PROJECT SUMMARY/ABSTRACT
Northeast Ohio has one of the highest rates of oral diseases (caries, periodontitis) and poor dental attendance
among low-income older adults. Professional organizations and the IOM recommend integration of oral health
(OH) activities into primary care for adults in order to reduce medical costs. But, published literature indicates a
lack of outcomes data to assemble an effective medical-dental integration. Impeding integration are also factors
such as lack of an electronic health record (EHR) based oral health (OH) assessment and referral, and
inadequate OH education and training for medical providers. Our survey data indicate that the majority of
providers would like OH facts to be communicated at primary care visits (PCV) but lack education and resources.
There are misperceptions about oral diseases among older adults that prevent regular dental attendance. The
proposed multi-level interventions will address factors that impede OH integration, and subsequently improve
self-regulatory behaviors in adults. The interventions are: Practice (medical assistants, nurses): EHR systems
based changes to ask, advise, assess, connect (AAAC). Provider (physician/nurse practitioner): improve
knowledge and skills using Common-Sense Model of Self-Regulation (CSM) theory based education and skills
training to communicate OH facts and reinforce importance of dental visits. A cluster-randomized clinical trial is
proposed to test implementation (practice) and behavioral (provider) intervention to address self-regulation and
increase dental attendance among low-income adults aged =55 years. The primary aims are: 1) UG3, Conduct
qualitative work with stakeholders and practices; system-based changes in EHR; and pilot-test the interventions
in 2 practices. UH3, randomize 8 practices to two arms to investigate the efficacy of a EHR based strategy at
the practice level to ask [OH risk assessment], advise [going to dentist], assess [willingness for referral], connect
[eReferral and/or resources] together with provider CSM theory-based education and skills to communicate OH
facts versus provider alone (standard or usual oral health care) to increase dental attendance (primary outcome);
and improve OH quality of life, oral hygiene behavior, and biometric measures of health (secondary outcomes).
Secondary aims (UH3) are to explore: the delivery and documentation of AAAC implementation strategy; and to
investigate causal pathways that affect the outcomes. The sample includes 209 providers and medical staff, and
800 Medicaid-enrolled adults. Data analysis (UG3) will utilize a mixed method design for qualitative and
descriptive statistics for quantitative data. Data collection (UH3) will follow the RE-AIM framework: adults
(outcome data from Medicaid claims, questionnaires, EHR); provider, practice (questionnaires); provider,
practice (process measures: reach, fidelity, adoption, maintenance from audits). A generalized estimating
equations approach will be used to assess effects of multi-level interventions on dental attendance and other
outcomes, while accounting for clustering within practice. Mediation methods will determine if intervention effects
occur through hypothesized mediators. A sustainable OH care model is proposed for primary care clinicians.
