1 Oral Health Referral Workflow OptimizationThis tool is a component of the Oral Health Integration Toolset, which accompanies the Organized, Evidence-Based Care Supplement: Oral Health Integration implementation guide. These tools are designed to support primary care practices in the process of incorporating oral health preventive services. This PowerPoint slide deck can be saved, modified, and used in your presentations with practice leaders and staff. You may find it helpful to use the speaker notes to guide your talking points during presentations. Also, see Oral Health Integration Referral Mapping: A Coach’s Guide for additional discussion of this process. View to download this and other tools in the toolset, and dozens of other helpful resources. The Oral Health Integration in Primary Care Project was sponsored by the National Interprofessional Initiative on Oral Health, a consortium of funders and health professionals who share a vision that dental disease can be eradicated, and funded by the DentaQuest Foundation, the REACH Healthcare Foundation, and the Washington Dental Service Foundation.

2 Attendee List Name RoleRecord the names and roles of attendees on this slide for inclusion in a summary report. For the most comprehensive and knowledgeable discussion, attendees should ideally include, at a minimum, those whose roles “touch” referrals: the clinician leader from the pilot team or a representative of the clinical care team implementing oral health integration, preferably the person who is responsible for completing the referral information; the referral coordinator or person responsible for tracking referrals; a quality improvement representative, someone who is knowledgeable about reporting; an information technology representative, someone who is knowledgeable about the practice’s EHR and making changes to support referral order entry and tracking; and dental partner (especially if co-located).

3 Oral Health Integration: Dentistry Referral WorkflowPurpose: Review an example referral workflow, and plan the future state for oral health referrals. Agenda items: Review referral example. Plan future state for dental referrals. Develop task list and plan oral health referral process pilot with follow-up. Mapping the oral health referral workflow is designed to help your practice think about how dental referrals resemble medical-surgical referrals, and how they may differ. In many practices this workflow will closely resemble existing processes. However, in order for the oral health workflow process to operate effectively and efficiently, there may be changes identified that will need to be tested. The agenda for this workflow mapping session includes review of an example primary care to dental referral, discussion of the steps and data needed to complete the referral handoff, planning your future state for dental referrals, and development of a task list and plan for implementing the referral pilot, which includes plans for evaluation and follow-up. 3

4 Goals of a “Structured Referral” to External DentistryPatient leaves primary care office with referral to specific dentist/dental office, understands what to do, what to expect, whom to contact. Agreed-upon set of information sent from primary care to dentist. Dentist sends consultation note back to primary care. All referrals documented in EHR as structured data. The goals of a “structured referral” to dentistry include: The patient leaving the primary care office with a referral to a specific dentist or dental office, understanding what to do, what to expect, and whom to contact if problems arise. An agreed-upon set of information being sent from the primary care office to the dentist, so the dentist understands the reason for the referral and has sufficient information about the patient’s health to be able to safely provide appropriate treatment. The dentist sending the primary care provider a consultation note documenting when the patient was seen, what was done, and any future treatment plans. All referrals being documented in the EHR as structured data so they can be tracked by the primary care team, and the referral process can be monitored to ensure patients found to have active disease are, in fact, referred. These goals exist irrespective of the patient’s insurance status, and whether or not the patient has a pre-existing relationship with a dentist. See the Referral Agreement Template (http://www.safetynetmedicalhome.org/sites/default/files/Referral-Agreement-Template.docx) for suggestions of topics to discuss and agree upon with a referral partner. 4

5 The dentist creates a consultation report after seeing the patient. The primary care oral health referral workflow requires 1) developing, or having a pre-existing, network of dentists prepared to receive formal referrals*, and 2) an agreement outlining shared understanding of the referral process between primary care providers and dentists. *It is important that a practice is able to refer all patients in need of dental care. This may necessitate having multiple dental referral partners to ensure a patient with Medicaid or no dental insurance has a referral option as well as patients with commercial dental insurance. This is an example of a common medical-surgical referral workflow that has been adapted for dental referrals to an external dentist. There are several key features pertaining to dental referrals: The referral is a joint clinical decision between the primary care clinician and the patient/family, which is reflected as an order in the electronic health record. This order is designed to prompt the ordering provider to enter the clinical context and information the dentist needs to address the reason for the referral. The clinical assistant ensures the patient leaves with written information on the referral: contact information for the dentist, what should happen next, and what to do if there are problems with the referral. The referral coordinator processes the referral order: includes verification of insurance, clerical and clinical information to accompany the referral, and transmission to dental office. The dental office reviews the referral, contacts the clinician for more information, if needed, or to answer the clinician’s question without having to see the patient. The dentist creates a consultation report after seeing the patient. The consultation report is sent to primary care, associated with the referral order, and is sent to the clinician to review. FACILITATOR NOTES How information is sent back and forth from primary care to dentistry is subject to available technology. Technologies include fax, e-fax, traditional mail, synchronous secure messaging, direct messaging of a continuity of care document, or via health information exchange. 5

6 In-House Referrals are Often Handoffs, Yet with Clear Information RequirementsIn-house referrals have the potential to be treated like handoffs, which reduces the administrative burden. However, the information requirements are the same as for external referrals. There are five main information requirements, each of which has a source of information, as well as a recipient: The decision to refer to dentistry, made by the provider, should be documented as an order so the person responsible for tracking the referral or handoff at a later point in time, can identify patients who were needed a dental appointment. This order can be set up close immediately upon being signed so that it does not create downstream work for the referral coordinator. Once the provider has made the decision to refer, the relevant clinical information that led the decision to needs to be available to the dentist at the time the patient is seen. Insurance information, obtained from the patient, is ultimately needed by the dental office. A practice will need to determine where the best step in the process is to obtain this information. However, the best time to obtain this information is when the patient is in the office, because this may determine whether the referral to dentistry can be an internal handoff or an external referral. The dental office is the source of appointment information, which the patient needs to know. In a co-located dental practice, the goal should be to schedule the dental appointment before the patient leaves the medical office. It may be possible for the appointment scheduler or the clinical assistant to schedule the dental appointment during end of visit activities while the patient remains in the office, or the patient may go to the front desk to schedule before leaving. Finally, the primary care team is responsible for communicating the process to the patient: what will happen next, what the patient needs to do, contact information for the dentist, and what to do if there are problems with the referral. This may be documented in an After Visit Summary or through some other method to enable the patient to leave the primary care office with complete process information. Remember: The goal for all of these information transfer tasks is to complete the task before the patient leaves the primary care office. Failure to do so increases the total amount of work required and reduces the chance that the patient will successfully complete the dental visit. 6

7 For Formal Referrals Frequently Most of the Work is Done by the Referral CoordinatorAppointment Information Insurance Information Clinical Information Process Information Documentation of decision These informational tasks occur in all referrals. The “culture” in many primary care clinics is such that signing the order is done by the provider, but frequently the referral coordinator is responsible for all other informational tasks, often including entering the clinical information into the referral order. Although there may be some perceived “advantages” to this method such as reducing work for a busy clinician, this workflow shifts a clinical task onto a non-clinician, which increases the amount of time the task requires, and it often leads to the specialist receiving large amounts of irrelevant information that can obscure the reason for the referral. 7

8 What’s Wrong with This Picture?Advantages Disadvantages Providers don’t have to spend time filling out clinical information. Care team doesn’t spend time on referrals. Note: These “advantages” are all due to workload shifting rather than efficiency. Referral office uses protocol to enter clinical information. Requests for more info from team takes far more time. Value of clinical information sent to consultant is limited. Bottleneck at referral office. Patient leaves office without key information. Language barriers for referral coordinator undermine the referral. The “advantages” noted above are primarily due to shifting the work that needs to be done to gather the referral information from the care team to the referral coordinator, rather than improving efficiency of the referral process. This shift in the work load leads to many disadvantages for the patient, for the referral coordinator, for the provider and care team, and for the dental consultant. 8

9 Doing “Right Now’s Job Right Now” Saves Total WorkInsurance Information Clinical Information Appointment Information Documentation of decision Process Information Contrast this with a workflow in all of the referral information work is done at the time the decision to refer is made while the clinician’s thinking is fully activated around the reason for the referral – doing “right now’s job right now” – This approach has many advantages. It reduces the total time required to complete referral, it means the patient can leave the visit in which the referral was made with all the information he or she needs to see the specialist, and it improves the quality of information the specialist receives which will lead to a better patient experience in the specialist’s office. 9

10 What’s Different? Advantages Disadvantages ???Person who understands reason for referral enters clinical information. Patient leaves clinic with all the information needed. Fewer costly interruptions for more info for care teams. Referral coordinator only gets involved if there are problems with insurance. Language resources are already in place for visit. Additional resources, if needed, go to care teams instead of referral office. ??? These advantages to the patient, care team and provider, and referral coordinator can lead to dramatically improved efficiency, turn-around time, and workload balance across all involved roles, and may allow a practice to allocated additional resources, if needed, to direct patient care, rather than the referral office. 10

11 Now that you know the basics of primary care oral health referral design, let’s get started!Now we’ll take a look at how you might want your future state oral health referral workflow to work, in much the same way as we did when you were optimizing your workflow to include oral health. We’ll keep in mind our goals of efficiency, minimal disruption, and doing “right now’s work right now”, and will also identify some simple metrics that will enable us to see if our changes are an improvement and to avoid unintended consequences. When mapping the future state for referrals, we’ll use the same basic simple office visit map and ask ourselves two questions related to the referral steps: Do we want to add this element of referrals? If we do, where does this component fit best in our process, and who should do it? Finally, we’ll discuss plans to test the future state. This will include: Identifying the scope of the test and what has to be done before the first test. Creating an action plan or task list that contains each task, who is responsible for completing that task, and when the task is to be done. Facilitator’s note: Review each of the information steps, and assist the team to think about how they want to accomplish this step in their practice. The blue text boxes represent the way in which other practices have shared that they accomplish gathering the information. As facilitator, you will: Delete the blue text box if not done in this practice OR Revise wording as needed and drag the connector line to connect with the appropriate box in the office visit map. Add any task(s) done by the practice team to complete the referral step, as indicated by team members. One cell is left blank intentionally on all subsequent slides so the care team members can add anything that is not currently included on the slide.

12 Documenting the DecisionStandard internal referral order Internal referral order that closes as it is signed Triplicate form; one sheet goes to person tracking handoffs For each step of the referral information flow, we’ll examine the tasks performed by members of the care team at that step in the process. We’ll be asking, Do we do this here? Do we do additional tasks that we need to add at this step? Are there things other practices have identified that we do NOT want to do? Facilitator’s note: Review the step of documenting the decision to refer the patient to dental, and assist the team to think about how they want to accomplish this step in their practice. The blue text boxes represent the way in which other practices have shared that they accomplish documenting the decision. As facilitator, you will: Review all blue text boxes, reminding practice that they may choose to keep the box, delete it, or create something new. Delete the blue text box if not done in this practice OR Revise wording as needed and drag the connector line to connect with the appropriate box in the office visit map. Add any task(s) done by the practice team to document the decision, as indicated by team members. 12

13 Gathering Insurance InformationLook online Ask at time appointment is made Include scripting on dental insurance in reminder call Verify dental insurance when patient checks in Gather dental insurance information when handoff decision is made Gather dental insurance information when processing the referral Continue with the next step in supporting the dental referral, gathering insurance information. Facilitator’s note: Review the step of gathering insurance information, and assist the team to think about how they want to accomplish this step in their practice. The blue text boxes represent the way in which other practices have shared that they accomplish gathering the information. As facilitator, you will: Review all blue text boxes, reminding practice that they may choose to keep the box, delete it, or create something new. Delete the blue text box if not done in this practice OR Revise wording as needed and drag the connector line to connect with the appropriate box in the office visit map. Add any task(s) done by the practice team to gather insurance information, as indicated by team members. 13

14 Clinical Information: Getting it from the Medical to the Dental ProviderDentist has access to clinical information in EHR Clinical information sent in referral delivered to dentist Common EHR/EDR platform Triplicate form, one of which goes to dental office Continue with the next step in supporting the dental referral, getting clinical information from the medical to the dental provider. Facilitator’s note: Review the step of getting clinical information from medical to dental provider, and assist the team to think about how they want to accomplish this step in their practice. The blue text boxes represent the way in which other practices have shared that they accomplish this process. As facilitator, you will: Review all blue text boxes, reminding practice that they may choose to keep the box, delete it, or create something new. Delete the blue text box if not done in this practice OR Revise wording as needed and drag the connector line to connect with the appropriate box in the office visit map. Add any task(s) done by the practice team to get clinical information to the dental provider, as indicated by team members. 14

15 Schedule Information: Making the Dental AppointmentClinical assistant has accesses to dental schedule and makes appointment from exam room Referral coordinator calls patient to schedule appointment once referral is processed Dental office calls patient to schedule appointment once referral is processed Patient takes triplicate form to dental office to schedule appointment Continue with the next step in supporting the dental referral, making the dental appointment. Facilitator’s note: Review the step of making the dental appointment, and assist the team to think about how they want to accomplish this step in their practice. The blue text boxes represent the way in which other practices have shared that they accomplish this step. As facilitator, you will: Review all blue text boxes, reminding practice that they may choose to keep the box, delete it, or create something new. Delete the blue text box if not done in this practice OR Revise wording as needed and drag the connector line to connect with the appropriate box in the office visit map. Add any task(s) done by the practice team to make the dental appointment, as indicated by team members. 15

16 Process Information: The Patient Knows the PlanPatient instructions for referral entered in AVS Referral coordinator calls patient to establish a plan after the referral is processed Patient takes one copy of triplicate form home Clinical assistant reviews plan with patient Continue with the next step in supporting the dental referral, helping the patient know the plan for the dental referral. Facilitator’s note: Review the step of process information, and assist the team to think about how they want to accomplish this step in their practice. The blue text boxes represent the way in which other practices have shared that they accomplish helping the patient know the plan. As facilitator, you will: Review all blue text boxes, reminding practice that they may choose to keep the box, delete it, or create something new. Delete the blue text box if not done in this practice OR Revise wording as needed and drag the connector line to connect with the appropriate box in the office visit map. Add any task(s) done by the practice team to assist the patient to know the dental referral plan, as indicated by team members. 16

17 What Happens with the Dental Team?B Now, let’s move on to the dental team, either co-located or a community-based office, and what they need to accomplish for a closed-loop referral to be created. In order to handle a closed-loop referral, the dental office needs to have 1) a process in place to identify patients who are referred from a particular clinician, and 2) a process to create a consultation report and return it to the primary care clinician. In a community-based dental practice the primary care team may have minimal ability to influence how these two processes occur, beyond creating a referral agreement that outlines what is needed. Even in a co-located dental practice, the EDR may need to be programmed to “flag” patients referred internally, or if this cannot be done, another electronic or manual process may need to be created to identify these patients. Once the dental practice can identify referred patients, they will need to create a process to create and return a consultation report, something than many dental teams are not familiar with. Thus, a referral agreement is essential to ensure effective communication and care coordination. Potential components of a referral agreement fall into three categories, not all of which are necessary for every referral relationship: What a primary care-dental referral agreement needs to address: parameters for appropriate referrals; pre-referral work-up, if any; timeliness of appointing patients, after referral is made; what to do about patients who can’t be contacted to schedule an appointment; what to do about patients who do not keep an appointment; parameters for requests for primary care information or clinical advice without a referral; responsibility for tracking referrals; and patient follow-up. What information needs to accompany a referral: service request of dentist/reason for referral, demographic information, additional relevant clinical information—the usual primary care medical-surgical referral template can be modified, as needed. What information should be sent back from the dentist: date patient was seen, what was found, what was done, brief treatment plan, follow-up arranged. See the modifiable Referral Template for Primary Care Referrals to Dentistry (http://www.safetynetmedicalhome.org/sites/default/files/Referral-Template-Primary-Care-Dentistry.docx) and a Sample Completed Referral Form (http://www.safetynetmedicalhome.org/sites/default/files/Sample-Referral-Primary-Care-Dentistry.pdf) for guidance as to what should be included in this information exchange. 17

18 Results Reporting Dental office sends reportReferral coordinator receives report Provider receives report Do you currently receive reports from either your co-located (if you have them) or community dentists? If yes, how are these handled? If no, remembering that we have adapted a medical-surgical referral workflow to dental referrals, what happens when the result comes back into your practice? Is there any reason that this workflow cannot be used for dental referrals, as well as for medical-surgical referrals? The challenge that community-based dental partner(s) face is identifying the patients who are referred by the primary care partner at the time they are seen, so that they can make sure the consultation report is sent back to the primary care provider. Facilitator’s note: Review each of the steps, and: Delete the step if it is not done in this practice OR Revise any wording as needed and drag the connector line to connect with each step above. Add any other tasks related to how results are reported, as indicated by team members. FACILITATOR REMINDER The work done to map the future state for oral health referrals should be verbally summarized for participants before moving on to review the task list. Following the workshop, a visual map of the future state should be shared with the team to ensure all members of the team are on the same page moving forward. 18

19 Consider Simple Data Measure routinely, more frequently when starting.Process Metrics Denominator - # patients referred Numerator - # patients referred with dental consultation report received Population Metrics (examples) Pediatrics - % with documented dentist by 15 months old Adults with diabetes - % seen by dentist within 12 months Pregnant women - % with dental visit within first two trimesters of pregnancy What metrics does the practice use to track their medical/surgical referrals? Can these be used or modified to apply to oral health referral tracking? Facilitator’s note: Keep notes about the team’s discussion of metrics, so that these can be included in the summary report. 19

20 Task List Task Who When Before the newly mapped future state oral health referral workflow can be tested, there will likely be items or tasks that need to be completed. If these have been identified during the mapping, they should be noted here. Noting who will be responsible for making sure the task is completed, and by when this will be done, should be included in the task list. The end product of this mapping is a summary report, which include a graphic future state report, a task list with assignments, and a timeline for task completion. (An example of this report can be seen in the appendix to Oral Health Integration Referral Mapping: A Coach’s Guide.)

21 Source: Developed by Qualis Health for the Oregon Primary Care Association “Body-Mouth-Spirit: Oral Health Integration Project.” Supported by the DentaQuest Foundation. 1st ed. Seattle, WA, August 2015. 21

22 About the Oral Health Integration in Primary Care ProjectThe Organized, Evidence-Based Care Supplement: Oral Health Integration joins the Safety Net Medical Home Initiative Implementation Guide Series. The goal of the Oral Health Integration in Primary Care Project was to prepare primary care teams to address oral health and to improve referrals to dentistry through the development and testing of a framework and toolset. The project was administered by Qualis Health and built upon the learnings from 19 field-testing sites in Washington, Oregon, Kansas, Missouri, and Massachusetts, who received implementation support from their primary care association. Organized, Evidence-Based Care Supplement: Oral Health Integration built upon the Oral Health Delivery Framework published in Oral Health: An Essential Component of Primary Care, and was informed by the field-testing sites’ work, experiences, and feedback. Field-testing sites in Kansas, Massachusetts, and Oregon also received technical assistance from their state’s primary care association. The Oral Health Integration in Primary Care Project was sponsored by the National Interprofessional Initiative on Oral Health, a consortium of funders and health professionals who share a vision that dental disease can be eradicated, and funded by the DentaQuest Foundation, the REACH Healthcare Foundation, and the Washington Dental Service Foundation. For more information about the project sponsors and funders, refer to: National Interprofessional Initiative on Oral Health: DentaQuest Foundation: REACH Healthcare Foundation: Washington Dental Service Foundation: The guide has been added to a series published by the Safety Net Medical Home Initiative, which was sponsored by The Commonwealth Fund, supported by local and regional foundations, and administered by Qualis Health in partnership with the MacColl Center for Health Care Innovation. For more information about the Safety Net Medical Home Initiative, refer to