As a result of the Surgeon General’s report on oral health, there has been a widespread emphasis on improving oral health care and access for vulnerable populations, especially socioeconomically disadvantaged children. However, there is a looming health crisis facing older adults, especially those living in long-term care facilities.
The U.S. Centers for Disease Control has found that one-third of people over age 65 have untreated dental needs, and the American Geriatrics Society estimates that more than three-quarters of residents of long-term care facilities have difficulty performing oral hygiene care or cleaning their dentures, yet receive little or no help with these tasks. The Blue Cross and Blue Shield of North Carolina Foundation and Fellows Anna Adams and Mary Lanier Zaytoun are doing something about that.
When UNC School of Dentistry clinical assistant professor Dr. Christine Downey, where both Anna and Mary Lanier are students, approached them about expanding a pilot project she launched to improve the oral health of geriatric patients in long-term care at the Durham VA’s Community Living Center, they saw an opportunity to develop a Schweitzer Fellowship project with potential to provide immediate impact. Since Dr. Downey did her residency at the Durham VA, she has relationships with key stakeholders which have proved invaluable in implementing the Fellows’ project.
As Fellows, Anna and Mary Lanier are establishing individual oral health care protocols for patients and conducting a training program for staff at Durham VA’s Community Living Center. A key element of their success has been educating nursing assistants to become Oral Health Champions in which they assume primary responsibility in managing the oral care of the residents on their assigned units. To formally document the oral health care delivered and needs identified, the Fellow created an oral care note in patient charting to integrate oral care into the daily workflow.
Anna and Mary Lanier each describe their efforts as “infiltrating” the culture of the facility in order to institutionalize oral care. “We have worked tirelessly to infiltrate their culture and instill in the nursing staff a greater understanding and appreciation for the role of oral health in overall health and wellness,” says Mary.
Their persistence has paid off—even if when it means conducting staff trainings at 4 a.m. During one graveyard shift training, Anna recalls a nursing assistant who perched on the edge of her chair nodding along throughout their presentation. The assistant stuck around at the end, asking questions about specific problems she faced brushing one of her patient’s teeth and told Anna and Mary that the training had been helpful.
“It was clear to me that she was invested in her patients’ oral care and that we had armed her with more tools to be able to serve them,” says Mary. “That was all that I needed to be convinced that we are making a difference.”
In another instance, Anna and Mary, while doing rounds with the nursing staff, encountered a resident that ostensibly provided his own oral care, but when asked to demonstrate his daily routine, it quickly became obvious he lacked the manual dexterity to perform the necessary tasks.
“Not only did we address this issue by stating in the patient’s Oral Care Note that he required partial assistance when brushing, but we were also able to refer him to a dentist for a lesion in his mouth, which had been bothering him for a long time,” Anna says. “But because no one had been assisting him with his daily oral hygiene routine, the lesion had gone unnoticed.”
The most surprising element of their Fellowship experience was learning that change takes time. The Fellows recall presenting all of their “grand ideas” about improving oral health care on the long-term care unit to their Durham VA mentor, Nursing Supervisor Lorraine Galkowski, who immediately cautioned them to focus on the most important pieces of oral health in order to avoid overwhelming nursing staff. Modifying the scope of their project, meanwhile, has ensured that everyone involved is looking at the overall goal of improving oral health.
Knowing the importance of developing relationships with patients, she accompanied the Fellows on a visit to facilitate trust. “Watching Lorraine with the residents was the perfect reminder of truly loving and respecting all people equally and unconditionally,” Mary Lanier said. “It emphasized the importance of not just caring for people’s teeth, but caring for people as a whole – body, mind, and spirit. This was a wonderful refresher on a lesson and an attitude that I hope to carry as we continue our Schweitzer year and beyond—throughout my whole health care career!”