC sites• Collection of data (asynchronous and/or synchronous telehealth)
