- Need: To improve rural residents' oral healthcare.
- Intervention: MORE Care creates interprofessional oral health networks to 1) better integrate oral health into primary healthcare and 2) coordinate oral health between primary and dental healthcare.
- Results: Operating in 3 states, MORE Care has led to increases in fluoride varnish administration, improvement in interprofessional communication, and patients' improved self-management of their daily oral health.
Rural areas face many challenges when it comes to oral healthcare: They are more likely than urban areas to be within Dental Health Professional Shortage Areas, have higher rates of poverty, and have fewer dental providers accepting Medicaid. Because of these and other factors, rural residents are more likely to have missing teeth and more dental caries.
However, the integration and coordination of oral health between primary and dental care teams can help rural patients improve their oral and overall health. The Medical Oral Expanded Care (MORE Care) Initiative connects Rural Health Clinics (RHCs) with dental care partners. These interprofessional oral health networks (IPOHNs) create interdisciplinary care teams that provide patient-centered oral care. The initiative began in South Carolina and is being replicated in Pennsylvania and Colorado.
MORE Care partners with:
- DentaQuest Institute
- Medical University of South Carolina James B. Edwards College of Dental Medicine
- Colorado Rural Health Center
- Pennsylvania Office of Rural Health
- South Carolina Office of Rural Health
The initiative in South Carolina includes a partnership with the Medical University of South Carolina that received additional funding from a 2016-2018 Health Resources & Services Administration (HRSA) Grant to States to Support Oral Health Workforce Activities.
MORE Care helps primary care providers:
- Develop oral health referral networks
- Integrate oral health preventive measures into their practice
- Test ways to overcome challenges in interprofessional practice
MORE Care helps dental providers:
- Develop referral networks with primary care providers
- Adopt medical-dental referral practice characteristics
- Encourage risk-based disease management practices
In efforts to improve health information technology (HIT) among rural partners, the Colorado Rural Health Center facilitated changes to the Quality Health Indicators (QHI) informatics system, which is traditionally used for hospital system metrics and quality improvement, to add a format that collects oral health data. This system change allows MORE Care clinics to integrate oral health into their current measurement system so that oral health is integrated into the established system rather than appearing as an extra stand-alone effort.
The Pennsylvania Office of Rural Health created the Dental Delivery Systems Coordinator (DDSC) position. The DDSC, a registered dental hygienist with public health licensure, provides oral health training to primary care providers and serves as liaison between the rural health teams and the Pennsylvania Office of Rural Health.
The South Carolina Office of Rural Health added new positions called quality improvement coaches (QICs). These coaches help rural practices implement and evaluate quality improvement measures and visit RHCs to help them identify challenges and opportunities.
MORE Care involves a total of 23 RHCs and 16 dental care partners in 3 states, resulting in:
- Increases in fluoride varnish administration
- Increases in oral health risk assessment and evaluation by medical providers
- Improvement in interprofessional communication between medical and dental care teams
- Improved dental home establishment
- Patients' improved self-management of their daily oral health
The program was featured in a 2017 DentaQuest white paper called MORE Care: Narrowing the Rural Interprofessional Oral Health Care Gap and in a 2017 RAC Monitor article.
In many private insurance and Medicaid plans, it is difficult for providers to get reimbursed for oral health services for older children and adults. Care teams will benefit from training in effective management of coding and billing as well as understanding of Prospective Payment System (PPS) and renegotiation strategies.
Other factors can prevent effective care coordination and integration:
- Breakdown in management or communication
- Differences in providers' education or training
- Lack of HIT interoperability
- Lack of a quality improvement environment
- Time constraints for providers
Program coordinators used a modified version of the Institute for Healthcare Improvement (IHI) Breakthrough Series Collaborative, the Qualis Health – Oral Health Delivery Framework, and Smiles for Life: A National Oral Health Curriculum during training and implementation.
State programs asked colleges of dentistry and existing oral health programs like Colorado's Cavity Free at Three and Pennsylvania's Healthy Teeth Healthy Children to provide personnel for onsite training at the RHCs. The three State Offices of Rural Health involved with MORE Care recommend yearly onsite training.
A program like MORE Care can be implemented at the clinic level, but program coordinators recommend implementing it at the community or state level to promote more widespread changes in oral healthcare integration. Program coordinators also give the following advice:
- Build a leadership team
- Develop a business plan
- Gain buy-in from the community and healthcare leaders
- Gather qualitative and quantitative data for program evaluation
- See if your state has an oral health coalition, which can provide additional support
For more information on planning and implementing an IPOHN, please read the "MORE Care: Narrowing the Rural Interprofessional Oral Health Care Gap" section titled State Offices of Rural Health and Medical Oral Expanded Care Initiation.
Kristine Tourkantonis, MORE Care Project Coordinator
Integrated service delivery
Networking and collaboration
Rural Health Clinics
Colorado, Pennsylvania, South Carolina
June 6, 2017
Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.