Older adults have limited access to oral health care, and currently, there is no preventive or therapeutic dental care benefit provided under Medicare. Approximately one half of older adults age ≥65 have no dental care benefit (Flowers et al., 2019). In addition, one third of older adults living in poverty have untreated decay, and 36% are edentulous. These rates are more than four times the rates of both conditions among older adults with annual incomes ≥$47,000. Rates of use for dental services among older adults reveal similar income disparities (Catalanotto et al., 2017).
Eighty-one percent of adults age ≥65 have multiple chronic health conditions (National Council on Aging, 2018). For several chronic health conditions, oral-systemic links have been reported. For example, the inflammatory process in diabetes, cardiovascular disease, kidney failure, and respiratory conditions (e.g., chronic obstructive pulmonary disease) is a common pathophysiological process that increases the risk for periodontal disease. Chronic conditions such as depression, hypertension, dyslipidemia, reflux, and asthma often require multiple medications, which result in decreased salivary production and xerostomia (Atchinson et al., 2019). The resulting dry mouth is a climate conducive to accumulation of plaque, bacteria, dental caries (tooth decay), and inflammation associated with risk for oral infection and transmission to the respiratory system (Atchinson et al., 2019). Chronic conditions affecting mobility, such as Parkinson's disease, stroke, arthritis, and dementia, make self-care, completing oral hygiene, and obtaining adequate nutrition a challenge. Older adults with cancer experience acute and chronic side effects of their chemotherapy and/or radiation treatments, including xerostomia, candidiasis, mucositis, oral ulcers, and osteonecrosis. Although oral side effects such as these make oral hygiene difficult, it is important to accomplish because xerostomia and oral lesions increase risk of infection in immunocompromised oncology patients. Older adults with mental health problems such as depression, schizophrenia, bipolar disorder, or substance use disorder may experience years of neglect of physical health, oral health, and nutrition. Use of mood stabilizers and/ or antipsychotic medications is associated with gingival hyperplasia, tooth decay, tooth loss, and periodontal disease (The Gerontological Society of America [GSA], 2017; Kressin et al., 2002). Educating older adults, as well as interprofessional teams of nursing, nurse practitioner, and dental students, about the importance of oral health promotion practices and their links to overall health is essential in preventing comorbidities associated with chronic health conditions and improving the overall health status of older adults, especially in underserved communities.
The Interprofessional Senior Oral Health Community program was funded by an Accelerating Interprofessional Community-Based Education and Practice grant from the National Center for Interprofessional Practice and Education, whose goals are to redesign health care education and delivery to be better integrated (Harder + Company Community Research Team, 2019). The aims of the Senior Oral Health program, an innovative workforce redesign project, were to: (a) meet the oral health needs of a high risk, underserved group of older adults; (b) encourage sustainability of the project through education of care managers, volunteer members of the Bronx Health Corps, and home health aides (HHAs); and (c) prepare nurse, nurse practitioner, and dental students to demonstrate evidence of mastery of oral health and Interprofessional Education Competencies (Interprofessional Education Collaborative [IPEC], 2016). The purpose of the current article is to report an innovative education–community partnership that impacts patients' oral and overall health, increases access to care, improves patient satisfaction and has a potential for reducing patients' costs while enhancing interprofessional clinical experiences for students.
The project received Institutional Review Board (IRB) approval through New York University (NYU) and was exempt from oversight. Students provided informed consent prior to their participation in the interprofessional project. The IRB did not require older adults, volunteer members of the Bronx Health Corps, care managers, or HHAs in the community to sign informed consent forms as all information was de-identified. Following participation in the program, older adults were given sample toothbrushes, toothpaste, and floss supplied by Oral Health America and NYU College of Dentistry (NYUCD). Volunteer members of the Bronx Health Corps, care managers, and HHAs did not receive an incentive to participate.
This initiative brought together the robust resources of the Hartford Institute for Geriatric Nursing (HIGN) and the Oral Health Nursing Education and Practice (OHNEP) Program, both located at NYU Rory Meyers College of Nursing (NYU Meyers), to accelerate interprofessional education and practice. Both entities play a national leadership role by developing interprofessional tools to integrate the Interprofessional Education Competencies and disseminating expertise in oral health and care of older adults (IPEC, 2016). The partnership also included NYUCD, a nationally recognized leader in dental education and practice.
The Core Competencies for Inter-professional Collaborative Practice report, developed in 2011 and updated in 2016, provided the foundation for the interprofessional component of the program. The Interprofessional Education Competencies emphasized the importance of educating future health care workers to be responsive to health care needs, working collaboratively, and incorporating the patient/family and/or the community as a team member (IPEC, 2016; IPEC Expert Panel, 2011).
Prior to initiating this program, the Senior Oral Health team met with the 15 other awardees of the Accelerating Interprofessional Community-Based Education and Practice grants at the National Center for Interprofessional Education in Minneapolis for a 3-day team-based kick off called New Models of Care Require New Models of Learning Institute. At this workshop, the team received technical assistance, expert consultation, and resources to support the program (Harder + Company Community Research Team, 2019). Ongoing support was provided throughout the project with webinars, personal coaching, and scheduled site visits (Harder + Company Community Research Team, 2019).
The Interprofessional Senior Oral Health Community Program was launched with an interactive, interprofessional development workshop with NYU Meyers and NYUCD faculty, and Regional Aid for Interim Needs (RAIN) community leadership. The workshop explored the shared nature of the team's work, the needs of the RAIN community, the importance of oral-systemic health for older adults, as well as significance of interprofessional education for students. This workshop was a catalyst for developing a collaborative environment for faculty, students, older adults, and staff. The RAIN leaders helped identify senior centers for educational programs based on location and older adults' ability to speak and understand English.
Between 2017 and 2018, interprofessional students from NYU Meyers and NYUCD were invited to participate in the Interprofessional Senior Oral Health Community Program. These students included undergraduate nursing students in the Hartford Institute Geriatric Undergraduate Scholars (HIGUS) program, graduate nursing students in the family nurse practitioner (FNP) program, and dental students in the predoctoral Doctor of Dental Surgery (DDS) program. Courses with time for student participation and learning objectives that met project objectives were selected. Students were then invited to participate. Students did not receive course or clinical credit but did receive a certificate of participation upon project completion. Previously successful collaborative work with Bronx Health Corps and community organization led to successful recruitment of older adults, HHAs, volunteer members of the Bronx Health Corps, and community care managers.
Table 1 indicates the number of students, older adults, HHAs, volunteer members of the Bronx Health Corps, and community care managers who participated in the program at nine RAIN senior centers. In Spring 2018, the equivalent HIGUS course did not run, and thus, undergraduate students did not participate that semester. By Spring 2018, as the total number of dental students was already higher than the total number of undergraduate and graduate nursing students and project objectives were met, further dental student recruitment was deemed unnecessary. Prior to their clinical experience, students were required to complete an assignment that included: (a) review of six Interprofessional Education and Practice (IPEP) eBooks addressing the Core Competencies for Interprofessional Collaborative Practice (Greenberg et al., 2016; IPEC, 2016), (b) completion of the Smiles for Life (SFL) Oral Health courses related to adult and older adult oral health (Clark et al., 2010), and (c) review of the Tooth Wisdom® education modules and teaching script developed by and used with permission from Oral Health America.
Interprofessional Students and Trainees Participation in Oral Health Education by Semester
A pre- and posttest study design was used to assess a change in oral health knowledge for older adults, volunteers, care managers, and HHAs following a standardized oral health education presentation. The design also included assessment of student self-reported change in attainment of interprofessional competencies based on completion of the Interprofessional Collaborative Competencies Attainment Survey (ICCAS). All students were assigned to an interprofessional student team (undergraduate nursing HIGUS, graduate FNP, dental) and required to meet prior to their assigned presentation date to coordinate their roles in presenting the Tooth Wisdom PowerPoint® at RAIN senior centers. On their scheduled date, each interprofessional team, accompanied by the project manager and/or project assistants familiar with the educational content and objectives, met at the designated senior center to present a Tooth Wisdom topic to either older adults, HHAs, care managers, or volunteers. Students completed an ICCAS prior to and following completion of the community oral health educational experience. Older adult, volunteer, and staff participants who attended the Tooth Wisdom community oral health sessions were asked to complete pre- and post-session knowledge surveys.
Based on a review of the literature, the ICCAS was selected to assess changes in students' self-reported interprofessional competencies following an interprofessional community-based clinical experience (Archibald et al., 2014; Schmitz et al., 2017). The ICCAS, a 20-item survey, has test items that are congruent with the Interprofessional Education Competencies and has appropriate validity. The Likert scale ranges from 1 (strongly disagree) to 6 (strongly agree) in the following six domains: Communication, Collaboration, Roles and Responsibilities, Collaborative Patient- and Family-Centered Approach, Conflict Management and Resolution, and Team Functioning. Open text boxes were available for students to add comments. Psychometric data for the ICCAS have shown strong internal consistency and reliability with a pre-exposure Cronbach's alpha of 0.96 and a post-exposure alpha of 0.98. Factor analysis data provide evidence of construct validity, as do mean rating differences from pre- to posttest for each pre- and post-experience item pair.
Older adults, HHAs, care managers, and volunteers completed paper versions of the Tooth Wisdom 10-item pre- and post-oral health knowledge questionnaire. The questionnaire also had an open text box to add narrative responses. Each questionnaire also included demographic questions focused on age, gender, race, type of insurance, last dental visit, and reason for dental visit. The pre- and post-oral health knowledge questionnaires were completed prior to and following the education session. The content validity for the knowledge questionnaire was established by an expert panel of dental hygienists.
In Fall 2017 and Spring 2018, students completed the pre- and posttest ICCAS. At each session, students collected the pre- and post-oral health knowledge paper surveys completed by participating older adults, HHAs, care managers, and volunteers. Data were uploaded into a Qualtrics database by the project manager or project assistant. Names were not included on knowledge questionnaires or surveys; demographic data were de-identified.
Community Oral Health Education Intervention
In Summer 2017, interprofessional student teams led Tooth Wisdom Oral Health presentations, each approximately 30 to 40 minutes long. Content delivery was monitored by the project manager and/or project assistant. Following completion of the Summer 2017 presentations, RAIN staff and older adults requested that student teams present new oral health content so that they could expand their oral health knowledge base. The presentation during Fall 2017 was adapted to meet this community need and based on the original Tooth Wisdom modules. Faculty oral health experts developed two new modules: Oral Health and Diabetes and Oral Health and Nutrition. All three oral health modules included content related to tooth brushing, flossing, oral hygiene, denture care, how oral health may affect overall health, cavities, root decay, gum disease, dry mouth, and oral cancer.
The Oral Health and Diabetes module included the oral-systemic link between diabetes and oral health, information about hidden sugar in foods, and mouth care for older adults with diabetes. The Oral Health and Nutrition module included links between the overall health of older adults, nutrition, and oral health. Nutritional content, such as diet meal planning, healthy eating choices, mobility, and access to food and food choices, was highlighted. Additions were made to the Tooth Wisdom Oral Health module offered to HHAs, care managers, and volunteers, including content on tips for providing oral health care to older adults with dementia.
Data analysis of the pre- and post-ICCAS and knowledge surveys were conducted by a NYU Meyers statistician. Data summaries were reported by semester cohort groups and included data from the ICCAS or oral health knowledge questionnaire. Data analysis included means and standard deviations, as well as p values and effect sizes (Cohen's d) where appropriate. Cohen's effect size standards were considered as follows: small = 0.2, medium = 0.5, and large = 0.8. For unmatched data in Summer 2017, only descriptive summaries were provided. For each semester cohort, available demographics were reported, as well as mean pre- and post-scores for oral health knowledge (for older adults, volunteers, care managers, HHAs), or mean ICCAS total and subscale scores (for students). Knowledge score summaries include ratings of the educational session, where available. Although a formal qualitative analysis was not completed, qualitative responses in ICCAS subscale open comment text boxes were noted.
Results include: (a) demographics; (b) changes in older adult, HHA, care manager, and volunteer oral health knowledge; (c) changes in student ICCAS pre- and posttest scores; and (d) student qualitative responses about interprofessional older adult oral health teaching experiences. Results are presented by semester because the composition of student, older adult, volunteer, HHA, and care manager participants varied each semester of program implementation. The amount of missing data on the knowledge questionnaires and ICCAS surveys is unknown.
Older Adult Findings
The findings reported in Table 2 reveal that for Summer 2017, older adult participant population was predominantly non-Hispanic Black (41%) and Hispanic (36%), reflecting the demographics of the community served by RAIN. Although the majority of participants (71%) were insured by Medicare, approximately one third (30%) were dually insured by Medicare and Medicaid, providing some evidence of the low-income level of a significant portion of the RAIN population. Despite the fact that 70% of older adults have no dental benefit (GSA, 2017), 62% of participants reported having a dental visit within the past 1 year, with 42% stating the visit was for a “regular checkup.” Two hundred seventy-three older adults completed the Tooth Wisdom module pre-knowledge survey and 203 older adults completed the post-knowledge survey. Although data were unmatched and significance could not be assessed, mean score on the knowledge survey increased from 6.26 (SD = 2.26) to 7.47 (SD = 2.00).
Older Adult, Home Health Aide (HHA), Care Manager, and Volunteer Participants
In Fall 2017, 168 older adults received oral health education using the Tooth Wisdom Oral Health and Diabetes module. Table 2 highlights that demographics data for ethnic/racial composition, insurance status, and dental visits within the past 1 year were similar to the Summer 2017 participants, albeit a smaller older adult cohort. For this semester, oral health pre- and post-knowledge data were matched. The mean score on the knowledge survey increased from 7.67 (SD = 2.54) to 8.28 (SD = 2.59). Although older adult participants started with a high level of knowledge and the effect size was small (Cohen's d = 0.24), the increase in oral health knowledge was significant (p = 0.01). In addition, older adults rated the educational workshop as favorable, with 52% reporting very good and 16% good.
In Spring 2018, a smaller cohort of 59 older adults received oral health education with the Tooth Wisdom Oral Health and Nutrition module. As illustrated in Table 2, although the percentage of non-Hispanic Black participants (22%) was lower than the previous two semesters, a similar percentage of Hispanic participants was noted. The percentage of non-Hispanic White participants (17%) more than doubled. Insurance status and dental visits within the past 1 year were similar to that of Summer and Fall 2017 participants. The oral health pre- and post-knowledge data were also matched for this cohort. The mean score on the knowledge survey decreased from 7.38 (SD = 2.04) to 7.23 (SD = 2.70), and the change in knowledge was not significant (Cohen's d = 0.06; p = 0.65). These findings may be explained by the fact that this cohort's level of knowledge was high at baseline and the cohort size of 59 was smaller than previous semesters.
Home Health Aide, Care Manager, and Volunteer Findings
In Fall 2017, 142 HHAs received oral health education with the Tooth Wisdom module. As highlighted in Table 2, the majority of HHAs were older than 50. The majority of HHAs reported themselves as non-Hispanic Black and Hispanic. Sixty-two percent reported having a dental visit within the past 1 year, with 49% stating “a regular check-up” as the reason for the dental visit. Pre- and post-knowledge data were matched. Mean score on the knowledge survey increased from 7.39 (SD = 1.95) to 7.80 (SD = 1.96). Although HHAs started with a high level of knowledge and effect size was small (Cohen's d = 0.21), the increase in oral health knowledge was significant (p = 0.04). In addition, more than 60% of HHAs rated the educational workshop as very good or good.
In Spring 2018, 30 care managers and volunteers received oral health education with the Tooth Wisdom module. Table 2 shows that, unlike older adults and HHAs, most care managers and volunteers were younger than 50. Data in Table 2 reveal that the ethnic/racial composition of care managers and volunteers align with demographics of the older adult care recipients. Seventy percent reported having a dental visit within the past 1 year, with 73% stating “a regular check-up” as the reason for the dental visit. Pre- and post-knowledge data for this group were matched. The mean score on the knowledge survey increased from 8.47 (SD = 1.63) to 9.23 (SD = 0.86). Although care managers and volunteers started with a high level of knowledge, they yielded a medium effect size (Cohen's d = 0.59), with a significant increase in oral health knowledge (p = 0.01). In addition, care managers and volunteers rated the educational workshop favorably with more than 93% reporting very good or good.
Most older adults, HHAs, and volunteers indicated that they would change oral care routine activities, such as brushing teeth twice daily for 2 minutes, cleaning between teeth, and reducing intake of sugary foods and drinks. It is unknown how many people were already doing these activities.
The findings reported in Table 3 reveal a total of 64 dental and 42 nursing students (26 undergraduate nursing HIGUS program and 16 FNP) participated in the interprofessional, older adult oral health experience. During the Summer 2017 semester, 17 undergraduate nursing HIGUS program students and 33 dental students participated in the interprofessional, older adult oral health educational experience. As reported in Table 3, the mean pre- and post-ICCAS scores for the undergraduate nursing HIGUS program students and dental students were similar. Student data for preand post-total ICCAS scores were not matched, hence, they could not be tested for significance. The six ICCAS subscales all had mean increases from pre- to post-interprofessional educational experience with the older adults (Figure 1).
Summer 2017 mean pre- and post-Interprofessional Collaborative Competencies Attainment Survey (ICCAS) subscale scores.
Data in Table 3 reveal that in Fall 2017, 21 nursing (nine undergraduate nursing HIGUS program; 12 graduate FNP) and 21 dental students participated in the educational experience. Matched mean ICCAS scores for this semester indicate a significant change from ICCAS pretest to post-test for nursing and dental students. There was a larger effect size and an increase of approximately 1 full point from pre- to post-total ICCAS scores for nursing (Cohen's d = 1.38) compared to dental (Cohen's d = 0.66) students. Total ICCAS score change was significant for nursing students (p = 0.003) and just above 0.05 for dental students (p = 0.06). Five of the six ICCAS subscales, namely Communication, Collaboration, Patient-and Family-Centered Approach, Conflict Management, and Team Functioning, showed significant changes from pre- to post-educational experience for nursing students (p value range = 0.002 to 0.04), but not dental students (p value range = 0.056 to 0.12), although all post-ICCAS mean subscale scores increased. The Roles and Responsibilities subscale had a significant change from pre- to post-educational experience for nursing (p = 0.006) and dental students (p = 0.038).
Table 3 reveals that in Spring 2018, the number of students participating in the older adult oral health educational experience was low; only four FNP students and 10 dental students participated. Inferential statistics were not interpretable based on the small sample size and, therefore, are not presented.
Qualitative student comments post-educational experience included: “This was a rewarding experience and I love working with dental students”; “This community outreach experience was very rewarding and enlightening. I learned a lot from presenting and working with the nursing students”; “It was a great learning opportunity to work together to educate patients through interprofessional teamwork on oral-systemic health care”; and “It was a great experience to volunteer with people outside of my program and it made me realize that we should have more interdisciplinary opportunities to work with other health professionals.” Some students noted negative experiences, usually related to difficulty contacting their project partner in advance of the educational experience.
The current article highlights the feasibility of implementing an interprofessional, older adult oral health community program designed to address the gap between older adult health education and care delivery. Given that 70% of adults age ≥65 do not have dental benefits, engaging older adults in oral health education programs aiming to promote oral health self-care addresses an important population health need for this age group (Kramarow, 2019). Moreover, increasing evidence about the linkages between oral health and chronic diseases, such as diabetes, cardiovascular and respiratory disease, stroke, kidney disease, and cancer, amplifies the importance of increased understanding about the importance of regular oral hygiene practices and overall health (Atchinson et al., 2019; Freed et al., 2019; Oishi et al., 2019; Seitz et al., 2019).
An important strength of the current project is that the results demonstrate significant improvements in knowledge acquisition on the Oral Health Knowledge Survey for older adults, HHAs, care managers, and volunteer members of the Bronx Health Corps. Student data for self-reported interprofessional competencies on the ICCAS reflect significant changes on all ICCAS subscales for nursing students and for the majority of ICCAS subscales for dental students. Another strength was students' overall enthusiasm to work together to deliver a quality educational experience for older adults, volunteers, care managers, and HHAs. An essential element for program success was support by the RAIN leadership team and staff. Their willingness to be flexible about accommodating the student teams, whose goal was to educate older adults about oral health and links to their overall health, was invaluable. For example, older adults attending the sessions went to staff and stated, “What is the good of all this information the students [are] providing if we don't have affordable dental care in our neighborhood?” The RAIN leadership team and staff took the issue seriously and undertook an oral health scavenger hunt of their catchment area to develop a list of affordable dental resources for their constituency that was disseminated at each senior center. The importance of leadership and their commitment to transforming the organization's culture in regard to oral health is key to ensuring organizational sustainability of this type of initiative.
Limitations included missing data on some of the ICCAS and knowledge questionnaires, student data based on self-report, lack of measurement of knowledge retention over time, and having some duplicate material in the oral health education modules even with the addition of new content related to diabetes and nutrition in Fall 2017 and Spring 2018. Limitations also included time and scheduling conflicts between undergraduate and graduate nursing students and dental students as well as older adults. Implementation barriers included: cost and time to travel to community senior centers, crowded and conflicting student schedules and clinical course requirements, and time to coordinate student schedules. Aligning student schedules with the availability of older adults and staff at community centers for oral health education sessions was also a challenge. Feasibility and generalizability may depend on further explorations.
This interprofessional, older adult oral health program allowed students an opportunity to work in a community setting where they could develop an awareness of the social determinants of health while engaging in a team building learning experience. Students learned how to collaborate to teach evidence-based oral health care modules to older adults as a team. This innovative project increased the number of nursing and dental professionals with gerontological competencies and interprofessional expertise to enhance oral health knowledge for underserved older adults living in the community. Results provide meaningful data to guide further interprofessional teaching and learning experiences.
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Interprofessional Students and Trainees Participation in Oral Health Education by Semester
|Dental||Nursing (Undergraduate)||Nursing (FNP)||Home Health Aides||Volunteers||Care Managers||Older Adults|
Older Adult, Home Health Aide (HHA), Care Manager, and Volunteer Participants
|Semester||Learners||Topic||Demographics||Insurance||Dental Visita||ICCAS Mean Scores (SD)||p Value|
|Summer 2017||273 older adults (273 pre-survey, 203 post-survey)||Tooth Wisdom® and Oral Health||90% age >65
41% non-Hispanic Black, 36% Hispanic, 5% non-Hispanic White||71% Medicare 30% Medicaid||62%||6.26 (2.26)||7.47 (2.00)||—|
|Fall 2017||168 older adults||Oral Health and Diabetes||90% age >65
38% non-Hispanic Black, 31% Hispanic, 8% non-Hispanic White||74% Medicare 23% Medicaid||67%||7.67 (2.54)||8.28 (2.59)||0.01|
|Fall 2017||142 HHAs||Tooth Wisdom and Oral Health||27% age <50, 34% age 50 to 59, 26% age 60 to 69, 5% age 70 to 79
37% non-Hispanic Black, 41% Hispanic, 2% non-Hispanic White||9% Medicare 18% Medicaid||62%||7.39 (1.95)||7.80 (1.96)||0.04|
|Spring 2018||59 older adults||Oral Health and Nutrition||90% age >65
22% non-Hispanic Black, 44% Hispanic, 17% non-Hispanic White||66% Medicare 24% Medicaid||64%||7.38 (2.04)||7.23 (2.70)||0.65|
|Spring 2018||30 care managers and volunteers||Tooth Wisdom and Oral Health||57% age <50, 20% age 50 to 59, 20% age 60 to 69, 3% age 70 to 79
30% non-Hispanic Black, 47% Hispanic, 3% non-Hispanic White||7% Medicare 10% Medicaid 57% private dental 47% private medical||70%||8.47 (1.63)||9.23 (0.86)||—|
|Semester||Students||ICCAS Mean Scores (SD)||p Value|
|Summer 2017||33 dental||4.39 (0.72)||5.25 (0.51)||—|
|17 nursing (undergraduate)||4.97 (0.97)||5.21 (1.01)||—|
|Fall 2017||21 dental||5.14 (0.68)||5.61 (0.74)||0.06|
|21 nursing (9 undergraduate, 12 FNP)||4.69 (0.69)||5.49 (0.44)||0.003|
|Spring 2018||10 dental, 4 nursing (FNP)||—a||—|
|Total||64 dental 42 nursing (26 undergraduate, 16 FNP)|