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Oral Health of Seniors Project - An Overview
 

Oral Health of Seniors Project - An Overview

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  • This statement comes from the keynote address by… I wanted to give give personal context to why we started this project From the perspective of a dentist It started with my experience with patients in my practice I noticed 3 things: The fee for service is ineffective That social assistance coverage stops when a person turns 65 – then receive old age pension only Even the rich do not get care because of other barriers We are the first study in NS that explores this issue “ cast a net” for preliminary data to begin to look at what the issues are for NS and determine which areas need more investigation.
  • In 1991, Canada’s population was 27 million; 3.2 million (11.7%) were over 65 years of age. By 2011, 14.1% of the population (5 million people) will be over 65 years, and in 2031, the population is expected to have 22% (8.9 million) of Canadians over the age of 65 (Rosenburg and Moore, 1997). The population aged 80 and over is the fastest growing age group in Canada. Over the past decade, this group incurred the largest percentage increase of any age group (41%) to 932 thousand. During the next decade, the population of those 80 and over is expected to continue to rise to 1.3 million (Statistics Canada 2001, 15). In 2001, Statistic Canada reported that there were 128,333 people over the age of 65 living in Nova Scotia (13.6% of our total population). We’ve almost reached the percentage expected for the nation in 2011. a 1990 Canadian study (MacEntee 1990) estimated that 80% of institutionalized elders wear at least one denture and 40% have some teeth. A 1997 Canadian study (Jokovik and Locker 1997) involving volunteer subjects over the age of 50 showed that close to 80% of subjects had teeth and only 40 % wore some type of denture. These data indicate a reversal in trend Student estimated that within 2 decades there will be 80,000,000 more teeth to care for
  • Statistics Canada reports that: 52.4% of seniors in Canada visited a dentist between 1993-1994 whereas 78.4% visited a physician 50% of seniors have gone 3 or more years without visiting a dentist 8-9% of NS seniors live in LTC whereas on average that rate is 4-5% - we have a higher number in NS Even though there is 8-9% living in LTC – some studies have shown that 40% of elders will live in LTC before they die.
  • Oral health services are MOSTLY discretionary No Central Authority In medicine, billing #s can be distributed; residencies can be established on the basis of needs
  • Practical importance in the provision of health care health issues concerning the mouth – because of its separation from the body (and hence from the health care system) have not garnered public interest or resources. The p practical activities influencing oral health are greatly influenced by this separation.
  • This has been a hugely influential report in both Canada and the US, focusing research, clinical and educational priorities
  • to expand the physiological basis of oral health to include what is collectively known as the craniofacial complex. With this, well-being associated with oral health would be under the influence of conditions affecting all aspects of the craniofacial complex including the teeth, gingiva (gums), their underlying supporting structures such as connective tissue and bone, the hard and soft palate, the tongue and floor of the mouth, the throat, the mucosa of the oral cavity and underlying salivary glands, the lips, muscles of mastication, and jaws (the mandible and maxilla). Conditions and dysfunction associated with this complex go far beyond the conventional perception that teeth and gums encompass all that is meant by “oral”. Signs of nutritional deficiencies, immune dysfunction and even metastatic cancers often manifest in the oral cavity. dysfunction and disease symptoms arising from the oral cavity (could affect the ability to eat and swallow, thereby affecting overall nutrition. Blood borne bacteria endocarditis in people afflicted with heart valve defects. The third theme of the report focuses on oral disease itself and on the role of professionals in the prevention of oral disease by reminding us that (US Department of Health and Human Services 2000, 3). The fourth and final theme of the Surgeon General’s Report reinforces the concept of a separate mouth and body by stating that (US Department of Health and Human Services 2000, 4).
  • Third theme of the report focuses on oral disease itself and on the role of professionals in the prevention of oral disease by reminding us that “safe and effective disease prevention measures exist that everyone can adopt to improve oral health and prevent disease” - role of professionals Fourth and final theme of the Surgeon General’s Report.
  • There are many ways that oral health can substantially impact an individual’s overall health and quality of life (MacGrath and Bedi 1999) For example, poor oral health can affect a person’s functional ability where the inability to chew can lead to poor nutrition Or physical symptoms such as pain or the inability to speak clearly Poor oral health can also affect social relationships such as social withdrawal because of dental appearance which can lead to poor self-esteem 
  • Financial Constraints Social assistance coverage stops at 65; old age pension only In 1996, 75% of men and 83% of women aged 75+ in Canada did not have dental insurance Dental insurance commonly cut-off at retirement or at 65 Insurance plans are too expensive (they are on fixed income and the NS average income is approx. $19,000 for someone over the age 65) and not designed for seniors (limited in treatment options) Access to Dental Care  physical capacity and/or disability (difficulty getting to and from the office) Transportation difficulties (none available or too expensive) Lack of knowledge of dental services or lack of dental services in the given community (in some rural communities)
  • Attitudes of the Elderly Accept dental disease as a natural part of aging Lack of experience with visits; anxiety and fear Feel care is unnecessary once they have dentures Lack of prevention/promotion materials Attitudes and Knowledge of Caregivers Family apathy Resources for personal care have not caught up with the fact that elders are keeping their own teeth.
  • Attitudes and Knowledge of Direst Care Providers Age may affect the treatment decisions of the dentist (seniors receive fewer preventive and restorative treatment options) MacEntee, Weiss, Waxler-Morrison, Morrison, 1992 reported that stereotypes and misconceptions are often a consequence of a lack of knowledge and inadequate contact with members of this age group. I nsufficient knowledge and education about gerontological issues (e.g. medical complexity) Nurses: Limited or no training  constraint in ability to provide care; also no time for care Unique barriers for Institutions Despite their high risk for oral diseases, seniors in LTC are among the least likely to receive preventive and restorative dental care Financial constraints; lack of interest by patient and family; transportation to dental office; lack of no space for treatment; insufficient equipment; difficulty engaging relevant parties (e.g administrators, physicians); not a primary concern because of other medical conditions.
  • Education System Lack of specialty training options Curriculum changes to meet the time: Vincent et al. 1992 (US) / Dolan & Saunders et al. 2001 (US and CDN) found that there was n o change in c urriculum from 1992-2001 to address the needs and treatment of the aging population Physiological Complications of Aging Inability to properly care for his/her oral health (e.g arthritis, cognitive impairment) “ Slower movements, less agility, impaired vision and hearing, urinary dysfunction and vascular insufficiency” may limit an individual’s ability to follow a proper oral care regimen or may complicate visits to the dentist As people age, chronic illnesses can become acute dental diseases which are costly and harder to manage. For example, mild cases of arthritis or stroke in the middle-aged years can become acute dental diseases because the person can no longer handle or control their illness as before
  • Oral health is marginalized from publicly funded health; which introduces many challenges including: Oral health being excluded from population health surveys Lack of oral health promotion and prevention initiatives. (lack of available financial support for initiatives) Insufficient training opportunities and specialized program for care providers.
  • Our project came about through discussions between Faculty of Dentistry and Atlantic Health Promotion Research Centre regarding collaboration on a project in the area of health promotion and dentistry We submitted a successful letter of intent to the Canadian Health Services Research Foundation (CHSRF) and then sought partnership funding from private sector partners and in June 2001 we were awarded national funding. The Project’s start date was April 15, 2002 so we are now a year into the project.
  • A new level of research CHSRF is a new funding agency CHSRF mandate: explores health policy, management, organization and the delivery of health services. The foundation funds research which examines such things as the governance, financing, effectiveness and efficiency of the health system from the perspective of the managers and policy makers working in it. The foundation's mandate excludes clinically oriented health research.
  • Why is This Research Important? Our project explores the pressing need for an integrated set of policies and practices for managing continuity of seniors' oral health care. Currently, there are few programs, policies and practices in place for seniors oral health care so we hope to make suggestions for an improved service delivery model We hope to clarify the private-public sector roles and required structural changes to affect policy. Through our research team and at the Oral Health Forum (discussed later) we will bring together private and public sectors. This will provide them an opportunity to discuss strategies on how to work collaboratively. We will also create linkages between stakeholder groups And ultimately, we hope this research will improve the oral health of seniors
  • Our two partners are the AHPRC and Faculty of Dentistry. The AHPRC…
  • Within Nova Scotia, these partners represent sectors from the public/private oral health care system. Within Canada, these partners have numerous associations with other organizations and governments. This will help results from the study find their way into the hands of people around the country and around the world.
  • We will address the question: What are the key components of a health services model, based on continuity of care which will improve the oral health of seniors? By continuity of care we mean from the age of 65 as an individual progresses through the senior years. For example, the transitions seniors make from being healthy and then becoming sick/immobile OR the period from pre to post retirement. Now I’ll pass the microphone over to Liz to explain the remaining parts of the project…
  • Despite high levels of need for oral health care, national data show that only 34% seniors in Canada reported having visited a dentist in 1994. There is very little data on the amount or types of the oral health care available to seniors in Nova Scotia and Canada. Thus, Objective #1 is a Health Services Evaluation: To examine continuity of care in the delivery of oral health services to seniors in Nova Scotia.
  • How e plan to achieve this objective is through three methods: Surveys (seniors, direct care providers – dentists and dental hygienists only ) Focus groups (seniors, direct care providers – dentists, dental hygienists, nurses which include RNs/LPNs/PCWs/HSWs) Key informant interviews (indirect care providers – those that develop policy and provide support for seniors) E.g. Insurance managers, Long-term care facility administrators, Academic program providers, Academic researchers, Policy experts, and Health critics.
  • The first two groups we recruited were seniors and direct acre providers: For the purposes of our project we are defining seniors as individuals 65 years of age and older. Including those living at home, homebound, hospitalized and in long-term care facilities. When recruiting we tried to select locations and participants that would best represent the demographic profiles of seniors living in NS including for examples, rural and urban seniors, those institutionalized and non-institutionalized, and various ethnicities. Direct care providers included in this study were: Dentists, dental hygienists, RNs/LPNs/PCWs/HSWs Our recruitment strategy for this group was to try to have representatives from a variety of different types of areas (e.g. urban, urban-rural, rural, rural-remote) within their region. There were definitely challenges associated with recruiting, particularly in the urban sites. I guess people are just too busy in the city! In Canso, it was a regular community event – almost the whole town of seniors showed up! It helped to have a key contact in each location
  • Open and closed ended questions Surveys for seniors, dentists and dental hygienists Purpose: Seniors: DCP: To provide demographic information and profile the participant’s work relating to seniors General topics included: Background questions: about the senior or the participants patients Health status: their opinion of their own or their patients’ general and oral health Practices and services: offered/available and received/used Level of satisfaction: with services Dental insurance: availability and current trends Access and barriers to oral health care One difference was that with RNs/LPNs/PCWs/HSWs we asked: How oral health care is currently being managed
  • Interview guides are designed for each type of indirect care provider Sections included in each guide: Management and funding of seniors’ oral health programs; Implementation and evaluation of seniors oral health programs/policies; Future direction of programs/policies to address seniors’ dental care issues.
  • Objective #2: Determine barriers and facilitators to the use of oral health services by seniors through critical analysis of experiences and lessons learned in existing systems in Canada and elsewhere. Nova Scotia does not have a publicly funded dental service for seniors. Hospital-based and volunteer clinics for example have not been successful in addressing the problem of inadequate access to dental care for seniors in Ontario. Three provinces have already attempted to enhance dental services for seniors. We will investigate all of existing programs in and around Canada and make suggestions for an effective system here in Nova Scotia.
  • This November we will h ost an Oral Health Forum to develop strategies for financial, organizational and policy interventions and a model for continuity of care that will improve private/public sector provision of oral health services in Canada. There will be representatives from the three categories of participants and key policy makers and managers from various provincial, national, and international sectors will be invited to attend.
  • To disseminate the project results to the Forum participants and then in turn to the public at large through the participants returning to their various jurisdictions and presenting the findings using information Toolkits we produce that address issues related to the oral health care of seniors; To build collaborations across sectors to help clarify roles and relationships and provide an opportunity for dialogue between seniors, direct and indirect providers, and decision-makers; To build a foundation for a provincial intersectoral Seniors Oral Health Working Group to support provincial initiatives that address the continuity of oral health care for seniors; To formulate strategies for a health-services model for Nova Scotia that improves the private-public provision of oral health services for seniors.
  • Key: Canadian Health Services Research Foundation Nova Scotia Health Research Foundation Drummond Foundation Manulife Financial Nova Scotia Dental Association Dentistry Canada Fund Other: Nova Scotia Senior Citizens’ Secretariat Nova Scotia Dental Hygienists Association Faculty of Health Professions – Dalhousie University Faculty of Dentistry – Dalhousie University

Oral Health of Seniors Project - An Overview Oral Health of Seniors Project - An Overview Presentation Transcript

    • “ What will it take to leave no senior behind?”
    • (Pyle, SCD 2002)
  • The Oral Health of Seniors Project
  • Overview
    • Demographics
    • Public Policy
    • Situating Oral Health
    • Barriers to Care
    • Is there a Crisis of Care?
    • Project History
    • Health Services Research
    • OHS Project
  • Demographic Trends
    • 128,333 seniors (65+) in NS; 13.6% of total population.
    • Dentate seniors 
    Population
  • Demographic Trends
    • 78.4% visited a physician whereas only 52.4% visited a dentist within a 1-year period
    • 50% of seniors have gone 3+ years without a dental visit
    • 8-9% of NS seniors live in LTC
  • Public Policy
    • Dentistry is a discretionary health service
    • No central authority for establishing priorities for care
    • Distribution occurs (almost exclusively) on the basis of free market exchange
    • Romanow “A Report Without Teeth”
    • No hospital residency programs in NS
  • Situating “Oral Health”
    • “… in dentistry, there has been a tendency for us to treat the oral cavity as if it were an autonomous anatomical structure that happens to be located within the body but is not connected to it (the body) or the person in any meaningful way. That is, the mouth as an object of enquiry has usually been isolated from both the body and the person.” (Locker, 1996)
  • Situating “Oral Health”
    • March 2000, US Surgeon General’s Report:
    • Recognized the serious situation facing marginalized groups such as the aged as the “silent epidemic” of oral disease
    • This report was meant to alert citizens to the “full meaning of oral health and its importance to general health and well-being”
  • Situating “Oral Health”
    • Themes of the US Surgeon General’s Report:
    • “ oral health means much more than healthy teeth” - the craniofacial complex.
    • “ oral health is integral to general health” - the mouth is a mirror of health and disease.
      • Difficulties chewing, tasting, and swallowing - effects eating patterns, nutrition status
      • Acute or chronic oral pain -  prevalence of caries in senior populations (est. 95%)
      • Salivary gland dysfunction - polypharmacy
  • Situating “Oral Health”
    • Themes of the US Surgeon General’s Report:
    • “ safe and effective disease prevention measures exist that everyone can adopt to improve oral health and prevent disease” - role of professionals
      •  number of seniors retaining their natural teeth will require more
      • complex preventive and restorative procedures
    • “ general health risk factors, such as tobacco use and poor dietary practices, also affect oral and craniofacial health”
    • Elders are at highest risk for oral cancer  least likely to receive early detection services
  • Goals for Healthy Aging?
    • Does oral health impact these goals?
      • Minimizing disease and disability
      • Maintaining physical function
      • Improving social relationships
        • (e.g. social withdrawal because of dental appearance  poor self-esteem) 
  • Barriers to care
    • Financial Constraints
      • Social assistance coverage stops at 65
      • Dental insurance commonly cut-off at retirement or at 65
      • In 1996, 75% of men and 83% of women aged 75+ in Canada did not have dental insurance
      • Insurance plans are too expensive and not designed for seniors
    • Access to Dental Care
      •  physical capacity and/or disability
      • Transportation difficulties
      • Lack of knowledge of dental services or lack of dental services in the given community
  • Barriers to care
    • Attitudes of the Elderly
      • Accept dental disease as a natural part of aging
      • Lack of experience with visits; anxiety and fear
      • Feel care is unnecessary once they have dentures
      • Lack of prevention/promotion materials
    • Attitudes and Knowledge of Caregivers
      • Family apathy
      • Health professionals:
        • Training
        • Time
  • Barriers to care
    • Attitudes and Knowledge of Direct Care Providers
      • Age may affect the treatment decisions of the dentist (seniors receive fewer preventive and restorative treatment options)
      • Insufficient knowledge and education about gerontological issues (e.g. medical complexity)
    • Unique barriers for Institutions
      • Financial constraints; lack of interest by patient and family; transportation to dental office; lack of space for treatment; insufficient equipment; difficulty engaging relevant parties (e.g. administrators, families); not a primary concern.
  • Barriers to care
    • Education System
      • Lack of specialty training options
      • Curriculum changes to meet the changing demographic
    • Physiological Complications of Aging
      • Inability to properly care for his/her oral health (e.g arthritis, cognitive impairment)
      • Chronic illnesses can become acute dental diseases
  • Is There a Crisis of Care?
    • Oral health is marginalized from publicly funded health care:
      • Exclusion of issues from population health surveys
      • Lack of oral health promotion and prevention initiatives (e.g. NS public health mandate is up to age 30)
      • Lack of available training opportunities and specialized programs for care providers
      • Fewer than 20% of Cdn. dentists report visiting nursing homes
  • Project History
    • Discussions between Faculty of Dentistry and Atlantic Health Promotion Research Centre regarding collaboration on a project in the area of health promotion and dentistry
    • Successful letter of intent to the Canadian Health Services Research Foundation (CHSRF)
    • After receiving partnership funding from private sector partners in June 2001, this project was awarded national funding.
    • The Project’s start date was April 15, 2002.
    • Explores:
    • Health policy; management; organization; delivery of health services
    • Governance; financing; effectiveness; and efficiency of the health system
    Health Services Research
  • Why is Our Research Important?
    • Explores the pressing need for an integrated set of policies and practices for managing continuity of seniors' oral health care
    • Clarifies the private-public sector roles and required structural changes to affect policy
    • Creates linkages between stakeholder groups
    • Ultimately, this research will improve the oral health of seniors
  • Partners
    • Atlantic Health Promotion Research Centre
    • Mission: To conduct and facilitate research in health promotion that influences policy and contributes to the well-being of Atlantic Canadians.
    • Faculty of Dentistry, Dalhousie University
    • Mission: To promote health in a caring and compassionate way through oral and maxillofacial health-based education, research and service.
  • Project Team
    • Faculty of Dentistry, Dalhousie University
    • Atlantic Health Promotion Research Centre
    • University of Toronto
    • Manulife Financial
    • Nova Scotia Dept. of Health
    • Nova Scotia Dental Association
    • Nova Scotia Dental Hygienists Association
    • Nova Scotia Seniors Secretariat
    • Northwoodcare Inc.
    • Senior Representative
    • Staff
  • Working Group Framework Research Team Methodology & Analysis Working Group Best Practices & Policy Working Group Recruitment, Forum & Communications Working Group Staff Support
  • Research Question What are the key components of a health services model, based on continuity of care, which will help improve access to oral health for seniors?
  • Objectives 1. Health Service Evaluation 3. Oral Health Policy Forum 2. Program Scan 4. Communication & Dissemination
  • Health Services Evaluation Examine the continuity of care in the delivery of oral health services to seniors in Nova Scotia
  • Methodology
    • Surveys (seniors, direct care providers – dentists and dental hygienists only )
    • Focus groups (seniors, direct care providers – dentists, dental hygienists, nurses)
    • Key informant interviews (indirect care providers – those that develop policy and provide support for seniors)
  • Recruitment
    • Seniors (65+)
      • Recruitment strategy - to reflect demographic profiles:
      • Age levels (65-74, 75-84, 84+), Urban/rural, Gender, Martial Status, Education level, Ambulatory and non-ambulatory, Long-term care facility residents/those living at home, Language, Ethnicity, Income level ( Statistic Canada Profile on Seniors, 2001 )
    • Direct Care Providers:
      • Dentists, dental hygienists, RNs/LPNs/PCWs/HSWs
      • Recruitment strategy –representatives from a variety of different types of areas (e.g. urban, urban-rural, rural, rural-remote) within their region.
  • Participant Locations- Seniors Northwoodcare Inc. - Halifax Canso Dartmouth Margaree Forks Saulnierville Bridgetown Bear River First Nations
  • Participant Locations- DCP Sydney Kentville Yarmouth Halifax Truro Antigonish
  • Methodology
    • Survey
      • Background questions
      • Health status
      • Dental care received in the past
      • Level of satisfaction
      • Dental insurance
      • Access and barriers to oral health care
    • Focus Groups
      • Types of oral health services
      • Things that make it difficult
      • Things that help
      • Whether the services meet the need
      • What can be done to help
  • Recruitment
    • Indirect Care Providers:
    • Purposeful sampling, 2-3 key informants from each group:
      • Insurance managers, long-term care facility administrators, academic program providers (dentistry, dental hygiene, nursing, medicine), academic researchers (geriatric and dental research), policy experts, health critics, senior advocacy groups
    • Questions: Management and funding of program, implementation and evaluation, future direction of programs/policies
  • Program Scan Determine barriers and facilitators to the use of oral health services by seniors through critical analysis of experiences and lessons learned in existing systems in Canada and elsewhere.
  • Methodology
    • U sing computerized databases, Internet searches and consultation with national and international experts
    • Scan for seniors’ oral health programs/services (nationally and internationally) at three levels:
        • Existing dental programs for seniors (direct service and insurance);
          • Questions include:
          • Background characteristics
          • Implementation/evaluation strategies
          • Recommendations
        • Geriatric training programs;
        • Oral health promotion/prevention programs.
  • Methodology
    • Comprehensive review of the literature.
      • Literature themes: a ttitudes, nutrition, status, barriers, quality of life, care of seniors in long-term care, private and public dental programs, promotion, prevention and education, training, insurance, policy
    • Scan of existing policies
    • Establish assessment criteria for existing programs and services for seniors’ oral health
  • Oral Health Policy Forum To develop strategies for financial, organizational and policy interventions and a model for continuity of care that will improve private/public sector provision of oral health services in Canada.
  • Objectives
    • To disseminate the project results
    • To build collaborations across sectors
    • To build a foundation for a provincial intersectoral Seniors Oral Health Working Group
    • To formulate strategies for a health-services model
  • Expected Outcomes
    • Researchers: Bring the issue to the forefront and encourage more oral health services research
    • Care providers: Affect policy and program development, and create the potential for improved access for seniors to oral health care services
    • Seniors: Improved access to oral health care will ultimately affect general well being and overall health.
  • Next Steps
    • Analyze data (focus groups, interviews, Program Scan)
    • Summarize information into reports
    • Host the Oral Health Policy Forum
    • Build a model of recommendations and strategies
    • Disseminate the project findings
  • Sponsors
    • Key:
      • Canadian Health Services Research Foundation
      • Nova Scotia Health Research Foundation
      • Drummond Foundation
      • Manulife Financial
      • Nova Scotia Dental Association
      • Dentistry Canada Fund
    • Other:
      • Nova Scotia Senior Citizens’ Secretariat
      • Nova Scotia Dental Hygienists Association
      • Faculty of Health Professions – Dalhousie University
      • Faculty of Dentistry – Dalhousie University
  • Questions? Project website: http://www.ahprc.dal.ca/oralhealth/Index.htm Oral Health of Seniors [email_address] (902) 494-1501 Fax: (902) 494-3594