When the intern teaches the doctor

Jamie Freitag-Dooley, RDH, oversees program at Ferris State University where dental hygiene students help establish broad-based community care programs in collaboration with other health professions.

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Ferris State searches for ways to initiate oral health as part of collaborative care

Jamie Freitag-Dooley, RDH, BIS, CLC

Providers and students from optometry, pharmacy, nursing, social work, and dental hygiene gather together at Ferris State University’s Interprofessional Wellness Clinic to discuss ways they can integrate oral health into an existing program that serves diabetes patients.

According to Oral Health in America: A Report from the Surgeon General, “all care providers can and should contribute to enhancing oral health.” Now that the medical community has finally embraced the oral systemic link as a care gap in their treatment, hygienists are being considered as affordable educators and disease screeners in health-care systems nationwide to improve health outcomes.

Confidence starts in school. What better place to prepare students to be part of the collaborative care model. Even so, are our dental hygiene program curriculums including this model in their teaching methods? How can current clinicians collaborate in their communities? There are exciting projects going on now that are making a difference in disease by integrating hygienists into collaborative care teams.

As our country moves toward a patient-centered model as part of Healthy People 2020, oral health integration has been at the forefront. The idea behind a patient-centered model is to offer multiple specialties under one roof, and encourage communication between providers. Ferris State University (FSU), located in Big Rapids, Mich., is a Health Resources & Services Administration (HRSA) workforce sub-grantee through collaboration with the Michigan Department of Health and Human Services (MDHHS) and Seal! Michigan. Because Mecosta County is a Health Professional Shortage Area (HPSA), our dental hygiene program was chosen to develop preventive outreach services under Michigan’s Pubic Act 161 (PA161), which allows an RDH to practice without a dentist present in a public heath setting. I am the licensed dental hygienist overseeing the students to expand the workforce and address the care gap.

Our hygiene students’ interest in public health has increased as a result of our dental outreach programs. Because they start working without supervision in school, their comfort levels increase and they seek out such settings. At Ferris State, we have many branches of dental outreach attached to our community dentistry class. Our students get extensive experience working in multiple community settings beyond clinic: school-based sealants, interprofessional collaboration, a homeless shelter, nursing home, Head Start, and working with the cognitively impaired.

Oral health integration

We are currently on cycle two of HRSA funding. The first cycle focused on developing and implementing a Seal! Michigan school-based sealant program utilizing students to provide sealants on children who are unlikely to receive them otherwise. We serve 12 area schools with over 50% free or reduced lunch to ensure we are helping those most in need. This is our fourth year of operation, and to date we have provided nearly 3,600 services at no charge to families. Just imagine the possible outcomes without these services!

Our hygiene students are positioned to be perfect educators in the medical arena as they are familiar with the current standards of care and evidence-based practices.

Part of our grant requirement is community education. This led me to think of how vital other professions in our community are, such as teachers, nurses and physicians. Without their support, our program would not be successful, so we added an interprofessional arm when we re-applied for funding. This second arm includes an innovative pilot program focusing on oral health integration in a medical setting for three student interns.

I started by offering inter-professional education (IPE) at lunch to a group of primary care physicians at Spectrum Health Big Rapids to give them an overview of the bi-directional link between periodontal disease and diabetes. They agreed to give my students a treatment room to perform free screenings on their diabetes patients. I encouraged them to look at the teeth and gums of their patients, ask about their last dental visit, and refer them to one of our screenings if it had been longer than one year.

Working with a large health care system has its challenges. Learning to navigate their system, along with key players moving into other departments and roles, caused the first year to move slowly. I was on-boarded as staff, and had to go through their application and screening process, even though I was not on payroll. However, everyone from front office staff to upper level administrative physicians were welcoming, and excited at the prospect of long overdue oral health integration, especially a program that gives students a unique experience. I’ve been surprised at how warmly I’ve been received as a needed addition to their team. Now they invite me to their meetings as they plan the next phase of a new dental clinic near their largest emergency room.

Our free screenings were not well attended. After three sessions of waiting in a back medical room for a patient to accept the doctor’s suggestion to see us, we found out the patients were saying, “I already know I have gum disease. My insurance (Medicaid or Medicare) doesn’t cover treatment, and I can’t afford to pay for it, so why get a screening?”

The providers tried their best to educate and send them our way, but finances were a barrier for all who had not seen a dentist in over one year, which was our protocol for who to refer for a screening. Their staff ran a report of all the diabetic patients in the practice to personally invite them to our screening days, and they were told the same thing.

We were forced to be creative for the second year of the project.

Internship programs

Our students have summers off, so I spent the next few months networking and exploring Spectrum Health’s needs to better tailor our programs to fit them. I also reached out to health professions within my own system at Ferris State. Our optometry department already has a diabetes interprofessional wellness clinic that partners with nursing, pharmacy, and social work students to provide comprehensive services and screenings at no additional cost. They welcomed me with open arms. We discussed ways we can integrate oral health into their existing programs, and what questions to ask the patients to best assess their dental needs.

For the first half of 2018, I will have three new student interns, all planning to go directly into public health. I met with each of them to find out what they were interested in, and we came up with three different, unique projects that they will present at our annual Michigan Oral Health Coalition meeting in May. I expect interest in these internships to grow each year among students as they see the impact these projects have.

Because our sealant program is already so successful, training school nurses and teachers is an easy way to further impact children’s oral health in our area. Spectrum Health provides nurses to schools that cannot afford their own. They are often assigned to more than one district.

We will provide a laminated flip chart that can be used when performing an oral screening on a child to determine the urgency of a referral, or the need for Child Protective Services (CPS) reporting for dental neglect. One side will have pictures of healthy teeth and gums, and the other side will feature pictures of dental disease.

The intern assigned to this project will also create a three-minute video for the nurses to play when they educate the school staff on health matters at the start of each year. The RNs informed me that they currently do not discuss oral health in their training as they do not feel well-versed on the subject. The teacher is often the bridge between the child and parent, and in many cases the one who calls the school nurse due to pain, neglect, or missed school. They are excited for us to educate them, and the staff, on what to look for, what questions to ask when they suspect dental neglect, and when to call CPS.

Another aspect of the project will be to offer education to students of other health professions attending FSU. A second intern interested in public speaking as a profession will offer oral-systemic education to students in nursing, optometry, pharmacy, respiratory care, and social work. Faculty and staff will also be invited to attend this presentation with a question-and-answer period to follow, so that they can find useful ways to implement what they learn.

In an attempt to improve on a situation we encountered last year, a third intern will create printed education for diabetes wellness clinic providers at FSU and Spectrum Health to hand out to their patients with diabetes, as well as a voucher for treatment in our clinic. She will also gain experience writing and applying for a grant, so that we can set up a fund that will provide periodontal treatment to low-income patients who are referred to our clinic at no charge. The voucher will detach from the printed education that providers hand out so that finances will no longer be a barrier for these already immune compromised patients.

After many of hours networking to set up these projects, I am excited to see them come to fruition and to supervise them as they begin. The student interns will complete the work and communicate with professionals from other areas of health care to best serve their needs, which will positively impact their patients.

While it may seem counterintuitive to have dental hygiene students educating seasoned professionals, our students know far more about current evidence-based treatment recommendations and oral microbiome science than practicing providers in other disciplines. I found this out recently while providing continuing education to a group of medical providers. It was apparent that words we use every day in dentistry, like periodontium and cementum, were confusing. When educating outside of dentistry, it is fully acceptable to use language you use to educate your patients. If you provide a dental term, explain what it means in lay terms as well. They really appreciate plain language because that is how they will present it to their patients.

Because the mouth has been kept separate from the body for such a long time, medicine is lacking in continuing education that discusses oral health. Our hygiene students are positioned to be perfect educators in the medical arena as they are familiar with the current standards of care and evidence-based practices.

Interaction with medicine

There are small steps any hygienist can take tomorrow to integrate oral health in their community. Current dental hygienists can discuss the oral systemic link with their own primary care physician at an existing appointment. Stress the importance of oral health discussion with each and every patient they encounter. Email them the link to American Academy of Oral Systemic Health (AAOSH) and the Bale Doneen Method so that they see other active physicians in the dental arena. Bring them oral health brochures to hand out. Show them that simple changes can make a big impact in their patient outcomes. Suggest they ask:

  • When did you last visit a dentist for a full exam?


  • Did you complete all treatment the dentist prescribed?


  • Did you know you cannot have a health body without a healthy mouth?


Remind the physician that all patients should visit the dentist at least once per year for a full exam and recommended treatment. Any patients who have not should be referred to a dentist and followed up on by their office. Tell them dentistry is just like any other specialty, and, if they don’t have a referral system of dentists set up, help them create one.

It is vital to start implementing interprofessional education in hygiene curriculum now because wellness clinics and patient-centered homes are the models of the future. Small assignments will increase our new graduate’s comfort level in being part of a collaborative team. In a university setting, faculty and staff can network within their existing system to educate students from other disciplines. Since time is precious, assign the students an experience as part of an existing class.

Networking, baby steps, and basic language are key to medical integration.

As professional health care providers, we can all get started by asking someone outside of dentistry out for coffee. Start the conversation with, “Tell me what you know.” If you come at them with too many ideas, they will assume adding a dental component will be too much work. I always ask, “How can I help you?”

I would have never come up with the project ideas my interns are assigned without asking questions and listening for small ways we could help. If I would have offered something too big and elaborate to start, I would have encountered many more closed doors. It can be challenging to create a collaborative care experience for students when their schedules are already busting at the seams. By offering our projects as self-directed, one credit internships during their last semester of school, we are giving those interested a flexible, affordable way to add a needed skill to their hygiene career. By giving students confidence in their ability to articulate the oral systemic link to other health professionals, we are preparing them to be members of the collaborative care model, which is long overdue.

Author’s note: Funding for this educational presentation was provided by the Department of Health and Human Services Health Resources and Service Administration. Grants to Support Oral Health Workforce Activities (HRSA-16-038). The contents of this presentation are solely the responsibility of the author and do not necessarily represent the official view of HRSA.

JAMIE FREITAG-DOOLEY, RDH, BIS, CLC, is the dental outreach coordinator at Ferris State University, founder of Dental Impact Foundation, and owner of Jamie Dooley Coaching. She lives to empower fellow hygienists to take meaningful action toward their dreams. Connect with her on Facebook or www.dentalimpact.org.

References

1. Oral Health in America: A Report of the Surgeon General (Executive Summary). Available at: https://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/Report/ExecutiveSummary.htm#. Accessed November 14, 2017.

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