History of Collaborative Practice in Chronic Disease Management

Chronic diseases affect a significant number of individuals nationally and internationally. A global report of the devastation of chronic disease on world health and economies by the World Health Organization entitled “Preventing Chronic Disease a vital investment”, presented a goal in 2005 to reduce death rates by 2% over 10 years and anticipated that this would lead to prevention of 36 million chronic disease deaths by 2015. In addition to the mortality associated with chronic disease experience, the aging of the population and development of chronic diseases that affect multiple systems have contributed significantly to disability in the population. Projections are that by year 2050 the number of individuals over 60 years of age in the world will double from 12.3% to over 20%. The Centers for Disease Control and Prevention (CDC) suggests that about 117 million people had one or more chronic health conditions in 2012 and one of 4 adults had 2 or more chronic health conditions. Seven of the top causes of death in 2013 were attributed to chronic diseases, such as heart disease and cancer, which together were responsible for nearly 65% of all deaths. In 2001, the Institute of Medicine released a report “Crossing the Quality Chasm: A New Health System for the 21st Century” that described a disconnect between health care knowledge and practice. Bringing together members of the health care team to coordinate care through reorganization of care delivery and utilization of improved systems of communication using clinical information systems, such as the electronic health record, seem to be significant components needed for improvement and management of chronic disease outcomes. Previously in 2000, the US Office of the Surgeon General released a report on the state of oral health and disparities in the nation. As such, numerous studies that have documented oral health disparities across life cycles and the connection between poor oral health and progression of systemic disease have been documented. Studies have indicated a relationship between severe periodontal disease or gum disease and worsening/progression in cardiovascular disease (CVD), end-stage renal disease, diabetes, pulmonary infections, human immunodeficiency virus (HIV)/AIDS, and numerous other disorders. Oral health is recognized as an important part of overall health and well-being but is often overlooked as an important component of many interprofessional collaborative models of care.

The purpose of this article is to examine established models of interprofessional collaborative practice in the management of chronic diseases. Collaborative models of care specifically as they relate to diabetes, CVD, HIV/AIDS, and mental health are described. There are still significant challenges bringing all of the members of the health care team together leveraging adequate opportunities for communication and decision-making. Going forward, future models of care must require that the oral health care provider take a more prominent position in helping to develop strategies for chronic disease management.

Established Models of Chronic Disease Management in Medicine

Chronic care model

The most well-known and accepted model in chronic disease management is the Chronic Care Model (CCM). The intent of the CCM was to transform the daily care for patients with chronic illnesses from acute and reactive to proactive, planned, and population based. An expanded version of the model has also been proposed that adds 3 additional strategies that includes patient safety, care coordination, and case management ( Boxes 1 and 2 ).

The CCM provided the framework for how we could approach morbidity in chronic disease management. Although it helped to improve health outcomes, the changes initially were small with many barriers identified. Specifically, there were definite challenges with organizational transformation of health care due to lack of specificity. Since its inception, the CCM has been used to guide national quality improvement initiatives involving groups of primary care practices, such as the Health Disparities Collaborative (HDC) established by the Health Resources and Services Administration’s (HRSA) Bureau of Primary Health Care. In addition to state-based and regional efforts, the CCM has been used in working with a significant number of physician practices in the United States and internationally. The CCM is also an integral part of existing patient-centered medical home models. The model has also been incorporated into several national initiatives aimed at minimizing disease progression and improving patient outcomes along with the Institute for Healthcare Improvement. The HDC relies on data and public health partnering to improve chronic disease care by improving health care delivery systems.

Medical and dental home

The Medical and Dental Home Model represents innovation and opportunity to not only positively impact health outcomes but to also incorporate oral health into collaborative interdisciplinary practice. Over the years, the American Academy of Pediatrics (AAP), the World Health Organization, the Institute of Medicine, the American Academy of Family Physicians (AAFP), Dr Edward Wagner (director of the W.A. MacColl Institute for Healthcare Innovation at the Center for Health Studies in Seattle), and others have honed this medical/health home model, expanding its scope and placing more emphasis on adults with chronic conditions. In 2007, the AAFP, the AAP, the American College of Physicians, and the American Osteopathic Association issued principles defining their vision of a patient-centered medical home. Also, other organizations along with health insurance purchasers created the Patient-Centered Primary Care Collaborative to advocate for widespread implementation of the medical home model. The core features include a physician-directed medical practice; a personal doctor for every patient; the capacity to coordinate high-quality, accessible care; and payments that recognize the medical home’s added value for patients. The model has not been as widely disseminated currently; in most clinical practices in the United States it is unavailable, although it is more of a reality in many other industrialized countries.

The Patient-Centered Medical-Dental Home (PCM-DH) has also been proposed. This model is an extension of the primary care medical home to include oral care. The goal of PCM-DH ensures patients have a personal physician or dentist who leads a team of clinical care providers and staff who take collective responsibility for delivering comprehensive, coordinated care that addresses all of a patient’s health care needs including dental. A more complete concept of the model has been further suggested by Northridge and colleagues that identifies the model as the health home.

Interdisciplinary Collaborative Models for Chronic Disease

It is reported that nearly half of the US health care expenditure is incurred for the treatment of just 5 chronic conditions, namely, mood disorders, diabetes, heart disease, asthma, and hypertension. The increasing prevalence, health burden, and cost of chronic diseases have increased interest in innovative care models that are able to incorporate community-based care and information technology into models to improve disease prevention, diagnosis, and treatment, particularly diseases that are multi-morbid. Among chronic diseases that impact health outcomes, oral infection and inflammation are often overlooked, even though dental caries and periodontitis represent the first and sixth most prevalent global diseases. Oral conditions have increased in prevalence because of significant population growth and aging. Oral diseases are largely preventable bacterial infections, opportunistic or viral in nature, and have reached epidemic proportions, particularly in underserved populations and countries. There are key reasons that oral health inequalities exist and are thought to contribute to poor health outcomes; these include gaps in knowledge and an insufficient focus on social policy, the separation of oral health from general health, and inadequate evidence-based data.

Collaborative care models that involve patient-centered as well as community-based preventive interventions and include oral health, have the ability to increase access to care, improve health outcomes, and reduce the burden of disease and the costs of care for those living with chronic disease. Additionally, the attention to how oral health may contribute to better overall health outcomes should be evaluated and made a part of innovation in chronic disease care management. The bidirectional impact of oral and systemic health has been extensively reported in the literature suggesting oral health has significant influence on quality of life and disease progression in those who are most vulnerable in the population. Understanding this relationship and development of models that will accommodate oral health outcomes as a measure of improvement in management of chronic diseases will be important to improved overall health outcomes in this group.

The following models describe an interprofessional paradigm to manage chronic illnesses, some of which include an oral health perspective.

Diabetes collaborative models

Diabetes is the seventh leading cause of death based on US death certificates in 2010. The division of Diabetes Translation at the CDC and HRSA have worked collaboratively since 1999 to provide guidance on management and treatment of diabetes. This chronic disease has reached epidemic proportions affecting more than 29.1 million, representing 9.3% of the population. Approximately 8.1 million individuals with diabetes are undiagnosed. Globally, 387 million individuals are thought to have diabetes. Several large randomized controlled trials nationally and internationally have confirmed that lifestyle interventions can be successful in reducing the incidence of diabetes from 29% to 58% in populations with the highest risk and good maintenance for up to 20 years.

Major complications and comorbid illnesses result from diabetes, including blindness and vision problems, nervous system disorders, kidney disease, amputations, periodontal disease, heart disease, stroke, and oral health disparities, that is, periodontal disease. With respect to periodontal disease, our current understanding of the relationship between diabetes and periodontal disease is based on epidemiologic studies that have clearly observed that diabetes is a major risk factor for periodontitis, increasing the risk approximately 3-fold compared with nondiabetic individuals with poor glycemic control. A report from a consensus workshop on periodontitis and systemic disease, indicates that severe periodontitis adversely affects blood glucose levels expressed as hemoglobin A1c (HbA1c) in individuals with and without diabetes. Also, moderate to severe periodontitis is associated with an increased risk for the development of diabetes. A recent Danish study sought to identify individuals presenting for dental care with undiagnosed diabetes or prediabetes. Participants had no history of diabetes and were placed in 2 groups: those with periodontal disease and those without. HbA1c levels were also measured at baseline. Investigators found that more patients with undiagnosed diabetes and prediabetes were observed in the periodontitis group than in the control group with 32.7% versus 17.4%, P >.054, respectively. The investigators concluded that routine evaluation of HbA1c in dental offices may help identify individuals with diabetes and prediabetes at early stages of disease and could potentially prevent future diabetes complications.

The report discussed earlier suggests recommendations for not only dental providers managing oral health for those with diabetes but also guidelines for physicians and individuals with diabetes/patients, thereby suggesting the need for an interprofessional collaborative ( IPC ) practice approach . The complex nature of diabetes prevention requires a multidisciplinary approach because diabetes affects all organ systems. Prevention/treatment strategies require collaboration among many health care professionals, especially those in oral health disciplines. Physicians and other health professionals, however, do not receive adequate training in oral health and do not feel comfortable performing periodontal examinations or advising patients on their oral health care needs. A survey by Kunzel and colleagues showed that similar to the medical counterparts, general dentists did not think that they had mastery of the knowledge or behavioral areas involved in management of patients with diabetes and viewed these activities as peripheral and did not think that their colleagues or patients expected them to perform such assessment activities. The need for team care for people with diabetes that include dental professionals as well as other health care providers is essential to improve outcomes for those with this chronic illness.

An innovative example of a model that includes dental and other health care professionals, such as pharmacists, podiatrists, and optometrists, has already been implemented by the National Diabetes Education Program (NDEP). The program is a joint effort of the CDC and the National Institutes of Health (NIH). The NDEP work group of pharmacists, podiatrists, optometrists, and dentists (PPOD) exist under the umbrella and has more than 200 public and private partners from multiple sectors that encompass public health, health systems, community programs especially targeting populations with a large burden of diabetes. The group is involved in the development and dissemination of evidence-based, focused, group-tested materials that include diabetes control and prevention messages. The NDEP has produced several resources, particularly the PPOD Primer tool. The tool is written for the other providers to read and educates each provider about the role that other professions play on the diabetes care team. Emphasis is placed on the importance of conducting routine examinations for complication prevention, recognizing danger signs, making recommendations regarding referrals, reinforcing among patients the need for self-examinations, and, of course, the importance of metabolic control. The goal of the PPOD Primer tool is to provide consistent messages across the disciplines and to encourage collaboration and a team approach in the caring for people with diabetes. The International Diabetes Federation’s (IDF) “IDF Guideline on Oral Health for People with Diabetes” is another good example of a collaborative model that recommends that diabetes care providers incorporate oral health into diabetes education and refer patients to dental health professionals annually for oral health care. The Building Community Supports for Diabetes Care program of the Robert Wood Johnson Foundation Diabetes Initiative works through clinic-community partnerships. Several projects demonstrate how various clinic-community partnerships promote diabetes self-management better than any organization could do so alone. This diabetes initiative was able to demonstrate that effective self-management programs and supports can be implemented in clinical and community settings. This model could easily integrate oral health care as a component. Provision of training for oral self-examination and educational materials designed to provide information on the relationship to diabetes and dental infection would greatly enhance the benefits communities receive to improve the health of patients who have diabetes.

Cardiovascular collaborative models

CVD is one of the leading causes of morbidity and mortality in the United States. The chronicity of CVD requires an interdisciplinary team to address the care of patients over a range of practice settings, including inpatient, outpatient, inner city, rural, and suburban. This interdisciplinary approach to the care of individuals with CVD has several advantages versus traditional models of care. Advantages of interprofessional team care exist for patients and providers. For patients, interprofessional teams improve care by increasing the coordination of services; integrating health care for a wide range of health needs; empowering patient/clients as active partners in care; orienting to serving patients of diverse cultural backgrounds; and allowing for more efficient use of time between patients and providers. For providers, interprofessional care increases professional satisfaction because of clearer, more consistent goals of care and facilitates a shift in emphasis from acute, episodic care to long-term preventive care and chronic illness management. The collaborative experience enables the provider to learn new skills and approaches to care, provides an environment for innovation, and allows providers to focus on individual areas of expertise. For health profession educators and health career students, interprofessional collaborative models for CVD offers multiple health care approaches to care and new models for training, fosters appreciation and understanding for other health care disciplines, demonstrates models for future practice, and breaks down outdated norms and values of a traditional discipline-centric approaches to care.

Studies have shown that the aforementioned approaches have been effective in CVD management. Teams with dense interactions among all team members were associated with fewer hospital days (rate ratio [RR] = 0.62; 95% confidence interval [CI], 0.50–0.77) and lower medical care costs (–$556; 95% CI, –$781 to –$331) for patients with CVD. Teams with more members reporting daily interactions with a greater number of team members showed better quality of care, as measured by a 38% reduction in hospital days and $516 less spent on average per patient in the previous 12 months. Furthermore, results suggest that teams with more daily face-to-face interactions had a 66% reduction in urgent care visits, a 73% reduction in emergency department visits, and $594 less spent in medical costs per patient in the previous 12 months.

This finding suggests that teams that overcome the limitation around communication between team members may be the most successful in the management of CVD. Models range from small teams of primary care physicians and a pharmacist working together to optimize hypertension management to non–physician-led provider teams. Other models are broader in their approach, using a team of primary care physicians, cardiologists, nursing, pharmacists, exercise physiologists or physical therapists, and social workers to care for patients with a variety of cardiac conditions.

Although these results seem encouraging, major challenges to their success include the lack of prominence of the dental care provider in the IPC framework for CVD treatment. Periodontal and now endodontic infections have been linked to CVD, including atherosclerosis and systemic inflammation, extensively in the literature. The incorporation of oral health care professionals in strategies to identify individuals at risk for coronary heart disease and diabetes will compliment preventive and screening efforts necessary to decrease the progression and development of these chronic illnesses and provide a portal for individuals who do not see a physician on a regular basis to gain access to the general health care system. The dental practitioner sees these patients on a regular basis for oral health needs and can more readily monitor CVD status, that is, blood pressure status.

Hypertension

Team-based care to improve blood pressure control is a health systems-level, organizational intervention that incorporates a multidisciplinary/interprofessional team to improve the quality of hypertension care for patients. Each team should include the patients, the patients’ primary care provider, and other professionals, such as nurses, dentists, pharmacists, dietitians, social workers, and community health workers. Team members provide process support and share responsibilities of hypertension care to complement the activities of the primary care provider. These responsibilities include medication management, patient follow-up, and adherence and self-management support. Patients are also central to their care and supplementing their knowledge with education about hypertension medication, adherence support, and tools and resources for self-management (including health behavior changes associated with oral health). The Community Preventive Services Task Force provided recommendations for team-based care to improve blood pressure control from strong evidence of effectiveness in improving the proportion of patients with controlled blood pressure and in reducing systolic and diastolic blood pressure. Evidence was considered strong based on findings from 80 studies of team-based care organized primarily with nurses and pharmacists working in collaboration with primary care providers, patients, and other professionals.

The economic evidence indicates that team-based care is cost-effective. Collaborative, team-based hypertension management interventions have shown the largest effects in blood pressure reduction in contrast with other tested interventions, such as patient education, clinician education, promotion of self-management, facilitated relay of clinical data, and financial incentives. Some of these approaches have been as simple as a primary care physician and pharmacist review of antihypertensive medication selection to optimize dosing and drug selection. Other approaches have added nursing to provide home blood pressure monitoring and medication adherence. The oral health care provider is essential to monitoring blood pressure on a regular basis with routine patient visits.

Congenital heart disease

Because of the advances in cardiac and pediatric care, greater numbers of children with congenital heart disease (CHD) are surviving into adulthood; now 85% to 90% of those born with CHD grow up to become adults. With the increasing survival, there has been an increasing number of adults who require special medical management given their congenital disease. These individuals are transitioned from pediatric to adult cardiology care, and their needs are typically different from patients with adult-onset CVD. Therefore, because of the complex nature, a team approach is necessary to provide optimal care for these patients. Some have suggested that the interprofessional teams for adult patients with CHD, including adult CHD specialists, adult and pediatric cardiologists and cardiovascular surgeons, specialized nurses, and other specific disciplines, are fundamental features in care facilities for adult CHD. Additional support from primary care medicine, psychology, and social work is necessary but often overlooked in the description of the multidisciplinary centers caring for these adults.

Adults with CHD (ACHD) carry lifelong emotional, psychological, and financial concerns in addition to cardiac structural, electrical, and mechanical issues. An expert consensus panel suggests that a system of lifelong preventative care by a qualified health care team of providers with knowledge both of CHD and age-related systemic health issues will ensure that early warning signs of impending problems are identified and appropriate intervention is initiated. The role of psychology, social work, and primary care should be considered as an additional key component of the team. This team, regardless of patients’ age, should include those with the best working knowledge of structural congenital heart anatomy and physiology. Adding a broader array of health professionals beyond the typical team of a qualified, board-certified pediatric cardiologist, including any of the subspecialties (electrophysiology, catheter intervention, echocardiography), as well as a certified congenital heart surgeon, is important to providing a comprehensive and invaluable service to the management and treatment of patients of any age with CHD. This combination allows a lifelong working association to optimize care.

The usefulness of the interprofessional team approach to the care of ACHD can be seen by the development of centers for ACHD. A Resource for ACHD is the Adult Congenital Health Association ( http://www.achaheart.org/ ). The complexity of clinical issues to be addressed within ACHD centers points directly toward establishment of clinical care teams as an ideal method to provide shared expertise to care for patients. Each team must include at least one individual who can be considered a CHD expert as well as a specialist in adult cardiology. Other personnel include surgeons, anesthesiologists, nurses and technicians, social and financial counselors, coordinators, and subspecialty physicians, particularly geneticists and obstetricians/gynecologists. A comprehensive collaborative care team can improve results for mother and child through a concerted collaborative approach that relies on a thorough understanding of patients’ underlying cardiac pathology and its anticipated interaction with the pregnancy and ongoing close evaluation and communication with a team of trained and experienced specialists, including (but not limited to) cardiologists, obstetricians, anesthetists, pediatricians, clinical nurse specialists, and clinical geneticists. Although data are limited, a collaborative interprofessional approach to care of ACHD has shown good outcomes. Based on information available concerning oral infection and bacterial endocarditis as well as CVDs in general, it is important that the oral health provider be considered as a valuable member.

Congestive heart failure management

Congestive heart failure (HF) is one of the major chronic diseases in the United States, with more than 5.1 million people affected, and accounts for 1 in 9 deaths. As part of the constellation of conditions known as heart disease, it is the number one cause of death in the United States. To meet the challenge of managing HF, multiple health professionals need to be involved; interprofessional models of care are proving to be useful. Teams consisting of several health professionals, including primary care medicine, cardiology, pharmacy, nursing, and exercise physiology, have been shown to be effective in providing quality care for patients with congestive HF. In a study of collaboration in the Veterans Affairs system to reduce HF hospitalization, a collaborative model with a primary physician and pharmacist performing medication reviews, the unadjusted results showed a 37% reduction in the rate of hospitalization for HF at any time (hazard ratio, 0.63; 95% CI, 0.44–0.89). Adjusted results showed a 45% reduction (hazard ratio, 0.55; 95% CI, 0.39–0.77) among those who had received a home medicine review. Unadjusted results showed a 37% reduction in rate of hospitalization for HF at any time (hazard ratio, 0.63; 95% CI, 0.44–0.89). Adjusted results showed a 45% reduction (hazard ratio, 0.55; 95% CI, 0.39–0.77) among those who had received home medicine reviews compared with controls.

Additionally, a retrospective chart review was performed on adult patients with an ejection fraction of 40% or less and a diagnosis of congestive HF. They were seen by a single provider type (HF team, cardiologist, or primary care physician) at least twice within a 12-month period at an academic county hospital. Utilization rates of any angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) and any beta-blocker were robust across provider types, though evidence-based ACEI/ARB and beta-blocker were greatest from the HF team. Doses of evidence-based therapies decreased markedly in the non-HF team groups. The percent of patients prescribed optimal doses of an evidence-based ACEI/ARB and beta-blocker was 69%, 33%, and 25% for the HF team, cardiologists, and primary care providers, respectively ( P < .0167).

Patients followed by the HF team were more frequently prescribed evidence-based medications at optimal doses. This finding supports using specialized interprofessional HF teams to attain greater adherence to evidence-based recommendations in treating systolic HF. Finally in a study to determine whether the management of HF by specialized multidisciplinary HF disease-management programs was associated with improved outcomes, subgroup analysis of the 9 studies using specialized follow-up by a multidisciplinary team showed similar results (summary RR = 0.77; 95% CI, 0.68–0.86; test of heterogeneity, P >.50). Seven of the 9 studies did not show any significant association between intervention and reduced hospitalization, but the 2 studies that used follow-up by primary care physicians and telephone failed to show any significant reduction in hospitalization (summary RR = 0.94; 95% CI, 0.75–1.19). In fact, one of the studies demonstrated a higher risk of hospitalization for patients receiving intervention (RR = 1.26; 95% CI, 1.04–1.52). Of the 11 studies, only 6 reported mortality as an outcome. None of these studies found any association between intervention and mortality (summary RR = 1.15; 95% CI, 0.96–1.37; test of heterogeneity, P >.15).

Human immunodeficiency virus/acquired immunodeficiency syndrome collaborative models

As discussed, the CCM is a widely adopted approach for ambulatory care improvement in the setting of chronic diseases like HIV. HIV disease is now a chronic illness requiring lifelong therapy. This therapy often prevents AIDS and results in rapid control of HIV viral replication but only partially restores immune function resulting in inflammation-associated and/or immunodeficiency-associated complications. HIV-infected adults with suppression of HIV replication remain at risk for progressive serious non-AIDS events that include CVD, cancer, kidney disease, liver disease, osteopenia/osteoporosis and neurocognitive disease, metabolic disturbances, and end-organ damage. This population is at greater risk than the general population of developing clinical manifestations of early aging.

The need for oral health care is at least twice as prevalent as the unmet need for medical care among people living with HIV. Within this chronically infected population, oral health is among the highest unmet need and the least federally funded. In 2011, Gardner and colleagues observed that “for individuals with human immunodeficiency virus (HIV) to fully benefit from potent combination antiretroviral therapy, they need to know that they are HIV infected, be engaged in regular HIV care, and receive and adhere to effective antiretroviral therapy” and based on these observations developed a treatment cascade. Optimally, the CCM for HIV occurs within the context of this “treatment cascade”, a commonly used conceptual model targeted largely toward medicine that quantifies the delivery of services to persons living with HIV across the entire continuum of care. Along this cascade, there are many opportunities for the oral health care team to provide appropriate interventions.

The PCM-DH represents a team-based enhanced health care model that could also work well in the setting of HIV. It has been suggested that in the setting of HIV, the health care team would be composed of the HIV/primary care provider, specialty medical care, clinical pharmacist, care coordinator, dentists, and nursing. This team would work closely with support services to ensure service delivery and integration. This combination would touch on multiple elements of the CCM model: self-management support, clinical information systems, health care organization, and community resources. Optimally, patients would have a trusted relationship with their physician and dentist, each of whom leads a team of clinical care providers and staff who take collective responsibility for delivering comprehensive, coordinated care that addresses all of a patients’ health care needs. Compassionate, culturally competent, comprehensive, prevention-based care is provided by both the medical and dental homes. Together this health home delivers comprehensive preventive care and broad-based multi-disease management within a multidisciplinary team-based setting. The importance of this collaboration is emphasized in the curriculum recently developed by the US Department of Health and Human Services HRSA HIV/AIDS Bureau on HIV oral health for primary care providers. Information technology, promotion of an active partnership with educated patients, and coordination of care are central tenants of the PCM-DH. It has been shown by the Institute of Medicine that this infrastructure helps reinforce patients’ compliance with prescribed treatments and behavioral interventions.

As a part of the health care team, the oral health provider is well positioned to impact the HIV epidemic across the continuum of care. The AIDS Care Cascade begins with knowledge of HIV status. Knowledge of status is critical. It has been demonstrated that individuals who are aware of their status are less likely to engage in risky behaviors. The oral health care team (OHCT) could advise individuals on the CDC’s current recommendations on routine testing, conduct a salivary rapid test, or refer for testing. The OHCT can ensure patients are linked to or retained in medical care and can inquire about adherence and compliance. Oral examination reveals oral mucosal manifestations of HIV in more than 50% of HIV-infected individuals who are not on antiretroviral therapy and in greater than 20% of those on antiretroviral therapy. These lesions may be a presenting sign of HIV infection and are often detected with lack of adherence, development of resistance, or incomplete immune reconstitution. This information is critical to the health of patients and to their health care team. Medical-dental interactions can have a significant local and potentially systemic impact within the HIV-infected individual.

The Special Project of National Significance (SPNS) Oral Health Initiative parent study, conducted by the HRSA, was intended to increase access to and promote retention in oral health for persons living with HIV through replicable and sustainable, delivery models. This initiative embodied multiple elements of the CCM. The data set (N = 2469) covered 12 US states, including rural and urban districts, and one US territory. Fifteen sites were located in New York, New York; San Francisco, California; Miami, Florida; New Orleans, Louisiana; Chapel Hill, North Carolina; Eugene, Oregon; US Virgin Islands; Lane County, Oregon; Norwalk, Connecticut; Hyannis, Massachusetts; Chester, Pennsylvania; Jefferson, South Carolina; Tyler, Texas; and Green Bay, Wisconsin. The sites delivered various models of oral health care in university hospital dental clinics, community health centers, private dental offices, mobile dental units, and AIDS service organizations. A recent analysis of SPNS data determined that oral intervention in chronically HIV-infected individuals could decrease oral morbidity. Among the 2178 HIV-seropositive individuals from the US-based SPNS study, chronically HIV-infected individuals were more likely to report oral problems, toothaches, tooth decay or cavities, and/or dental sensitivity in the 12 months before baseline data collection compared with newly diagnosed individuals. Chronically HIV-infected subjects were also more likely to require oral surgeries, restorative treatments, endodontic treatments, and more than 10 clinic visits as compared with newly diagnosed subjects. Subjects had worse oral health compared with newly HIV-diagnosed subjects. Overall, findings based on both self-perceived oral health and service utilization data suggested that oral health care delivery within the first year of HIV diagnosis may protect HIV-positive individuals from declining oral health as one moves to chronic infection (R Burger-Calderon, JS Smith, K Ramsey, J Webster-Cyriaque. SPNS Innovations in Oral Health Care Initiative Team, Oral Health Outcomes in Relation to Time Since HIV Diagnosis: The Potential Impact of Early Oral Care. 2016, unpublished).

Interactions at the University of North Carolina, Chapel Hill site incorporated several CCM principles. The team included infectious disease experts, dentists, a dental case manager/hygienist, and community partners. The dental case manager/hygienist worked closely with social workers and nurses to coordinate dental care and appointments with medical care clinical case management to ensure regular follow-up by the care team. Electronic patient records accessible to both the treating physicians and dentists meant that clinical information systems were available to ensure ready access to patient data. Aggressive patient education about oral manifestations of HIV and oral hygiene facilitated effective self-management support for patients. Provider education on oral health and HIV/AIDS oral manifestations through Area Health Education and local community health care centers facilitated building partnerships with community programs to promote referral for comprehensive dental care and allowing for the building of medical-dental homes. At baseline, subjects received comprehensive examination and treatment plan. Participants were seen at least every 6 months for dental prophylaxis/debridement, oral HIV education, and oral self-care instruction; information was collected including periodontal metrics. Comprehensive dental care included dental prophylaxis at least every 6 months, scaling and root planing, oral hygiene instruction, extractions, and restorative and prosthetic dental treatment. Although at baseline periodontal inflammation was prevalent regardless of antiretroviral therapy status, the intervention resulted in improved oral and systemic health outcomes. In virologically suppressed subjects, the intervention decreased periodontitis with concomitant interleukin 6 decrease and CD4 increase. These findings suggest a relationship between periodontal inflammation, oral microbial translocation, and HIV status. Recognizing that the control of oral infection and inflammation is critical to the HIV chronic disease model, collaboration between medical and dental professionals is important to achieve the goals of increasing access to care, reducing new infections, and most importantly improving health outcomes.

Mental health collaborative models

Interprofessional care is useful in mental health because of its capacity to provide and coordinate a variety of responses to individuals with complex health and social care needs. Health care providers, such as psychologists, mental health nurses, pharmacists, occupational therapists, social workers, and case managers, play increasingly important roles in the delivery of mental health services. As part of the National Mental Health Strategy developed by the Commonwealth of Australia, the National Standards for Mental Health Services in Australia provide guiding principles to mental health service providers on the delivery of services, treatment, care, and support to mental health consumers.

In the United States, interprofessional collaboration has been used to manage a variety of mental health disorders. In the mental health setting, interprofessional collaboration was perceived to facilitate shared decision-making by addressing time barriers and providing more opportunities for patients to discuss their medical-related concerns. Some health care providers also perceived that mental health patients may be more comfortable in discussing certain treatment concerns with nonmedical providers (such as pharmacists) compared with their medical practitioners. Examples of interprofessional collaborative care for alcohol/substance abuse, schizophrenia/psychosis, and dementia is provided next.

Alcohol/substance abuse

In the area of alcohol and substance abuse, there are currently several approaches to collaborative interdisciplinary education, practice, and/or research referred to as interdisciplinary collaborative addiction education (ICAE). The ICAE movement is still in the early stages of development. The Substance Abuse and Mental Health Service Administration (SAMHSA) is facilitating the evaluation and adoption of the best of these practices through various grant programs. These programs have focused on teams of trained health professionals from medicine (particularly primary care, psychiatry, and emergency medicine), nursing, psychology, pharmacology, and social work. Community health centers have also become a major location of care. These community settings use a variety of health care professionals (eg, advanced practice nurses, physicians, dentists, social workers, counselors, and pharmacists). The patient population in these settings is largely underserved, disenfranchised, and of low income. They commonly present with chronic social and health-related problems. Providing effective quality care for these patients is a constant challenge for health professionals, and team support is a key factor in maintaining workplace harmony and satisfaction for team members. As mentioned, to promote collaboration in alcohol and substance abuse, the SAMHSA has awarded grants to promote the Screening, Brief Intervention, and Referral for Treatment (SBIRT) approach with adults in primary and community health settings to intercede in the problem of alcohol and substance abuse as early as possible.

The promotion of ICAE initiatives is essential for implementing SBIRT in individuals with potential or actual alcohol and other drug abuse problems. Interprofessional collaboration in addictions has the promise of using team models to implement SBIRT as appropriate depending on the professional role. At the University of Pittsburgh, SBIRT uses collaborative groups by impacting risks associated with substance abuse, which is an ideal health issue for interprofessional collaborative practice because substance abuse is an individual patient and overall community health concern. Bringing together the health disciplines in collaborative practice helps to deconstruct stereotypes associated with substance use and facilitates linkages between fragmented health care sectors.

Schizophrenia/psychosis

Psychotic disorder, one of the most debilitating mental conditions, requires a coordinated approach to provide the best outcomes of care. The ability to find effective methods to involve a variety of health care disciplines in the clinical decision-making processes for the management of psychotic disorders can improve care and yield benefits for patients. An interprofessional approach that involves the collaborative efforts of psychiatry and pharmacy services can be vital in achieving positive therapeutic outcomes within an inpatient care setting. The collaboration between psychiatrists and pharmacists in the inpatient psychiatric setting has the potential to reduce the incidences of polypharmacy and lead to effective patient care as a result of (1) obtaining an accurate medication and physical history, (2) linking each prescribed medication to the psychiatric condition, (3) identifying medications that are being used to treat side effects, (4) initiating interventions to ensure medication compliance or adherence, and (5) prevention by regularly considering the appropriateness of the medication for the condition. Additionally, the side effects of many antipsychotic medications result in development of a dry mouth or xerostomia that could lead to severe dental caries. The inclusion of an oral health care provider to this team could help to significantly improve oral health outcomes as well as overall health and well-being.

Dementia

The management of patients with dementia requires a multifaceted approach as well as multi-professional collaboration of key health care disciplines to ensure a high-quality outcome for this devastating and debilitating disease. The ability to achieve a positive therapeutic outcome with patients with dementia generally involves the active participation of multiple disciplines given the complex and progressive nature of dementia. The quality of individualized treatment revolves around the interprofessional relationship that exists among the disciplines of psychiatry, pharmacy, and psychology with geriatrics/primary care medicine and nursing as it relates to the management of the observable behavioral and psychological disturbances of the disorder. Again, patients with dementia may lack the ability to effectively maintain adequate oral hygiene and access routine dental care. It is important that an oral health provider is knowledgeable and skilled in caring for the special needs population, including those with mental health challenges.

Cancer

Care of patients with cancer has a long-standing tradition of collaborative practice, particularly across multiple subspecialties in medicine. Tumor boards (or cancer committees) that bring together health professionals from a broad a range of medical professions have been the standard of care for patients with cancer for 4 decades. More recently, these models have incorporated dental, nursing, pharmacology, and social work professionals to bring their professional expertise to cancer care. Collaborative research across multiple clinical centers has been the mainstay of improvements in cancer treatment with the Cooperative Group Program (Eastern Cooperative Oncology Group, the Southwest Oncology Group, and so forth) that has now evolved into the National Clinical Trials Network, providing many of the latest advances in chemotherapy protocols for patients with cancer. Even surveillance of cancer survival has involved a collaborative process through Surveillance, Epidemiology, and End Results programs.

Thus, cancer treatment has had a long-standing history of a collaborative approach to care of patients with cancer. However, this approach has been relatively slow to incorporate other health professionals outside of medicine. More than 55% of the National Cancer Institute (NCI)–designated comprehensive centers (the high level of designation for cancer treatment) did not have a dental program. At these centers, two-thirds of patients with head and neck cancer had a dental evaluation with oral assessment before receiving radiation therapy. None of the centers in this survey of NCI-designated cancer centers had standard protocols in place for preventive dental care to prevent oral complications from cancer treatment.

In a study to evaluate the effect of the intensity of interprofessional collaboration on hospitalized patients with cancer, the analysis revealed the existence of significant differences between patients who are cared for by teams operating with a high intensity of collaboration and those who are cared for by teams operating with a low intensity of collaboration, as measured by the mean satisfaction ( P <.001) among a specific group of patients (patients who have a high level of education and perceive their state of health as poor), mean uncertainty ( P = .047), and adequacy of pain management ( P = .047). The analysis also found no significant difference ( P = .217) in their length of hospital stay.

Despite the deliberate pace of progress, education and training for health professionals caring for patients with cancer has led to collaborative models for training health professionals. Building on the Interprofessional Education Collaborative Expert Panel’s recommendations, oral health has been used as one exemplar of interprofessional cancer education. Also, the Transforming HEENT to HEENOT program at New York University has incorporated oral cancer screening and oral assessment into nurse practitioner, physician, physician assistant, and nurse-midwife training.

In another example, the National Center for Integrative Primary Healthcare was launched as a collaboration between the University of Arizona Center for Integrative Medicine and the Academic Consortium for Integrative Health and Medicine to develop a core set of integrative health care competencies and educational programs that embraces interprofessional primary care training and practice, has become a required part of primary care education. As part of this program, primary care screening and management of patients with cancer is part of the core competencies. The program has developed a shared set of 10 “meta-competencies” involving a diverse interprofessional team. Team members represent nursing, the primary care medicine professions, pharmacy, public health, acupuncture, naturopathy, chiropractic, nutrition, and behavioral medicine. Also, the University of Massachusetts Medical School implemented the Cancer Prevention and Control Education initiative, an interdisciplinary curriculum focusing on behavioral and psychosocial aspects of cancer prevention, control, and research. This curriculum uses an interdisciplinary operations committee that developed courses, clerkships, and programs. Each education program stressed the team approach. The evaluation of this curriculum demonstrates its potential for shaping a collaborative attitude among health care providers.

Models of interprofessional education have also extended to various service learning activities for health care profession students. The University of Texas at San Antonio has developed an interprofessional care program for refugees in the San Antonio area. The use of this interprofessional model has resulted in holistic and accessible health care for the refugees in San Antonio. Patients receive complimentary comprehensive care, and students benefit from development of cultural competence reinforcement of humanitarian values. As the dental students reflected, “We started attending the clinic as a service learning project. We then became their advocates, treated them at our dental school, and became knowledgeable about our community’s dental clinics while offering tailored referrals.”

Discussion/Future Direction

The collaborative models that involve patient-centered as well as community-based preventive interventions have the ability to increase access to care, improve health outcomes, and reduce the burden of disease and the cost of care for those living with chronic disease, “a perfect storm” for the Triple Aim of Berwick. Understanding of this relationship and development of interprofessional models that will accommodate oral health outcomes as a measure of improvement in management of chronic disease will be important to improved overall health outcomes in this group of patients. As stated earlier, challenges exist that have impeded integration of oral health into team-based models of care, keeping this concept from being fully implemented. In order to improve integration of oral health care into chronic disease management models, there will need to be continued growth and development in reorganization of health care systems as well as reimbursement systems that cover oral screening or preventive serves for other nondental providers and electronic records that allow access for all health providers. Using a combination of these approaches, some groups have been able to innovate and demonstrate improvement using a variety of theories and models and advances in technology aimed at chronic diseases that are most devastating and debilitating among citizens nationally and globally. Although there has been implementation of models and systems that will enhance the collaborative model and interdisciplinary practice, there are still significant challenges in bringing all of the members of the health care team together leveraging adequate opportunities for communication and decision-making. Additionally, the attention to how oral health may contribute to better overall health outcomes should be evaluated and made a part of innovation in chronic disease management.

The challenges discussed earlier only muddy the waters because the health care system is a very confusing and complex entity that has not adequately addressed the needs of those who are chronically ill. In order to reverse this trend, we all must learn to embrace models that address all facets of health care, all members of the health care team, and technology that will facilitate better communication and more effective and efficient management for those who fall into this group of patients. Additionally, the oral health care provider must take a more prominent place in model evolution for chronic disease management. Inclusion will inevitably bring about a more comprehensive approach and better disease outcomes.