Lessons learned from a “boots on the ground” experience providing oral hygiene in nursing homes Pam Stein, D.M.D., M.P.H. University of Kentucky College of Dentistry Special Care Dentistry Association Annual Meeting April 29, 2012 This project was funded by the Dental Trade Alliance Foundation

The Why and How of our Project Issue: Very few nursing home residents receive adequate daily oral hygiene care. Aim: To improve daily oral hygiene care by training a nursing assistant to become one nursing home’s “oral health specialist”.

There is good evidence to support this model of oral care. A 2008 study in a Florida nursing home found: Nursing home residents who had daily mouth care provided by nursing assistants whose only job was to provide oral care had much less risk (3 times less risk) of dying from pneumonia than those residents who did not receive the daily care from the nursing assistant designated to do oral care. Bassim CW, Gibson G, Ward T, Paphides BM, DeNucci DJ. Modification of Risk of Mortality from Pneumonia with Oral Hygiene Care, J Am Ger Soc, 2008, 56 (9):

The first step was to develop a partnership with local long-term care facility. Administrator Director of Nursing Social Worker

We developed a written plan and shared with the leadership of the facility. Ask for advice as to how the plan might realistically work for their residents and staff.

We then identified nursing assistant to be trained and developed the curriculum. We researched literature for elements of past successful training programs

Training began with 4 Self-Instructional PowerPoints Importance of Daily Oral Care Guidelines for Daily Oral Care Checking for Problems Residents Requiring Special Care

A video helped overcome barrier of care-resistance. Video Created by Dr. Rita Jablonski - Strategies for Care Resistance during oral care - Available for viewing on POGO Jablonski RA, Munro CL, Grap MJ, et al. Mouth care in nursing homes: knowledge, beliefs, and practices of nursing assistants. Geriatr Nurs 2009;30: Chalmers JM. Behavior management and communication strategies for dental professionals when caring for patients with dementia. Spec Care Dentist 2000;20(4):

Hands-on training with oral hygiene tools helped build confidence.

Ongoing bedside coaching included weekly visits to the facility. -traveling room to room to deliver oral hygiene care with the nursing assistant -talking with the nursing assistant about her struggles -providing positive feedback for successes

We had a presence at the nursing home for months. This allowed us to get to know residents and their families and learn about their concerns and suggestions.

We spent time in conversations with nursing staff (esp charge nurses) because we wanted to know: What are the real challenges they face every day with other care (besides oral) How our oral health training might help them address their other more general concerns -“Outbreaks” of flu or other contagious illness -Trying to prevent pneumonia and hospital admits -Lots of talk about “wound care”

AHA! Now maybe we can get buy in for sustainability! -Wound animation -Incorporate infection control into our training -Provide stats (research) about decreased pneumonia due to oral hygiene to administration Azarpazhooh A, Leake JL. Systematic review of the association between respiratory diseases and oral health. J Periodontol 2006;77(9):

Wound Care Animation

We scheduled follow-up meetings with the leadership. This included the DON, administrator and the CEO of the parent company Short OH basic training for everyone with infection control review Respiratory connection

We were both teacher and student THIS WAS A VERY VALUABLE LEARNING EXPERIENCE FOR US!!!! That’s why we are here…. to share lessons learned.

Lesson Learned It is essential to identify a point person in leadership at the nursing home to communicate issues and concerns. For us this was the Social Worker, but it could be the Director of Nursing, Assistant Director of Nursing or Administrator.

Lessons Learned Must have a dentist available to treat residents because with increase in oral health awareness and daily oral care there was an increased need to refer.

Lessons Learned Some residents were on a diet prohibiting thin liquids. A regimen which included mouthwash, water and toothpaste could have been a choking hazard. Further, resident’s dietary restrictions often changed making it difficult to know on a daily basis who was at risk of choking.

Addressed the dietary restrictions by: YouTube video Red “Safety Precautions” Flash card Added to PowerPoint Presentations

Before providing oral care to anyone check with the charge nurse or care plan each day. Do you need to change the oral hygiene routine to eliminate liquids and toothpaste for any residents?

Do NOT use toothpaste, mouthwash or water for the following residents Comatose residents Residents on a restricted diet of thickened liquids that can’t have thin liquids Care resistant residents Residents who hold liquids in mouth/ can’t or won’t spit but instead swallow liquids placed in mouth 22 of 59

How to provide oral care without toothpaste, mouthwash or water? Simply moisten a toothbrush with a very small amount of water or mouthwash and brush teeth as you normally would. If possible, floss teeth After brushing and flossing wipe the mouth out with a toothette or gauze moistened with mouthwash.

Lessons Learned The nursing assistant we trained as the oral health specialist worked 6am-2pm Residents enjoyed having their teeth brushed and asked for the care at other times. We developed a 25 minute presentation for all nursing assistants at the facility.

We created a free website that provides resources for dental professionals, nursing homes and families: Powerpoints (30 min, 1 hr, 2 hr) Powerpoints with voice over YouTube Video (11 minutes) Written Materials Task and Supply Lists, Safety precautions Competencies Pre-test and Post-test Forms (referral, documentation) Links to other on-line resources References for related research

Kentucky House Bill 510 signed into law 4/12/12. Appropriates $150,000 from penalty fund to train nursing assistants to become “oral health specialists” in several long term care facilities in Kentucky to study the health and financial outcomes. DOES THIS SAVE MEDICAID MONEY??? Will use our training materials and model for this pilot project.

Web Address of resources created.

Acknowledgements For their assistance with this project, the authors of this program would like to thank: Joanna Aalboe, MPH, Registered Dental Hygienist, Assistant Professor, University of Kentucky College of Dentistry Ada Carlile, Registered Dental Hygienist Sandy Challman, Master of Instructional Technology, University of Kentucky College of Dentistry Kathryn Cunningham, MS Ed, Center for the Enhancement of Learning and Teaching, University of Kentucky Tom Dolan, Senior Medical Illustrator and Multimedia Developer, University of Kentucky Stephanie Harper, Social Services/Butterfly Program Coordinator Dr. Robert Henry, Chief of Dental Services, Veteran's Administration Hospital, Lexington Kentucky Esther Nealy, Certified Nursing Assistant Dr. Judith Skelton, PhD, Director of Outreach and Engagement, University of Kentucky College of Dentistry