TeleDentistry Better Practice Award - Darling Downs Hospital and Health Service

Good oral health is vital in maintaining overall health and wellbeing and can minimise the risk of developing diseases and conditions such as gum disease, tooth decay, heart disease, stroke and aspiration pneumonia in older adults. Poor oral health can also affect residents quality of life. Contributing factors include pain, discomfort, speech and swallowing difficulties which can impact upon appetite and nutrition, lack of sleep, change in behaviour and social withdraw due to low self-esteem. Regular dental check-ups and daily oral hygiene routines are essential in maintaining a healthy mouth, teeth and gums. A multidisciplinary team approach is also important when undertaking oral health assessments and developing care and treatment plans for residents.

Darling Downs Hospital and Health Service’s (DDHHS) Residential Aged Care Facilities were recently awarded the 2016 Better Practice Award in the category of “Health and Wellbeing, Clinical Care/Medication Management, Technology” for their TeleDentistry initiative to maintain mature mouths. The innovative project involved a collaborative approach between three DDHHS RACF’s & a Multi-purpose Health Service, the Telehealth team, the Oral Health Clinic (OHC), residents and their families. TeleDentistry allows residents to undergo oral checks and dental reviews via a live videoconferencing appointment with a dentist while remaining in the comfort of their own room and Darling Downs have shared their project and the positive outcomes achieved.

Why TeleDentistry?

Over 20% of the Darling Downs region is classed as “outer regional” and a further 1.2% as “remote”. Older adults are at high risk of developing oral diseases and dental problems and 16.60% of the regions population are aged over 65 years. It is projected that by 2036 Darling Downs will have the third largest proportion of its population aged over 65 years in Queensland (24.80%).

Prior to the TeleDentistry initiative a dentist from the DDHHS Oral Health Clinic would visit each residential aged care facility, however visits were not maintained due to the ad hoc nature of appointments which were often leading to an inefficient use of the dentist’s time. Residents would instead have to make a visit to the Oral Health Clinic with frail residents requiring transportation via Queensland Ambulance Service due to increasing physical and cognitive needs. A standard check-up was taking approximately 4-8 hours out of the residents day causing disruption to their daily routine.

What we did?

The TeleDentistry program was trialled at Darling Downs Nursing Home in Toowoomba in November 2014. The Oral Health Therapist visited the RACF and performed a chart audit, reviewing dental care plans. Each consenting resident received an oral review in the privacy of their own room. The Oral Health Therapist records the dental review and management plan in the resident’s record in collaboration with the Registered Nurse. If the Oral Health Therapist finds an issue that requires further investigation, a referral is made by the Registered Nurse for the resident to be reviewed by a Dentist via TeleDentistry. A clinic time is then scheduled where the Oral Health Therapist uses live streaming of the aged care resident via an inline flexi scope camera with an intra-oral probe attached. The Dentist views the live feed from their office and advises on appropriate treatment to commence locally, or advises that the resident is required to be seen in person at the Oral Health Department.

Each aged care facility has a nurse allocated to the oral health portfolio. When the Oral Health Therapist makes initial contact with the facility, they spend time with this nurse to educate them on the requirements to make the program successful including ordering of specific products to be used in oral health care.

To improve the knowledge, skills and attitude of aged care staff in oral health, each nurse working in an aged care facility is required to undertake mandatory online training regarding oral health. Training is delivered online via the DDHHS online learning portal. Modules included:

• oral health assessment
• scenarios
• standard precautions
• oral health care planning
• hazardous techniques activity
• toothbrush alternatives, and
• daily oral hygiene.

After the successful trial, it was decided to expand this program to the remaining aged care homes in a similar rural environment. The program was rolled out successfully to a further three RACFs (including one Multi-purpose Health Service) in 2015.

TeleDentistry Process/Staff Roles:

The following outlines the staff roles in the TeleDentistry project;

• DDHHS Telehealth Team set up the initial TeleDentistry equipment
• RACF residents and/or their family consented to TeleDentistry through the RACF Facility Manager
• Chart audit completed for each consenting resident by the Oral Health Therapist and Dental Assistant
• Oral health plan reviewed by the Oral Health Therapist
• Audit of bathroom and current oral health storage by the Oral Health Therapist
• Oral review of each resident by the Oral Health Therapist
• If further investigation/referral was required, the Registered Nurse of the RACF would refer the resident to the dentist
• The Oral Health Therapist would revisit the facility and use the TeleDentistry equipment to send images, via live feed, to the Dentist
• DDHHS’ Dentist identified the issue and recommended further intervention either on site or at the oral health clinic
• The Facility manager would advise the Oral Health Therapist when new residents arrived so a review for them could also be arranged.

Learnings:

A review of the pilot was undertaken from December 2014 to February 2015. During which time a total of 34 residents were seen. Of the 34 residents, 25 exams (74%) were performed and required no further treatment. Nine residents (26%) were reviewed by the Dentist via TeleDentistry and of those, only 3 (9%) were required to be seen in person at an Oral Health Clinic. In addition, all new residents are now seen within two months of being admitted to the Nursing Home. After the trial was extended to incorporate a further three RACFs/MPHS, an evaluation found that a total of 116 residents from the four RACFs/MPHS had dental screening at their residential facility. Of these residents, 33 residents required a TeleDentistry review (28%). Of those requiring a TeleDentistry review, only 19 residents (16%) required an in-person appointment at an Oral Health Clinic.

TeleDentistry was positively supported by RACF residents and their families. Although the majority were not aware of TeleDentistry before the program commenced, they were happy to support a system whereby residents did not need to be taken out of their familiar environment into a foreign clinical environment.

TeleDentistry was also well supported by RACF staff due to the decreased pressure on staff and families to escort residents to oral health facilities. This in turn saw a decrease in the use of medication to prevent anxiety in residents.

Outcomes & Benefits:

Findings to date from the four RACFs/MPHS have shown that the TeleDentistry program has prevented 97 residents (out of 116, or 84%) from travelling unnecessarily to an Oral Health Facility. In addition, the following outcomes have been achieved:

• Increased awareness of residents’ oral health needs and oral health requirements
• Reduction in Queensland Ambulance Service and nurse escort time and costs for transporting residents to Oral Health Clinics
• Addresses a major barrier for residents accessing appropriate oral health care
• Reduction in the number of inappropriate referrals to a dentist by first screening residents 
• More efficient use of Dentist time
• Minimum disruption to resident's daily routine
• Patient comfort maintained
• All residents are up to date with yearly visits
• Proactive approach finding areas of concern before they become a problem to the residents i.e. pain
• Staff are becoming more in-tune with technological advances.

Future:

The TeleDentistry program will be rolled out to an additional 4 RACFs in 2016. It is also planned that a formal evaluation/research project will also commence this year. With the expansion of the program, other Oral Health Therapists and another Dentist have been trained in the TeleDentistry model to ensure continuity of service and sustainability.

It is anticipated that 2017 will see the program rolled out to other private RACFs across the Darling Downs region.

Jacinta Pitt, DON/Facility Manager, Mount Lofty Heights Nursing Home