Longitudinal analysis of cost and dental utilization patterns for older adults in outpatient and long-term care settings in Minnesota.

BACKGROUND: Dental utilization patterns and costs of providing comprehensive oral healthcare for older adults in different settings have not been examined. METHODS: Retrospective longitudinal cohort data from Apple Tree Dental (ATD) were analyzed (N = 1,159 total; 503 outpatients, 656 long-term care residents) to describe oral health status at presentation, service utilization patterns, and care costs. Generalized estimating equation (GEE) repeated measures analysis identified significant contributors to service cost over the three-year study period. RESULTS: Cohort mean age was 74 years (range = 55-104); the outpatient (OP) group was younger compared to the long-term care (LTC) group. Half (56%) had Medicaid, 22% had other insurance, and 22% self-paid. Most (72%) had functional dentitions (20+ teeth), 15% had impaired dentitions (9-19 teeth), 6% had severe tooth loss (1-8 teeth), and 7% were edentulous (OP = 2%, LTC = 11%). More in the OP group had functional dentition (83% vs. 63% LTC). The number of appointments declined from 5.0 in Year 1 (OP = 5.7, LTC = 4.4) to 3.3 in Year 3 (OP = 3.6, LTC = 3.0). The average cost to provide dental services was $1,375/year for three years (OP = $1,427, LTC = $1,336), and costs declined each year, from an average of $1,959 (OP = $2,068, LTC = $1,876) in Year 1 to $1,016 (OP = $989, LTC = $1,037) by Year 3. Those with functional dentition at presentation were significantly less costly than those with 1-19 teeth, while edentulous patients demonstrated the lowest cost and utilization. Year in treatment, insurance type, dentition type, and problem-focused first exam were significantly associated with year-over-year cost change in both OP and LTC patients. CONCLUSION: Costs for providing comprehensive dental care in OP and LTC settings were similar, modest, and declined over time. Dentate patients with functional dentition and edentulous patients were less costly to treat. LTC patients had lower utilization than OP patients. Care patterns shifted over time to increased preventive care and decreased restorative care visits.

The demand for preventive and restorative dental services among older adults.

Many older Americans have poor access to dental care, resulting in a high prevalence of oral health problems. Because traditional Medicare does not include dental care benefits, only older Americans who are employed, have post-retirement dental benefits or spousal coverage, or enroll in certain Medicare Advantage plans are able to obtain dental care coverage. We seek to determine the extent to which poor access to dental insurance and high out-of-pocket costs affect dental service use by the elderly. Using the 2007-2015 Medical Expenditure Panel Survey and supplemental data on dental care prices, we estimate a demand system for preventive dental services and basic and major restorative services. Selection into dental and medical insurance is addressed using a correlated random effects panel data specification. Consistent with prior studies of the nonelderly population, dental service use was not sensitive to out-of-pocket prices. However, private dental insurance increased preventive service use by 25%, and dental coverage through Medicaid increased basic and major service use by 23% and 36%, respectively. The use of services was more responsive to dental insurance for women than men. These estimates suggest that a Medicare dental benefit could significantly increase dental service use by older Americans.

Evaluation of time and resources required for professional dental cleaning in nursing home residents.

AIM: We aimed to describe time requirements and costs associated with professional dental cleaning (PDC) performed by a dental nurse in one German nursing home, and to reveal potential differences in required time for demented versus nondemented and mobile versus immobile residents. METHODS AND RESULTS: We performed a retrospective, cross-sectional analysis of treatment time and costs, including a transparent, easily adaptable path of action that allows implementation of PDC in nursing homes. Total mean (±SD) treatment time for one session per resident was documented, including differences in demented and immobile residents, and projected treatment costs (€/$) per resident. We found no differences in required time for one PDC (37 ± 11 minutes) in residents with or without dementia (P = 0.803) or, immobile versus mobile residents (P = 0.396). Mean projected treatment costs of PDC were €14.98/$17.07 per resident per cleaning session, resulting in total costs of €13.5 million ($15.4 million). CONCLUSION: Cognitive status and mobility does not affect the mean time required to perform PDC by a dental nurse in nursing home residents. Main cost factor is working time of dental staff; consumable supplies have less impact. Our data may stimulate to include PDC as initial step toward implementation of long-term oral hygiene strategies.

Designing a New Payment Model for Oral Care in Seniors.

With 10,000 baby boomers turning 65 every day, many will be on fixed incomes and will lose dental insurance upon retirement. This article presents why a dental benefit in Medicare might save the US government money, and who would likely benefit. It details an approach to estimating costs of inclusion of a dental benefit in Medicare, and compares the proposed approach to existing proposals. Additionally, the ensuing steps needed to advance the conversation to include oral health in healthcare for the aged will be discussed.

Dental care for the elderly through a Capped-fee funding model: Optimising outcomes for primary government dental services.

OBJECTIVE: The objectives of this study were to (i) compare a Capped Payment formula for adults, to the fee-for-service model and the New South Wales Government services payment model; (ii) identify the presenting oral health needs of a 65+ years of age cohort during the period January 2011 to March 2015. BACKGROUND DATA DISCUSSING THE PRESENT STATUS OF THE FIELD: Australia faces an ageing population with the vast majority accessing free market dental care, whilst the poor access Government services. This cohort retains most of their dentition increasing demand on Government services. MATERIALS AND METHODS: The analysis of New South Wales Government adult de-identified patients' record unit data was from 2011 to 2015, for the three payment models and undertaken in three stages; (i) development of the Capped Payment Model; (ii) evaluation of twenty (20) case studies of adults 65+ years of age; (iii) analyse the cost efficiency of the three payment models. RESULTS: This study found that the Government model was the most cost effective. The Capped-fee model performed less efficiently, particularly in the 75+ age group, with the fee-for-service model generally more costly. It was $2580 (85%) more costly for the 65-74 age cohort, and $4619 (66%) for the 75+ age cohort. CONCLUSION: Policy makers in partnership with Government and private service providers should seek to develop partnerships with Government, private services and universities, scope opportunities in applying a Capped-fee funding model, and one that helps address the oral needs of the elderly.

Meeting commentary: Santa Fe Group Salon Expanding Oral Healthcare for America's Seniors, September 28-30, 2016.

BACKGROUND AND OVERVIEW: A meeting to explore ways to expand access to oral health care for seniors-possibly by expanding a dental benefit in Medicare-was convened in Arlington, VA, by the Santa Fe Group. Four factors motivated the meeting: PRACTICAL IMPLICATIONS: The model Medicare dental benefit presented generated much discussion. There was agreement that any dental benefit must attract participating dentists. Agreement was also reached on the importance of public demonstration projects to further establish cost savings from dental care for patients with comorbid diseases, the need to collaborate with nondental advocacy and policy groups to establish that overall health benefits for seniors are gained by adding oral health care, and the necessity of oral health literacy campaigns working directly at the community level with the general public and others, including educators and the media, as well as with policy makers and providers from all health fields and at all levels of professional training.

Did you know Medicare does not usually include a dental benefit? Findings from a multisite investigation of oral health literacy.

OBJECTIVES: Medicare does not usually include a dental benefit. Adults who are unaware of this fact risk unanticipated expenses after retirement. This report will explore the sociodemographic and oral health literacy determinants of this knowledge. METHODS: Data came from the Multi-Site Oral Health Literacy Research Study, a survey of patients presenting to two university dental clinics. Sociodemographic descriptors included age, sex, race/ethnicity, education level, and dental insurance status. Oral health literacy was measured by the Rapid Estimate of Adult Literacy in Medicine and Dentistry (REALM-D). RESULTS: Only 34 percent of respondents knew the correct answer to the Medicare question. Knowledge was significantly associated with age, race/ethnicity, education level (bivariate only), and REALM-D score. CONCLUSIONS: Policymakers and those assisting in Medicare enrollment should ensure information regarding dental coverage is communicated in ways that individuals of varying literacy, language, and culture understand what is necessary to make appropriate decisions.

Seeking Dental Care For Older Americans.

Since Medicare doesn't cover most dental care, seniors often go without treatment.

Cost-related dental non-attendance in older adulthood: evidence from eleven European countries and Israel.

BACKGROUND: Although relevant for health policy, so far only little is known about the extent to which persons avoid dental attendance because of associated costs. OBJECTIVES: To examine the cost-relatedness of dental non-attendance in various older adulthood populations. MATERIAL AND METHODS: Secondary analyses were conducted of data from wave 1 of the Survey of Health, Ageing, and Retirement in Europe (SHARE), which includes unique information on recent dental non-attendance and care foregone due to costs by persons aged 50+ from eleven European countries and Israel. Multivariate logistic regression analysis was used to detect differences in the extent to which dental non-attendance is attributable to associated costs. RESULTS: The study sample comprised 13 935 persons who did not access dental care within the past year. Levels of cost-related non-attendance differed between the twelve examined countries, ranging from 6.8% in Israel to 0.5% in Austria. Cost-related non-attendance was 47% less likely among persons with good as compared to compromised chewing ability (Odds Ratio: 0.53; 95% CI: 0.43-0.66). Cost-related non-attendance was 33% less likely among persons with tertiary as compared to (pre-) primary educational attainment (Odds Ratio: 0.67; 95% CI: 0.47-0.96). Cost-related dental non-attendance was significantly more likely among persons with low levels of general health (Odds Ratio for lowest vs. highest level of general health: 3.05; 95% CI: 1.88-4.95). CONCLUSIONS: The findings of the present study suggest that a relatively small proportion of dental non-attendance in older adulthood is cost-related. For specific population subgroups in various countries, however, dental care costs may still pose a relevant barrier to dental care.

Opinions of dentists on the barriers in providing oral health care to community-dwelling frail older people: a questionnaire survey.

OBJECTIVE: The aim of this study was to investigate to what extent dentists in the Netherlands experience barriers in providing oral health care to community-dwelling older people. BACKGROUND: As most publications on the barriers in providing oral health care to older people consist of surveys on oral health care in care homes, it was decided to investigate the barriers dentists experience in their own dental practices while providing oral health care to community-dwelling frail older people. MATERIAL AND METHODS: A representative sample of 1592 of the approximately 8000 dentists in the Netherlands aged 64 or younger were invited to respond to a questionnaire online. The dentists were asked to respond to 15 opinions concerning oral healthcare provision to community-dwelling frail older people aged 75 years or more who experience problems in physical, psychological and social areas, as well as possible financial problems. RESULTS: The total response rate was 37% (n = 595; male=76%; average age 49). The majority of those who responded agreed that the reimbursement of oral health care to older people is poor. Two thirds of those who responded (66%) agreed that there are limited opportunities to refer the frail and elderly with complex oral healthcare problems to a colleague with specific knowledge and skills. CONCLUSION: Dentists experienced barriers in two domains; a lack of knowledge and practical circumstances. It was concluded that the dentist's gender, age, year of graduation and the number of patients aged 75 years or more treated weekly were in some respect, related to the barriers encountered.

Cost-analysis of teledentistry in residential aged care facilities.

INTRODUCTION: The purpose of this research was to conduct a cost-analysis, from a public healthcare perspective, comparing the cost and benefits of face-to-face patient examination assessments conducted by a dentist at a residential aged care facility (RACF) situated in rural areas of the Australian state of Victoria, with two teledentistry approaches utilizing virtual oral examination. METHODS: The costs associated with implementing and operating the teledentistry approach were identified and measured using 2014 prices in Australian dollars. Costs were measured as direct intervention costs and programme costs. A population of 100 RACF residents was used as a basis to estimate the cost of oral examination and treatment plan development for the traditional face-to-face model vs. two teledentistry models: an asynchronous review and treatment plan preparation; and real-time communication with a remotely located oral health professional. RESULTS: It was estimated that if 100 residents received an asynchronous oral health assessment and treatment plan, the net cost from a healthcare perspective would be AU$32.35 (AU$27.19-AU$38.49) per resident. The total cost of the conventional face-to-face examinations by a dentist would be AU$36.59 ($30.67-AU$42.98) per resident using realistic assumptions. Meanwhile, the total cost of real-time remote oral examination would be AU$41.28 (AU$34.30-AU$48.87) per resident. DISCUSSION: Teledental asynchronous patient assessments were the lowest cost service model. Access to oral health professionals is generally low in RACFs; however, the real-time consultation could potentially achieve better outcomes due to two-way communication between the nurse and a remote oral health professional via health promotion/disease prevention delivered in conjunction with the oral examination.

Health economic analyses of domiciliary dental care and care at fixed clinics for elderly nursing home residents in Sweden.

OBJECTIVES: Dental care for elderly nursing home residents is traditionally provided at fixed dental clinics, but domiciliary dental care is an emerging alternative. Longer life expectancy accompanied with increased morbidity, and hospitalisation or dependence on the care of others will contribute to a risk for rapid deterioration of oral health so alternative methods for delivering oral health care to vulnerable individuals for whom access to fixed dental clinics is an obstacle should be considered. The aim was to analyse health economic consequences of domiciliary dental care for elderly nursing home residents in Sweden, compared to dentistry at a fixed clinic. METHODS: A review of relevant literature was undertaken complemented by interviews with nursing home staff, officials at county councils, and academic experts in geriatric dentistry. Domiciliary dental care and fixed clinic care were compared in cost analyses and cost-effectiveness analyses. RESULTS: The mean societal cost of domiciliary dental care for elderly nursing home residents was lower than dental care at a fixed clinic, and it was also considered cost-effective. Lower cost of dental care at a fixed dental clinic was only achieved in a scenario where dental care could not be completed in a domiciliary setting. CONCLUSIONS: Domiciliary dental care for elderly nursing home residents has a lower societal cost and is cost-effective compared to dental care at fixed clinics. To meet current and predicted need for oral health care in the ageing population alternative methods to deliver dental care should be available.

Barriers to dental care for older minority adults.

OBJECTIVES: To explore factors that motivate and/or discourage use of dental care among low-income minority older adults METHODS: Participants were recruited from low-income senior housing in Hartford, CT. In-depth semistructured interviews were conducted to obtain data on demographics, oral health status, oral health knowledge, and factors that affected use of dental care. RESULTS: Seventeen participants completed interviews. The major perceived barriers to dental care were cost/lack of dental insurance, fear/mistrust of the dentist, and transportation problems. Other factors included having complex medical conditions, no perceived need for care, and lack of knowledge about the importance of dental care. CONCLUSIONS: Participants would like to have dental care provided on-site in the housing complexes. Improving communication between dentists and their older patients would help reduce fear and mistrust. Other health care providers could help educate older patients about oral health, conduct simple oral health screenings, and refer for acute and/or comprehensive care.

Listening to older adults: community consultation on a new dental service.

BACKGROUND: Increased life expectancy, retention of a natural dentition often heavily restored, and increasing risks of oral disease mean that older people have particular dental needs and yet uptake of care is low. A new health and wellbeing centre in south London offering student-delivered care has been built to serve the local community. Community views could informed the planning of acceptable care for older people. OBJECTIVE: To explore the views and expectations of older adults towards dental services and ascertain how a new dental centre may best provide dental care. RESEARCH DESIGN: This qualitative study used in-depth and triad interviews to explore the views of older people. Purposive sampling of local centres/groups for older adults was undertaken and all willing clients interviewed. Interviews were audio recorded, transcribed and analysed using Framework Methodology with emerging themes categorised according to Maxwell's six descriptors of quality. RESULTS: Nine sessions (five triad and four in-depth interviews) involving 17 older adults were conducted in local day centres. Barriers to dental care were largely related to fear, cost, transport, lack of perceived need and the attitude of clinicians. Outcomes related to acceptability featured highly in a dental service for older adults; the overarching principles of 'delivering mutual benefit' for students and older people, 'experiencing warm humanity' and 'restoring dignity and worth' were central to their views of quality care. The importance of clinicians, whether student or staff, delivering person centred care with warm humanity was dominant: comprising 'welcoming', 'valuing', 'listening' 'communicating' and 'caring' for older adults to enhance relationships and contributing to 'restoring dignity and worth'. CONCLUSION: Community engagement identified a willingness amongst older adults to utilise dental services where mutual benefit was perceived and, importantly, there were low barriers to care and a warm humanity was exhibited.

Executive directors' perceptions of oral health care of aging adults in long-term care settings.

PURPOSE: The objective of this study was to investigate knowledge and perceptions of executive directors of long-term care facilities in a large western state regarding oral health of residents, barriers to the provision of optimal oral health care and the collaborative practice role for dental hygienists. METHODS: A descriptive, exploratory online survey research design was utilized. A purposive sample of executive directors of long-term care facilities in a large western state certified for Medicare/Medicaid reimbursement was used. An online survey was developed to investigate perceptions and knowledge regarding oral health of long-term care residents, protocol for provision of, and barriers to optimal oral health care, and support for employment of dental hygienists in long-term care facilities. Statistics used for data analysis included frequency distributions, Spearman's rho correlation coefficient and the Mann-Whitney test. RESULTS: Executive directors in long-term care facilities included in the study perceived oral health as an important aspect of general health; however, a knowledge deficit was identified related to oral disease as an exacerbating factor to systemic disease. Financial concerns and low interest among residents/families were identified as major barriers to accessing care. Executive directors supported interprofessional practice of nurses working with dental hygienists to optimize oral health care of residents. No significant associations were found between demographics and facility characteristics. CONCLUSION: Awareness of the knowledge and perceptions of executive directors providing leadership in these facilities can provide avenues to creating needed change, which can foster improvement in the oral and overall health status of long-term care residents. Support for interprofessional work of nurses and dental hygienists can open a door for innovative practice that optimizes oral health care of long-term care facility residents through the application of shared expertise.

Barriers to dental services for older adults.

OBJECTIVE: To explore barriers to older adults' accessing dental care. METHODS: We performed oral exams on 184 community-dwelling older adults; those who needed dental care were contacted 6-12 weeks later to determine if they were able to access treatment. Those who could not access care were interviewed regarding barriers. RESULTS: Of those examined, 89% needed dental treatment. After 6 weeks, 52% had received treatment, 48% had not. Those unable to access treatment had fewer teeth, were more likely to be referred regarding dentures, and were less likely to have a dentist. Reasons cited for not accessing care among the 35 participants we interviewed included a lack of finances, transportation, or assistance in navigating dental service. CONCLUSIONS: Older adults have a high burden of oral disease and access barriers remain.

Oral health needs and barriers to accessing care among the elderly in Johannesburg.

OBJECTIVES: The study sought to determine barriers to accessing oral health services amongst the elderly residing in retirement villages in Johannesburg. The objectives were to determine the normative and perceived oral health needs, the barriers experienced and the predictors of oral health utilisation. MATERIALS AND METHODS: This was a cross-sectional study. Three hundred and eight (n=308) participants were recruited from 10 retirement villages in Johannesburg. Data were collected from questionnaires and clinical oral examinations assessing the DMFT and CPITN scores. RESULTS: The clinical findings of the oral health status indicated a caries experience of 46%, whilst 58% of participants suffered from periodontal conditions. Sixty four percent (64%) acknowledged the need to visit a dentist, however only 28% of the study population had utilised oral health care in the past 12 months, due to perceived barriers. The barriers most frequently reported included the belief that they were not able to afford dental treatment and the lack of transport availability. The multivariate analysis indicated that a significant positive predictor of utilisation was Perceived Need. CONCLUSION: Though oral health access was freely available in the public sector and normative and perceived need for oral health care were high, the barriers experienced prevented 72% of the participants from utilising oral health services.