P0791 - Implementing fluoride varnish application by medical staff and effect on health center dental operations

Background: Dental caries are the most common chronic disease of childhood and cause significant morbidity which fluoride varnish can help prevent. Despite national recommendations to apply fluoride varnish in the medical setting, concerns about negative impacts on establishing a dental home exist. For health centers with dental and medical operations, lower reimbursement for fluoride varnish in the medical setting would have financial implications. Chiricahua Community Health Centers, Inc (CCHCI) is a federally qualified health center that acts as a medical and dental home for the majority of children in Cochise County, AZ where we did a quality improvement project to increase fluoride varnish application.

Methodology: This quality improvement project to improve rates of fluoride varnish application in children less than six years who receive primary care at CCHCI underwent multiple Plan-Do-Study-Act cycles. Overarching interventions included: integrating a dental hygienist in medical clinics to apply varnish one day per week, training medical providers and support staff regarding fluoride varnish and applying it in medical setting, creating standing orders, workflow optimization, and workflow reminders. Percentage of eligible children seen for a well visit that had any dental or medical fluoride varnish application procedure code submitted within CCHCI in the last six months was tracked.

Results: Rates of fluoride varnish application increased overall in the study period: from dental visits alone (10-15%) to having a dental hygienist integrated in the medical setting one day per week (15-20%) to implementing standard workflows for medical support staff / providers to apply fluoride varnish (40-50%). Rates of dental fluoride varnish codes and dental visits for children less than six years increased overall during the study period. Remaining children include missed opportunities, inaccurate billing, caregiver refusal, or because the child had fluoride varnish recently applied outside of CCHCI.

Discussion: We were able to improve fluoride varnish application by expanding dental operations into the medical setting but had greater success with continued quality improvement by following national recommendations to apply fluoride varnish in the medical setting. Our experience showed concurrent improved utilization of pediatric dental services overall when applying varnish in the medical setting which is important for sustainability of health system operations overall. Possibilities behind improved rates of dental visits include added emphasis of preventative dental care during medical appointments, specific referrals regarding dental findings found during fluoride application, and separate outreach activities.

Conclusion: Quality improvement to apply fluoride varnish within the medical home increases the percentage of children receiving varnish application. Contrary to prior concerns, we saw improved utilization of pediatric dental services in our health system. These results can reassure multidisciplinary health systems that medical staff applying fluoride varnish in the medical home is not a threat to and can strengthen dental operations.