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Service Delivery Innovation Profile

Adding Diabetes and Hypertension Screening to Oral Health and Hygiene Program Identifies Many Seniors With or at Risk for These Chronic Illnesses


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Snapshot

Summary

In an expansion of a program known as ElderSmile, which provides oral examinations and oral hygiene education to mostly Hispanic and African-American seniors at community centers throughout northern Manhattan, dental school faculty, staff, and students provide education and screening for hypertension and diabetes, including measuring systolic and diastolic blood pressure and hemoglobin A1c levels and, as appropriate, making referrals for treatment. The program has identified many undiagnosed seniors who have or are at risk for these two conditions, along with many previously diagnosed individuals who do not have the condition(s) under control. It has also helped many seniors access needed followup care.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the proportion of undiagnosed participants identified as having or being at risk for diabetes or hypertension, the proportion of previously diagnosed individuals with readings suggesting that the condition (hypertension or diabetes) is not being adequately managed, and the proportion of individuals referred for additional care who attended their followup appointment.
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Developing Organizations

Columbia University College of Dental Medicine
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Date First Implemented

2010
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Patient Population

The program primarily serves those age 65 years and older, with roughly 68 percent of participants being Hispanic, 22 percent African American, and 8 percent white.Age > Aged adult (80 + years); Race and Ethnicity > Black or african american; Vulnerable Populations > Frail elderly; Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Racial minorities; Age > Senior adult (65-79 years)end pp

Problem Addressed

Hypertension and diabetes are common problems among older Americans, particularly African Americans and Hispanics. However, these illnesses often go undiagnosed or are poorly managed, leading to a range of health problems. Dental appointments provide a good opportunity for at-risk individuals to be screened for hypertension and diabetes, but relatively few seniors have access to such services during a dental visit.
  • A common problem, especially among minority seniors: An estimated 67 percent of Americans age 60 years and older have hypertension,1 and 27 percent of those age 65 years or older have diabetes.2 In 2005, African Americans older than age 50 years were roughly twice as likely as whites to have diabetes, whereas older Hispanics had a 78-percent higher prevalence of the disease than whites.3 Comparable statistics on hypertension in minority seniors are not available, but the high prevalence of the disease in the general population of seniors and among African Americans1 suggests that many minority seniors have hypertension.
  • Often undiagnosed or poorly managed, leading to many health problems: An estimated 30.5 percent of adult Americans have undiagnosed hypertension, and 9.9 percent have undiagnosed diabetes.4 Left undiagnosed and untreated, hypertension is a major risk factor for stroke, myocardial infarction, vascular disease, chronic kidney disease, and diabetes. Undiagnosed or poorly managed diabetes is associated with heart disease, stroke, blindness and eye problems, kidney disease, nervous system disease, and amputations. Health problems associated with these conditions most commonly manifest in middle and old age.
  • Unrealized opportunity to screen during dental visits: Many (though by no means all) seniors regularly see a dentist, either a private practitioner or through outreach programs held at sites where seniors congregate. (The Context Section provides more information on the proportion of seniors who visit the dentist regularly and on the creation of the original ElderSmile program, which was designed to boost that figure by conducting outreach in senior centers.) Consequently, dental visits represent an excellent opportunity to address other common health issues facing seniors, such as screening for chronic conditions. In general, relatively few dental providers offer such services, although in recent years a growing number have begun to offer screening for hypertension during routine checkups.5

What They Did

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Description of the Innovative Activity

In an expansion of a program known as ElderSmile, which provides oral examinations and oral hygiene education to mostly Hispanic and African-American seniors at community centers throughout northern Manhattan, dental school faculty, staff, and students provide education and screening for hypertension and diabetes, including measuring systolic and diastolic blood pressure (BP) and hemoglobin A1c (HbA1c) levels and, as appropriate, making referrals for treatment. Key program components are described below:
  • Convenient sites in the community: The ElderSmile program serves older adults at 51 sites in the Harlem and Washington Heights–Inwood communities, located in northern Manhattan. Most sites are senior centers where older people regularly gather for social and educational activities. A team consisting of 1 or 2 faculty members, 1 or 2 staff, and 1 or 2 dental students visits each site for 3 or 4 hours roughly every 6 months.
  • Educational presentation on oral health, diabetes, and hypertension: Under the original program, each visit began with a 20-minute group presentation in English or Spanish in which team members discuss oral health care in later life (e.g., potential oral health problems, how to choose oral health care products, how to access oral health care) and demonstrate proper techniques for brushing, flossing, and taking care of prosthetic devices. In November 2010, program leaders amended the presentation to incorporate information on hypertension and diabetes, including basic information about causes, symptoms, and treatments for these two illnesses. (The oral health component was shortened to keep the overall length of the presentation at 20 minutes.) Dental school faculty deliver the presentations, whereas staff and dental students help with setting up the presentation.
  • Screenings for all three conditions: After the group session, team members set up three separate stations for screenings. At the first station, a dental school faculty member conducts oral cancer and oral health examinations on each individual who elects to participate. At a second station, another member of the dental faculty team or staff performs diabetes screenings. At the third station, a dental assistant (added to the team after expansion of the program) or a third faculty member conducts the hypertension screenings. Dental students assist by helping participants with paperwork, recording data, and managing the flow of participants between stations.
  • Referrals for (and assistance in accessing) followup care: Anyone requiring followup dental care (e.g., cleanings, having cavities filled) receives a referral to their dentist. Those without a dentist are referred to one of three community-based dental treatment centers affiliated with Columbia University. Anyone whose primary care screenings suggest they have or are at risk for hypertension or diabetes are referred to their primary care physician (PCP). Those without a PCP receive a referral to one of three community-based centers that offer treatment for these two conditions. (Two of these sites share space with the aforementioned dental treatment centers, whereas the third is a separate site.) Team members, including students, take an active role in helping participants access followup care, including making appointments for them, arranging transportation when needed, placing a reminder call in advance of the scheduled appointment, and rescheduling an appointment if necessary.

    Context of the Innovation

    Founded in 2006 by several faculty members of the Columbia University College of Dental Medicine, the ElderSmile program was originally designed to improve the oral health of older residents in northern Manhattan, many of whom had limited access to dental care. Overall, 40 percent of seniors have not visited a dentist in the past year,6 and that figure tends to be higher among racial and ethnic minorities.7 These faculty members also wanted to provide practical experience to students interested in geriatric dentistry. The goal was to provide dental education and services through outreach programs held at community centers where seniors often congregate.

    In the ensuing years, two trends convinced these faculty members to add the hypertension and diabetes components to the program. First, the dental profession was becoming more involved in general health care, with many dental schools (including at Columbia University) now training students to routinely screen for and monitor chronic diseases. Second, the faculty members began to realize that, in addition to their dental problems, many program participants had (often undiagnosed) chronic health problems. In northern Manhattan, lack of access to adequate dental care often went hand in hand with low screening rates for chronic conditions (e.g., diabetes, hypertension), particularly among seniors. Accordingly, faculty members believed that adding screening for hypertension and diabetes was a logical program enhancement.

    Did It Work?

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    Results

    The program has identified many previously undiagnosed seniors who have or are at risk for diabetes or hypertension, along with many previously diagnosed individuals who do not have the condition(s) under control. It has also helped many seniors access needed followup care.
    • Identifying many with or at risk of hypertension and diabetes: In a study of 580 individuals screened by the program for hypertension and diabetes between November 2010 and June 2012, 62.3 percent of those not previously diagnosed with hypertension either had the condition or were at risk of getting it. Overall, 37.7 percent had BP readings in the prehypertensive range (systolic BP between 120 and 139 or diastolic BP between 80 and 89), whereas an additional 24.6 percent had readings in the hypertensive range (systolic BP of 140 or above or diastolic BP of 90 or above). The same study found that roughly one-half of those not previously diagnosed with diabetes either had or were at risk for the condition. Overall, 42.2 percent had HbA1c levels in the prediabetes range (between 5.7 and 6.4 percent), whereas 7.8 percent had levels suggesting the presence of diabetes (6.5 percent or higher).
    • Finding many with uncontrolled conditions: Among those previously diagnosed with hypertension, more than three-quarters did not have the condition adequately under control, including 39.7 percent with BP readings in the prehypertensive range and 37.8 percent in the hypertensive range. Among those previously diagnosed with diabetes, 38.3 percent had HbA1c levels indicating inadequate control of the disease (7.0 percent or higher).
    • Connecting many with needed followup care: Overall, roughly one-half of participants referred for followup care end up attending their appointments.

    Evidence Rating (What is this?)

    Suggestive: The evidence consists of post-implementation data on the proportion of undiagnosed participants identified as having or being at risk for diabetes or hypertension, the proportion of previously diagnosed individuals with readings suggesting that the condition (hypertension or diabetes) is not being adequately managed, and the proportion of individuals referred for additional care who attended their followup appointment.

    How They Did It

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    Planning and Development Process

    Key steps included the following:
    • Securing grant to purchase equipment: In early 2010, program leaders secured a $200,000 grant from the Fan Fox and Leslie R. Samuels Foundation that enabled the purchase of a sphygmomanometer to measure BP, an HbA1c analyzer to screen for diabetes, and related supplies, and also funded the hiring of additional staff.
    • Revamping group presentation: Program leaders condensed the portion of the presentation dedicated to oral health (reducing it from 20 to 12 minutes) and used the freed-up time to incorporate information on the 2 chronic illnesses.
    • Training dental students: Before implementing the program enhancements, faculty members held a training session to teach dental student volunteers their role in the hypertension and diabetes screenings.

    Resources Used and Skills Needed

    • Staffing: The ElderSmile program is staffed by 5 faculty members, a part-time program coordinator, a dental assistant, and 12 to 15 dental student volunteers. Faculty members spend between 5 and 10 percent of their overall work time on the program, and the dental assistant devotes approximately 10 percent of her time on the program. The addition of the hypertension and diabetes screenings required the addition of a dental assistant and one faculty member.
    • Costs: The incremental costs of adding the hypertension and diabetes screening totaled roughly $200,000, consisting primarily of the aforementioned equipment purchases and staff time.
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    Funding Sources

    Fan Fox and Leslie R. Samuels Foundation; Sunstar Foundation
    As noted, the Fan Fox and Leslie R. Samuels Foundation provided a grant that covered the costs of the screening equipment and staff time; this foundation previously provided a grant to fund the launch of the original program. The Sunstar Foundation and other charitable organizations have also provided funding for the program.end fs

    Adoption Considerations

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    Getting Started with This Innovation

    • Assess population needs: Leaders of oral health programs who may be interested in adding general health components should first evaluate the population being served to determine what types of screenings are warranted and feasible. BP screening is often a logical component to add, because hypertension is so common among seniors and screening tends to be inexpensive and easy to perform. Diabetes screening and the provision of other health services (such as vaccinations, if permitted) may also make sense.
    • Seek external funding from multiple sources: Grant funding may be available to cover the cost of adding screening components to an existing oral health program. With the ElderSmile program, the foundation that provided the original funding had a policy prohibiting the awarding of more than one grant for the same activity. In this instance, the foundation agreed to offer a second grant because the addition of hypertension and diabetes screening represented a new aspect of the program. Charitable organizations dedicated to addressing specific illnesses may also be interested in supporting this kind of program.
    • Adapt program model as needed: Although this large-scale model serving many community centers has been successful, dentists in private practice may be able to replicate the program's key elements, albeit on a smaller scale. For example, a dentist and dental assistant from a private practice could partner with an outside nurse or social worker to provide similar services at one or two local community centers a few times each year.

      Sustaining This Innovation

      • Communicate with senior center staff: The program's long-term success depends on maintaining strong relationships and frequent communication with senior center directors and their staff. To that end, ElderSmile program leaders contact center directors 3 or 4 months in advance to schedule a date for the next visit. A few weeks before that date, they contact them again as a reminder about the impending visit. Around the same time, a staff member or dental student visits the center to post flyers designed to raise awareness about the visit among center staff and visitors. This approach helps ensure that the requisite space is available on the day of the screenings and helps generate a large turnout for the event.
      • Emphasize followup care: Getting participants to attend needed followup visits remains an ongoing challenge. Having program staff play an active role in scheduling these appointments and getting seniors to them can enhance the program's impact.

      More Information

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      Contact the Innovator

      Stephen Marshall, DDS, MPH
      Associate Professor of Clinical Dental Medicine
      Columbia University College of Dental Medicine
      P&S Box 20
      650 West 168th Street
      New York, NY 10032
      (212) 305-0764
      E-mail: sm15@columbia.edu

      Innovator Disclosures

      Dr. Marshall reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.

      References/Related Articles

      Marshall S, Northridge ME, De La Cruz LD, et al. ElderSmile: a comprehensive approach to improving oral health for seniors. Am J Public Health. 2009;99(4):595-9. [PubMed]

      Marshall SE, Cheng B, Northridge ME, et al. Integrating oral and general health screening at senior centers for minority elders. Am J Public Health. 2013;103(6):1022-5. [PubMed]

      Footnotes

      1 Centers for Disease Control and Prevention. NCHS data brief: hypertension among adults in the United States, 2009–2010. No. 107. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Health Statistics. 2012 Oct. Available at: http://www.cdc.gov/nchs/data/databriefs/db107.htm.
      2 Centers for Disease Control and Prevention. 2011 National diabetes fact sheet: diagnosed and undiagnosed diabetes in the United States, all ages, 2010. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 2011 May. Available at: http://www.cdc.gov/diabetes/pubs/estimates11.htm#1.
      3 AARP. Chronic conditions among older Americans. In: Chronic care: a call to action for health reform. 2009. Available at: http://assets.aarp.org/rgcenter/health/beyond_50_hcr_conditions.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
      4 Fryar CD, Hirsch R, Eberhardt MS, et al. NCHS data brief: hypertension, high serum total cholesterol, and diabetes: racial and ethnic prevalence differences in U.S. adults, 1999-2006. Hyattsville (MD): Centers for Disease Control and Prevention, National Center for Health Statistics. 2010 Apr. Available at: http://www.cdc.gov/nchs/data/databriefs/db36.pdf.
      5 Lamster IB, Eaves K. A model for dental practice in the 21st century. Am J Public Health. 2011;101(10):1825-30. [PubMed]
      6 Centers for Disease Control and Prevention. Fast stats: oral and dental health. Hyattsville (MD): Centers for Disease Control and Prevention, National Center for Health Statistics. 2012 Dec. Available at: http://www.cdc.gov/nchs/fastats/dental.htm.
      7 Jones JA, Fedele DJ, Bolden AJ, et al. Gains in dental care use not shared by minority elders. J Public Health Dent. 1994;54(1):39-46. [PubMed]
      Comment on this Innovation

      Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

      Original publication: February 26, 2014.
      Original publication indicates the date the profile was first posted to the Innovations Exchange.

      Last updated: February 26, 2014.
      Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.