1. AUDUBON CLINIC QUALITY IMPROVEMENT PROJECT 2011-2012 Optimizing Dental Health

2. Background

3. Dental caries prevalence:  41% of children between age 2-11 years  80% of children between age 5-18 years Visit to physician/visit to dentist: 250/1  89% of <1 year old have physician visits  1.5% of <1 year old have dentist visits Average wait time to see a Pediatric dentist in NYC is 3-6 months.

4. AAP Recommendations Periodic oral health risk assessments Dietary counseling and anticipatory guidance Use of fluoride containing toothpaste Fluoride varnish application Established dental home by 1 year of age

5. Aim Statement Pediatric Dental Referrals:  Increase the percentage of patients referred to a pediatric dentist by 1 year of age from 10% to 40% by June 2012  Improve the teaching and anticipatory guidance for dental issues delivered by the pediatricians in our clinic  Include age based counseling for ages 1-3  Increase documentation of dental referrals and counseling

6. Baseline Measurement: July 2011

7. Interventions PDSA Cycle 1  QI Didactic for Health Care Providers  Age-Appropriate Dental Information Handouts  Dental Clinic Referral Sheets

8. Age-Appropriate Dental Information Handouts

9. Dental Clinic Referral Sheets

10. Interventions PDSA Cycle 1  QI Didactic for Health Care Providers  Age-Appropriate Dental Information Handouts  Dental Clinic Referral Sheets PDSA Cycle 2  Signs hung in Rooms  Informed MAs, Nurses, and PFAs  PFAs given copies of referral handouts

11. Dental Screening Poster

12. Chart Review Patient Name

13. Interventions PDSA Cycle 1  QI Didactic for Health Care Providers  Age-Appropriate Dental Information Handouts  Dental Clinic Referral Sheets PDSA Cycle 2  Signs hung in Rooms  Informed MAs, Nurses, and PFAs  PFAs given copies of referral handouts PDSA Cycle 3  Staff Education  Dental Board created in Hallways

14. Dental Board

15. Chart Review: Results Table Baseline Measurement Phase After PDSA Cycle 1 After PDSA Cycle 2 After PDSA Cycle 3 % of 12mo Dental Referrals 10 (4/38) 25 (5/20) 80 (20/25) 50 (16/33) % of 15mo Dental Referrals 10 (4/38) 40 (4/10) 77 (17/22) 70 (14/20) % of 18mo Dental ReferralsN/A 70 (7/10)

16. Percent of Patients Receiving Dental Referrals

17. Percent of Patients Receiving Dental Referrals A Different Way to Look at the Same Data

18. Percentage of Patients with Scheduled Dental Appointments

19. QI Project Final Chart Review: May 2012

20. Aim Statement Revisited Pediatric Dental Referrals:  Increase the percentage of patients referred to a pediatric dentist by 1 year of age from 10% to 40% by June 2012  Improve the teaching and anticipatory guidance for dental issues delivered by the pediatricians in our clinic  Include age based counseling for ages 1-3  Increase documentation of dental referrals and counseling ✔ ✔ ✔ ✔

21. Limitations and Difficulties “No Teeth” recorded on multiple charts when reviewed  No dental referral given at that time Ultimate outcome measure of the project is that each child has a dental "medical" home  Project was limited in its ability to measure this Anticipatory guidance for 1 year visit in Eclipsys does not prompt dental referrals  But the anticipatory guidance page for the 2 year visit does

22. Limitations and Difficulties “No Teeth” recorded on multiple charts when reviewed  No dental referral given at that time Ultimate outcome measure of the project is that each child has a dental "medical" home  Project was limited in its ability to measure this Anticipatory guidance for 1 year visit in Eclipsys does not prompt dental referrals  But the anticipatory guidance page for the 2 year visit does

23. Spreading QI Project to Other ACN Sites

24. Fluoride Varnish: The Next Step? o Fluoride varnish can be applied by a Pediatrician in office and by Pediatric Dentists o Fluoride Varnish is recommended for all high risk patients identified

25. Alex Glick Jennifer Guimbellot Caitlin Haxel Marleine Ishak Elaine Lin Genevieve London Katie Offer Ryan Morgan Erin C. Qualter Shawndip Sen Evan Sherman Rebecca Turcotte Doctors: Mariellen Lane Connie Kostacos Melissa Stockwell Valerie Niketakis Betsy Pfeffer Karen Soren Nikki Timko Betsy Wedemeyer Larry Williams Daryl Wisler QI at Audubon Jackie Baker Kelly Burke Nitin Chanana Wendy Chang Amelie Collins Danis Copenhaver Nina Dadlez Valerio Dorrello Pam Fazzio Cristina Fernandez Sarah Fleet

26. QI at Audubon Nurses Beverly Kim Diana Decharo Ernestina Amoah Estela Padron Jasmine Ortiz Adora Brown Vicki Bernstein Medical Assistants Doreen Pittman Hasse Nolasco Ivette Pinto-Velez Jean Adedipe-Jonadu Jessie Lyons Stacyann Halm Site Administrators and Patient Financial Advisors Luis Brito Dulcelyn Caba Kecia Davis Roxanne DeSoto Alfred Mancebo Vivian Yajayra Rojas Yoima Sosa Kim Moore Steele Tina Veloz

27. QI at Audubon Nurses Beverly Kim Diana Decharo Ernestina Amoah Estela Padron Jasmine Ortiz Adora Brown Vicki Bernstein Medical Assistants Doreen Pittman Hasse Nolasco Ivette Pinto-Velez Jean Adedipe-Jonadu Jessie Lyons Stacyann Halm Site Administrators and Patient Financial Advisors Luis Brito Dulcelyn Caba Kecia Davis Roxanne DeSoto Alfred Mancebo Vivian Yajayra Rojas Yoima Sosa Kim Moore Steele Tina Veloz

28. References o http://www.usetinc.org/Libraries/THPS/Fluoride_Varnish_Manual.sflb.ashx o http://pediatrics.aappublications.org/content/115/1/e69.full o http://www.youtube.com/watch?v=8A5jrVuxSHc o http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdf o http://pediatrics.aappublications.org/content/122/6/1387.full.pdf+html