Maximizing the Impact of Your Dental Program Dori Bingham SNS - - PowerPoint PPT Presentation

Maximizing the Impact of Your Dental Program

Dori Bingham SNS Program Manager

Dori realizes she is the first speaker after lunch!

Learning Objectives

• Learn how to determine the maximum potential

capacity of your dental program

• Understand how to utilize the dental schedule to

maximize patient access and program revenue

• Learn strategies for minimizing broken appointments
• Learn strategies for making the best use of dental

resources to maximize patient outcomes

Defining Program Capacity

• Every dental program has a finite capacity
• Capacity depends on available resources (the number

and type of staff, number of dental chairs and days/hours

• f operation)
• While most safety net dental programs have more

demand than can be met, that is not always the case

• Many factors can negatively impact a program’s ability to

maximize its potential capacity

• Very important to manage capacity strategically

Typical Factors Determining Dentist Capacity

• Level of provider experience
• Number of available operatories
• Number, type and experience of dental assistants
• Scope of services provided
• Age and type of patients
• Effectiveness of scheduling
• Failed appointment rate
• Number of expected visits/hour can vary from 1.2 to 2

Determine Daily Visit Capacity, Dentists (Example for Dentists)

# of FTE Providers X 1.7 Visits/Clinical Hour X # of Clinical Hours Potential Visit Capacity Mon. 2 1.7 15 26 Tues. 3 1.7 22.5 38 Wed. 4 1.7 30 51 Thurs. 4 1.7 30 51 Fri. 2 1.7 15 26

Typical Factors Determining Hygienist Capacity

• Level of provider experience
• Do they take x-rays? Conventional or digital?
• Work out of more than one room?
• Responsiveness of dentists for exams
• Age and type of patients
• Effectiveness of scheduling
• Failed appointment rate
• Number of expected visits/hour can vary from 1 to 2

Determine Daily Visit Capacity, Hygienists (Example for Hygienists)

# of FTE Providers X 1.2 Visits/Clinical Hour X # of Clinical Hours Potential Visit Capacity Mon. 2 1.2 15 18 Tues. 2 1.2 15 18 Wed. 2 1.2 15 18 Thurs. 2 1.2 15 18 Fri. 1 1.2 7.5 9

Determine Daily Visit Capacity (Example)

• Monday: 26 dentist visits + 18 hygienist visits = 44 visits
• Tuesday: 38 dentist visits + 18 hygienist visits = 56 visits
• Wednesday: 51 dentist visits + 18 hygienist visits = 69

visits

• Thursday: 51 dentist visits + 18 hygienist visits = 69

visits

• Friday: 26 dentist visits + 9 hygienist visits = 35 visits

Total weekly visit capacity = 273 Total annual visit capacity (273 x 46 weeks) = 12,558

Excess Demand

• Sample program has capacity to accommodate

12,558 visits given current staffing and hours of

• peration
• Represents approximately 5,000 unduplicated

patients

• What happens if 10,000 unduplicated patients

are trying to get in for dental care?

• What happens if the practice tries to

accommodate 10,000 unduplicated patients?

Excess Demand (cont.)

• Too many new patients in the daily schedule
• High rate of “emergencies” as new patients try and game

the system to get into the practice

• Long waits between appointments for existing patients

with identified dental problems

• High rate of patients lost to follow-up as they get

frustrated and discouraged at the amount of time to get their problems resolved

• Short appointment lengths as practice tries to

accommodate as many patients as possible

Excess Demand (cont.)

• Inability to complete treatments in a timely manner
• Lots of chaos in the dental department due to high

volume of patients—long waits to check in, to be taken into clinical area and in dental chairs as the practice becomes overwhelmed and routinely falls behind

• Patients get fed up and leave without being seen—many

unhappy patients who will badmouth the practice and seek care elsewhere

• Staff are exhausted, frustrated and stressed out—poor

staff morale and high turnover rates

Unmet Demand

• Empty chairs means lost revenue the dental program

needs to meet operating costs

• Staff with too much free time can develop bad work

habits

• Dental program can become inefficient without

challenges presented by full schedules

• Good staff may leave to find more rewarding jobs

elsewhere

• Inability to meet operating costs can lead to reductions in

staff, operatories, sites and hours of operations

Managing Excess Demand

• Define maximum capacity and explain capacity

determination to executive leadership and Board

• Document and demonstrate negative outcomes of failing

to manage demand appropriately

• Understand and accept that the dental program has a

finite capacity that cannot currently meet the demand

• Best way to increase ability to meet demand is to

manage current capacity effectively to generate needed financial resources to add more providers, more

• peratories, more dental sites, increase hours of
• peration, etc.

Managing Excess Demand (cont.)

• Designate priority populations for dental care (eg,

children, pregnant women, people with chronic health conditions such as diabetes, heart disease, HIV/AIDS)

• Create designated appointments in the daily schedule to

preserve and protect access for priority populations

• Use scripting to explain why access to the dental

program is limited

• Consider limiting access to patients of record of the

health center or those who live in the defined service area

Managing Excess Demand (cont.)

• Track completed treatments to determine the number of

patients (daily, weekly, monthly) whose dental problems are eliminated—this is the number of new patients that can be brought into the dental program without bogging things down

Managing Unmet Demand

• Determine root causes for lack of demand
• Low population in need of care
• Competition from others for your patients
• Barriers to care (transportation issues, distance,

inconvenient operating hours, cost of care, language/cultural issues, etc.)

• What is the patient experience of care? (Look carefully at

facilities, operations, wait times, length of time between appointments, number of appointments needed to complete treatment, staff attitudes, etc.). Are patients choosing to go elsewhere because their experience in your dental program is less than optimal?

Managing Unmet Demand (cont.)

• Remove barriers to care wherever possible
• Improve the patient experience of care to the extent

possible

• Mine internal and external sources of referrals to dental

(eg, pediatrics, family practice, OB/GYN, WIC, Head Start, other health and human service agencies serving children and families)

• Invest in culturally and linguistically appropriate outreach

workers to infiltrate service area to assist in education, relationship-building, enrollment and case management

Questions?

Scheduling by Design

Why is Scheduling Important?

• The daily schedule is the single most important

tool the dental program has to position itself for success

• Scheduling is an art
• If done well, scheduling sets the stage for an

efficient and effective dental practice

• Scheduling done poorly creates chaos and

stress and undermines the program’s ability to be successful

What is Scheduling by Design?

Use of the dental schedule to achieve three key strategic objectives:

• 1. Improved oral health status for patients
• 2. Maximum access to care for patients
• 2. Financial viability of the dental program

Key Strategic Objectives

• Completion of Phase 1 Treatments
• Maximum Access for Patients
• Financial Viability—”no margin, no mission”

Completion of Phase 1 Treatments

• Important quality indicator for all safety net dental programs
• HRSA Definition: “Prevention, maintenance and/or elimination
• f oral pathology that results from dental caries or periodontal

disease”—diagnosis and treatment planning, preventive services, emergency treatment, restorative treatment, basic (non-surgical) periodontal therapy, basic oral surgery, non-surgical endodontic therapy and space maintenance and tooth eruption guidance for the transitional dentition

• The daily schedule is an important tool for maximizing the

number of patients whose Phase 1 treatment needs are completed

Maximum Patient Access

• Understand (and document) the sociodemographic

make-up of your service area

• As a safety net dental provider, your mission should

be to provide access to all disadvantaged patients who have difficulty getting care

• But special populations can be designated as priorities

(eg, children, pregnant women)

• The daily schedule is an important tool in maximizing

access to care

Financial Viability

• Net revenue needs to be sufficient to meet total direct

and indirect expenses

• Net revenue includes patient care revenue plus any
• ngoing, predictable grants (such as 330 grants for

FQHCs)

• The daily schedule is an important tool for ensuring the

generation of sufficient revenue to at least cover direct and indirect expenses (and ideally generate a surplus)

Keys to Success

• Define program goals (access, revenue and
• utcomes)
• Create a formal scheduling policy that defines all

related processes

• Develop strategies to address all of the factors

that undermine maximum practice efficiency (eg, broken appointments, staffing issues,

• perational issues)

Set Goals: Daily Revenue Goal

• Divide your total direct and indirect expenses by the number
• f clinic days per year (the number of days per week the

clinic is open x 46 weeks)—that is the daily net revenue goal that must be achieved to break even

• For example:

Total expenses = $950,000 5 days per week x 46 weeks = 230 clinic days per year $950,000 ÷ 230 = daily net revenue goal of $4,131

Daily Revenue Goal (cont.)

If you prefer to base your daily revenue goal on gross charges rather than net, you must look back historically to determine the percentage of gross charges that the program collects For example:

• In a typical year, the program bills out $1,500,000 in gross charges

and collects $950,000 in net revenue

• This is a 63% collection rate
• Thus, to net the $4,131 per day in net revenue needed to cover

direct and indirect expenses, dental needs to generate $6,557 in gross charges for each day (63% more than net)

• The actual collection rate should be checked regularly to make sure

the underlying assumption of 63% is accurate

Setting Goals: Daily Visit Goal

• Based on number of FTE providers and hours each

provider works each day

• Apply productivity benchmarks but factor in extenuating

circumstances (new grad, student, resident, dentist with

• nly one assistant, dentist with EFDA(s), dentist

providing specialty care)

• Separate goals for different provider types
• Schedule needs to support attainment of visit goals for

each provider

Setting Goals: Outcomes

• Many possible outcomes to track
• Healthy People 2020
• HRSA
• Prevention (fluoride, sealants)
• Completion of Phase I treatment
• Use dummy codes to track
• The schedule needs to support attainment of
• utcome goals

The Scheduling Policy

• How far out will appointments be scheduled?
• Only one appointment at a time (exception: dentures)
• Define how operatories will be used (how many per

provider)

• Define appointment lengths for various procedures (use

RVUs and time studies to establish times)

• Indicate where in each appointment type the dentist is

needed vs. dental assistant time

• Indicate what types of appointments can be double-

booked

The Scheduling Policy (cont.)

• Start and end times for appointments each day
• Who is authorized to schedule appointments
• Providers should always be working to the top of

their license (eg, dentists being dentists, hygienists being hygienists)

• If expanded function dental assistants are

available, they should also be working to the top

• f their ability

Create the Schedule Template

• Use the “Perfect Day” feature in your dental software (if

available)

• Create designated appointment types (eg, new adult

patient, new pediatric patient, perio, restorative, emergency, extraction, recall appointments, etc.) with time allotted for each

• Once this is set up, the time blocks are built into the day

as a guide to meeting practice goals

• Make sure staff responsible for scheduling know how to

use the templates

Biggest Threats to Success

• For this to work, template must be followed faithfully
• When a specific appointment type is filled for a particular

day, scheduler needs to look for the next available appointment (works best if the practice doesn’t schedule

• ut beyond 30-45 days)
• Designated slots only get filled in with other appointment

types if unfilled 24 hours prior to day

• Monitor the process closely, provide immediate feedback

when staff deviate from the process and tweak the templates as needed to ensure attainment of strategic goals

Schedule Busters

• Patients who cancel at the last minute
• Patients who don’t show up
• Patients who show up late
• Double- or triple-booked patients who all show up

unexpectedly

• Too many emergencies/walk-ins worked into the daily

schedule

• Logjams at check-in or out
• Providers run late; practice falls behind
• Patients put in wrong appointment slots (eg, hygiene

patient in dentist’s column; single restoration put in crown prep slot; multiple filling appointment put in short- procedure slot)

What to Do?

• Create a strong policy defining all aspects of this

issue

• Review the policy with staff
• Post the policy in patient waiting areas
• Include the policy in new patient packets
• Review the policy with patients and require sign-
• ff
• Scan (or place) the policy into patient chart

What to Do? (cont.)

• Consider implementing strategies that have proven

successful in other dental programs

• Track broken appointments to monitor percentage over

time—is the rate decreasing, staying the same or actually getting worse?

• Apply PDSA approach to broken appointments
• Ultimate goal: eliminate need for large-scale double- and

triple-booking

The Broken Appointment Policy

• Definition of a broken appointment
• Determine how many broken appointments will be

allowed and in what time period (eg, two broken appointments in a year, two BAs in any time period, three BAs, etc.)

• Determine what the consequences will be of failing

the policy (eg, no further appointments for a certain amount of time, put on same-day status only, have to write a letter, etc.)

• Designate approach to late patients (how late is late,

how are late patients going to be addressed [eg, rescheduled, worked in if possible])

Tracking Broken Appointments

• Calculate BAs as percentage of scheduled appointments

for which the patient failed to show, cancelled at the last minute or showed up too late

• Don’t subtract open slots caused by no-shows/last

minute cancellations that staff were able to fill with walk- ins/emergencies

• Example: 8,000 scheduled appointments, 2,400 no-

shows/last minute cancellations (even if the practice managed to fill 1,800 of those open slots with emergencies/walk-ins) = 30% No-Show Rate

• Use dummy codes to track no-shows

Best Practices to Manage Risk

• Make reminder calls 48 hours in advance and consider

removing (or double-booking) appointments for patients who don’t have a working phone.

• When forced to leave a voicemail message while

confirming appointments, require the patient to call back no later than the day before scheduled appointment to confirm

• If they do not respond/confirm, their appointment will be

removed from the schedule (or double-booked

• Don’t schedule appointments out past 30-45 days

(including hygiene patients)

• Don’t make multiple appointments at the same time

(except for RCTs, dentures)

Best Practices (cont.)

• Emergency patients often break follow-up appointments—they

feel better after palliative treatment and decide they don’t need to return. Consider having them call a few days after the emergency visit to schedule follow-up care

• Consider sending out recall cards or developing recall call list

instead of scheduling recalls 6 months in advance

• New patients are always at high risk for being no-shows;

consider strategies for reducing impact on daily schedule (eg, limit number of new patients each day)

• Do not schedule appointments for multiple family members on

the same day unless these patients have a track record of reliability in showing up for their appointments

Managing Emergencies

• Providing emergency care is a crucial part of our

mission, BUT

• Emergencies add to overall chaos, stress and

unpredictability in the practice

• Emergency visits tend to reimburse poorly
• Emergencies can interfere with the care of regularly

scheduled patients

• Key is to develop a system and policy for managing

emergencies that provides sufficient access while preserving the care of regularly scheduled patients, minimizing disruption to the practice and maintaining financial sustainability

Managing Emergencies

• Understand current volume of emergency visits
• Calculate emergencies using D0140 and/or D9110 (or

create a dummy code to track emergencies)

• Use one of these codes in every emergency visit, even if

definitive treatment is provided (eg, extraction) (or use a no-charge dummy code)

• Calculate emergency rate as percentage of overall visits
• Example: 8,000 visits; 1,500 visits were coded as

emergencies = 18.8% emergency rate

• Goal: emergency rate no more than 6-8%

Other Operational Issues

Logjams at check-in/out

• Flow-chart these processes
• Root cause analysis—why is this happening?
• Develop and test strategies to improve patient flow (re-

engineer tasks, redesign physical space, address staffing issues, etc.)

Providers running late/practice falling behind

• Root cause analysis-why is this happening?
• Develop and test strategies to stay on time (reconfigure
• peratory assignments, availability of support staff, scheduling

tweaks, seating and preparing patients, workflow around x- rays, etc.)

Other Operational Issues (cont.)

Scheduling errors

• Root cause analysis—why is this happening?
• Review scheduling process with current staff
• Provide additional training if necessary
• Review frequently to enhance accountability

Stretch Break!

Medical/Dental Integration To Improve Oral Health

The Challenge

• The people who are at highest risk for dental disease

have the greatest difficulty in accessing care (lack of access points, lack of insurance, out-of-pocket costs, etc.)

• The public health infrastructure for oral health is

insufficient to address the needs of disadvantaged groups

• Integration of oral health into medical care expands the

potential for high-risk individuals to have access to care that halts and even reverses dental disease, avoiding or reducing the need for expensive treatment

Oral Health and Overall Health

• Good oral health is part of optimum overall health and well-being
• Dental pain can be debilitating and lead to lost work days and

excessive emergency room visits

• Untreated dental disease can lead to potentially life-threatening

systemic infections

• People need healthy teeth and gums to be able to eat a varied and

healthy diet

• In addition to the health effects, poor oral health negatively impacts

people socially, emotionally and economically

• Nonsurgical interventions are available to halt or reverse

disease progression and to manage oral diseases as bacterial infections

Inclusion of Oral Health in the Medical Home

Primary care providers can play an important role in improving each patient’s oral health by educating/promoting self-care and utilizing therapies to reverse or prevent the progression of disease

More Fully Integrated Model Features…

• Primary care team has comfort level with oral health
• Patient experiences oral health as a key component of a

routine medical visit

• Primary care team incorporates oral health into the care of

patients with chronic diseases

• Primary care team treats ordinary oral health conditions in their

practice; consult with dentist if patient does not improve; refers patients with treatment needs to dentists; retains responsibility for routine care

• For patients at high risk, primary care team follows clinical

protocols designed to lower risk factors

The Primary Care Team’s Role

• Identify whether the patient has a dental home
• Screen for disease and risk
• History, risk assessment, and examination
• Educate patients on the nature of dental disease and

self-care strategies to prevent/reverse disease

• Recommend/prescribe therapies to maintain optimum
• ral pH levels, reduce unhealthy bacteria and

remineralize teeth

• Make appropriate referrals for dental care
• Work in tandem with the dental program to integrate

medical and dental care for patients

Risk Assessments by the Primary Care Team

• CAMBRA (Caries Management by Risk Assessment)
• Tools for ages 0-5 and >5 (including adults)
• Other risk assessment tools available
• Assessment tools should be simple and easy to

administer

• Goal to identify factors that put patients at high risk for

dental problems

Key Message to PCPs: Caries is a Transmissible Bacterial Infection

• PCPs are trained to deal with bacterial infections

Key Messages to Patients

Primary caregivers should counsel patients and caregivers on the need (and strategies) to:

• 1. Maintain optimum oral pH levels
• 2. Reduce levels of bad bacteria in the mouth
• 3. Practice effective home care

Role of Oral pH Levels

• Prolonged periods of low (acidic) pH in the mouth

provide the biologic oral environment that promotes the growth of cavity-causing bacteria

• Low pH (below 5.5) is responsible for the

demineralization and net mineral loss of the teeth

The Role of Diet in Oral pH

• Eating/drinking lowers plaque pH to an acidic level
• Saliva is designed to restore pH to a healthy (alkaline) level
• In balanced oral environment, we eat or drink something, pH

drops, some mineral is lost from the teeth, pH recovers and mineral returns to the teeth

• When the system is out of balance, prolonged periods of low

pH result in demineralization of teeth and decay

• Frequent exposure to food/drink (except water) increases the

number of acid attacks on the teeth

• Therapies are available to neutralize acidity and increase pH

to more favorable levels (oral rinses, sprays, gels and gum)

The Role of Home Care

Increases protective factors to outweigh disease indicators and risk factors

Home Care Products

• pH neutralization
• Antibacterial agents

(chlorhexidine, sodium hypochlorite)

• Fluoride (toothpaste, gel, oral

rinse, varnish)

• Xylitol (oral rinse, spray,

toothpaste/gel, gum, lollipops)

• Remineralizing agents

(nanohydroxyapatite)

Primary Care Referrals for Oral Health Care

• Encourage patients to see a dental professional regularly for

examination and preventive care

• Patients with signs of disease need to be evaluated by a dental

professional

• Understand that patients may have health insurance but be

uninsured or underinsured for dental care (potential barrier to care)

• Develop referral pathways to dental (if part of health center) or

referral network of appropriate resources for care in the local community, especially for patients who are uninsured or have Medicaid dental coverage

• Full integration between medical and dental technology will promote

referrals and sharing of pertinent information

Dental’s Role in Integration

• Ensure access in the dental schedule for patients

referred by primary care providers

• Incorporate screening for common health problems (eg,

high blood pressure, diabetes)

• The dental health history should determine whether the

patient has an ongoing medical home

• The dental health history should ask about chronic and

special conditions affected by dental disease (eg, diabetes, heart disease, HIV/AIDS, pregnancy)

• Assess full periodontal status of patients with chronic

health conditions

• Include treatment of periodontal disease in patient’s

treatment plan

• Full integration between medical and dental technology

will promote referrals and sharing of pertinent information

Dental’s Role (cont.)

Collaboration vs. Integration

• Collaboration = primary care and oral health

working with one another

• Integration = oral health working within and

as part of primary care or vice versa…..Provision of dental services within primary care

Benefits of Integration

• Referring to oral health providers that medical

providers know (and vice versa)

• Quick access for medical patients with acute oral

health situations (and for dental patients with potential medical issues)

• Warm hand-offs and curbside consults
• More effective chronic disease management
• Preventive oral health care and effective self-care

strategies extended to medical settings

Benefits of Integration

• More reimbursement options now (e.g., 40 states

reimburse non-dental professionals for fluoride varnish applications)

• Pay-for-performance coming one day to dental (some

pilots now being tested [Medicaid programs and Commercial insurers])

• Focus on priority populations improves outcomes and

helps with financial sustainability

Barriers to Integration

• PCPs traditionally see the mouth as the property of

dentists

• Sharing of information rarely occurs
• Medical and dental care are seen by the public/patients as

separate

• Limited oral health training for health professionals
• Time
• Comfort
• Reimbursement
• Referrals
• Medical and dental services not co-located

Creating a Vision for Integration

How can we create effective population-based integration?

• The strategic planning process- vision to reality
• What linkages do we already have between medical and dental in

the health center?

• Who are the key stakeholders?
• Who are the champions within the health center?
• What populations do we serve?
• What populations will we focus on?
• What financial models fit best?
• Where are the opportunities?
• Where are the gaps?

Creating the Integration Plan

• Forming the team
• Creating the action steps and timeline
• Strategic plan
• Business plan- operations and systems
• Policies and procedures
• Goals
• Evaluation plan

Components of Integration

• Staff training (primary care providers and dental

professionals)

• Caries Risk Assessment
• EMR/EDR Interfaces/Information Sharing
• Oral Health Screenings in Medical
• Health Screenings in Dental
• Patient/Caregiver Educational Materials
• Preventive Therapies
• Referral Process (medical to dental and vice versa)
• Case Management
• Warm-Handoffs
• Designated Access Appointments
• Oral Health Services in Primary Care Settings (by PCPs

and/or by dental professionals)

Challenges

• Education and training for PCPs
• Training for general dentists to treat small children
• Patient communication – low literacy, culturally

appropriate education materials

• Policies defining key processes
• Case management system
• Reimbursement for preventive therapies
• Designated access appointments
• Time allotment
• User-friendly CRA tool

Smiles for Life

Other Resources

• DentaQuest Institute Online Learning Center (free

Disease and Practice Management Modules) www.dentaquestinstitute.org

• Health Resources and Services Administration

www.hrsa.gov

• National Network for Oral Health Access
• www.nnoha.org
• National Interprofessional Initiative on Oral Health

www.niioh.org

• U.S. National Health Alliance

www.usalliancefororalhealth.org

• www.carifree.com

Questions?

Partnering to Strengthen and Preserve the Oral Health Safety Net

2400 Computer Drive, Westborough, MA 01581 Tel: 508-329-2280 Fax: 508-329-2285 www.dentaquestinstitute.org

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