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Darling Downs Hospital and Health Service - Rural Aged Care Facilities, Qld

Maintaining mature mouths utilising TeleDentistry
Darling Downs Hospital and Health Service - Rural Aged Care Facilities, Qld

Mt Lofty Nursing Home
EAF McDonald Rural Aged Care Facility
Millmerran Multi Purpose Health Services
Milton House Rural Aged Care Facility

Residential - Regional, 80 + beds 

Award descriptors:
Health and wellbeing, Clinical care / medication management, Technology

About the program
Maintaining Mature Mouths utilising TeleDentistry is an innovative model of care enabling Darling Downs Hospital and Health Service’s (DDHHS) Residential Aged Care Facility (RACF) residents to have oral checks and dental reviews via a live streaming videoconference appointment with a dentist.

The Oral Health Therapist, with the support of a Registered Nurse, uses an inline flexi scope camera with an intra-oral probe attached, to provide a real time live feed. From their office in Toowoomba, the Dentist can direct the Oral Health Therapist to locate the probe into the resident’s mouth for examination.

This integrated approach is between DDHHS’ Oral Health Clinic (OHC), Telehealth team, four aged care homes, as well as residents and their families. TeleDentistry has allowed residents to receive optimal dental care while remaining in their own surroundings and eliminated the need for frail residents to be transported to the oral health clinic via ambulance with a nurse escort.

What we did
The TeleDentistry program was initially trialled in January 2014 using a dental probe connected to video conference equipment. The trial highlighted some technical issues which had to be overcome and also provided the opportunity to fine tune operational, administrative and nursing processes. Once the issues were addressed, the trial was recommenced 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 camera. 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. TeleDentistry is not recorded as a service event but is Resident Focused Care.

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.

Video conference equipment exists in all DDHHS RACFs although systems vary with both wireless and connected systems. 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.

In the initial pilot, the flexiscope inline camera was initially on loan to test the feasibility of TeleDentistry. Once the trial concluded, DDHHS elected to purchase the camera as well as an additional machine and travelling hard cases for each machine. A web camera called a MOVI camera was also purchased and installed at the Oral Health Clinic for use in the dental surgery for consultations. Several procedures were also developed for “Telehealth – flexiscope micro vision inline camera set-up” and “Oral health assessment in residential aged care facilities” to document and systemise the current program.

Why we did it
DDHHS covers a large geographical area (85,854 km²) with over 20% of the region classed as “outer regional” and a further 1.2% classed as “remote”.  RACF residents are at significant high risk of developing complex oral diseases and dental problems. In Darling Downs region, 16.6% are aged over 65 years (Queensland 13.6%). By 2036, Darling Downs is projected to have the third largest proportion of its population aged over 65 years in Queensland (24.8%).

Historically, a dentist from a DDHHS Oral Health Clinic would visit RACFs for the resident’s oral health needs. However appointments were often ad hoc leading to an inefficient use of dentist’s time. Over time, these visits were not maintained and became sporadic - some over three years previously. Visiting the Oral Health Clinic became the only option. However, due to the increasing physical and cognitive needs, frail residents required transportation to the Oral Health Clinic via Queensland Ambulance Service. A standard check-up took the resident 4-8 hours away from their residence, causing disruption to the resident’s daily routine, familiar environment and comfort.
Some residents would also arrive at the Oral Health Clinic without a nurse or carer with staff not adequately trained to manage the nursing/medical needs of these residents.

Who worked with us
This innovative TeleDentistry initiative was a collaboration between DDHHS’ RACF staff, Telehealth team and Oral Health Department.  Residents and their families/ carers were also integral stakeholders. 
Four DDHHS RACFs/ MPHS were involved in the program.

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.

 

What we learned:
A review of the pilot at
one of our homes, 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.
 

How the program can be transferred into other aged care initiatives
Due to the success of the original trial, TeleDentistry was rolled out successfully to a further 3 RACFs/ MPHS.

This model of TeleDentistry is replicable and the technology is available to assist in the oral health care of our aging population anywhere in the country. There is also potential for the involvement of private as well as public dentists or Aged Care facilities.

Sustainability
An additional 4 RACFs will commence the program later 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.

Outcomes and benefits achieved
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

During the implementation of the program, several lessons learnt and continuous quality improvement actions that arose included:

  • DDHHS should purchase TeleDentistry equipment to make it sustainable
  • Have a designated oral health nurse within the facility to continue to work with the oral Health Clinic to ensure compliance and follow through
  • Residents have become more accepting of TeleDentistry through familiarity with the staff carrying out the program
  • There was poor picture quality from the patient side at RACF in trial and the dentist was unable to make a diagnosis due to the pixelated transmission. This issue was resolved by the Telehealth Technician who adjusted the bandwidth of images being sent and received (normally 50/50 and changed to 90/10). The dentist could then see a clear picture of the resident’s mouth and make a diagnosis.

Next Steps
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. 

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

More information on this program:
Shayne Stenhouse, 
, or phone (07) 4616 4933
Debbie McKenzie, , or phone (07) 4616 5641 
Jacinta Pitt, , or phone (07) 4616 4900 

 
Changed
Friday, 21 December 2018 - 6:47am