Barriers and Facilitators to integrate Oral Health care for Older Adults in General (Basic) Care in East Netherlands. Part 2 Functional Integration.

OBJECTIVE: to synthesise a framework of barriers and facilitators in the functional integration of oral health care (OHC) into general health care for frail older adults at macro (system), meso (organisation and interprofessional integration) and micro (clinical practice) levels. BACKGROUND: Identification of these barriers and facilitators is expected to promote better and more appropriate care. METHODS: For this qualitative study, comprising 41 participants, representatives of 10 different groups of (professional) care providers, and OHC receivers (home-dwelling and nursing-home patients) were interviewed. Transcripts of the in-depth, topic-guided interviews were thematically analysed. In a subsequent workshop with 52 stakeholders, results and interpretations were discussed and refined. RESULTS: Two themes were identified: (1) compartmentalised care systems and (2) poor interprofessional and communication infrastructure. Barriers related to (1) included lack of integrative policies and compartmentalised healthcare education (macro level); poor embedding of OHC in care procedures, instruments and guidelines (meso level); and poor interprofessional skills (micro level). Barriers related to (2) included poor financial incentives for collaborative practices (macro level) and badly connected ICT systems (meso level). Identified facilitators included integration of an OHC professional into care teams, and interdisciplinary consultations (meso level); and integration of OHC in individual care plans (micro level). CONCLUSION: In The Netherlands, OHC for older people is at best poorly integrated into general care practices. Barriers and facilitators are interconnected across macro-, meso- and micro levels and between normative and functional domains and are mainly related to compartmentalisation at all levels and to poor interprofessional and communication infrastructure.

[What promotes and hinders integration of oral care in general care? Part 1. Vision, attitude and culture]. / Wat bevordert en belemmert integratie van mondzorg in de algemene zorg? Deel 1. Visie, houding en cultuur.

To identify facilitators and barriers to integrate oral health care into general healthcare for frail elderly, 41 participants from 10 different groups of (professional) caregivers and care-recipients (residents living at home and nursing home patients) in the east of the Netherlands were interviewed. They were asked about normative integration (vision, attitude, culture) at the macro (system), meso (organizational and interprofessional), and micro (patient care) level. After thematic analysis of the interviews, the results were refined on the basis of a workshop with 52 stakeholders. Subsequently, two main themes were identified: 1. a compartmentalized care culture in which oral healthcare and general healthcare are seen as two separate domains; 2. prioritization, awareness, and attitude towards oral healthcare integration. Barriers to integration are: low political attention (macro level); unclear responsibilities, hierarchical relationships, and lack of vision (meso level); poor awareness and low prioritization by healthcare providers and patients (micro level). Leadership (meso level), a supportive personality of individual caregivers, and ownership of patients (micro level) promote integration.

[What promotes and hinders integration of oral care in general care? Part 2. Policy, organization, implementation]. / Wat bevordert en belemmert integratie van mondzorg in de algemene zorg? Deel 2. Beleid, organisatie, uitvoering.

To identify facilitators and barriers to integrate oral healthcare into general healthcare for frail elderly, 41 participants from 10 different groups of (professional) caregivers and recipients (residents living at home and nursing home patients) in the east of the Netherlands were interviewed. They were asked about functional integration at the macro (system), meso (organizational and interprofessional) and micro (patient care) level. After thematic analysis of the interviews, the results were refined on the basis of a workshop with 52 stakeholders. Subsequently, two main themes for functional factors were identified: 1. compartmentalized care systems and 2. deficient interprofessional and communication infrastructure. Barriers to integration are lack of integrative policies, compartmentalized education (macro level), poor embedding of oral healthcare in healthcare procedures and diagnostic tools, poor communication systems (meso level) and poor interprofessional skills (micro level). The integration of oral healthcare providers in care teams, agenda-setting during interdisciplinary consultations (meso level) and integration of oral care and care in individual care plans (micro level) promote integration. Oral healthcare for the elderly is poorly integrated in general care in the Netherlands.

[Training and interprofessional collaboration to improve oral care for older people]. / Training en samenwerking ter verbetering van mondzorg voor ouderen.

Collaboration between oral care providers, district nurses and/or carers and nurse practioners in primary care is necessary to improve the oral health of frail and care-dependent older people. On the one hand, this is important when the oral health of older people is at risk of deteriorating and support in daily oral hygiene care is needed. On the other hand, it makes it easier for district nurses and carers to consult the oral care provider when they identify oral health problems. In general, interprofessional care contributes to a better awareness of the importance of good oral health and oral care in older people. On-the-job training could be an effective method for training oral health care skills by care professionals. .

[Oral healthcare for frail and care-dependent older people in Germany and the Netherlands]. / Mondzorg voor kwetsbare en zorgafhankelijke ouderen in Duitsland en Nederland.

To improve oral health for frail and care-dependent older people, both intra- and extramurally, in the Euregio Rhine-Waal area in the Netherlands and Germany, we inventoried barriers to oral care for the target group according to the literature, the organisation of oral care in both countries and the implications of this organisation for daily and professional (oral) healthcare and oral care. Results show most identified barriers are common to both countries, but the organisation of oral healthcare differs in both countries. The main differences lie in the financing and organisation of oral care in the intramural situation. In the Netherlands, this is to a large degree regulated and organised on the basis of the Chronic Care Act (Wlz), using the Verenso Oral Care Directive for care-dependent clients as a base for enforcement. In Germany, on the other hand, the provision of oral care in the home situation is more effectively facilitated. In both countries, various initiatives have recently been employed to improve, among other things, information supply, education and financing of oral healthcare.

[A view on collective oral care for frail older people: united we stand]. / Visie op de collectieve mondzorg voor kwetsbare ouderen: eendracht maakt macht.

Oral health in frail older people is often poor. There are a number of reasons for this, such as increased morbity and decreased motivation for (self) care. Good oral health is, however, very important. Studies have revealed poor oral health to cause or aggravate several medical and psychological problems. Illness and medication can, in turn, damage oral health. Oral health among the elderly should therefore be carefully monitored and maintained. This requires multidisciplinary and interprofessional collaboration on the part of healthcare professionals and others involved. Such collaboration is now still very limited; hardly anything has been written about how such collaboration in the area of oral care for frail older people should or could be organised. This article provides an overview of the possibilities and the relevant factors in the area of oral care for the elderly in promoting collaboration among healthcare professionals and others involved. All of this is under the banner of 'united we stand'.

[Research agenda oral care for older people in the Netherlands and Flanders (Belgium)]. / Wetenschapsagenda 'Mondzorg voor ouderen' in Nederland en Vlaanderen.

Oral care for older people is an underexposed topic in dentistry as well as in general healthcare, while oral care professionals are increasingly confronted with frail and multimorbid older people with complex care needs. The research agenda 'Oral care for the elderly' was developed to encourage the collaboration of researchers in the Netherlands and Flanders (Belgium) to do more research in this area and in this way, to achieve an expansion and implementation of knowledge. This will make possible the provision of a socially responsible and robust basis for sustainable oral care for frail older people. The focus of the agenda is on 3 themes, namely oral health and oral function for older people; multi/interdisciplinary collaboration within primary care and the costs, benefits and long-term effect(s) of oral care throughout the entire course of life. This article provides an overview of this research agenda and the way in which it has been established.

[A PhD completed. Oral health care and oral health-related quality of life of frail and care-dependent older people]. / Serie: Hora est. Mondzorg en mondgezondheidgerelateerde levenskwaliteit van kwetsbare en zorgafhankelijke ouderen.

When older people become frail, they often give up making dental visits, while their oral health care and oral health deteriorate. Open interviews and questionnaires were used to explore why frail older people change their oral health care behaviour and which (frailty-related) factors contribute to this change. These are mainly motivation-related factors. There seems to be a turning point where frail older people discontinue their oral health care routines and stop caring whether or not they loose teeth, because the perceived efforts no longer outweigh the perceived benefits of making dental visits and upkeep of oral hygiene. The use of standard questionnaires such as the validated Geriatric Oral Health Assessment Index-NL to measure oral health-related quality of life is limited, because they do not provide personal context required to interpret the outcomes. From a pre-frail stage (oral) care providers should monitor specific factors that might negatively affect oral health and oral health care behaviour, like chronic pain or diminished mobility, dexterity, cognition, will to live, energy and social support.

[The impact of frailty on the oral care behaviour and dental service use of elderly people]. / De invloed van kwetsbaarheid op mondzorggedrag en tandartsbezoek van ouderen.

In order to explore how the level of frailty and various frailty factors affect the dental service use and oral self-care behaviour of frail elderly people, 51 frail elderly people were interviewed. Additional information on age, gender, living situation, prosthetic status, self-reported health and oral health, chronic diseases and an index for frailty was collected. A thematic qualitative analysis of the collected data reveals that frail elders maintain long-established oral hygiene routines as long as possible to sustain a sense of self-worth. When burdened by severe health complaints they discontinue visits to the dentist first and oral hygiene routines subsequently. A loss of confidence in the results of dental service use, the trivializing of complaints and a diminishing sense of the importance of oral health play a role in these developments. Frail elderly people also experience psychological and social barriers to oral healthcare and dental service use when they are institutionalized.

[Diagnostic image (311). A newborn with a strange leg. Congenital knee luxation type I (genu recurvatum)]. / Diagnose in beeld (311). Een pasgeborene met een vreemd been. Congenitale knieluxatie type I (genu recurvatum).

A newborn girl's right leg was fixed in hyperextension due to congenital knee luxation type I (genu recurvatum).