Lessons learned from a

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Lessons learned from a boots on the ground
experience providing oral hygiene in nursing
homesPam Stein, D.M.D., M.P.H.University of
Kentucky College of Dentistrypam.stein_at_uky.edu

• Special Care Dentistry Association
• Annual Meeting
• April 29, 2012

This project was funded by the Dental Trade
Alliance Foundation
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The Why and How of our Project

• Issue Very few nursing home residents receive
  adequate daily oral hygiene care.
• Aim To improve daily oral hygiene care by
  training a nursing assistant to become one
  nursing homes oral health specialist.

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There is good evidence to support this model of
oral care.

• A 2008 study in a Florida nursing home found
• Nursing home residents who had daily mouth care
  provided by nursing assistants whose only job was
  to provide oral care had much less risk (3 times
  less risk) of dying from pneumonia than those
  residents who did not receive the daily care from
  the nursing assistant designated to do oral care.

Bassim CW, Gibson G, Ward T, Paphides BM, DeNucci
DJ. Modification of Risk of Mortality from
Pneumonia with Oral Hygiene Care, J Am Ger Soc,
2008, 56 (9) 1601-1607.
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The first step was to develop a partnership with
local long-term care facility.

• Administrator
• Director of Nursing
• Social Worker

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We developed a written plan and shared with the
leadership of the facility.

• Ask for advice as to how the plan might
  realistically work for their residents and staff.

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We then identified nursing assistant to be
trained and developed the curriculum.
We researched literature for elements of past
successful training programs
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Training began with 4 Self-Instructional
PowerPoints

• Importance of Daily Oral Care
• Guidelines for Daily Oral Care
• Checking for Problems
• Residents Requiring Special Care

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A video helped overcome barrier of
care-resistance.
Video Created by Dr. Rita Jablonski -
Strategies for Care Resistance during oral
care - Available for viewing on POGO
Jablonski RA, Munro CL, Grap MJ, et al. Mouth
care in nursing homes knowledge, beliefs, and
practices of nursing assistants. Geriatr Nurs
20093099-107. Chalmers JM. Behavior management
and communication strategies for dental
professionals when caring for patients with
dementia. Spec Care Dentist 200020(4)147-54.
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Hands-on training with oral hygiene tools helped
build confidence.
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Ongoing bedside coaching included weekly visits
to the facility.

• -traveling room to room to deliver oral hygiene
  care with the nursing assistant
• -talking with the nursing assistant about her
  struggles
• -providing positive feedback for successes

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We had a presence at the nursing home for months.

• This allowed us to get to know residents and
  their families and learn about their concerns and
  suggestions.

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We spent time in conversations with nursing staff
(esp charge nurses) because we wanted to know

• What are the real challenges they face every day
  with other care (besides oral)
• How our oral health training might help them
  address their other more general concerns

• Outbreaks of flu or other contagious illness
• Trying to prevent pneumonia and hospital admits
• Lots of talk about wound care

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AHA! Now maybe we can get buy in for
sustainability!

• -Wound animation
• -Incorporate infection control into our training
• -Provide stats (research) about decreased
  pneumonia due to oral hygiene to administration
• Azarpazhooh A, Leake JL. Systematic review of the
  association between respiratory diseases and oral
  health. J Periodontol 200677(9)1465-82.

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Wound Care Animation
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We scheduled follow-up meetings with the
leadership.

• This included the DON, administrator and the CEO
  of the parent company
• Short OH basic training for everyone with
  infection control review
• Respiratory connection

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We were both teacher and student

• THIS WAS A VERY VALUABLE LEARNING
• EXPERIENCE FOR US!!!!
• Thats why we are here. to share lessons
  learned.

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Lesson Learned

• It is essential to identify a point person in
  leadership at the nursing home to communicate
  issues and concerns.
• For us this was the Social Worker, but it could
  be the Director of Nursing, Assistant Director of
  Nursing or Administrator.

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Lessons Learned

• Must have a dentist available to treat
  residents because with increase in oral health
  awareness and daily oral care there was an
  increased need to refer.

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Lessons Learned

• Some residents were on a diet prohibiting thin
• liquids. A regimen which included mouthwash,
• water and toothpaste could have been a choking
• hazard.
• Further, residents dietary restrictions often
• changed making it difficult to know on a daily
• basis who was at risk of choking.

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Addressed the dietary restrictions by

• YouTube video
• Red Safety Precautions Flash card
• Added to PowerPoint Presentations

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Before providing oral care to anyonecheck with
the charge nurse or care plan each day.

• Do you need to change the oral hygiene routine to
  eliminate liquids and toothpaste for any
  residents?

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Do NOT use toothpaste, mouthwash or water for the
following residents

• Comatose residents
• Residents on a restricted diet of thickened
  liquids that cant have thin liquids
• Care resistant residents
• Residents who hold liquids in mouth/ cant or
  wont spit but instead swallow liquids placed in
  mouth

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How to provide oral care without toothpaste,
mouthwash or water?

• Simply moisten a toothbrush with a very small
  amount of water or mouthwash and brush teeth as
  you normally would.
• If possible, floss teeth
• After brushing and flossing wipe the mouth out
  with a toothette or gauze moistened with
  mouthwash.

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Lessons Learned

• The nursing assistant we trained as the oral
• health specialist worked 6am-2pm
• Residents enjoyed having their teeth brushed
• and asked for the care at other times.
• We developed a 25 minute presentation
• for all nursing assistants at the facility.

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We created a free website that provides resources
for dental professionals, nursing homes and
families

• Powerpoints (30 min, 1 hr, 2 hr)
• Powerpoints with voice over
• YouTube Video (11 minutes)
• Written Materials
• Task and Supply Lists, Safety precautions
• Competencies
• Pre-test and Post-test
• Forms (referral, documentation)
• Links to other on-line resources
• References for related research

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Kentucky House Bill 510 signed into law 4/12/12.

• Appropriates 150,000 from penalty fund to train
  nursing assistants to become oral health
  specialists in several long term care facilities
  in Kentucky to study the health and financial
  outcomes. DOES THIS SAVE MEDICAID MONEY???
• Will use our training materials and model for
  this pilot project.

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Web Address of resources created.

• http//www.uky.edu/NursingHomeOralHealth/

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Acknowledgements

• For their assistance with this project, the
  authors of this program would
• like to thank
• Joanna Aalboe, MPH, Registered Dental Hygienist,
  Assistant Professor, University of Kentucky
  College of Dentistry
• Ada Carlile, Registered Dental Hygienist
• Sandy Challman, Master of Instructional
  Technology, University of Kentucky College of
  Dentistry
• Kathryn Cunningham, MS Ed, Center for the
  Enhancement of Learning and Teaching, University
  of Kentucky
• Tom Dolan, Senior Medical Illustrator and
  Multimedia Developer, University of Kentucky
• Stephanie Harper, Social Services/Butterfly
  Program Coordinator
• Dr. Robert Henry, Chief of Dental Services,
  Veteran's Administration Hospital, Lexington
  Kentucky
• Esther Nealy, Certified Nursing Assistant
• Dr. Judith Skelton, PhD, Director of Outreach and
  Engagement, University of Kentucky College of
  Dentistry