Oral Health Baseline of Need at A Predominantly African American PACE

Geriatric Nursing 40 (2019) 353 359 Contents lists available at ScienceDirect Geriatric Nursing journal homepage: www.gnjournal.com Feature Article An oral health baseline of need at a predominantly African American Program of All-Inclusive Care for the Elderly (PACE): Opportunities for dental-nursing collaboration Matthew M. Oishi, DMD, MPH, MSa,*, Joan I. Gluch, PhD, RDH, PHDHPa, Robert J. Collins, DMD, MPHa, Greta R. Bunin, PhD (Retired)b,c, Ingrid Sidorov, MSNe, Boryana Dimitrova, DMDa, Pamela Z. Cacchione, PhD, CRNP, BC, FGSA, FAANd a University of Pennsylvania School of Dental Medicine, 240 S. 40th Street, Philadelphia, PA 19104, United States University of Pennsylvania School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States d University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States e LIFE UPenn, University of Pennsylvania School of Nursing, 4508 Chestnut St, Philadelphia, PA 19139, United States b c A R T I C L E I N F O Article history: Received 25 September 2018 Received in revised form 19 December 2018 Accepted 20 December 2018 Available online 14 March 2019 Keywords: PACE Dual eligibles Interprofessional education Oral health Older adults Dentistry A B S T R A C T This descriptive study sought to establish an oral health baseline of need for enrollees at a Program of AllInclusive Care for the Elderly (PACE) and identify opportunities for nursing interventions. The Oral Health Assessment Tool (OHAT) was applied to a random sample of 120 enrollees, 64 of whom met inclusion criteria, agreed to participate to assess their oral health status, and were included in the analysis. The mean OHAT score was 4.4 (SD = 2.6; range 0 12).

Higher scores indicate poorer oral health. The oral conditions found needing the most attention were gums, saliva, natural teeth, dentures, and oral cleanliness. Oral cleanliness scored the worst on the OHAT, highlighting opportunities for nursing interventions and the necessity for oral hygiene routines. This study also identifies the need for nurses to address enrollees’ oral health and relay information back to the PACE interdisciplinary team (IDT) to initiate referrals to the dentist as needed. © 2019 Elsevier Inc. All rights reserved. Oral Health Baseline of Need at A Predominantly African American PACE

Introduction There is a growing population of older adults who are dually eligible for Medicare and Medicaid. This population, more commonly known as “dual eligibles” (DEs), is generally in poor health, requires more medical and social supports than other Medicare or Medicaid beneficiaries, and consumes a significant amount of Medicaid resources.1 As described in the 2000 Surgeon General’s Report, “Oral Health Care in America”, many dual eligibles have poor oral health due to racial and ethnic disparities in accessing dental care. It was this report that alerted Americans to the importance of oral health care to general health and well-being.2 Since then, other reports3,4 have highlighted the need for all health professionals to be involved in oral health promotion and disease prevention, and the importance of interprofessional based care to improve both general and oral health. * Corresponding author: Currently at the University of Iowa College of Dentistry; 801 Newton Rd, DSB N329, Iowa City, IA 52242, United States. E-mail address: matthew-oishi@uiowa.edu (M.M. Oishi). https://doi.org/10.1016/j.gerinurse.2018.12.014 0197-4572/$ see front matter © 2019 Elsevier Inc. All rights reserved. Nursing care involves meeting patients most basic needs including oral care.5 However, oral hygiene care is not always recognized as a priority6 and, in nursing facilities, it is often crowded out by other nursing and caregiver tasks, such as bathing and dressing.7 Nurses are responsible for developing plans of care for their patients across health care settings. Understanding the extent of the oral hygiene care need within their health care setting and the population they serve is essential, particularly because frail older adults are not usually concerned with their oral health and complain or seek help for oral problems only when in pain.8 Older adults who are minorities or have low incomes suffer disproportionately from oral diseases.9 11 Individuals in nursing homes or those who receive home care tend to have poorer oral health when compared to independent, community dwelling older adults.12

For African Americans, these disparities are related to low dental care utilization, limited oral health knowledge, and seeking only problemfocused dental care.13 16 These disparities are significant because poor oral health can negatively impact older adults not only causing local pain and infection, but also putting them at risk for aspiration pneumonia. Dental 354 M.M. Oishi et al. / Geriatric Nursing 40 (2019) 353 359 plaque is a reservoir for multiple pathogens.17 Multiple medications for chronic diseases can also contribute to poor oral health and quality of life as these drugs often cause xerostomia, significantly increasing the risk for rapid oral health deterioration among older adults.18 Dual-eligibles (DEs), in particular, have low utilization of preventive dental services, such as examinations and cleanings.19 Medicare does not cover preventive dental services. Therefore, DEs receive their dental benefit from Medicaid. Adult dental care under Medicaid varies by state with limited coverage contributing to lower utilization.20 A program that is composed of mainly DEs21 and provides and finances dental care regardless of the state’s adult Medicaid benefit is the Program of All-Inclusive Care for the Elderly (PACE),17 where nurses play an expanding role in enrollees’ health care.22 PACE began in the early 1970s in San Francisco when a public health dentist and a social worker recognized a need for long-term care (LTC) services that kept individuals in the community and focused on maintaining their quality of life.23 In 2018, there were 124 programs with 255 centers in 31 states serving 45,000 older adults.24,40 Enrollees must be deemed nursing home eligible and are typically frail with almost half of the enrollees (49%) having a diagnosis of dementia.25 PACE is an opt-in, capitated program where care is coordinated by an Interdisciplinary Team (IDT); however, oral health professionals are not required by the Centers for Medicare and Medicaid Services (CMS) to participate in the team. Oral Health Baseline of Need at A Predominantly African American PACE

PACE services include the full spectrum of long-term services and supports (LTSS) and include but are not limited to medical care, therapies, noon meals, socialization, home care, nursing care, optometry, podiatry, mental health, transportation, and dentistry.26 Many of the services occur at the PACE day health center. PACE enrollees are expected to complete their daily hygiene at home prior to coming into the center, including oral care. This may be done independently or with the assistance of home care nurses or caregivers. At the center, the caregivers and nursing staff can provide oral hygiene care as needed and ensure it is part of their interdisciplinary care plan. Historically, oral care has been described as a basic nursing intervention.5 Since nurses play a wide variety of vital roles at PACE, from mental health specialists to diabetes educators and foot care providers,22 they are a natural choice to monitor oral health status, identify any points of intervention, adjust the care plan, and relay information between the IDT and oral health professionals. Thorne et al.27 found that the effectiveness of a dental program in long-term care was contingent on three pillars: dental care, routine and continual oral hygiene, and assessment. In particular, they found routine oral hygiene and assessment were most important to a program’s success and that simply providing dental services is insufficient to having an effective dental program. They suggested that a program’s ability and willingness to address these components is linked to the values and communication patterns of an organization that promotes quality of life and supports interactions among staff.27 This is pertinent to PACE as it is required by CMS to provide dental care and routine assessments of dental status (although who is required to provide this assessment and what specifically is to be assessed have not been defined).

In particular, the IDT is uniquely positioned to address the coordination of dental care and ongoing oral hygiene and assessment because it provides an established philosophy of care and built-in communication to coordinate all necessary services for enrollees in a care plan.26 No previous studies have documented the oral health status of PACE enrollees or explored the role of nurses in oral care in PACE. This study aimed to establish a baseline of oral health of PACE enrollees, compare oral health among the PACE participants with that of those in other LTSS, and explore the role of nurses in oral health care in order to direct future interprofessional oral health interventions. In addition, this study tested the hypothesis that oral health does not differ by age, sex, or dentition status in this group of PACE enrollees. Methods and materials Setting This descriptive study was conducted at one PACE center in Philadelphia. At the time, it was operated by the University of Pennsylvania School of Nursing (SON) and was the first PACE program in the country to be operated by a SON.28 Dental students in their final year at the University of Pennsylvania School of Dental Medicine provided dental care one to two days per week only to those members who expressed interest in receiving dental care.29 At the Philadelphia PACE, prior to this study, nurses conducted most of the oral assessments but did not use a formalized screening tool. Participants As of May 2014, there were 426 enrollees in this Philadelphia PACE, with an average of 230 enrollees coming to the center daily. At the time of the study, 72.4% of enrollees were female and 27.6% male. The majority of enrollees were African American (95.2%) with the remaining identifying as Caucasian or other. Oral Health Baseline of Need at A Predominantly African American PACE

The mean age of the enrollees was 79.0 years with a mean number of years enrolled in this PACE being 3.6 years. Approximately 40% of enrollees in this program had some degree of cognitive impairment.30 The sample selection A systematic random sample of 120 enrollees from this PACE center was selected. The sample size of 120 was chosen based on power calculations using OHAT scores and sample sizes from previous studies.31,32 The systematic random sample of enrollees was completed to avoid the bias of only enrolling members who were conveniently at the PACE center, those who had dental problems, or those interested in oral health thus, would presumably have better oral health and as a result would want to participate in this study.

One hundred and twenty enrollees were randomly selected and those who scored 24 or greater on their last routine Mini Mental Status Exam (MMSE) were contacted either by phone or in person at the PACE center, and a time was scheduled to conduct the oral assessment. Those with cognitive impairment (MMSE < 24) were excluded (n = 39). Each participant who consented was able to describe the risks, benefits and purpose of the study to demonstrate their ability to provide informed consent. Inclusion criteria included having an MMSE score of 24 and being able to come to the PACE center. Among eighty-one remaining enrollees, two died prior to consent. This left seventy-nine enrollees (65.8%) who were approached, of which 13 declined. Those who declined did so due to factors such as weather, illness, and family commitments, thereby affecting consistent attendance at the PACE center. Sixty-six enrollees (55%) participated in the study with a final sample of sixtyfour (n = 64, 53.3%) after two participants were removed for incomplete scoring. IRB approval was granted through a full review by the Human Subjects Committee at the University of Pennsylvania (Protocol #820468). Oral Health Assessment Tool (OHAT) The OHAT is a screening tool to identify and document any major oral issues. It is specifically indicated for use by non-dentists in patients with cognitive impairment, xerostomia, chronic health problems, and swallowing and/or feeding issues, as well as patients who require assistance with self-care.33 The OHAT evaluates the M.M. Oishi et al. / Geriatric Nursing 40 (2019) 353 359 355 Table 1 OHAT categories and the corresponding descriptions for scores of 0, 1, or 2. Category 0 = Healthy 1 = Changes 2 = Unhealthy Lips Smooth, pink, moist Dry, chapped, or red at corners Tongue Gums and tissues Normal, moist roughness, pink Pink, moist, smooth, no bleeding Saliva Moist tissues, water and free flowing saliva No decayed or broken teeth/roots Patchy, fissured, red, coated Dry, shiny, rough, red, swollen, one ulcer/sore spot under dentures Dry, stick tissues, little saliva present, resident thinks they have a dry mouth 1 3 decayed or broken teeth/roots or very worn down teeth 1 broken area/tooth or dentures only worn for 1 2 h daily, or dentures not named, or loose Food particles/tartar/plaque in 1 2 areas of the mouth or on small areas of dentures or halitosis Are verbal &/or behavioral signs of pain such as pulling at face, chewing lips, not eating, aggression Swelling or lump, white/red/ulcerated patch; bleeding/ ulcerated at corners Patch that is red &/or white, ulcerated, swollen Swollen, bleeding, ulcers, white/red patches, generalized redness under dentures Tissues parched and red, very little/no saliva present, saliva is thick, resident thinks they have a dry mouth 4+ decayed or broken teeth/roots, or very worn down teeth, or less than 4 teeth More than 1 broken area/tooth, denture missing or not worn, loose and needs denture adhesive, or not named Food particles/tartar/plaque in most areas of the mouth or on most of dentures or severe halitosis Are physical pain signs (swelling of cheek or gum, broken teeth, ulcers), as well as verbal &/or behavioral signs (pulling at face, not eating, aggression) Natural teeth Dentures Oral cleanliness Dental pain No broken areas or teeth, dentures regularly worn, and named Clean and no food particles or tartar in mouth or dentures No behavioral, verbal, or physical signs of dental pain condition of eight specific categories: lips, tongue, gums and tissue, saliva, natural teeth, dentures, oral cleanliness and dental pain (Table 1). Oral Health Baseline of Need at A Predominantly African American PACE

For each of the eight areas, patients are given a score of 0 = healthy, 1 = changes, or 2 = unhealthy; thus, lower scores indicate healthier oral conditions and higher scores indicate poor conditions. The total OHAT score is calculated by adding the eight individual category scores. Total possible scores range from 0 to 16 and there are no cut-offs based on points to determine severity or significant score. However, if the total score is different from zero, the patient should ideally be referred to a dentist. While the total score is important, the scores of each category should also be considered individually. The OHAT provides some quantitative information but it was not intended to measure oral health. It has mostly been used to evaluate interventions that improve oral health and identify individuals who need an examination by a dentist. Chalmers et al.32 tested the reliability and validity of the OHAT over a 12-month period in a residential care facility and found the mean total OHAT scores to be between 2.4 and 2.7. Jablonski et al.31 used the OHAT to assess the efficacy of an intervention to reduce care resistant behaviors in nursing home residents with moderate-to-severe dementia. They found the baseline mean total OHAT score to be 7.2. With the intervention and twice daily mouth care for 14 days, the score decreased to 1.0, demonstrating the OHAT is sensitive to change. Similarly, Amerine et al.34 applied the OHAT to a convenience sample in three LTC facilities in Arkansas and found improved OHAT scores for tongue health, denture status, and oral cleanliness when oral health interventions were conducted by nurses and a dental hygienist who served as an oral health champion. Although these studies were conducted in different populations of older adults, they suggest that the OHAT is valid and reliable in establishing oral health status and evaluating oral health interventions.

Four dental students in their final year of school conducted the assessments and were trained using the University of Iowa’s Geriatric Education Center website which provides an online training module for individuals who will administer the OHAT.35 After obtaining informed consent from each study participant, oral assessments were conducted with gauze and tongue depressors. Data collection occurred between November 2014 and March 2015. Data analyses Age, sex, and dentition status were categorized and summarized with counts and percentages and corresponding mean total OHAT scores. ANOVA was used to assess differences in mean total OHAT score by age group and dentition status. Post hoc comparisons were conducted with Scheffe tests. A t-test was used to assess differences in mean OHAT scores between males and females. For all tests, statistical significance was noted at the p < 0.05 level. SPSS Version 25 was used for data analyses and summary statistics. Oral Health Baseline of Need at A Predominantly African American PACE

Results A total of 66 enrollees met the inclusion criteria and agreed to participate in the study. Sixty-four participants were included in the final analysis of which 70% were female and 30% male, with a mean age of 74.1 years (SD = 8.9; Range 60 95 years). All study participants were African American. The descriptive characteristics can be seen in Table 2. No statistically significant difference could be detected in mean total OHAT scores by age group (p = 0.56) or sex (p = 0.27). A statistically significant difference was noted by dentition status (p = 0.001). Post hoc tests showed that no statistically significant relationship could be detected between participants who had teeth only and those who had teeth and dentures, but that those with natural teeth only (p = 0.004) or natural teeth with dentures (p = 0.005) had significantly higher mean total OHAT scores than those with only dentures. The mean total OHAT score for the 64 participants was 4.4 (SD = 2.6; Range 0 12) out of a possible score of 16. The OHAT score distribution for individual categories is presented in Fig. 1. A majority of participants had healthy lips (95%), tongues (66%), and did not report any dental pain (89%) at the time of assessment. Scores were Table 2 Descriptive statistics of sample (N = 64). Demographics Age 60 69 70 79 80 Sex Male Female Dentition Natural teeth (a) Dentures (b) Dentures and natural teeth (c) N (%) Mean OHAT Score SD P-Value 24 (37.5) 23 (35.9) 17 (26.6) 4.4 4.0 4.9 2.7 3.1 1.6 0.56 19 (29.7) 45 (70.3) 5.1 4.1 3.6 2.0 17 (26.6) 16 (25) 31(48.4) 5.3 2.4 4.9 2.0 2.2 2.6 0.27 0.001* * p < 0.05 ANOVA- Post Hoc Scheffe test revealed statistical difference natural teeth (a) and dentures with natural teeth (c) different from dentures only (b). 356 M.M. Oishi et al. / Geriatric Nursing 40 (2019) 353 359 Fig. 1.

Percentage of individuals receiving 0, 1, 2 score for each of the eight categories of the OHAT. distributed differently for the categories of gums, saliva, teeth, dentures, and oral cleanliness. Over 40% of participants had a score of 0 for gums and saliva, with 37 51% having a score of 1 and approximately 6 15% a score of 2. For the categories of natural teeth, dentures, and oral cleanliness, between 26 and 47% of participants had a score of 0, 19 37% a score of 1, and 33 35% a score of 2. Oral cleanliness (1.09, SD = 0.79) and teeth (0.72, SD = 0.84) scored highest among the eight items …
Oral Health Baseline of Need at A Predominantly African American PACE