If we were to examine the leading causes of death within a typical community of modest size and diversity, we would likely find heart disease, cancer, stroke, respiratory diseases, diabetes, Alzheimer’s, and possibly suicide. If we switched our lens to causes of disability, we would probably see depressive disorders, anxiety disorders, and substance use disorders on the list. If we turned to risk factors for premature death and disability, we would find smoking, overweight, poor diet, sedentary lifestyle, and substance abuse.
One thing we would probably not see among the statistical summaries is the number of people who have combinations of chronic physical conditions, behavioral health challenges, and oral health problems. Yet if we ask our local clinicians, they will tell us story after story about patients presenting with multiple risks across these domains of health. They will also describe the clinical challenges of treating patients who have potentially deadly combinations of physical illness, mental illness, substance use problems, and oral health problems. How can we motivate a patient to manage their diabetes if they are also struggling with depression? How can we help a patient with high blood pressure practice healthy eating if their mouth is full of pain?
These are not easy questions to answer, but they are not uncommon, especially in safety net health care settings. Here we have an opportunity to learn from safety net providers who are taking steps to create patient-centered care models that integrate medical care, dental care, and behavioral health care. We also have obstacles to address in the form of distorted payment models, health information technology gaps, and educational programs that silo the disciplines of medicine, dentistry, and behavioral health. These obstacles are standing in the way of what community clinicians really want to do, which is provide excellent care within a comprehensive, integrated care model.
This is a time of great uncertainty for the future of health care. It can also be a time of opportunity if we use it to spotlight the need for integrated care models that will improve health and contain costs. As starting points, we can think about how to advance integrated care models through collaborative strategies in which:
- Community providers are laboratories for designing and testing integrated care models.
- Health foundations are strategic conveners, connectors, and co-funders.
- Health plans, Accountable Care Organizations, and State Medicaid agencies are policy partners and payment innovators.
- Health professions education programs are producers of inter-professional training activities.
- Advocacy groups and public health agencies are sources of insight and guidance.
- Federal agencies such as CMS and HRSA are catalysts and sources of innovation funding.
- Elected officials are policy leaders for systems of care that improve health and contain costs.
This is a daunting agenda, but good things are already happening. We can accelerate this work by starting strategic conversations within our own spheres of influence. We can also learn from research and promising practices from the field, as reflected in the annotated bibliography below.
The association between dental, general, and mental health status among underserved and vulnerable populations served at health centers in the US. Vy.H. Nguyen, et. al. Journal of Public Health Dentistry, July 2017.
Abstract. Counties aim to provide comprehensive care to residents. It is critical to ensure that this care incorporates primary, behavioral and chronic disease management and oral health care. Approaches such as accountable care organizations, service integration and the implementation of parity for behavioral health services and treatment offer opportunities to treat the whole person rather than provide fragmented services and treatment. Both oral health and mental health are integral components of an individual’s health and well-being and can impact an individual’s economic productivity and ability to work. Poor oral health has been shown to:
- lead to malnutrition, which in turn influences physical health
- cause serious or fatal infections
- be linked to heart disease, stroke and diabetes, and
- be associated with respiratory diseases such as pneumonia.
When treating individuals with mental illness, particularly those with serious mental illnesses, paying attention to oral health is important because it is often neglected and deteriorates. This population has an average of 6 or more decayed, missing or filled teeth than the general population and is 3.4 times more likely to have lost teeth. Individuals living with mental illness are susceptible to certain oral health conditions, including enamel erosion, gingivitis, tooth abrasion, oral pain disorder, dry mouth and jaw and muscle pain. For example, depression and stress increase the level of the hormone cortisol, which can contribute to periodontal disease. Furthermore, medications, lack of motivation for maintaining good dental hygiene, dental phobia, dental care costs, geography and access to care have all been shown to contribute to oral diseases.
Abstract. More knowledge is needed regarding what works to prevent oral health problems and reduce disparities in oral health. Motivational interviewing (MI) has demonstrated utility for improving health behavior, including among those with severe mental illness. This study tests whether MI enhances the efficacy of an oral health education intervention in individuals with severe mental illness. Sixty individuals were randomly assigned to MI plus oral health education or oral health education alone. Plaque scores, oral health knowledge, and self-regulation were assessed at baseline and at 4 and 8 weeks. Repeated-measures ANOVA showed improvement (p < 0.05) in plaque, autonomous regulation, and oral health knowledge across time for both groups; however, individuals receiving MI improved significantly more when compared with those receiving oral health education alone. Results suggest that MI is effective for enhancing short-term oral health behavior change for people with severe mental illness and may be useful for the general population.