SImproving access to healthcare and enhancing health promotion and disease prevention are major priorities for the well-being of the public and a central focus of current federal health initiatives. Furthermore, as recognized by the U.S. Surgeon General in 2000, evidence surrounding the critical importance of the oral-systemic connection is mounting. The unique partnership of the New York University (NYU) Colleges of Dentistry and Nursing provides an opportunity to put into operation a vision of how to increase access to primary healthcare and proactively address oral-systemic issues through an innovative NP-Managed Faculty Practice Model. The following article describes the evolution of the model, which has been guided by evidence-based research and federal legislation urging new paradigms of healthcare delivery.
The Institute of Medicine's (IOM) report, “Crossing the Quality Chasm: A New Health System for the 21st Century,” delineated required elements to overhaul the healthcare system in the United States. The elements included:
- reengineering care processes
- integrating effective information technology
- brokering knowledge and workforce skills
- fostering interdisciplinary team building
- reinforcing care coordination across patient conditions, services, and sites of care across a continuum.1
NYU has responded by incorporating these elements in an innovative primary care collaboration between Dentistry and Nursing, through a unique organizational partnership that promotes oral and systemic health, positively impacting health outcomes. The rationale for such a partnership proves to champion the call for action set forth by the IOM report in 2001, as well as uphold and reinforce the overall mission of NYU, which is to operate as a private university in the public service.
It is essential to understand the strengths that both the NYU Colleges of Dentistry and Nursing bring to this innovative practice model. The NYU College of Nursing (NYUCN) is one of the oldest academic nursing programs with approximately 350 RNs, APNs, and nurse researchers graduating from its baccalaureate, masters, and doctoral programs each year. The College's longstanding focus has been on innovation in research, education, and practice. It continues to be a leader in increasing access to healthcare for underserved urban populations and addressing barriers to improved health. The NYUCN emphasizes and teaches nurses how to optimize the quality of healthcare delivered; a core value is health promotion and disease prevention. The College has a long history of primary care, community outreach, and commitment to expanding healthcare access through school-based health centers, community clinics, mobile health vans, and nurse-managed centers, thereby contributing to reducing health disparities, especially in underserved urban populations and communities.
In a parallel fashion, the NYU College of Dentistry (NYUCD) shares the core values of health promotion and disease prevention. The NYUCD Clinic has over 60,000 new patients, and averages 300,000 patient visits/year. An estimated 15% of Americans see a dentist each year but do not see a primary healthcare provider,2 and 45.8 million people are uninsured.3 Given these statistics, a vision emerged about impacting global health through an innovative primary care model that provided “one stop primary healthcare shopping” by linking individuals enrolled in the NYUCD's oral healthcare system with a primary care practice led by the NYUCN NP Faculty Practice.
Aside from the goals of preparing the next generation of nurses and dentists committed to addressing both the oral and systemic health needs of patients, the NYUCN and NYUCD were also committed to breaking down the “silos” of their respective disciplines. Both colleges and their respective curricula share a core value centering on health promotion and disease prevention,4 which align with the goals of the Healthy People 2010 Initiative5 and the recommendations set forth by the IOM which outline the educational needs of future healthcare professionals.6 NYUCN and NYUCD are engaging in interprofessional collaboration to ultimately increase access, decrease barriers to comprehensive healthcare, and improve clinical outcomes.
NP-managed faculty practice model
The NYUCN NP-Managed Faculty Practice is a primary care practice located on-site at the NYUCD. It operates as a New York State Article 28 Diagnostic and Treatment Center that provides a core of services addressing not only patient-centered, disease-based clinical management but also health promotion and disease prevention in a setting conducive to NP growth and development. A reciprocal referral and consultation pattern between the NP primary care practice and faculty and students in the dental clinics reflects our aim of expanding the healthcare lens through which primary care providers (PCPs), dentists, and NPs view the delivery of effective healthcare throughout the life cycle so that seamless oral-systemic healthcare can genuinely take place under one roof.
A needs assessment survey was conducted to verify the extent of unmet primary care needs and to determine the scope of services at NYUCD that could be provided at the NP-Managed Faculty Practice. Surveys were distributed by the NYUCD staff to all new dental patients over a 14-week period during the spring of 2006. Of the 2,580 patients registered in the admissions clinic who received surveys, 946 (36.7%) surveys were completed and returned. Of the 946 respondents, 293 (33%) indicated they did not have a PCP and 245 (27%) reported they had no medical insurance. In terms of seeking care when ill, 442 (46.7%) respondents said they went to a PCP, 223 (24%) said they visited the ED, and 201 (21%) used hospital-based clinics or health centers for care. Overall, 366 (42%) respondents said they were interested in learning about the primary care services that were offered by the NP-Managed Faculty Practice (see Number and percentage of needs assessment responses by survey item).
Mirroring national survey data, results of this survey indicated that primary care needs were not being met.2 In addition, the results positively confirmed that development of the interprofessional collaboration between nursing and dentistry seizes an opportunity to address unmet primary care health needs within the local population. Based on the needs assessment survey results, primary care services were added to the Article 28 NYUCD operating certificate, which allowed for delivery of dental services as well as primary care services by NPs in a setting familiar and accessible to existing dental patients. This innovative model reinforces the concept of collaboration and care coordination for both oral and physical health problems across dental and nursing sites of care (see Services provided at the NP-managed faculty practice).
Patients are seen by a faculty NP from NYUCN. Patients who have a PCP are offered health promotion services that complement the care they already receive. Those lacking a PCP are offered the option of receiving all of their primary care at the NP Faculty Practice. To provide for continuity of care, every attempt is made for the patient to be seen by the same NP at each visit.
NP faculty practice
The oral-systemic health connection
An emphasis of all of the NYU Nursing and Dental Faculty Practices is to uphold the Surgeon General's recognition that “oral health is integral to overall health” and that the “mouth is a mirror for general health and well-being.”7 Evidence supports that dentists and other oral healthcare providers play a role in influencing healthcare services beyond oral hygiene and treatment. Dentists have the opportunity to screen for general yet highly prevalent health conditions such as diabetes and heart disease.8–10 Further, periodontal disease can be examined relative to a range of other medical conditions, such as: osteoporosis, low birth weight babies and adverse pregnancy outcomes, and certain autoimmune conditions.11–14 Due to the NYUCN and NYUCD collaboration, marketing, educational outreach, and teaching strategies involving nursing, dental, and dental hygiene faculty, the need to consider and proactively address the bidirectional relationship of oral health and physical health has increased (see Case example 1).
The older adult
One of the major healthcare challenges of the 21st century is the provision of quality, comprehensive, cost-effective care for a rapidly changing nation. The elderly population in the United States is expected to double, if not triple, by 2030 with the greatest growth in those age 80 and older.15 The prevalence of chronic illness and disability, especially in those over age 85, is expected to skyrocket.15–17 Healthcare costs are expected to escalate at a rate not seen before with costs for chronic illness estimated to rise 60% by 2050.16 This will occur in a healthcare system where despite recent increased emphasis on gerontology in medical, nursing, and dental curriculum, as well as the emergence of specialized care units in hospitals and the development of alternative long-term care options, the demand for care is predicted to overwhelm the supply of qualified healthcare providers.
Management of chronic illness associated with aging presents numerous challenges. Patients must deal with physical symptoms, disability, emotional impact, complex medication regimens, difficult lifestyle adjustments, and obtaining necessary medical and dental care. The majority of patients face the physical, psychological, and social demands of their illnesses without much help or support from the healthcare system. Even when help is received, it frequently fails to afford optimal clinical care or meet the patients' needs to effectively manage their illnesses (see Case example 2).
It is estimated that despite progress in clinical and behavioral interventions for chronic illnesses, only less than half of U.S. patients with hypertension, depression, diabetes, and asthma are receiving comprehensive care.17 Increased demands on medical care (due to the rapid increase in disease prevalence and the inability of the system to meet the demands because of a poorly organized delivery system) have been cited as factors in this quality gap.6 According to Dr. Donald Berwick of the Institute of Healthcare Improvement, the same systematic downfalls of the healthcare system that plague patients, tax staff as well: “Staff need a culture that acknowledges that the best care comes from people working as a team…they desperately need new systems that make the environments safe for them and their patients.”18
In light of the above projections and within the context of the current situation with regard to chronic illness care, it is obvious that there is a need for the development of comprehensive and effective forms of healthcare delivery to support and promote the health of an ever-increasing number of older adults.6,19 Many of the problems related to chronic illness are preventable through more effective prevention and management. It is well established that premature mortality can be reduced through changes in health risk factors and timely receipt of clinical preventive services. There is evidence in the literature that supports the benefit of interventions for older adults directed at lifestyle behaviors. Proactive, population-based, collaborative, patient-centered care is recommended, as the traditional symptom-based, reactive approach has not proven adequate.16
In the first 18 months since the doors of the NP Faculty Practice opened, 1,089 patient visits have been recorded. Of those, 266 (24%) were individuals age 65 and older, which is greater than the 15% of NYUCD Clinic's segment of older adults. Additionally, half of the clinic visits involved return patients (n = 549). Based on completed patient satisfaction surveys, 95% of respondents (116/122) agreed or strongly agreed that they would recommend the NP Faculty Practice to friends or family searching for a PCP. Of the 510 new patient visits, 220 (43%) were referrals made by dental school faculty or students for health promotion services, diagnosis, and management of systematic health problems, or for medical consultations prior to a dental procedure. These preliminary data support that the NP Faculty Practice at the NYUCD is on track to promote access to high-quality, cost-effective care to patients within a traditional oral healthcare setting.
The NYU NP Faculty Practice at NYUCD continues to evolve and shape a new paradigm of healthcare delivery to meet the bidirectional healthcare needs of adults across the adult life cycle, especially those in advanced age.
It is always an interesting challenge for two health disciplines to colocate their practices, do more than “parallel play,” and actually collaborate in a way that genuinely changes referral and practice patterns. As a group, the NPs have done a considerable amount of internal marketing at NYUCD to familiarize faculty, students, and dental clinic staff about the nursing profession and, specifically, about the role and scope of practice of NPs. For example, NPs have taught second year dental students how to accurately take BP. A chairside NP consultation project with the third and fourth year dental students was designed to raise their consciousness about their patients' health risk profile and the need for primary care and specialty referrals. The community outreach collaboration with the NYUCD Senior Smiles Program has taken the NPs to senior centers throughout the city for Healthy Lifestyles presentations. Both the professional and administrative staff in the dental clinics have been oriented about the NP Faculty Practice and each dental clinic has information available about the NP Faculty Practice including location, numbers to call for appointments, and hours of operation. Direct referral is also made by dental clinic staff and, when possible, NPs see patients on a walk-in basis. It has been interesting to observe a difference in patients' perceptions about the importance of obtaining primary care services versus dental services. Patients appear more accustomed to paying for dental care out-of-pocket but hesitate to allocate personal funds for primary care fees and copays.
With the overall goals of promoting and maintaining health and improving quality of life, the NP Faculty Practice provides a core of services that address not only patient-centered, disease-based clinical management, but also health promotion and disease prevention needs, resulting in truly comprehensive care. Beyond clinical service delivery, data systems capturing the feasibility of this practice model are in place. These systems focus on operations and business results. The systematic collection of the data will allow us to more accurately and efficiently understand many facets of the quality of our performance, including:
- clinical indicators and achievement of benchmarks (quality of care)
- staff and patient satisfaction (people)
- outreach and marketing (service)
- revenue/expenditure balance (financial)
- increased patient enrollment, retention, productivity, credentialing (growth).
The cost-effectiveness of operating the NP-Managed Faculty Practice will take several years to actualize, like building any primary care practice.
Meeting today's challenges
NYU is actualizing a visionary new model of integrated primary healthcare that rises to meet the critical challenges posed by the IOM and other federal calls to action. Our NP Faculty Practice team has overcome challenges that have arisen during this initial period of development; the potential benefits of this model and its impact on global health is promising.
Reconceptualizing healthcare delivery practice patterns and interprofessional collaboration to maximize patient outcomes to better meet the complex bidirectional healthcare needs of adults, especially among those age 65 and older, represents one of the most significant commitments of the NYUCN and NYUCD. The impact of this model may help form a new healthcare paradigm that ultimately reengineers primary care systems that struggle to keep pace with a changing national climate.
Services provided at the NP-managed faculty practice
- Comprehensive health and lifestyle assessments focused on the identification of risk factors for cancer, cardiovascular disease, diabetes, and other chronic illnesses
- Preventive services such as screening for diabetes, hypertension, heart disease, cancer (breast, cervical, colon, prostate), and osteoporosis
- Risk factor reduction interventions including, but not limited to, counseling regarding diet for weight management and general health; exercise for weight loss, aerobic conditioning, and fatigue management; smoking cessation, and birth control
- Full physical exams, including gynecological services
- Diagnosis and management of common acute illnesses
- Management of chronic conditions such as hypertension, diabetes, and asthma
Case example 1
The following case example illustrates the potential of an oral-systemic collaborative practice and is an actual example of an individual who benefited from the collaboration between treatment received at the NYU NP Faculty Practice and NYUCD dental faculty and students.
Prior to initiating dental treatment for severe periodontal disease, a third–year NYU dental student referred his patient, Robert, a 62-year-old businessman, to the in-house NYU Nursing Faculty Practice for a medical consultation related to elevated BP (190/100 mm Hg). Because Robert's periodontal disease was more severe than expected for his age, the dental student realized that his patient could have an undiagnosed systemic disease. Robert had no PCP and stated that he had not had any healthcare in over 20 years due to his self-disclosed "fear of doctors." A comprehensive history, physical exam, and lab work were conducted by the NP.
Upon physical exam, Robert was obese (220 lbs, body mass index 31), had elevated BP (180/110 mm Hg), elevated fasting blood glucose level of 323 mg/dL with a potential diagnosis of type 2 diabetes mellitus and evidence of dyslipidemia (low-density lipoprotein 198 mg/dL; high-density lipoprotein 32 mg/dL). Additional physical exam findings and his electrocardiogram were normal. The NP prescribed antihypertensive medications and a 3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) to reduce his cholesterol, made a referral to cardiology for risk stratification and a stress test to detect asymptomatic atherosclerotic heart disease. His treatment plan included weekly counseling with the NP on therapeutic lifestyle behaviors with weight loss, exercise, smoking cessation, and improved nutrition as priorities.
After 8 weeks, Robert's BP stabilized and his fasting glucose decreased to 162 mg/dL; he was referred back to his dental student for treatment of his periodontal disease, including extensive root planing and scaling. Robert continued to make appointments and see his NP for management of his hypertension, diabetes, related comorbidities and health promotion and disease prevention strategies such as prostate and colon cancer screening and immunizations. Robert's involvement in weekly lifestyle health education visits with the NP was key to the lifestyle modifications he made, all of which contributed to stabilizing and improving his BP, blood glucose, and cholesterol so that he could begin treatment with his dental student for his periodontal disease.
Case example 2
The following case example illustrates primary care provided to an older adult who is a patient at the NYUCN NP Faculty Practice.
Ivan is a 78-year-old recent immigrant from Eastern Europe who presented with the chief complaint of painful oral lesions and weight loss. With the use of an interpreter, Ivan described the gradual onset of a severe sore throat and mouth pain 3 months earlier. At the time, he attributed these symptoms to an upper respiratory infection, but became concerned when they did not improve after a week or so. The patient reported that the pain worsened over time to the point that he was unable to tolerate swallowing solid food and acidic beverages. His decreased intake resulted in a 10-pound weight loss.
Ivan denied any concomitant symptoms including fever, cough, night sweats, fatigue, lymphadenopathy, abdominal pain, diarrhea, melena, or rash. His past medical history was remarkable only for well-controlled hypertension. His current medications included hydrochlorothiazide 12.5 mg and a multivitamin. However, his healthcare maintenance was out of date, having received only minimal preventive healthcare in Eastern Europe. Family history was unknown.
On physical exam, Ivan was found to be thin with multiple oropharyngeal ulcerations of varying size on a base of erythematous, swollen mucosa, compatible with pemphigus vulgaris. His vital signs and physical exam were otherwise unremarkable.
Per clinical guideline recommendations Ivan was referred to oral medicine for mucosal biopsy. Unfortunately, due to extensive disease and fear of mucosal shredding, biopsy was unable to be performed. Blood tests were drawn for circulating antibodies to desmoglein (Dsg), a molecule responsible for cellular adhesion that supports (but does not confirm) the diagnosis of pemphigus vulgaris.
Based on his positive blood test and classic presentation of pemphigus vulgaris, Ivan was started on a high dose of oral corticosteroids and referred to an NYU Medical Center physician who specializes in autoimmune diseases of the skin. His NP was able to comanage his care with oral medication. His oral lesions responded quickly to mucosal prednisone and he was able to have a confirmatory biopsy within several weeks. Baseline labs were drawn to check for signs of systemic illness, including infection, anemia, and liver and kidney disease. Ivan was also referred for a colonoscopy to ensure that his weight loss and anorexia were not due to gastrointestinal malignancy. Healthcare maintenance included appropriate vaccination and discussion regarding prostate cancer screening. Within 2 months, Ivan was tapered off the prednisone, had regained the 10-pound weight loss, and remained a primary care patient in the NYUCN NP Faculty Practice.
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