1. Geriatric Dentistry: Care Delivery Systems Kenneth Shay, DDS, MS VA Office of Geriatrics and Extended Care

2. Community (“private” settings) Dental school Aggregate day settings Home care Institutional settings –Assisted living –Nursing home* –Hospital* Geriatric Dentistry: Care Delivery Systems

3. Department of Veterans Affairs (“VA”) About 25,000,000 veterans –42%>65 yr 8 million enrolled; 6M receive care from VA –56%>65 yr. VHA, VBA, NCA VHA is appropriated about $35B/yr About 220,000 employees –Approximately 9,000 MDs;14,000 nurse staff >900 outpatient clinics 134 Hospitals (each with a dental clinic)

4. 784 DDSs (includes 102 residents) 183 RDHs 991 DAs, CDAs 239 Lab technicians 381,000 unique patients treated in 2006 (includes about 35,000 “fee” patients) 2006 expenditures $351M ($62M “fee”) –budget submission was $419M 2008 budget submission: $501M 2009 budget submission: $551M Department of Veterans Affairs (“VA”) (all data are unofficial) Increased prevention and “medically adjunct” care

5. Priority levels regarding care and co-pay obligations “Standard” vs “Special and Limited” benefits –Dental is “limited” to 2 yr post-discharge 70+% service-connected Service-related oral/dental trauma Former Prisoners of War Emergency care Participants in VA Vocational Rehab programs Inpatients (includes LTC) “as resources allow” Medically adjunct “as resources allow” diminishing priority

6. Geriatrics in VA 134 Nursing Home Care Units –Average Daily Census (ADC) ~10,500 and dropping –Subacute, palliative, rehab, long-term Community Nursing Home Care –ADC approximately 7,500 and stable State Veterans Homes –State-administered –ADC approximately 18,000 and climbing –Life stay “Non-institutional extended care” –Home-based primary care, respite, home hospice, adult day health care, homemaker/home health aide, skilled home care –ADC approximately 26,000 and climbing

7. Geriatric Dentistry in VA --fantasies and realities “Everyone is eligible for dental care” –as resources permit Political pressures favoring recent dischargees Performance pressures favoring rapid turnover Personal pressures favoring particular case types “Integration of medicine and dentistry” Pressures to minimize “medically adjunct” Absence of an evidence base linked to treatment Dental inferiority complex Electronic health record

8. Geriatric Dentistry in VA --what might it be telling us? Dentists like to treat who they like to treat –(healthy people with clean mouths) Dentists like to do what they like to do –(work on teeth; –sometimes on mouths ; –less commonly on people ; –And almost never, ever on teams ) Supply and demand aren’t just capitalism –(as long as there aren’t enough dentists, less desirable patients will be untreated)

9. Geriatric Dentistry: Care Delivery Systems Kenneth Shay, DDS, MS VA Office of Geriatrics and Extended Care