Funding Oral Healthcare for Institutionalized Elderly Patients

What dentists who serve Medicaid patients in long-term care facilities need to know

The “secret” is out. Funding is available for the treatment of dentists’ neediest and most vulnerable patients—residents of this country’s more than 16,0001 government-funded long-term care facilities (LTCFs). The trick is in knowing how to access it.

Oral care for the elderly is a big problem that’s likely to get much bigger, says Nolan W. Allen, DDS, who is associated with National Elder Care Advisory Committee (NECAC) through the American Dental Association (ADA) Council on Access, Prevention and Interprofessional Relations (CAPIR). “Approximately 1.3 million nursing home residents face the greatest barriers to accessing dental care of any population group,” he says. This number, he says, is expected to increase rapidly with the aging of the Baby Boomer generation, which comprises those individuals who were born between 1946 and 1964.

The aging of this group is now producing what the Clearwater, Florida–based private practitioner calls “the perfect storm.” This enormous group of Americans is not only living longer, but they are also retaining more of their teeth. Because of the recessionary economy and pullback in company-provided retirement benefits in recent years, however, many lack the financial resources to care for them. Given what is now understood about the connection between oral and systemic health, this is cause for alarm that extends far beyond the dental community.

The State of LTCF Oral Care

As it exists today, oral healthcare for LTCF residents is generally haphazard and inefficient, according to Allen L. Finkelstein, DDS. Finkelstein, who is chief executive officer of Bedford HealthCare Solutions and an adjunct clinical assistant professor of Pediatric Dentistry at New York University College of Dentistry, paints a dismal picture of the care typically rendered in LTCFs such as nursing homes.

“It is delivered mainly on a pain-initiated, episodic basis, with no attention paid to prevention, just the chief complaint,” Finkelstein explains. Dental needs, he says, are met mainly through mobile dentistry or transport to an outside office. Yet removal from the familiar environment of their residential facility for dental treatment is associated with an entirely different set of issues. “For various reasons, including fear or cognitive problems, these patients may be unable to cooperate, necessitating sedation or even general anesthesia in a hospital setting,” he explains.

Further complicating treatment, Finkelstein says, are challenges posed by comorbidities that lead to polypharmacy among patients, who are typically taking up to eight different types of medications for multiple systemic problems. These include diabetes, cardiovascular disease, and respiratory problems, which are the most common source of hospital admissions from nursing homes.

Basically, maintains Finkelstein, under these circumstances, the treating dentists are forced to focus on short-term goals, such as attempting to restore function for proper mastication and improvement in caries without the ability to institute effective ongoing preventive care and treatment.

“We can’t render ideal care when patients are treated episodically,” Finkelstein says. “We must first treat them to be asymptomatic to the best of our ability, which means keeping the disease of caries under control, and restoring so they can function. But the other piece to it is maintaining the periodontium in a state of health so you don’t have the inflammatory process as part of everyday life for these patients.”

An Approach to a Solution

Frank A. Catalanotto, DMD, chair of the department of Community Dentistry & Behavioral Sciences
at the University of Florida College of Dentistry, shares his colleagues’ concern. He calls care for these patients “an important but not well understood topic,” and sees hope for a solution in the Incurred Medical Expenses (IME) option described in an American Dental Association report.^2,3 This mechanism, he explains, is used to access Medicaid funds allotted to LTCFs to pay for oral healthcare, which is otherwise covered inadequately or not at all by Medicaid.

Allen says that the IME “empowers dentists to care for patients in need without placing a financial burden on their practices.” Although most dentists are not aware of it, he explains, IME billing is already routinely used to pay for eyeglasses and hearing aids, and can likewise be used to help LTCF residents get dental care by helping practices get reimbursed for services. He urges dentists to be prepared to use IME billing for patients who meet its criteria for dental services in states that have limited or no dental coverage for adults who are on Medicaid. To qualify, patients must be a resident of a LTCF, be enrolled in Medicaid, and receive Social Security or other income.

Catalanotto notes that the IME billing process is being successfully applied by El Harris, president of PrevMed, a company that handles the required paperwork and hires dentists to provide care, and Louisiana dentist Greg Folse, DDS, who both uses and teaches about the mechanism.

Folse provides geriatric dental care in a mobile practice using the ADA IME model and is actively involved in teaching it to others across the country as part of his commitment to delivering needed oral healthcare to this patient population.

“This model is only a ‘secret’ because many in the dental profession and nursing home industry haven’t understood how the IME mechanism can provide critical oral health services for nursing facility residents,” Folse explains, emphasizing that he is not blaming either group. “Nationally, as we both increase our knowledge and use the IME funding mechanism, patient care, overall health, and quality of life will improve. This is crucial because these patients are highly vulnerable to infection. When they get a toothache or dental infection, they don’t just get grouchy, they can get sepsis and wind up in the hospital or die. I’ve seen it happen many times.”

Folse says that using IME has significantly improved his ability to serve this population. “Until I started using this process in Louisiana, I wasn’t able to meet all the needs of my patients. Now that I’m using it, I can provide good, appropriate dentistry for this needy and wonderful population,” he explains.

Beth Truett, president and chief executive officer of Oral Health America, regards the use of the IME mechanism to increase access to care for these vulnerable Americans as a step in the right direction. “The IME is an important tool for providing preventive and restorative services to older adults and lowering the nation’s high cost of care,” she says.

Conclusion

Allen says, “The frail elderly need special care because they suffer from extensive oral diseases, and have medical problems that complicate their care.” The ADA’s new dental team member, the community dental health coordinator, is a position that Allen says, “can provide much needed oral health education.”

Finkelstein voices the hope that it will one day be possible to deliver ideal care to patients in LTCFs through the daily, supervised practice of preventive dentistry. He explains, “This would not be on a yearly basis, not on a pain basis, but on daily basis—take bacteria that get organized on a 24-hour cycle and disorganize them so we can decrease the risk that these patients will have more problems.”

References

1. FastStats. Nursing Home Care. Centers for Disease Control and Prevention website. www.cdc.gov/nchs/fastats/nursingh.htm. Accessed March 27, 2013.
2. How-to guide for IME. American Dental Association website. www.ada.org/news/6295.aspx. Accessed March 27, 2013.
3. Paying for Dental Care: A How-To Guide. American Dental Association website. www.ada.org\IME. Accessed March 27, 2013.