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  • The University of Washington Family Practice Residency Network is one of the largest and most successful residency networks in the United States. This has helped earn UW its rank as number 1 primary care training nationwide for how many years. This is the 30th year of the Network’s operation. The Network now comprises fifteen residency programs in Washington, Alaska, Montana, and Idaho. Eleven programs are located in Washington: Bremerton (Naval program), Olympia, Renton, Seattle (Group Health Cooperative, Swedish First Hill, Swedish @ Providence, and University of Washington Academic Medical Center), Spokane, Tacoma, Vancouver, and Yakima. Two programs are sited in Idaho (Boise and Pocatello) One program in Billings, Montana One program in Anchorage, Alaska Two programs in Wyoming are currently under negotiation for affiliation with the Network. Four programs have separate rural training track programs. One hundred twenty-six physicians graduated from Network programs during 2001–2002, bringing the total number of Network graduates to 1,702.
  • Based on early 2000 data on civilian graduates, 56% practice in Washington State, while 15% practice in Alaska, Montana, and Idaho. Approximately 31% practice in communities with populations under 1,000. Almost all (94%) are board-certified in Family Practice, with nearly 80% in active practice.
  • Yakima: Community-based residency program with emphasis on rural/underserved
  • Thank Kathy for these slides.
  • Seattle: UWMC, one of the two Network residency programs in academia
  • Spokane: Community-based residency program with emphasis on rural/urban underserved
  • Future training to take place in Olympia, Anchorage, and Boise.
  • Our initial search for best practices in Web resources led us to believe that a systematic review of available Web resources could help identify gaps in content, interface design, educational/informational resources (e.g., visual materials, etc) critical to training primary care physicians in oral health care
  • Presentation File

    1. 1. Interdisciplinary Children’s Oral Health Promotion (ICOHP) University of Washington Supported by a cooperative agreement from the Bureau of Health Professions, Health Resources and Services Administration ICOHP Coop Agreement
    2. 2. Additional Support <ul><li>UW Comprehensive Center for Oral Health Research (NIDCR at NIH) </li></ul><ul><li>UW Center for Health Sciences Inter-professional Education and Research (UW and Macy Foundation) </li></ul><ul><li>UW Department of Pediatrics </li></ul><ul><li>UW Department of Pediatric Dentistry </li></ul><ul><li>UW Department of Dental Public Health Sciences </li></ul>
    3. 3. Partnership <ul><li>Department of Pediatric Dentistry </li></ul><ul><li>Department of Family Medicine </li></ul><ul><li>UW Family Practice Residency Network </li></ul><ul><li>Department of Medical Education and Bioinformatics </li></ul>
    4. 4. Team Representation <ul><li>Wendy Mouradian, MD, MS (PI) </li></ul><ul><ul><li>Pediatrics, Pediatric Dentistry, Health Services (Public Health) </li></ul></ul><ul><li>Penelope Leggott, DDS, MS </li></ul><ul><ul><li>Pediatric Dentistry </li></ul></ul><ul><li>Sara Kim, PhD </li></ul><ul><ul><li>Family Medicine, Medical Education </li></ul></ul>
    5. 5. ICOHP Team <ul><li>Wendy Mouradian, MD, MS, Principal Investigator </li></ul><ul><li>Robert Crittenden, MD, MPH </li></ul><ul><li>Peter Domoto, DDS, MPH </li></ul><ul><li>Penelope Leggott, DDS, MS </li></ul><ul><li>Charlotte Lewis, MD, MPH </li></ul><ul><li>Heather Lynch, MD </li></ul><ul><li>Russell Maier, MD </li></ul><ul><li>Nancy Stevens, MD, MPH </li></ul>
    6. 6. ICOHP Team <ul><li>Project Evaluation </li></ul><ul><li>Doug Schaad, PhD </li></ul><ul><li>Sara Kim, PhD </li></ul><ul><li>Additional Consultants </li></ul><ul><li>Diana Cantrell, RN </li></ul><ul><li>Noel Chrisman, PhD, MPH </li></ul><ul><li>Cristine Trahms, RD, MS </li></ul><ul><li>Project Staff </li></ul><ul><li>Cheryl Shaul </li></ul><ul><li>Linda Yedlin </li></ul>
    7. 7. Advisory Board <ul><li>University/ community rep: Dec 2002 </li></ul><ul><li>Positive response </li></ul><ul><li>Interest in expanding trainings to other target audience </li></ul><ul><li>Interest in models of sustainability at the community level </li></ul><ul><li>Interest in Web review project </li></ul>
    8. 10. ICOHP <ul><li>Goal 1: Train family medicine residents and faculty in oral health </li></ul><ul><li>Objectives: </li></ul><ul><li>Develop curricula in children’s oral health </li></ul><ul><li>Pilot, implement, disseminate </li></ul><ul><li>Evaluate effect of training on knowledge, attitudes, behavior </li></ul>
    9. 11. ICOHP <ul><li>Goals 2 and 3: </li></ul><ul><li>Explore sustainable mechanisms for training and delivery of oral health services </li></ul><ul><li>Develop leadership in primary care fields to advance oral health </li></ul>
    10. 12. University of Washington <ul><li>Health Sciences Center for WWAMI: </li></ul><ul><li>Washington </li></ul><ul><li>Wyoming </li></ul><ul><li>Alaska </li></ul><ul><li>Montana </li></ul><ul><li>Idaho </li></ul><ul><li>Almost 30% land mass of US </li></ul>
    11. 13. UW FP Residency Network: Sites Spokane* UW* Yakima* Boise Olympia Anchorage Billings Alaska Washington Montana Idaho Wyoming Family Practice Residency Affiliation Under Negotiation Rural Training Track
    12. 14. UW FP Residency Network: Graduate Distribution
    13. 15. Geographical barriers
    14. 16. Cultural factors
    15. 17. Racial & Ethnic Diversity
    16. 18. ICOHP Pilot Training Site Alaska Washington Montana Idaho Wyoming Yakima
    17. 19. Yakima, Washington Central Washington Family Medicine N = 18
    18. 20. Choice of Pilot site <ul><li>High need area; typical of Network sites </li></ul><ul><li>Receptive dental community (ABCD) </li></ul><ul><li>Community health center (Yakima Valley Farmworker’s Clinic with UW pediatric dental residents on site (HRSA) </li></ul><ul><li>Family medicine faculty “champion” </li></ul>
    19. 21. FP Residency Network <ul><li>Sites to some extent self-sustaining </li></ul><ul><ul><li>Closer to a typical community practice </li></ul></ul><ul><li>Have didactic hours set aside </li></ul><ul><ul><li>Culture of learning is present </li></ul></ul><ul><li>System across 15 sites that connects by intra-net, regular faculty development and communication, staff training </li></ul>
    20. 22. Assumptions <ul><li>Biggest obstacle will be buy-in </li></ul><ul><li>Tailor curriculum to physician needs </li></ul><ul><li>Integration with dental sector in community is critical </li></ul><ul><li>Sustainability will require additional work and resources </li></ul>
    21. 23. Focus Groups: Faculty/ Residents, Staff <ul><li>Barriers </li></ul><ul><li>Oral health not on their radar screen; lack knowledge/self-efficacy </li></ul><ul><li>Providers busy: oral health not a priority </li></ul><ul><li>Concerned about the evidence base </li></ul><ul><li>Confusion about physician role </li></ul><ul><li>Lots of baggage about dentists </li></ul>
    22. 24. Focus Groups: Faculty/ Residents, Staff <ul><li>Opportunities </li></ul><ul><li>Care about children in pain </li></ul><ul><li>Unable to answer parents’ questions </li></ul><ul><li>Prevention is a high priority </li></ul><ul><li>Already providing health education </li></ul><ul><li>Acutely aware of access issues, emergencies </li></ul><ul><li>Committed to underserved </li></ul>
    23. 25. Training Strategy <ul><li>Address barriers and opportunities </li></ul><ul><li>Increase motivation </li></ul><ul><ul><li>Oral health important </li></ul></ul><ul><ul><li>Impact on children </li></ul></ul><ul><li>Increase practitioner knowledge </li></ul><ul><ul><li>Normal dental development </li></ul></ul><ul><ul><li>Caries process </li></ul></ul>
    24. 26. Training Strategy <ul><li>Review evidence base (USPSTF; CDC Fluoride recommendations) </li></ul><ul><li>Frame in terms of primary care roles: </li></ul><ul><ul><li>Anticipatory guidance </li></ul></ul><ul><ul><li>Nutrition/feeding </li></ul></ul><ul><ul><li>Injury prevention; emergency management </li></ul></ul><ul><ul><li>Special issues for CSHCN </li></ul></ul>
    25. 27. Training Strategy <ul><li>Apply principles of family-centered, culturally competent care </li></ul><ul><ul><li>already part of residency culture / training </li></ul></ul><ul><li>Involve dental practitioners </li></ul><ul><ul><li>partner with ABCD, community health clinics, pediatric dental trainees </li></ul></ul><ul><ul><li>Increase communication, lines of referral </li></ul></ul>
    26. 28. Modules* <ul><li>Module 1: Public Health Overview; Oral Health Promotion and Practice </li></ul><ul><li>Module 2: Normal Dental Development/ Pathology </li></ul><ul><li>Module 3: Dental Caries; Collaborating with Dentists </li></ul><ul><li>Module 4: Dental Trauma and Emergencies </li></ul><ul><li>Module 5: Oral-systemic Health Interactions </li></ul><ul><li>*Approximately 1 hour each including Q&A </li></ul>
    27. 29. Additional Modules Requested <ul><li>Atraumatic Restorative Technique </li></ul><ul><li>Maternal oral health (planned) </li></ul>
    28. 30. Module 1: Learning Objectives <ul><li>After completion trainees will: </li></ul><ul><li>Understand public health context of children’s oral health </li></ul><ul><li>Understand evidence base in children’s oral health </li></ul><ul><li>Provide culturally competent, family-centered oral health care </li></ul><ul><li>Engage in “public health practice” in primary care </li></ul>
    29. 31. Key Public Health Points <ul><li>Provide rationale for oral health training: </li></ul><ul><li>1. Disparities in oral health: </li></ul><ul><ul><li>Need to work with under-served communities </li></ul></ul><ul><li>2. Science of caries prevention: </li></ul><ul><ul><li>Need to reach children early </li></ul></ul><ul><li>3. Dental workforce shortages: </li></ul><ul><ul><li>Need to prevent disease in primary care </li></ul></ul><ul><li>4. Education gaps: </li></ul><ul><ul><li>Need for primary care training programs </li></ul></ul>
    30. 32. WA Smile Survey 2000: Children with Early Childhood Caries Washington 1-year-olds (10%) Washington 2-year-olds (19%) NHANES III 2-year-olds (8%) 10 19 8
    31. 33. WA Smile Survey 2000: Trends (Phipps et al) Caries Experience 1994 19.2 40.7 Sealants 46.0 54.6 16.9 21.6 Untreated Decay 0 10 20 30 40 50 60 Percent of Children 2000
    32. 34. Module 3: Caries and Collaborating with Dentists <ul><li>After completion trainees will: </li></ul><ul><li>1. Understand the caries process (ECC) </li></ul><ul><li>2. Understand PCP’s role in oral health care </li></ul><ul><li>3. Assess risk, take brief oral history </li></ul><ul><li>4. Recognize caries on an oral exam </li></ul><ul><li>5. Apply fluoride varnishes </li></ul><ul><li>6. Make appropriate dental referrals </li></ul><ul><li>7. Provide appropriate anticipatory guidance </li></ul>
    33. 35. Primary Care Providers <ul><li>Role in Preventive Oral Care: </li></ul><ul><ul><li>1. Anticipatory guidance/ counseling </li></ul></ul><ul><ul><li>2. Oral screening exam </li></ul></ul><ul><ul><li>3. Risk assessment (includes oral history) </li></ul></ul><ul><ul><li>4. Applying fluoride varnish </li></ul></ul><ul><ul><li>5. Dental referral / collaboration </li></ul></ul><ul><ul><li>6. Monitor oral-systemic health interactions </li></ul></ul><ul><ul><li>7. Manage simple dental trauma </li></ul></ul><ul><ul><li>[8. Maternal oral health counseling] </li></ul></ul>
    34. 36. Additional support in Yakima <ul><li>Hands on training for varnishes </li></ul><ul><li>Pediatric dental resident on site weekly for first 6 months </li></ul><ul><li>Reference materials </li></ul><ul><li>Close contact with ICOHP team </li></ul><ul><li>ABCD providers to accept referrals </li></ul>
    35. 37. Year 2-3 <ul><li>Trainings in Olympia, Boise, Alaska, ? Montana </li></ul><ul><li>Evaluation in progress in all sites </li></ul><ul><li>Mesh with community or statewide oral health plans when possible (ie, Idaho, AK) </li></ul><ul><li>Disseminate through intra-net </li></ul><ul><li>Continued leadership in primary care </li></ul>
    36. 38. ICOHP Training Sites Alaska Washington Montana Idaho Wyoming Seattle
    37. 39. Seattle (UW) Feb 2003 N = 8 (R 1’s)
    38. 40. ICOHP Training Sites Alaska Washington Montana Idaho Wyoming Spokane
    39. 41. Spokane, Washington Feb 2003 N = 27
    40. 42. ICOHP Training Sites Alaska Washington Montana Idaho Wyoming Olympia Anchorage Boise
    41. 43. Future trainings <ul><li>APRIL, 2003 </li></ul><ul><li>Olympia, Washington </li></ul><ul><ul><li>N = 17 </li></ul></ul><ul><li>Boise, Idaho </li></ul><ul><ul><li>N = 27 </li></ul></ul>
    42. 44. Anchorage: Train the trainer Dec 2002 (N = 24)
    43. 45. What have we learned <ul><li>We can teach it: knowledge, attitudes and self-efficacy shift </li></ul><ul><li>Taps into training need in underserved communities </li></ul><ul><li>Family practitioners v pediatricians </li></ul><ul><li>Long term evaluation needed </li></ul><ul><li>Fiscal issues loom large </li></ul>
    44. 46. Caveats <ul><li>Medical and dental training models differ </li></ul><ul><li>Vocabularies, conceptual frames differ </li></ul><ul><li>Shifting priorities in medical setting </li></ul><ul><li>Diagnosis and management, risk assessment, medical vs dental conditions </li></ul><ul><li>How to determines content of curriculum and framing for medical audience? </li></ul><ul><li>FM desire oral health knowledge for older patients </li></ul>
    45. 47. Unexpected outcomes <ul><li>Leverage opportunities with other HRSA grants </li></ul><ul><li>Family medicine /pediatric dental residents work well together </li></ul><ul><li>Family Medicine Network cultural change </li></ul><ul><li>Expanded interest in oral health in the UW (educational research; public/rural health area) </li></ul><ul><li>Best Practices review expanded into Web review project </li></ul><ul><li>Political battles less apparent at local level </li></ul><ul><li>Interest in curriculum outside of WWAMI region </li></ul>
    46. 48. Strategies for Success <ul><li>FACULTY CHAMPION </li></ul><ul><li>Ensure buy in: frame for PCPs </li></ul><ul><li>Address barriers: logistics, knowledge, attitudes </li></ul><ul><li>Create / reinforce dental collaborations </li></ul><ul><ul><li>Use pediatric dental residents for training </li></ul></ul><ul><li>Identify other stakeholders </li></ul><ul><li>Evaluate impact </li></ul><ul><li>Plan for sustainability </li></ul>
    47. 49. <ul><li>To identify /review Web resources in pediatric oral health for primary care physicians </li></ul><ul><li>  </li></ul><ul><li>To develop strategies for designing Web-based training tools for primary care physicians. </li></ul>Review of Web Resources: Purpose
    48. 50. Future Directions <ul><li>Sustainability at community level: partner with local health depts </li></ul><ul><li>Move down educational level – medical school family practice clerkships </li></ul><ul><li>Regional center for training trainers </li></ul><ul><li>Important educational research questions </li></ul><ul><li>Creation of WEB site </li></ul>
    49. 51. Future Directions <ul><li>Longer term follow up needed: evaluation study </li></ul><ul><li>Train RNs, PAs, others </li></ul><ul><li>Sustainability within AHC </li></ul>
    50. 52. Module 2: Normal Dental Development <ul><li>After completion trainees will: </li></ul><ul><li>1. Examine the teeth of young children </li></ul><ul><li>2. Know the names/number of teeth, basic tooth anatomy </li></ul><ul><li>3. Differentiate normal from abnormal eruption </li></ul><ul><li>4. Identify causes of tooth discoloration </li></ul>
    51. 53. Module 4: Dental Trauma and Emergencies <ul><li>After completion trainees will: </li></ul><ul><li>1. Understand causes/ mgt dental pain </li></ul><ul><li>2. Identify and manage simple dental infections </li></ul><ul><li>3. Identify and manage simple tooth injuries </li></ul><ul><li>4. Know complications of dental injury/infection </li></ul><ul><li>5. Understand when to refer injury/infection </li></ul><ul><li>6. Counsel families to decrease injury risk </li></ul>
    52. 54. Module 5: Oral Systemic Health Interactions <ul><li>After completion trainees will: </li></ul><ul><li>1. Understand why CSHCN are more vulnerable to </li></ul><ul><li>oral disease/access problems </li></ul><ul><li>2. Recognize systemic impact of oral disease </li></ul><ul><li>3. Recognize the impact of systemic disease/ medical therapies on oral health, dental care </li></ul><ul><li>4. Recognize and manage common oral lesions </li></ul><ul><li>5. Refer appropriately </li></ul>