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Mobile Equipment delivered during the evening Complete mobile dental office operational on-site contractual responsibilities for meeting the oral health care needs of an institution, they take on a uniquely public health character, functioning as dental care access programs. Nursing homes and Medicaid programs that pay for services demand nondiscriminatory care and cost-accountability. All these factors point to the need for new, nonprofit delivery systems with interdisciplinary organizational structures. New legal agreements are needed to clarify dental and nursing staff responsibilities and assure regulatory compliance. New methods of communicating, care planning, record keeping, and scheduling are needed for on-site teams to function smoothly. To maintain and improve quality, new team management structures, levels of accountability, and management information systems are essential. On-site providers must provide documentation that meets the needs of the nursing home and can be incorporated into the medical record. The use of terminology appropriate to the training of nursing staff will facilitate communication and follow-up care. Interpretation of dental records and typical follow-up orders should be included in the training of nursing personnel. Just as with any dental practice, effective scheduling is essential. Mobile care schedulers must first determine a monthly schedule of site visits to each of the facilities served. Visits must be scheduled with sufficient frequency to keep facilities up-to-date while effectively utilizing the time of dental personnel. Schedulers must track the number of new patients, patients undergoing treatment, dental emergencies, and those due for recall. Each site visit must be coordinated through the facility’s dental liaison. As the number of sites served by the mobile practice grows, the complexity of this task is magnified. Large facilities may need weekly visits, while small ones may need a combination of on-site visits and off-site referrals to assure that resources are used cost-effectively.
Nondental personnel in the long-term care setting are critical in identifying their residents’ oral health needs and connecting them to dental personnel who can address those needs. Nursing homes that receive federal reimbursement are required by OBRA 1987 regulations to demonstrate that they can “actively provide or obtain dental care for their residents.” They are required to:
1. Assist residents to obtain routine/emergency dental care.
2. Provide/obtain dental services by hiring staff or contracting with a dentist.
3. Assist/arrange for appointments and transportation to a dental office.
4. Refer a resident with lost or damaged dentures to a dentist promptly.48
Making these more than “paper requirements” requires that non dental personnel, particularly the nursing staff, can identify problems to refer and facilitate care as necessary. An important function that can be performed by a non dental nursing home employee is that of “Dental Liaison.” The Apple Tree Dental (ATD) model illustrates the key roles this individual plays in facilitating dental care. The Dental Liason fufills the following responsibilities:
1. Training nursing staff and intake workers on protocols and procedures for routine and emergency care, and assuring that all residents are referred for routine care.
2. Serving as the dental communication link, routing reports of dental problems to the dental team and conveying information from the dental team back to the facility.
3. Assuring that the dental team receives charts, health status, and nursing assessment information and other assistance needed to provide care.
4. Assuring the availability of the work area, and making arrangements to have it cleaned before and after on-site clinic days.
5. Assuring that nursing staff and residents are informed in advance of appointments.
6. Providing regular feedback for quality improvement.
In this system, nurses play several key roles, such as providing health status updates when necessary, and relaying dental concerns to the dental liaison. Following on-site visits,nursing staff are responsible for carrying out postoperative orders and for modifying daily oral care plans as directed. Nurses must also be involved in medical-dental consultations and in the coordination and administration of medications needed to provide dental care. Finally, nurses may need to assist with communication, mental status assessment, resident transfers, and behavior management to enable every resident to obtain needed care. The contributions of the interdisciplinary care planning team are valuable adjuncts in the provision of appropriate oral health care to the functionally dependent adult. Physical therapists can evaluate existing function. Occupational therapists can make recommendations regarding the resident’s oral self-care ability. Social workers can provide insights into family interactions and any discharge potential. Nurses and physicians can provide critical information about the resident’s medical condition and nursing interventions. Just as dental personnel should refer unknown or inadequately controlled medical problems like diabetes and hypertension, so non-dental personnel should refer patients when oral disease is detected. They can advocate for the importance of oral health care to general health, stress that oral disease can exacerbate other health problems, and dispel the misconception that oral disease and tooth loss are unavoidable parts of aging.