Transcript Iatro-Compliance

Iatro-Compliance
An unintended consequence for oral health
of excessive autonomy in long term care
facilities.
1. Relationship between oral pathogens and lower
respiratory infections (LRI) in long term care
facilities (LTCFs).
2. Cost hospitalization for LRIs versus that of
preventive plaque control in LTCFs.
3. The autonomous resident
4. Oral Health Care Director (OHCD) in LTCFs.
OBJECTIVES
Oral Pathogens
LRIs
• What has been established in literature
• Oral health
• “Mouth-body connection”
• Oral pathogen-pneumonia correlation
“Aspiration pneumonia is a leading cause of illness and death in
persons who reside in long-term-care facilities and, combined
with the lack of proper oral health care and services, the risk of
aspiration pneumonia rises.”
Cherin C. Pace, & Gary H. McCullough,
2010
Dysphagia (2010) 25:307–322 DOI 10.1007/s00455-010-9298-9
• Pneumonia:
• “an infection of the lungs caused by bacteria, mycoplasma,
viruses, fungi or parasites”
• “bacterial being the most common and a significant cause of
mortality and morbidity in human populations”
• with influenza, together are leading cause of death in elderly
long term care residents
• Results in:
• morbidity
• decline in quality of life
• Increased medical costs
• Nosocomial pneumonia (NHAP)
• Often caused by organisms that populate the oral cavity in
institutional settings
• Mortality rate can be as high as 25%
S. Paju & F.A. Scannaopieco 2007
Oral Diseases (2007) 13, 508–512. doi:10.1111/j.1601-0825.2007.1410a.x
PMID:17944664
Oral Cavity
• Dental Plaque:
• Tooth-borne biofilm (hard surfaces)
• Initiates periodontal disease
• “persistent reservoir for potential pathogens”
• (oral & respiratory bacteria)
• Can shed into saliva then aspirated into LR tract/lungs
• Organisms NHAP
• Pseudomonas aeruginosa, Prophyromonous gingivalis
• Staphylococcus aureus
• Enteric gram negative bacteria
• Periodontal enzymes and cytokines
• From periodontally inflamed tissues also transferable
• Stimulate local inflammatory processes that precede infection
S. Paju & F.A. Scannaopieco 2007
Oral Diseases (2007) 13, 508–512. doi:10.1111/j.1601-0825.2007.1410a.x
PMID:17944664
• In Health:
• Respiratory tract can defend against aspirated pneumonia
• Factors in elderly
•
•
•
•
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Diminished salivary flow
Decreased cough reflex
Swallowing disorders (dysphasia)
Poor oral hygiene
Physical / cognitive disabilities
• Dysphasia and Aspiration Pneumonia
• Significant risk factor
• Predictor
• (Langmore et al, 1998-PMID:9513300)
Factors
• This study identified two modifiable risk factors in NHAP
• Inadequate oral care
• dysphagia
 Improved oral
care indirectly
improved
swallowing reflex
 Single
intervention may
reduce NHAP
Modifiable Risk Factors
Modifiable Risk Factors for Nursing Home-Acquired Pneumonia. V. Quagliarello,
et.al. Clinical Infect Dis 2005;40:1-6 PMID 15614684
• Seminal Article:
Findings: those who received daily oral care:

had fewer febrile days

reduction in risk for pneumonia

mortality rate ½ half that of without oral care
Strategies to improve OH in LTC
Oral care reduces Pneumonia in Older patients in Nursing Homes
T. Yoneyama, et. al, J. Am. Geriatr Soc. 50:430-433, 2002 PMID:11943036
1. Relationship between oral pathogens and lower
respiratory infections (LRI) in long term care
facilities (LTCFs).
2. Cost hospitalization for LRIs versus that of
preventive plaque control in LTCFs.
3. The autonomous resident
4. Oral Health Care Director (OHCD) in LTCFs.
OBJECTIVES
• 4.3% of Americans >65 years old reside in nursing homes
• Develop pneumonia at rate of 1 / 1000 days of care (CDC)
•
Centers for Disease Control and Prevention. National Center for Health Statistics. National nursing
home survey. Available at: http://www.cdc.gov/nchs/about/major/nnhsd/nnhsd.htm.
• By 2030, there will be an estimated 1.9 million episodes of
nursing home—acquired pneumonia annually
•
Muder R. Management of nursing home acquired pneumonia: unresolved issues and priorities for future investigation. J Am
Geriatr Soc 2000;48:95-6. http://www.serialssolutions.com/images/AL_Button_grey.gif
• Hospital inpatient care
•
•
•
•
Number of discharges: 1.1 million
Average length of stay: 5.2 days
Number of residents with pneumonia: 33,700
Percent of residents with pneumonia: 2.3%
Hospitalizations
Modifiable Risk Factors for Nursing Home–Acquired Pneumonia
Quagliarello et al, 2005. Clin Infect Dis. 2005 Jan 1;40(1):1-6. Epub 2004 Dec 1
PMID:15614684
• 2004
•
•
•
•
•
•
•
4.0 million illness episodes
22,000 deaths
445,000 hospitalizations
774,000 emergency department visits
5.0 million outpatient visits
4.1 million outpatient antibiotic prescriptions
Direct medical costs totaled
• $3.5 billion.
• accounted for 22% of all cases
• 72% of pneumococcal costs.
Costs
Healthcare utilization and cost of pneumococcal disease in the United States.
S.S. Huang et al. Vaccine Volume 29, Issue 18, 18 April 2011, Pages 3398–3412
PMID:21397721
• A single patient with NHAP transferred to an acute care
hospital can average well over $1000 a day or $10,000
per admission.
• Much of this cost
• involves expenditures for transportation to and from the
hospital,
• emergency room evaluation, hospital admission, and
• nursing home readmission
• Treatment within the LTC
• Estimated to by $458.00 above the cost of usual care
• Medicare disincentives
• MDs benefited at higher rate for hospital care than for LTC
• LTC supplies and nursing staff
Costs of Admissions for NHAP
Should I Hospitalize My Resident With Nursing Home–Acquired Pneumonia?
David Dosa, MD, MPH. DOI: 10.1016/j.jamda.2005.06.005
Estimated cost of provision of care
• Estimated annual salary of a RDH
52,000.00 (ADHA)
• Estimated cost of hospitalization for pneumonia
• $1,000.00- $10,000.00 / hospitalization (up to 5 days)
David Dosa, MD, MPH, 2005
• Transportation costs (EMS), ER costs, Medication costs,
• Physician fees, readmission to LTC
• Reduction in febrile days (not assoc. w/ UTI)
• Medications, supplies,
How to pay for care
• Incurred Medical Expense
• Currently enrolled in Medicaid
• Have Retirement Income (for non-Medicaid covered services)
• Social Security
• Personal
• Available dental benefits are based on the State regulations
• Are those services not covered by
• State Medicaid program
• Third party payer
• Determined to be medically necessary
• Not administratively simple
Strategies in literature
• Strategies
• Dr. M. MacEntee et.al. 1999 Six strategies in
Canada
1.
2.
3.
4.
On-sight FFS DDS and assistant
On-sight Salaried DDS and RDH
On-sight FFS DDS, RDH and assistant
RDH referring for emergency care (on-sight) elective
off-sight
5. On-sight Independent DDS with mobile equipment
6. Staff, resident and family seeking services off-sight
Conflicting priorities: oral health in long term care
M.I .MacEntee, et al. Spec.Care Dent., Vol. 19 No 4 1999
Strategies (findings)
• Success:
• Must include a formalized routine
• for periodic examinations
• daily oral hygiene
• easy access to dental professionals
• On site facilities
• care staff took minimal responsibility for oral care
• Minimal access
• Care staff assumed full responsibility for oral care
Conflicting priorities: oral health in long term care
M.I .MacEntee, et al. Spec.Care Dent., Vol. 19 No 4 1999
Oral Health Coordinator
• Utilized Nursing Assistants (NA)
• In house training
• One hour didactic course
• Basic oral health, brushing techniques, oral/systemic connection
• Dental / root caries, behavior management
• Shadowing/training
• Trainer shadows NA while provided care
Oral health coordinators in long-term care—a pilot study
Gilda J. Pronych. Spec Care Dentist 30(2): 2010
OHC (findings)
• “Training alone may be insufficient in ensuring that improved mouth
care actually takes place.”
• Poor background in health care sciences, lack of understanding
• “The OHC sets the tone for how seriously mouth care of the resident
was taken.”
• Does not acquire competency associated with understanding
• “While the OHC held a position of authority they did not feel they
could act on it.”
• Were not significantly different from co-worker CNA is administrative
structure of LTC
Oral health coordinators in long-term care—a pilot study
Gilda J. Pronych. Spec Care Dentist,(30)2, 2010
1. Relationship between oral pathogens and lower
respiratory infections (LRI) in long term care
facilities (LTCFs).
2. Cost hospitalization for LRIs versus that of
preventive plaque control in LTCFs.
3. The autonomous resident
4. Oral Health Care Director (OHCD) in LTCFs.
OBJECTIVES
The current Equation of Care
Leads to Iatro-compliance = benign neglect
• Direct Care staff:
• Certified Nursing Aide (CNA), Licensed Vocational Nurse
(LVN), Registered Nurse (RN)
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•
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Little time / understaffed
Little knowledge
Low skill level
Little desire to perform oral hygiene care
• Resident:
• Autonomous, non intubated, non ventilated
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Developed kinship-style relationships
Guard independence
Aware of time constraints on staff
Lack confidence in care staff knowledge and skills
Low oral health literacy due to lack of professional contact
Refuse assistance
Exploring Daily Oral Hygiene Tasks in a Long Term Care Facility
Melanie Taverna MS, RDH Thesis presentation 2011
Themes about relationships
• Ageism
• Discriminating against an older person on the grounds of
age. In society, is negative In closed environment is
preferred by resident
Themes (continued)
• Respect:
• Is reciprocal and involves showing regard and
consideration for one another.
• Initial respect of elders
• Must be continually reinforced by actions and words
“There are certain things
I should be able to by
myself. But if not, I’ll
ask for help” (Resident).
“If they can do it
on they own they
should. If the
patient can do it
we let them do
it” (Care staff).
Themes (continued)
• Time Constraints:
• Based on work requirements, affecting the amount of time
available for each resident.
• Residents were very aware of care staff time constraints
• Care staff take advantage of that awareness
“I mean like I’m not against it.
Anything pertaining to the wellbeing
of the patient, that’s what I’m here
for. I would say though if I were
super-duper crunched for time it’s
not a priority” (Care Staff).
Direct Care Staff: CNA
• Barriers to improving oral health
“ I don’t what kind of
course they give (them),
but I bet its one a fifth
grader could pass!”
(Resident)
The Resident
• Higher level of education than direct care staff
• Majority of residents = two years of College
• Majority of care staff = high school diploma or GED
• Despite the respectful relationships
• Residents
• Lacked confidence in the oral hygiene knowledge and
skills of care staff
• Refused intervention in oral hygiene
• Placed a low priority on oral hygiene
• “ a simple task”
• Did not perceive the need for professional care
• Excessive autonomy
The Resident
“It’s a simple task I
have done all my
life.”
“ I usually do
everything myself”
• 50% did not have a dentist/hygienist
• Lack perceived need for professional dental care.
• Lack education in oral changes
1. Relationship between oral pathogens and lower
respiratory infections (LRI) in long term care
facilities (LTCFs).
2. Cost hospitalization for LRIs versus that of
preventive plaque control in LTCFs.
3. The autonomous resident
4. Oral Health Care Director (OHCD) in LTCFs.
OBJECTIVES
Cost of provision of care
“ The time taken to evaluate and
develop an oral care plan may
prevent an individual from moving to
a
more
medically
expensive
environment such as a hospital.”
Health benefits and reductions in bacteria from enhanced oral care.
Fozia Ferozali et.al. Spec. Care Dent. 2007
Proposal
• Oral Health Care Director (OHCD)
• Mediator in the equation
• Resident:
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•
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Supports autonomy with oral hygiene education
Interaction focusing or oral health issues
Improve resident confidence in care staff
Reduce refusal of assistance
• Care staff
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Hands on education
Daily reinforcement of skills
Have more confidence in the skills of resident
Motivated to provide more oversight
Oral Health Care Director
• On-sight intake oral evaluations/electronic transfer to
contract dentist for treatment diagnosis and planning
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•
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•
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Validated oral health evaluations and impact forms
Financial information
Health and demographic information
Dental and periodontal charting
Intra-oral photos and radiographs
• Provide:
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•
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Dental hygiene diagnosis
Professional hygiene care plan
Daily care plan
Referrals for dental treatment
Oral Health Care Director (OHCD)
MS, RDH
• Coordinate:
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•
•
•
•
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Physician(s) – multiple systemic diseases
Dentist – coordinate and follow-up on referrals
Pharmacy – Polypharmcy and oral adverse effects
Care staff – daily care, in-service and support of knowledge
Occupational and physical therapy – physical issues
Dietitian – diet / nutrition influences on oral cavity
Social Director – coordinate education of residents
Family / Legal Guardian – support of referrals, resident
education and daily care plans
Oral Health Care Director
• Oral Health Care Director
• An MS, RDH
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•
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Added skills sets
Oriented to the geriatric population
Decrease Iatro-compliance of staff
Increase care staff oral health literacy care skills
Enhance the oral hygiene autonomy of the resident
Conclusion
• Beneficial:
• to support and encourage the oral hygiene autonomy of
residents
• Not beneficial
• care staff often allows excessive autonomy to occur.
• Oversight
• must remain a component of care.
• OHCD
• Improved oral health can be delivered to this population
under the supervision of an onsite oral health care prof.
References:
• Cherin C. Pace, & Gary H. McCullough, 2010 Dysphagia
(2010) 25:307–322 DOI 10.1007/s00455-010-9298-9
• S. Paju & F.A. Scannaopieco 2007 Oral Diseases (2007)
13, 508–512. doi:10.1111/j.1601-0825.2007.1410a.x
PMID:17944664
• Modifiable Risk Factors for Nursing Home-Acquired
Pneumonia. V. Quagliarello, et.al. Clinical Infect Dis
2005;40:1-6 PMID 15614684
• Oral care reduces Pneumonia in Older patients in
Nursing Homes. T. Yoneyama, et. al, J. Am. Geriatr Soc.
50:430-433, 2002 PMID:11943036
References:
• Healthcare utilization and cost of pneumococcal disease
in the United States. S.S. Huang et al. Vaccine Volume
29, Issue 18, 18 April 2011, Pages 3398–3412
PMID:21397721
• Should I Hospitalize My Resident With Nursing Home–
Acquired Pneumonia? David Dosa, MD, MPH. DOI:
10.1016/j.jamda.2005.06.005 PMID:16500288
• Conflicting priorities: oral health in long term care. M.I.
MacEntee, et al. Spec.Care Dent., Vol. 19 No 4 1999
PMID:10765882
References:
• Oral health coordinators in long-term care—a pilot study
Gilda J. Pronych. Spec Care Dentist 30(2): 2010
PMID:20415802
• Exploring Daily Oral Hygiene Tasks in a Long Term Care
Facility. Melanie Taverna MS, RDH Thesis presentation
2011
• Health benefits and reductions in bacteria from enhanced
oral care. Fozia Ferozali et.al. Spec. Care Dent. 2007
PMID:17990475
References:
• Centers for Disease Control and Prevention. National
Center for Health Statistics. National nursing home
survey. Available at:
http://www.cdc.gov/nchs/about/major/nnhsd/nnhsd.htm
• Muder R. Management of nursing home acquired
pneumonia: unresolved issues and priorities for future
investigation. J Am Geriatr Soc 2000;48:95-6.
http://www.serialssolutions.com/images/AL_Button_grey.gif