Case Study: Bridging Medical and Dental Care at Marshfield Clinic and the Family Health Center

A community health center system in Wisconsin is seeking to demonstrate how better connections between dental and medical providers can improve health care and outcomes for low-income individuals with diabetes. It may provide a model for states seeking new strategies to promote integrated care for high-cost beneficiaries.

Program Summary:

Family Health Center of Marshfield, Inc. (FHC), a large Federally Qualified Health Center[1] system in Wisconsin, and the Marshfield Clinic, one of the largest private group medical practices in the state, are working together on initiatives to better integrate medical and dental care for people with diabetes. Taking advantage of FHC’s network of nine large dental clinics across the northern and central parts of the state, these clinics represent a new model of service delivery for rural areas. FHC’s goal is to eliminate disparities in access to oral health care between uninsured or Medicaid-enrolled individuals and the privately insured.

Approximately three quarters of FHC’s dental patients receive medical care from the Marshfield Clinic Health System. This represents an opportunity for collaboration, and FHC’s capacity to deliver dental care allows FHC and Marshfield to engage medical providers in identifying and managing oral health conditions, because medical providers can be confident that patients they refer can access dental care.

FHC began looking at linkages between oral health and overall health out of an interest in providing whole-person care, and in light of evidence linking untreated gum disease to worsened diabetic control. FHC has pursued a number of strategies to bridge oral health and primary care, including developing fully integrated medical and dental electronic health records and clinical decision support tools to assist both dentists and physicians to co-manage patients with diabetes. Grant funding from the DentaQuest Foundation supported a pilot program, conducted in coordination with a managed care plan, to test patient education and incentive strategies to encourage individuals with diabetes to establish regular oral health care.

Medical providers at pilot sites are able to conduct routine visual oral examinations for their diabetic patients along with annual foot and eye exams to treat common consequences of diabetes, and track whether their diabetic patients are receiving treatment for gum disease. The clinical decision support tools prompt medical providers to talk to patients about their use of dental care, and refer if necessary. FHC dentists at pilot sites now monitor diabetics’ blood sugar in the dental office. To complement the integrated systems, Marshfield Clinic Research Foundation, Marshfield Clinic Division of Education and FHC have also focused on training their clinicians to work in this new paradigm and developed the Institute for Oral-Systemic Health to research, update, and advance these integrative efforts.

Although the pilot programs are still being implemented and evaluated, integration has already led to noticeable improvements for FHC patients, according to Greg Nycz, FHC’s executive director. “You don’t have to talk to many of our dentists and hygienists to convince them of the connection between periodontal disease and major health complications. In patient after patient, we see that if we address their periodontal disease and get their health back on track, we can provide a new lease on life.”

State Roles:

State policies underpin FHC’s efforts to coordinate medical and dental care.

Medicaid adult dental coverage. Greg Nycz notes that Wisconsin Medicaid’s consistent coverage of adult dental services is critical to FHC’s ability to expand its capacity to deliver oral health care and improve access to integrated oral health services for its patients. Medicaid-enrolled patients comprise about 65 percent of the clinics’ caseload; if adult dental services were not a Medicaid benefit, FHC would not be able to financially sustain these services.

State appropriations. The state has also used direct annual appropriations to support safety net dental capacity in rural areas of the state. In November 2002, FHC received $232,000 in state funding to support a 17-chair dental clinic in Ladysmith, Wisconsin, a town in rural Rusk County (county population: 14,395). A second 29-chair FHC clinic in Chippewa Falls (in Chippewa County, population 63,132) opened in September 2005, and was supported by an appropriation of $400,000. While annual state appropriations for the clinics have fallen over time to a current level of approximately $526,000, these funds remain important to sustaining the program.

Program Successes:

  • In FY2014, FHC dental centers treated 49,389 unique patients. Over the last decade, over 100,000 unique patients from all 72 counties in Wisconsin have had access to dental services through these dental centers. The rural clinics’ reach extends to distant urban areas, often drawing people more than three hours from major metropolitan areas to far more remote parts of the state in order to get dental services.
  • FHC reports that it has been successful in reducing visits to hospital emergency rooms for treatable dental conditions. In the year following the opening of the Chippewa Falls clinic, the number of non-traumatic dental-related emergency room visits fell from 139 in 2009 to 115 in 2010, and continued to fall to just eight in 2012.
  • Researchers at the Marshfield Clinic Research Foundation (MCRF), through the Institute for Oral and Systemic Health, have developed one of the first fully integrated medical-dental Electronic Health Records in the nation.
  • The pilot project training dental providers to conduct blood glucose tests at chairside for at-risk diabetic patients will likely be expanded to all 9 FHC dental centers in the next 8-12 months. Likewise, Marshfield Clinic is planning to expand training for medical providers on how to conduct routine visual oral examinations for diabetic patients to 4-5 other Marshfield Clinic medical centers in the next 12 months.

Resources:

[1] Federally Qualified Health Center (FQHC) is a designation granted by the federal Health Resources and Services Administration to Community Health Centers that must be located in a medically underserved area or serve a medically underserved population.