Medical-Dental Integration: A Promising Approach To Address Unmet Dental Needs of Children and Youth With Special Health Care Needs

Karen Raju, BDS, MPH, DPH-Cert., is an associate specialist at the University of California, San Francisco, School of Dentistry. Conflict of Interest Disclosure: None reported.

Yogita Butani Thakur, DDS, MS, is the chief dental officer at Ravenswood Family Health Center in East Palo Alto, California. Conflict of Interest Disclosure: None reported.

Cambria Garell, MD, is a board-certified general pediatrician practicing primary care at Venice Family Clinic’s Simms-Mann Health and Wellness Center and pediatric multidisciplinary weight management with the UCLA Fit for Healthy Weight Program. Conflict of Interest Disclosure: None reported.

Irene V. Hilton, DDS, MPH, is a staff dentist at the San Francisco Department of Health and the dental consultant for the National Network for Oral Health Access (NNOHA). Conflict of Interest Disclosure: None reported.

ABSTRACT

Background: This review presents strategies on how medical-dental integration and a patient-centered approach may address the unmet dental needs of children and youth with special health care needs (CYSHCN).

Methods: Programs, strategies and frameworks to implement medical-dental integration to improve the overall quality of life of CYSHCN were reviewed. The authors propose a patient-centered health home (PCHH) as a step toward a patient-centered approach to medical-dental integration for CYSHCN.

Results: Many federal, state and local organizations have emphasized the importance of medicaldental integration. Models and frameworks to implement integrated care in multiple settings have been developed and can be applied for CYSHCN. The proposed PCHH model includes integrated education, improved clinical collaboration, integrated health information technology and integrated financing. Ravenswood clinic is an example of an organization that has developed an integrated care model that serves children and adults with special health care needs.

Conclusion: CYSHCN often seek services from multiple specialties that may or may not integrate care with a patient-centered approach. It is imperative to develop care systems that make oral health an inseparable part of general health and well-being.

Practical implications: The PCHH is a promising approach to improve the overall health of CYSHCN. Incorporating oral health competencies for primary care providers and increasing the skills of dental providers to care for CYSHCN are important steps. Improved communication and clinical collaboration between dental and primary care providers to increase preventive dental services to CYSHCN will reduce the burden on the health care system. However, PCHH can only be practical by reforming the health care financing system.

Keywords: Special needs dentistry, vulnerable patients

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Dental diseases have affected humans since the advent of recorded history. However, the genesis of the dental profession in the U.S. can be dated to the 1840s. Dentistry developed as a separate profession from the practice of medicine in the U.S. and this separation has continued to the present day. There are many reasons for this historical separation to have become so entrenched; however, three reasons in particular stand out: distinct paths of education and training for dentists and physicians; lack of a common electronic health record (EHR) platform; and different payment systems for medical and dental care in addition to the complex health insurance system in the U.S. [1]

Like many chronic disease conditions, the incidence of oral diseases is socially patterned, with an enormous burden of disease occurring among marginalized groups, including those living in poverty, racial and ethnic minorities, frail elderly, immigrant populations, those with special health care needs and others. These groups may face numerous barriers to accessing routine preventive and other dental services. [2]

In the U.S., the most commonly cited unmet health care needs for children with special health care needs (CSHCN) are prescription medications and dental care. [3–6] Dental status is greatly influenced by social and structural determinants of health. [7] Although oral health has greatly improved since the 1960s, not all Americans have equal access to these improvements. 8 Older adults, especially those living in long-term care facilities, and Americans who live in rural areas and/or belong to low socioeconomic backgrounds have a higher prevalence of oral health problems and face more challenges accessing dental care. [9]

Individuals with disabilities also constantly encounter access barriers, regardless of their financial resources. 9 The link between oral health and systemic health is well established. [10] Lack of timely oral health care for people with special health care needs (SHCN) has a strong influence not only on oral health status but on the deterioration of overall health. A study assessed eight strategies to promote respiratory health in children with neurologic impairment and found that only a history of dental care was associated with decreased risk of subsequent pneumonia hospitalization. [11] Despite these and other findings that demonstrate how oral health is integral to overall health, dental care remains fragmented and not integrated for CSHCN, especially those with more severe chronic conditions. [5,12] This review presents strategies on how medical-dental integration and a patient-centered approach may address the unmet dental needs of children and youth with special health care needs (CYSHCN) and illustrates examples of programs that have taken a step toward a patient-centered approach to medicaldental integration for CYSHCN.

Oral Epidemiology of CYSHCN

Nearly 1 out of every 5 children in the U.S. has SHCN. []13 According to the American Academy of Pediatrics (AAP), children with SHCN are “those who have or are at increased risk for a chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” [14]

Other agencies/organizations have defined people with special health care needs as shown in the BOX.

Despite different phrases used to define this population, the primary constructs remain the same. CYSHCN are differently abled humans who might face additional challenges accessing required dental care due to physical, behavioral or developmental conditions. Successful dental treatment requires patient cooperation and depends on good communication between patient and dentist. CYSHCN may find it difficult to cooperate when undergoing a needed dental procedure. [18] In addition, the dentist needs to have up-to-date medical information on the patient’s condition to plan safe delivery of treatment. Limited access to dental care is not the only reason for poor oral health. Complex medical conditions may affect the motor skills needed to perform home oral hygiene. Limited speech and high pain tolerance may inhibit communication about toothaches. Physical disabilities may limit a child’s ability to sit still in a dental chair during dental visits. Additionally, sugars added to medications to enhance taste put the patient at higher risk of developing caries [19] and several medications commonly used by CYSHCN cause dry mouth that also increases the risk of developing dental caries. [20–22]

The 2016-2018 National Survey of Children’s Health (NSCH) found that the prevalence of teeth in fair or poor condition was twice as high among CYSHCN as non-CYSHCN, and CYSHCN had higher rates of decayed teeth and cavities, toothaches and bleeding gums compared with non- CYSHCN. 18 A Healthcare Cost and Utilization Project (HCUP) Statistical Brief presents statistics on emergency department visits involving dental conditions using the 2018 Nationwide Emergency Department Sample (NEDS). [23] The brief highlighted that there were more than 2 million dentalrelated emergency department visits, which represented 615.5 visits per 100,000 population in 2018. Non-Hispanic Black individuals and those residing in the lowest income communities were found to have had the highest rates of dentalrelated emergency department visits. The recent Legislative Analyst’s Office (LAO) report using Denti-Cal Claims Data (2014-2016) reported that the majority of Department of Developmental Services consumers enrolled in Denti-Cal fail to see a dentist each year as compared to the Denti-Cal beneficiaries overall. [24]

An analysis of data from the 2005 Medical Expenditure Panel Survey for children younger than 18 showed that some CSHCN, particularly those with more complex SHCN, were more likely to receive only nonpreventive care and not receive any preventive dental care services. [4] However, findings from 2016-2018 parent/caregiver NSCH reported that CYSHCN have higher preventive oral health services rates, yet are significantly more likely to have poor oral health. [18] This may be because of increased exposure to health care providers due to their worse oral health status, which can lead to more referrals for preventive oral health services. [25] Additionally, CYSHCN with a medical home were more likely to receive preventive oral health services. [18] The National Standards for Systems of Care for Children and Youth with Special Health Care Needs recognizes that CYSHCN must have access to specialty services facilitated through a medical home that coordinates care to meet medical, dental and social-emotional needs. [26] Although CYSHCN were found to have more preventive oral health services, the study found that 1 in 6 CYSHCN did not have a preventive dental visit in the past year. Therefore, there were missed opportunities to integrate preventive dental care into medical homes. [27]

Medical-Dental Integration: A Potential Solution

Medical-dental integration is an approach to care that integrates and coordinates dental medicine into primary care and behavioral health to support individual and population health. [28] This model has gained attention at the local, state and national levels as depicted in FIGURE 1. According to a recent DentaQuest report, the vast majority of patients, dentists, physicians, employers and Medicaid dental administrators believe oral health and overall health are connected and agree that greater collaboration across medical and dental providers would improve patient care. [29]

The Substance Abuse and Mental Health Services Administration- Health Resources and Services Administration Center for Planning created a Standard Framework for Levels of Integrated Healthcare, outlining elements of integration to include:

■ Creating a common language to discuss integration, progress and financing.

■ Supporting assessment and benchmarking efforts.

■ Explaining integration efforts to stakeholders.

■ Clarifying differences in vision between two or more partnering organizations. [30] The framework defines key elements as follows: coordinated care to be communication, co-located care to be physical proximity of care and integrated care to reflect change in health care providers practice. Collaboration and integration are defined differently such that collaboration is how health care professionals and resources are brought together, while integration describes how services are delivered and practices are organized and managed.

A medical-dental integration model of care adds another critical component to the dental-patient parent triad: the primary care medical provider.

The California Dental Association devoted two journal issues in 2014 to medical-dental integration. The issues highlighted the importance of building a foundation for interprofessional education and practice, the role of federal legislation and evolving health care systems in promoting medical-dental collaboration and bringing medical-dental integration to the private practice. [31]

The American Academy of Pediatric Dentistry’s best practices report on behavior guidance for pediatric dental patients promotes a continuum of interaction involving the dental team, the patient and the parent. The focus is on communication and education while also ensuring the safety of both the oral health professionals and the child during the delivery of medically necessary dental care. [32] A medical-dental integration model of care adds another critical component to the dental-patientparent triad: the primary care medical provider as depicted in FIGURE 2.

CYSHCN have complex medical histories and often see multiple specialists. While multispecialty clinics seem to be a great way to serve these children, one well-known model is the multidisciplinary craniofacial team clinic found across the country at large children’s hospitals. The craniofacial teams are usually multispecialty teams that focus on coordination of care often involving a pediatric dentist and an orthodontist to address the children’s oral health needs, alongside pediatricians, plastic surgeons, otolaryngologists, speech and language pathologists and social workers among other specialists. The craniofacial multidisciplinary team care model allows for opportunities to establish a dental home and provides care coordination to improve overall health outcomes. Moreover, the American Cleft Palate-Craniofacial Association has standards of approval/accreditation of multidisciplinary craniofacial teams with specific requirements around team composition, team management, patient and family communication, cultural competence, psychological and social services and assessing outcomes. [33] While there has been a concerted effort to integrate dental care into primary care, such as the Center for the Integration of Primary Care and Oral Health and the Harvard School of Dental Medicine Initiative, [34] there are not many well-established models in the care of CYSHCN other than with specific diagnoses, like the integrated craniofacial teams that treat cleft lip and palate and other craniofacial deformities.

With the way the medical and dental practices are set up in the U.S., physical co-location of medical and dental services is not the norm, except in government-funded programs such as the Veterans Administration, Indian Health Service, federally qualified health centers, correctional facilities, etc. Co-location allows for easier access to medical and dental services for patients, and integration is further facilitated if the medical and dental providers share a common EHR. Co-located clinics with a shared EHR and infrastructure have been seen as promising pieces to achieve medical-dental integration. 35 Because co-location is not the norm in most health care delivery, creative solutions are needed to achieve medicaldental integration without co-location. A wide spectrum of action steps to serve CYSHCN are needed, ranging from collaboration when needed and integration when possible. Emphasis is needed on an integrated practice of care that enables evaluation, diagnosis, prevention and/or treatment of dental diseases in a technically and emotionally supportive environment to promote the health and well-being of individuals with special health care needs. The Health Resources and Services Administration’s (HRSA) Advisory Committee on Training in Primary Care Medicine and Dentistry supports dental integration into a patient-centered medical home (PCMH) and proposed the development and evaluation of the patient-centered medical and dental home, a PCMH model that includes dentistry. This was later revised to be called the patientcentered health home (PCHH). [36,37]

PCHH for CYSHCN

The notion of having a dental home is to connect children to dental providers at an early age (within six months of the eruption of the first tooth or by the first birthday). This early dental home concept can be characterized as a philosophy embraced by the dental practice instead of a physical location, a team that cares for patients starting in early childhood and following them through life and focusing on prevention and risk assessment. [38] Although various programs and organizations have adapted and redefined the concept of a dental home, consistent elements across the dental home concept are: an ongoing relationship between dentist and patient, family-centered care and sharing many standard characteristics of a medical home (e.g., comprehensive, continuous and coordinated). [39]

CYSHCN require individualized, coordinated, multidisciplinary and comprehensive preventive oral health services and treatment.

CYSHCN require individualized, coordinated, multidisciplinary and comprehensive preventive oral health services and treatment. FIGURE 2 depicts the PCHH for CYSHCN. Many are dependent on their parents/caregivers, primary care providers and dental provider for their health care, among other allied health professionals. All who are engaged in providing care for the patient with complex care needs should be knowledgeable about the child’s specific SHCN and interact with each other effectively and easily. PCHH can serve as a doorway to a one-stop shop for families of CYSHCN to get needed health care services without compromising the quality of these services. An ideal PCHH should be able to cater to the dental needs of CYSHCN and their families by providing them with anticipatory guidance according to patient-specific caries risk assessment, screening, the option for virtual teledentistry and easy access to preventive dental services from primary care providers and dental providers. To improve the oral health outcomes of CYSHCN, specific action steps around education, communication and payment mechanisms must be taken to truly create an integrated PCHH for CYSHCN.

Integrated Education

Interprofessional education (IPE) has been recognized as an important tool for increasing competency for all health care providers [40] and has been widely accepted by dental schools. [41] Interprofessional education can target a known deficit in training for pediatric providers in oral health care [42,43] as well as improve competencies among dentists in caring for CYSHCN. [44] Indeed, the Commission on Dental Accreditation requires that all oral health professionals receive didactic and clinical training on the oral health of people with special health care needs, and the AAP recommends all pediatric providers be familiar with the management and prevention of pediatric dental caries. [45]

For example, at the University of California, Los Angeles, the Strategic Partnership for Interprofessional Collaborative Education in Pediatric Dentistry (SPICE-PD) aims to establish an integrated oral and primary health care clinical training program for UCLA pediatric dental residents, pediatric medical residents and nurse practitioner students. This IPE program also includes specific competencies around caring for CYSHCN including opportunities for dental residents to work alongside pediatricians and other allied professionals caring for patients with behavioral challenges, including autism. The program has trained over 300 health professional students and shows positive outcomes. [44] Continuing education to increase competencies for current practicing dental and pediatric providers will be necessary to ensure that the existing workforce can adequately care for the oral health needs of CYSHCN. The AAP has addressed the need to improve oral health training for practicing pediatricians by offering Education in Quality Improvement for Pediatric Practice on oral health best practices. This training in oral health and quality improvement allows pediatricians to obtain the required Maintenance of Certification credits required by the American Board of Pediatrics, which also offers continuing education courses on the oral health care of CYSHCN.

The National Interprofessional Initiative on Oral Health funded by the DentaQuest Foundation, the Washington Dental Service Foundation, the Connecticut Health Foundation and the Reach Healthcare Foundation supports the Smiles for Life curriculum, which is endorsed by 20 national organizations and provides standardized oral health training to primary care clinicians. 46 The second edition curriculum material was downloaded from the project website more than 60,000 times prior to its retirement in June 2010. In 2020, the fourth edition of Smiles for Life was released. The University of Pennsylvania, with support from Delta Dental, has initiated the “Persons with Disabilities Presentation Series,” a series of professional development programs aimed at building awareness of the barriers to equitable oral health for individuals with disabilities and developing competency to provide oral health care to this vulnerable population. This series is open to dentists and their support personnel at no charge, and participants will receive a certificate of completion from Penn Dental Medicine as a disabilities dentistry clinician expert after completing 18 or more of the courses within a three-year period. [47]

For dental providers, in-depth training around management of CYSHCN in a dental office is found within pediatric dentistry residency programs. Given the small number of pediatric dentists who graduate every year compared to general dentists, there is a need to incorporate the nonpharmacological behavior management of CYSHCN into the dental education curriculum at the predoctoral level. The training should include an integrated didactic and clinical component that would prepare the graduating dentist to be more comfortable in providing dental care to CYSHCN in a PCHH approach.

Improved Clinical Collaboration

Dental providers are vital but insufficient to address all of the unmet dental needs of CYSHCN. Several publications highlighting the oral health clinical skills/competencies for primary care providers need to be developed. In 2014, the HRSA published a white paper with five oral health core clinical competencies: risk assessment, oral health evaluation, preventive interventions, communication and education and interprofessional collaborative practice. [48] In 2015, the Qualis Health and National Network for Oral Health Access (NNOHA) provided frameworks for implementing the five oral health core clinical competencies in multiple practice settings. The NNOHA approach engages members of the primary health care team in identifying and referring people who need care. [49] It uses the ask, look, decide, act and document approach within the scope of primary care. The NNOHA framework took a system approach and recommended five steps to implement the five oral health core clinical competencies in safety-net systems: planning, modifying training systems, updating health information systems, modifying clinical care systems and developing evaluation systems. [50]

In 2003, the AAP recommended that health care professionals conduct an oral health risk assessment and in 2012 revised the risk factors and developed an oral health risk assessment tool for caries risk assessment. [51] Despite this, studies report the low implementation of caries risk assessment by primary care providers. [52] The “Bright Futures in Practice: Oral Health Pocket Guide” provides a structured and comprehensive approach to oral health anticipatory guidance for the health care professional. [53] Additionally, the United States Preventive Services Task Force (USPSTF) has been recommending that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride and that fluoride varnish be applied to the primary teeth of all infants and children starting at the age of primary tooth eruption. [54] The use of evidence-based guidelines for screening, anticipatory guidance and oral health counseling by primary care providers must be increased by funding more nationwide demonstration projects in primary care settings. Considering the higher unmet dental needs for CYSHCN, greater emphasis must be laid on evidence-based prevention in a PCHH. The use of 38% silver diamine fluoride (SDF) is recommended to prevent and arrest cavitated carious lesions in primary teeth as part of a comprehensive caries management program. [55] Moreover, a systematic review indicated that SDF at concentrations of 30% and 38% is more effective than other preventive management strategies for arresting caries in the primary dentition and shows potential as a caries preventive treatment in primary teeth and permanent first molars. 56 While not yet formally recommended to be applied by primary care providers, one study found it to be feasible. [57]

The use of evidence-based guidelines … must be increased by funding more nationwide demonstration projects in primary care settings.

Medical-dental integration to incorporate preventive dental strategies such as fluoride varnish application and use of SDF to arrest cavitated lesions during a medical visit became even more relevant during the COVID-19 pandemic when dental care was further delayed and withheld initially because of dental practice closures and then due to families’ fear and logistical challenges. The COVID-19 pandemic offered an opportunity for primary care providers to perform oral health assessments and reconnect patients back to their dental homes and/or establish dental homes.

Effective implementation of medical-dental integrated practice requires primary care providers to have convenient access to a list of dental providers who accept Medi-Cal Dental and be equipped and trained in catering to people with SHCN. The PCHH approach will allow patient referral with a note on treatment needs and what special needs accommodations will be required by the patient based on their SHCN for dental care. Moreover, PCHH is also the best suited to provide behavior modification therapies like desensitization by allowing collaboration with behavioral therapists who will not only prepare CYSHCN to perform daily activities including social interactions but also ensure that they have a good dental visit experience. This is even more critical for children with hypersensitivity issues such as those with autism spectrum disorders.

Integrated Health Information Technology

An integrated electronic medicaldental record allows for bidirectional information regarding the medical and dental history between providers. Interoperability is defined as the ability of different IT systems to connect in a coordinated manner within and across organizational boundaries to access, exchange and cooperatively use data. [58] Anticipatory guidance given by one discipline can be reviewed and reinforced by the other. Furthermore, caries risk assessment, treatment planning and coordination of care can be more easily accomplished through direct communication within the EHR or electronic dental record (EDR). The potential for more streamlined billing and reimbursement mechanisms can also be achieved through the integrated EHR. While a unified electronic medical-dental record is starting to be recognized as an important component of medical-dental integration, [59] there are few examples of integrated systems in the literature. An increasing number of FQHCs are moving toward integrated electronic medical-dental records. The Department of Veterans Affairs (VA) announced in late 2021 its updated plan to move forward with a systemwide EHR modernization program. [60] This new system connects VA medical facilities with the Department of Defense, the U.S. Coast Guard and participating community care providers, allowing clinicians to easily access a veteran’s full medical history in one location. HealthPartners, a health system based in Minnesota, is one of the handful of organizations in the U.S. that uses integrated electronic medical-dental records to help improve patient outcomes collaboratively. [61] Kaiser Permanente Northwest is a comprehensive health care system that serves approximately 605,000 medical members and 250,000 dental members in Oregon and Washington. It implemented medicaldental integration in 2018 that has been successful in facilitating the delivery of preventive and disease management medical services. [62] Integrating health information technology allows both the primary care provider and dental provider to work jointly using the most up-todate health information of CYSHCN.

The potential for more streamlined billing and reimbursement mechanisms can also be achieved through the integrated EHR.

Integrated Financing

The costs of providing dental services have traditionally not kept pace with the reimbursement for services in dentistry. Cost of care has significantly gone up recently due to the COVID-19 pandemic, with dentists now needing to upgrade their personal protective equipment and their operations, while the reimbursement rates remain unchanged. Caring for CYSHCN requires a highly skilled dental team dedicated not only to dental care delivery but also to focus on care coordination, case management and managing referrals. This requires an upfront investment into operations, which adds to the cost of care delivery. These investments in personnel costs are not reimbursed and are therefore not the norm in dental practices, thus causing barriers for CYSHCN to access dental services.

State Medicaid programs show low participation rates due to low reimbursement and lack of confidence treating patients with special needs. 63,64 In California, only 20% of dentists participate in Medi-Cal Dental, resulting in longer wait lines for appointments, farther distance to travel and delayed dental care for patients. [24] Delta Dental administers California’s Medi-Cal Dental Program. The reimbursement rates for dental procedures have been reported to be one-half to one-third of dentists’ usual fees, second to last among the six states studied by the California HealthCare Foundation. [66]

The lag between dental reimbursement from the state Medicaid programs and private dental insurance payers negatively impacts dentists’ participation in the Medicaid program and impacts access to dental services. [66] In addition, insurance coverage, annual maximum allowances and out-of-pocket expenditures associated with obtaining dental services are all welldocumented barriers to accessing dental services. [67] Both low reimbursement rates and lack of additional skilled staff negatively influence access to services for those with special needs enrolled in the state Medicaid program. Promoting access to oral health through a PCHH with medical-dental integration increases the costs of providing care while improving access and ultimately enhancing the oral health quality of life for patients with SHCN. A PCHH and provision of medical and dental services under one umbrella or unified health system are only possible when the payments are aligned. Value-based reimbursement models that include reimbursement for both medical and dental services and consider medical and dental outcomes would further integrate care successfully.

A Medi-Cal Dental procedure code, D9920, was introduced as an adjunct code to be billed for the extra time it takes to see a patient with special needs. It is billable up to four times per year along with billable dental services. However, in some instances where children with behavioral disorders need desensitization visits, this code does not allow for reimbursement if no billable services were rendered that day. Moreover, an approximately 25% denial of claims was observed because of inadequate documentation by the dentist describing the patients’ medical conditions that required additional time for the dental visit. 68 The Medi-Cal Dental Program is doing outreach to promote awareness on how to bill D9920, however, it needs more local county-level engagement to reach the clinical dental providers.

In addition to increasing dental providers willingness to see CYSHCN, efforts are needed to improve the reimbursement process and the reimbursement amount paid to primary care providers to conduct a caries risk assessment, screening and counseling and provide preventive treatment. Moreover, the increased provider reimbursement rates must be supplemented with an easy administrative process. [65] Furthermore, integrating the financing system can produce significant cost savings to the overall health system. For example, Aetna’s Dental-Medical Integration Program [69] and Cigna’s Oral Health Integration Program [70] offer integrated medical and dental benefits for members with chronic medical conditions. The business model of integrated care is characterized by integrated funding based on multiple sources of revenue, resources shared and allocated across whole practice and billing maximized for an integrated model and simple billing structure. [30]

A PCHH and provision of medical and dental services under one umbrella or unified health system are only possible when the payments are aligned.

Dental Services for CSHCN at Ravenswood Family Health Center

Ravenswood Family Health Network is an FQHC headquartered in the low-income East Palo Alto area of San Mateo County. The clinics provide a comprehensive scope of health care services including dentistry, pediatrics, family practice and adult medicine and are a certified “patientcentered medical home.” Ravenswood’s dental clinic has served as a critical access point to oral health care for children and families in the community since 2010 and have long served children and adults with special health care needs. This has been possible with a mission-aligned vision for what is possible with a dental service delivery model unique to this FQHC rather than duplicating what is happening at other health centers or clinics.

Both pediatric and general dentists at Ravenswood have access to the operating room at a local hospital and work not only with the patient’s primary care physician to meet the needs of the patient, but also work with the hospital specialists to coordinate care. One distinction in the philosophy of care delivery at Ravenswood is the commitment to preventive care and managing CYSHCN in the dental clinics through frequent recall visits, parent education, dental desensitization and utilizing teledentistry to manage care. Several aspects of the program design described here encourage medical-dental integration although the dental clinics are not actually colocated with the medical clinics:

■ AEGD residency site: Ravenswood serves as a site for an AEGD dental residency in collaboration with NYU Langone and UCSF. As part of this program, two dental graduates spend a year gaining clinical experience at the clinic. This provides teaching opportunities to residents beyond restoring teeth to learning about essential communication skills with the physician and parents. They are actively engaged in learning about the medical considerations relevant to the patient’s dental conditions.

■ Dedicated referrals by care coordinator and OR scheduler: Ravenswood has dedicated staff who handle incoming referrals and care coordination with the medical specialists. The staff complete an intake form for CSHCN. This assists with understanding the scheduling needs of the patient in the dental office so as to successfully plan preventive and restorative care in the outpatient setting. The staff assist with coordinating patient surgeries with other specialists and are also responsible for scheduling treatment completions as part of dental clearances prior to patients undergoing other advanced procedures such as chemotherapy or organ transplant.

■ Ongoing participation in C.E. courses: Ravenswood provides dentists and other team members time and C.E. allowance to encourage and provide opportunities for participation in learning new techniques.

■ Transition of care within the organization: Ravenswood’s dental team is trained and equipped to manage the needs of patients with SHCN such that the transition from pediatric to general dentistry is seamless within the facility. Both general and pediatric dentists can care for patients with special needs and provide dental treatment, both in office and in the operating room.

■ Facility design: The clinic design meets all AwDA standards to accommodate patients with special needs. However, certain other design considerations allow for smooth in-office care delivery. For example, the clinic color scheme is very inviting and warm and does not overpower the senses. The dental operatories can accommodate a wheelchair in the room if needed to provide dental treatment for patients in the wheelchair without the need to transfer patients.

■ Scope of services: The clinic has pediatric and general dentists, dental assistants and hygienists on staff who are trained and comfortable providing dental treatment to the special needs population in an out-patient dental clinic setting. In addition, having specialists such as oral surgeons and endodontists on staff allows for fewer referrals and more treatment that can be completed in the clinic. The providers have hospital privileges that allow for care coordination and consultation to limit overall general anesthesia exposures for the patient.

■ Asynchronous teledentistry model with integration at a medical therapy unit and special education programs in the county: Ravenswood has an asynchronous teledentistry model that utilizes dental hygienists in alternative practice who work primarily at preschool or community sites across the county and who work at the California Children’s Services’ medical therapy unit and a preschool for CSHCN. These specific locations provide for an early introduction to oral health services, care coordination and dental desensitization for CSHCN.

■ Integrated electronic medical records that offer interoperable solutions with other health care entities: Recent transition to Epic/Wisdom not only allows medical-dental integration within Ravenswood but also makes communication among the providers easier. The combined record allows coordination with specialists and medical providers outside of the organization who use the same EHR. This is possible through a feature of the EHR known as “Care Everywhere.”

Integrated electronic medical records [such as Epic/Wisdom] offer interoperable solutions with other health care entities.

Barriers

While the clinic strives to achieve its mission and vision through a thoughtful design and care delivery model, the following barriers remain to expanding services for its patients:

■ High patient volume: As an FQHC, Ravenswood serves the most medically underserved in the community. The dental needs of this patient population are high, and accommodating all patients who need the services is an ongoing challenge.

■ Limited OR time: Dentists at Ravenswood compete for OR time that is shared with other dentists, and there are often increased wait times to get patients in for services.

■ Reimbursement: The dental reimbursement model through Denti- Cal allows billing for procedures, and the reimbursement does not keep pace with the ever-rising cost of providing dental services. As an FQHC, Ravenswood’s reimbursement model is that of a fee for visit rather than a fee for service. The costs of providing dental care have climbed steadily every year and with the pandemic have skyrocketed. However, the reimbursement rates do not keep pace. To realize our mission to serve those with special needs, Ravenswood relies on philanthropy in addition to patient revenue.

Conclusion

While the definition of CYSHCN describes this population as needing multispecialty care, not all CYSHCN have the same medical and or dental needs. For example, a child with autism or other developmental delays may require dental desensitization visits to cope successfully with a dental appointment. However, someone with a hematology/oncology condition may require consultations to determine the best timing for care and medical parameters to deliver the care rather than desensitization. Therefore, this paper highlights the PCHH model in fostering a robust health care practice for all CYSHCN. It mentions ongoing national initiatives with a spotlight on the Ravenswood Family Health Center in the East Palo Alto area of San Mateo County, California, to reduce the gap between dental and primary care practice. Additionally, the paper identifies four areas — education, clinical practice, HIT and financing — to guide the planning and implementation of the PCHH to improve the overall quality of care for CYSHCN. Improved communication between dental and primary care providers with open doors to collaboration and integration can help diagnose and treat dental and other health conditions like diabetes and hypertension early in life. The gravity of barriers to implementing integrated practice underscores the current effort and momentum to change how dental care is delivered within a holistic framework. Therefore, it is imperative to break down the medical and dental educational silos and establish interprofessional education to improve oral health competencies among primary care providers and, among dental providers, competencies caring for CYSHCN. Full integration between medicine and dentistry requires the free flow of clinical information between the two disciplines, achieved best through an integrated EHR/EDR system. Finally, without changes to medical and dental insurance and reimbursement systems, medical-dental integration will be difficult to achieve for CYSHCN.

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THE CORRESPONDING AUTHOR, Karen Raju, BDS, MPH, DPH-Cert., can be reached at dr.karenraju13@gmail.com.