The main aim of oral health promotion and prevention programme for people requiring domiciliary care is to improve their oral health and reduce the impact of poor oral health on their overall health and well being. Aneurin Bevan University Health Board has established a domiciliary oral health improvement practitioner for vulnerable adults as part of an integrated referral care pathway for dental domiciliary care.
The promotion of oral health in this care setting is a key feature of the NICE guidance NG48 Oral Health for Adults in Care Homes and the practice set out in this example aligns with the recommendations from the NICE guideline. Specifically, the recommendations
- 1.6.1 Develop and provide care homes with oral health educational materials and training to meet the oral health needs of all residents.
- 1.6.1 Provide care homes with regular support and advice about oral health to meet the needs of residents, especially those with complex needs.
- 1.6.2 Help care home managers find out about local oral health services, create local partnerships or links with general dental practice and community dental services.
Aims and objectives
The main aim of oral health promotion and prevention in people requiring domiciliary care is to improve their oral health and reduce the impact of oral health on their health and well being.
- To implement oral health risk assessment and integrate an oral care plan into general care plan for people residing in care homes/units;
- Provide oral health training to carers and other staff, as appropriate;
- Promote good oral health and increase uptake of oral health care prevention regimes and dental care
- Ensure the delivery of a fluoride based preventive programme.
Reasons for implementing your project
The implementation of the project was delivered to support NHS general dental service domiciliary providers covering a population of approximately 630,000 people with 130 care homes for older people and further 70 for other vulnerable adult groups.
Previously there had been an unstructured and not triaged approach to service provision which indicated that patients receiving domiciliary dental care may not be eligible for it or were not receiving care by the appropriate dental services.
We identified that a more robust referral care pathway was required to ensure that domiciliary referrals were appropriate and being seen by the right person at the right time in the right place.
It also indicated that people receiving care under the existing pathway did not receive ongoing oral health promotion, prevention or carers with sufficient training which is vital for this vulnerable group.
We developed a robust referral criteria checklist which has a series of questions that identifies whether or not the referring patient meets the criteria for a domiciliary visit – if they do not then the referrers are given a list of practices taking patients on for NHS dental care and have accessible premises.
General dental practitioners did not have the time to spend providing preventive advice and training and so OHIP was commissioned to do this for them.
How did you implement the project
In Aneurin Bevan University Health Board, all referrals for domiciliary dental care are triaged centrally through the Community Dental Services andaged referrals are either seen by community or general dental services or have shared care. Within the community dental service there are Oral Health Educators and Dental Care Professionals to support the prevention for people in care homes but not those seen by the general dental service.
This proposal was considered and agreed by Primary Care for a Band 5 Dental Nurse with enhanced skills and certificate in Oral Health Promotion. Their title would be Oral Health Improvement Practitioner (OHIP) employed by the community dental service. They would receive referrals from the general dental service domiciliary dental service and provide oral health promotion and prevention services for those patients for a one year period. This includes providing one on one carer training in oral health care, diet, smoking and alcohol advice, delivery of fluoride and denture care.
A new NHS Domiciliary Dental Care model was introduced working with primary care, Community Dental Services, Dental Public Health, Local Dental Committee and patient representation as part of Aneurin Bevan University Health Board Integrated Oral Health Group.
The OHIP receives referrals for preventive dental care from the all NHS General Dental Services Dental Domiciliary providers to provide support to provide support for oral health promotion and prevention to patients and carers using DDS.
Key responsibilities of the OHIP include:
- Oral health care training for carers and patients who are receiving dental domiciliary care including different training approaches and education resources
- Close liaison with the DDS providers and promote use of supplemental fluoride products for dentate adults
- Work with existing Oral Health Educators within the CDS as part of the Wales Improving the Oral Health of Older People in Care Homes programme and other relevant stakeholders to implement oral health care protocol that includes an Oral Health Risk Assessment and Oral Care Plan for all dependent older people, especially within care homes.
Primary care funding was identified from remodelling of the current NHS general dental service DDS and extra funding was identified within the general dental service budget for the OHIP (£20K). Rather than GDS Units of Dental Activity (UDAs) being used for review visits it was more cost effective (Prudent Healthcare) to employ an OHIP to support the NHS general dental service DDS.
All referrals for dental domiciliary service are sent centrally to community dental service and triaged.All patients referred onto general dental service DDS are also seen by the oral health improvement practitioner (OHIP) who liaises with the dental domiciliary service practices for the referrals for preventive care. The number of referrals for 2015/16 for domiciliary triage has been 627 with 248 referred onto general dental service.
The project has been running 2 years and patient/carer feedback has been excellent as well as integrated working between GDS/CDS. The OHIP works with the current community dental service Older Person Oral Health Educator team to help implement oral health risk assessments/care plans within care homes.
The integrated model of working has been a great success in that patients are seen by the right healthcare professional. This is more efficient and cost effective in that all patients are given patient centred oral health prevention which links into the community dental service oral health promotion care home programme, should the patient reside in a care home. Aneurin Bevan University Health Board has agreed for the programme to continue with annual reviews of its progress.
Key learning points
This initiative would not work unless there is a good relationship between the general dental service, community dental service and primary care teams as well as an OHIP who is self-motivated and understands the role and what the outcomes should be achieved.
The management by the community dental service means that the OHIP is trained and supported as part of the Older Person OHE team providing the carer training in care homes as well as support from the community dental service clinicians.