Improving the Quality of Oral Healthcare through Case Management

1. Improving the Quality of Oral Healthcare through Case Management Dental Case Management – Motivational Interviewing D9993

2. Acknowledgements Improving the Quality of Oral Healthcare through Case Management is a professional education and training program designed to advance the knowledge, skill, and competency of the dental workforce. The curricula is made up of 6 training modules which have been made available through the generous support of the following organizations and agencies: • Rhode Island Department of Health • Rhode Island Executive Office of Health and Human Services • Rhode Island Dental Association • Medicaid|Medicare|CHIP Services Dental Association • Health Resources and Services Administration

3. Module 9 Learning ObjectivesParticipants will: • Identify ways in which motivational interviewing can improve a patient’s desire to decrease or avoid oral disease; • Understand key components of delivering motivational interviewing services and how each effects the patient experience; • Develop a working knowledge of how community supports, the Medicaid Health Plans and the Medicaid agency contribute to effective communication and care coordination; • Understand the role each dental office professional plays in both assessing needs and in delivering case management services; • Effectively document and bill Medicaid for case management services delivered in the dental office setting to help monitor and track patient care.

4. Improving the Quality of Oral Healthcare through Case Management Take Module 9 Pre-Test Now https://www.surveymonkey.com/r/M9Pre

5. RI EOHHS Case Management Policy A Toolkit for Billing

6. Implementation of Dental Case Management • Before launching more broadly, RI EOHHS will “test” the four new codes. • 2017 Pilot Initiative - volunteer dental practices - services are billed, reimbursed and tracked - certain outcomes will be evaluated • A decision for a full launch of codes will be made in 2018

7. Dental Provider Qualifications • RI Medicaid-enrolled • Complete 5 online Case Management Learning Module Series • Complete 5 Module Pre and Post-Tests • Certification from RI EOHHS

8. Who Provides the Services? Employing a dedicated dental case manager can be difficult financially, which is why the dental case management services can be provided by a trained dental team.

9. Assessing Needs

10. Tips for Conducting a Needs Assessment Some important principles that apply to all assessment areas are: • Start with active listening and allow patients to express their needs and desires • Build a relationship on mutual respect and focus on strengths • All of the needs areas should be addressed and prioritized, as per the consumer’s ability to participate. • Ask open-ended questions. • Involve family members and appropriate social resources

11. Dental Treatment Case Management Considerations • Can take multiple visits for complex dental treatment plan • Management of covered vs. non-covered dental procedures • Patient Education, instructions, language, literacy • Transportation assistance • Advocacy/Education/Assurance: Does CM have to advocate on behalf of patient to dental provider? or educate and assure patient? • Behavioral issues, intervention management (lots of unknowns when patient is in new environment) • • Monitor co-occurring conditions (D/A, MH, chronic conditions) • Follow-up after extractions and intensive procedures (infection, pain management) • Coordination of treatment between emergency provider, hospital, dental provider, and outside referrals • Other life case management: Benefits, housing, substance use, medical, etc. http://www.achch.org/uploads/7/2/5/4/72547769/dental_poster_achchp_nhchc_5-2016final.pdf

12. Understanding Dental Case Management CDT Codes D9993 Dental Case Management – Motivational Interviewing Patient-centered, personalized counseling using methods such as Motivational Interviewing (MI) to identify and modify behaviors interfering with positive oral health outcomes. This is a separate service from traditional nutritional or tobacco counseling.

13. Understanding Motivational Interviewing

14. What is Motivational Interviewing (MI)? • A method that works on facilitating and engaging intrinsic motivation within the patient in order to change behavior. • …MI is a goal-oriented, patient-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.

15. Ambivalence:“The Dilemma of Change” • “I want to, and I don’t want to” • Ambivalence is a normal aspect of human nature • Passing through ambivalence is a natural phase in the process of change • Ambivalence is a reasonable place to visit but you wouldn’t want to live there!

16. The Righting Reflex The desire to set things right … …often leads to acting on the inclination to advise, teach, persuade, counsel or argue for a particular resolution to a patient’s ambivalence

17. Strategies for the Dental Team

18. Four General Principles of Motivational Interviewing • Express Empathy • Develop discrepancy • Support self-efficacy • Roll with resistance

20. Core Motivational Interviewing Steps “OARS” • Open-Ended Questions • Affirmations • Reflections • Summaries

21. MotivationaI Interviewing Resources

22. Video Examples Watch the next four brief videos to illustrate the concepts we’ve been learning about Motivational Interviewing strategies that illicit behavior change.

23. https://www.youtube.com/watch?v=f8QSA_5PEFM

24. Video https://www.youtube.com/watch?v=8i2XDHZi7GA

25. https://www.youtube.com/watch?v=nhMhp6LRmcE

26. https://www.youtube.com/watch?v=HMS6acj3Fjw

27. Typical Delivery of D9993 • Patients receive a comprehensive assessment - identifies potential barriers to care • Services are developed based on assessment - patient’s interest in receiving case management services. 3. The intent is for Case Management services like D9993 to be provided with other dental services on the same day.

28. EXAMPLE- Case Study 1 Motivational Interviewing to Address Severe Cheek-biting Issue: A young Medicaid-insured adult female exhibits bilateral cheek biting of the oral mucosa. A needs assessment reveals the patient has a number of stressful life experiences resulting in this unconscious nervous habit. Solution: Through motivational interviewing techniques, the hygienist works with the patient to assess the patient’s needs and develop a reasonable plan of action to eliminate the habit and to follow-up at the next appointment. Billing: D9993 is billed to Medicaid along with the CM Pilot Form and the appropriate notes are entered into the patient record.

29. EXAMPLE - Case Study 2 Motivational Interviewing to Support Treatment for Drug Addiction Issue: A Medicaid-insured adult male’s Medicaid History indicates he is in treatment for drug addiction. Many years of oral neglect have left the man in need of ongoing dental treatment. Solution:After a needs assessment, it is apparent the patient could benefit from staff support through motivational interviewing techniques to understand the nature of the patient’s behaviors and his drug treatment plan and to assist him in modifying the unhealthy behaviors that caused his oral disease. Billing:D9993 is billed to Medicaid along with the CM Pilot Form and the appropriate notes are entered into the patient record.

30. EOHHS Policy-Code Use During Pilot • May be billed for all non-RIte Smiles enrollees (older children & adults (ages 21+) • Initial Assessment should be completed and filed - Dental Needs Assessments: part of medical history or supplemental • D9993 code may be billed to EOHHS one time per date of service for the same patient • Additional dental services (including other case management) may be billed on the same day

31. EOHHS Policy-FQHC Code Use During Pilot • May be billed for all non-RIte Smiles enrollees (older children & adults (ages 21+) • Initial Assessment should be completed and filed - Dental Needs Assessments: part of medical history or supplemental • D9993 code may be billed to EOHHS one time per date of service for the same patient • D9993 must be billed with at least one other covered dental service (besides the other 3 CM codes) on the same day in order to qualify as a dental encounter

32. EOHHS Guide for Billing During the Pilot • RI Medicaid has authorized you to bill for CM services, so your practice’s claims will be monitored and tracked as they are submitted • Submit Medicaid dental claim using the same process as all other Medicaid adult claims • Exception: FQHCs must bill D9993 with another Medicaid-covered dental service on same day • Including NOTES on the claim will always enhance the quality and integrity of your documentation

33. Recordkeeping

34. Recordkeeping • Maintain patient records, whether written, taped, computerized, or stored in any other medium, in a manner designed to ensure confidentiality.

35. Recordkeeping Tips • Document the type of support your office provided for the patient on that day in: -- the paper record and/or -- the electronic record • Don’t forget to indicate the staff person’s name who provided the CM support • Complete the RI EOHHS Data Collection Form

36. Data Collection Forms

37. Data Collection Form Instructions • Complete each of the required boxes on the Form. • Don’t forget to include the date and the baseline scoreand all subsequent scores to track change over time. • Please complete the Form in Excel and save it for each individual Case Management patient with name and the initial date of service in the file name.

38. Data Collection Form Instructions To track patient progress, please choose the most appropriate score.

39. Data Collection Form Instructions • The Form should be used as a patient agreement to engage patients in their care and updated on their progress. • During the Pilot, please save the Form electronically. • The Form should be submitted to Medicaid’s fiscal agent DXC (formerly HPE) with the paper claim form via fax or mail.

40. Data Collection Form Instructions • The saved electronic Forms should be sent weekly to the following e-mail address: Samuel.Zwetchkenbaum@health.ri.gov • Electronic files are due either by close of business (COB) on Fri. of the current week, or by COB the following Mon.

41. In Closing… • The bottom line is that there are a number of ways to integrate dental case management into your organization, no matter your size or resource limitations. • The most important thing is to make dental case management an integral part of clinic/practice operations.

42. Improving the Quality of Oral Healthcare through Case Management Take Module 9 Post-Test Now https://www.surveymonkey.com/r/M9Post