Improving Oral Health Care for Frail, Community-Dwelling Older People: Exploring Barriers and Facilitators for Interprofessional Collaboration.

Background: Oral health among frail home-dwelling older persons in Flanders (Belgium) is often insufficient, partly due to limited access to oral care and insufficient interprofessional collaboration in primary care. Objective: Frail home-dwelling people aged 65 and above have limited access to oral health care due to e.g. problems with transport and mobility, financial constraints, and the lack of knowledge about the importance and added value of oral health care. Furthermore, insufficient interprofessional collaboration between healthcare and welfare professionals (due to e.g. unclear roles and insufficient knowledge and skills) contributes to a fragmented care delivery. However, poor oral health has a negative impact on their overall health and quality of life. The Gerodent Plus project aims to improve oral health care for frail home-dwelling older people by (1) improving the accessibility and continuity of care and (2) better integrating oral healthcare into primary care. Methods: This project is conducted in three phases, starting with a needs assessment by using a combination of qualitative (interviews and focus groups) and quantitative (online surveys) methods. In phase two, a complex intervention is being developed using an intervention mapping approach and the updated Medical Research Council framework. Phase three comprises the implementation and evaluation of this intervention. Throughout these three phases, a stakeholder group (frail home-dwelling older people, informal caregivers, healthcare and welfare professionals, organisations, and research groups) provides participant recruitment support and feedback. Recommendations will be provided using Valentijn’s rainbow model. Results: For the needs assessment, experiences in health care delivery, accessibility, and interprofessional collaboration are explored among both, frail home-dwelling older people, their informal caregivers, as well as their healthcare and welfare professionals. Results of the broad qualitative exploration and quantitative data will identify the various barriers in oral health care delivery, accessibility, and interprofessional collaboration. These results combined with evidence from the literature, will be used to develop a complex intervention. This intervention will act at the level of frail home-dwelling older people, their (informal) caregivers, as well as their healthcare and welfare professionals. Based on the evaluation, the interventions can be further optimised and implemented on a larger scale. Conclusion: Results will provide insights into the current practices concerning oral health care delivery, accessibility, and interprofessional collaboration. Moreover, it will provide recommendations on how to optimise oral care at all levels of Valentijn’s rainbow model. At micro level, recommendations will relate to how continuity of oral health care can be improved for frail home-dwelling older people. At meso level, these will relate to how collaboration between healthcare and welfare professionals can be improved. Moreover, different organisations act as collaborative partners to exchange essential information. At macro level, recommendations will relate to a health policy that makes it easier for organisations and professionals from different primary care and social care disciplines to work together on oral health improvements. Overarching, a distinction will be made between normative and functional integration.

to synthesise a framework of barriers and facilitators in the normative integration of oral health care (OHC) into general health care for frail older adults at macro (system), meso (organisation and interprofessional integration) and micro (clinical practice) levels. Identification of these barriers and facilitators is expected to promote better and more appropriate care. For this qualitative study, comprising 41 participants, representatives of 10 different groups of (professional) care providers, and OHC receivers (home-dwelling, and nursing home patients) in East Netherlands were interviewed. Transcripts of the in-depth, topic-guided interviews were thematically analysed. In a subsequent workshop with 52 stakeholders, results and interpretations were discussed and refined. Two main themes were identified: (1) a compartmentalised care culture in which OHC and general health care are seen as two separate realms, and (2) prioritisation, awareness and attitude regarding OHC integration. Subthemes such as low political attention (macro level); unclear responsibilities, hierarchical relations and the lack of vision of organisations (meso level); and poor awareness and low prioritisation by care providers and patients (micro level) were identified as potential barriers. Subthemes such as leadership (meso level), and the supportive personality of individual caregivers and ownership of patients (micro level) were identified as facilitators. Barriers and facilitators in normative OHC integration in The Netherlands are interrelated and apparent at macro-, meso- and micro levels. They are mainly related to (a) a compartmentalised care culture, and (b) related low prioritisation, and poor awareness of and attitude towards (integration of) oral health (care).

Poor nutritional status can impair oral health while poor oral health can influence the individual's dietary intake, which may result in malnutrition. This interaction between nutritional status and oral health in older age requires attention, coordination and collaboration between healthcare professionals. This qualitative study explores dental hygienists' and dietitians' opinions about current collaboration with the aim of identifying success factors and barriers to this interprofessional collaboration. Three focus group interviews were held with Dutch dental hygienists and dietitians about nutritional and oral healthcare in community-dwelling older people. In total, 9 dietitians and 11 dental hygienists participated in three online focus group interviews. Dental hygienists and dietitians seldom collaborated or consulted with each other. They struggled with the professional boundaries of their field of expertise and experienced limited knowledge about the scope of practice of the other profession, resulting in conflicting information to patients about nutrition and oral health. Interprofessional education was scarce during their professional training. Organizational and network obstacles to collaborate were recognized, such as limitations in time, reimbursement and their professional network that often does not include a dietitian or dental hygienist. Dental hygienists and dietitians do not collaborate or consult each other about (mal)nutrition or oral health in community-dwelling older people. To establish interprofessional collaboration, they need to gain knowledge and skills about nutrition and oral health to effectively recognize problems in nutritional status and oral health. Interprofessional education for healthcare professionals is needed to stimulate interprofessional collaboration to improve care for older people.

BackgroundOlder people are encouraged to remain community dwelling, even when they become care-dependent. Not every dental practice is prepared or able to provide care to community-dwelling frail older people, while their ability to maintain oral health and to visit a dentist is decreasing, amongst others due to multiple chronic diseases and/or mobility problems. The public oral health project ‘Don’t forget the mouth! (DFTM!) aimed to improve the oral health of this population, by means of early recognition of decreased oral health as well as by establishing interprofessional care. A process evaluation was designed to scientifically evaluate the implementation of this project.MethodsThe project was implemented in 14 towns in The Netherlands. In each town, health care professionals from a general practice, a dental practice, and a homecare organization participated. The process evaluation framework focused on fidelity, dose, adaptation, and reach. Each of the items were examined on levels of implementation: macro-level, meso-level, and micro-level. Mixed methods (i.e., quantitative and qualitative methods) were used for data collection.ResultsThe experiences of 50 health care professionals were evaluated with questionnaires, 22 semi-structured interviews were conducted, and the oral health of 407 community-dwelling frail older people was assessed. On each level of implementation, oral health care was integrated in the daily routine. On macro-level, education was planned (dose, adaption), and dental practices organized home visits (adaption). On meso-level, health care professionals attended meetings of the project (fidelity), worked interprofessionally, and used a screening-referral tool of the project DFTM! in daily practice (dose, adaption, reach). On micro-level, the frail older people participated in the screening of oral health (fidelity, dose), had their daily oral hygiene care observed (adaption) and supported if necessary, and some had themselves referred to a dental practice (reach). The semi-structured interviews also showed that the project increased the oral health awareness amongst health care professionals.ConclusionsThe project DFTM! was, in general, implemented and delivered as planned. Factors that contributed positively to the implementation were identified. With large-scale implementation, attention is needed regarding the poor accessibility of the oral health care professional, financial issues, and increased work pressure.Trial registration The Netherlands Trial Register NTR6159, registration done on December 13th 2016. URL: https://www.trialregister.nl/trial/6028

Objectiveto synthesise a framework of barriers and facilitators in the functional integration of oral health care (OHC) into general health care for frail older adults at macro (system), meso (organisation and interprofessional integration) and micro (clinical practice) levels.BackgroundIdentification of these barriers and facilitators is expected to promote better and more appropriate care.MethodsFor this qualitative study, comprising 41 participants, representatives of 10 different groups of (professional) care providers, and OHC receivers (home‐dwelling and nursing‐home patients) were interviewed. Transcripts of the in‐depth, topic‐guided interviews were thematically analysed. In a subsequent workshop with 52 stakeholders, results and interpretations were discussed and refined.ResultsTwo themes were identified: (1) compartmentalised care systems and (2) poor interprofessional and communication infrastructure. Barriers related to (1) included lack of integrative policies and compartmentalised healthcare education (macro level); poor embedding of OHC in care procedures, instruments and guidelines (meso level); and poor interprofessional skills (micro level). Barriers related to (2) included poor financial incentives for collaborative practices (macro level) and badly connected ICT systems (meso level). Identified facilitators included integration of an OHC professional into care teams, and interdisciplinary consultations (meso level); and integration of OHC in individual care plans (micro level).ConclusionIn The Netherlands, OHC for older people is at best poorly integrated into general care practices. Barriers and facilitators are interconnected across macro‐, meso‐ and micro levels and between normative and functional domains and are mainly related to compartmentalisation at all levels and to poor interprofessional and communication infrastructure.

The integration of primary oral health care has a pivotal role in improving oral health outcomes and providing accessible and affordable health care. This article contributes to the deep understanding of the cultural aspects of the integration of oral health into primary health care at an Indigenous health organization. Proceeding from a collaborative and interdisciplinary research project evaluating the integration of oral health care within primary care in Eeyou Istchee, this research is based on group discussions (6) and individual interviews (36) with 74 participants (care providers, administrators, and patients) held in four Eastern James Bay Cree communities. This study anthropologically explored participants’ perceptions about primary health care conceptualizations, culturally based approaches, and experiences of oral care services at this organization using a “two-eyed seeing” Indigenous framework. The study identified three key factors related to the integration of primary oral health care: Cree perception of primary health and oral health care, cultural safety, and health provider–patient communication and the role of silence. Study findings reflected a dichotomy of perception of primary health care and the relevant units of care between the Cree structural and cultural perspective and the non-Cree professional perspective. The Cree people perceived “household” as a unit of care in comparison to non-Cree who viewed “health care services” as units of care. Our results also underline the role of cultural safety agents to address the needs for cultural competence and the role of silence as implicit cultural protocol. Our anthropological analysis illustrates the potential for increasing the level of appreciation for both users and workers in oral care in the future by ameliorating communication skills and intercultural knowledge.

The integration of primary oral health care has a pivotal role in improving oral health outcomes and providing accessible and affordable health care. This article contributes to the deep understanding of the cultural aspects of the integration of oral health into primary health care at an Indigenous health organization. Proceeding from a collaborative and interdisciplinary research project evaluating the integration of oral health care within primary care in Eeyou Istchee, this research is based on group discussions (6) and individual interviews (36) with 74 participants (care providers, administrators, and patients) held in four Eastern James Bay Cree communities. This study anthropologically explored participants' perceptions about primary health care conceptualizations, culturally based approaches, and experiences of oral care services at this organization using a "two-eyed seeing" Indigenous framework. The study identified three key factors related to the integration of primary oral health care: Cree perception of primary health and oral health care, cultural safety, and health provider-patient communication and the role of silence. Study findings reflected a dichotomy of perception of primary health care and the relevant units of care between the Cree structural and cultural perspective and the non-Cree professional perspective. The Cree people perceived "household" as a unit of care in comparison to non-Cree who viewed "health care services" as units of care. Our results also underline the role of cultural safety agents to address the needs for cultural competence and the role of silence as implicit cultural protocol. Our anthropological analysis illustrates the potential for increasing the level of appreciation for both users and workers in oral care in the future by ameliorating communication skills and intercultural knowledge.

REVIEW QUESTION/OBJECTIVE The objective of this review is to critically appraise and synthesize evidence on the effectiveness of professional oral health care intervention on the oral health of aged care residents with dementia. More specifically the objectives are to identify the efficacy of professional oral health care interventions on general oral health, the presence of plaque and the number of decayed or missing teeth. INCLUSION CRITERIA Types of participants This review will consider studies that include residents with a formal diagnosis of dementia currently residing in permanent care in Residential Aged Care Facilities. This review will exclude participants that have not received a formal diagnosis of dementia as well as those who are not living as a permanent admission in Residential Aged Care Facilities. Studies conducted on community dwelling individuals with a formal diagnosis of dementia will be excluded. Types of intervention(s)/phenomena of interest This review will consider studies that evaluate the efficacy of professional oral health care performed by a dental hygienist. These studies involve professional oral health care performed by a dental hygienist using a toothbrush, interdental brushes, floss and hand scalers if necessary to remove plaque and food debris and in some instances hardened calculus or tartar. If there are studies involving the professional oral health care being performed by dentists or a combination of dentists and dental hygienists they will be included in the analysis. This review will exclude interventions involving staff training interventions and interventions performed by nurses/assistant nurses. TRUNCATED AT 250 WORDS

To identify facilitators and barriers to integrate oral health care into general healthcare for frail elderly, 41 participants from 10 different groups of (professional) caregivers and care-recipients (residents living at home and nursing home patients) in the east of the Netherlands were interviewed. They were asked about normative integration (vision, attitude, culture) at the macro (system), meso (organizational and interprofessional), and micro (patient care) level. After thematic analysis of the interviews, the results were refined on the basis of a workshop with 52 stakeholders. Subsequently, two main themes were identified: 1. a compartmentalized care culture in which oral healthcare and general healthcare are seen as two separate domains; 2. prioritization, awareness, and attitude towards oral healthcare integration. Barriers to integration are: low political attention (macro level); unclear responsibilities, hierarchical relationships, and lack of vision (meso level); poor awareness and low prioritization by healthcare providers and patients (micro level). Leadership (meso level), a supportive personality of individual caregivers, and ownership of patients (micro level) promote integration.

Poor oral health can influence an individual's dietary intake, which may result in malnutrition. Both problems in oral health and function and malnutrition are common in older people. The aim of the present study was to explore the associations between oral health and oral function and malnutrition in community-dwelling older people within three different databases. Data analyses were performed on three existing Dutch databases (Interrai: n = 3876, LPZ: n = 966, PRIMa mouth CARE: n = 975). Logistic regressions (adjusted for age and gender) tested the relation between oral health and oral function (independent variable) and malnutrition (dependent variable). Problems in oral health and oral function such as broken teeth (OR: 1.43 [95%CI: 1.12-1.81]), oral pain and discomfort (OR: 2.58 [95%CI: 1.52-4.39]), chewing difficulties (OR: 1.99 [95%CI: 1.54-2.57]), swallowing problems (OR: 6.63 [95%CI: 2.85-15.42]), coughing (OR: 6.05 [95%CI: 2.08-17.61]) and food adaptations (OR: 5.46 [95%CI: 2.60-11.4]) were found to be significantly associated with malnutrition in older people. This study demonstrated a significant link between oral health problems and oral function with malnutrition in community-dwelling older people. Oral health care and healthcare professionals need to consider oral health and oral function in relation to nutritional status and vice versa in community-dwelling older people.

A scoping review into the explanations for differences in the degrees of shared decision making experienced by patients

Objective: The Finnish Medicines Agency (Fimea) initiated a programme in 2012 for enhancing interprofessional networking in the medication management of the aged. The goal is to develop national guidelines for interprofessional collaboration with respect to medication management. This study aims to explore the challenges and potential solutions experienced by existing health care teams in managing medication of the aged: (1) at the individual and team level (micro level), (2) organisational level (meso level) and (3) structural level (macro level).Design: Group discussions (n = 10), pair (n = 3) and individual interviews (n = 2). Abductive content analysis combining data and theory was applied. Networking was used as a theoretical framework.Setting: Meetings (n = 15) organised by Fimea in the formation phase of the interprofessional network in 2012.Subjects: Health care professionals (n = 55).Main outcome measures: Challenges and solutions in the medication management of the aged at the micro, meso and macro levels.Results: Challenges in interprofessional collaboration, problems with patient record systems, and the organisation of work and lack of resources were present at all the levels contributing to patients’ medication problems. Participants suggested multiple potential solutions to improve interprofessional collaboration, sharing of tasks and responsibilities, better exploitation of pharmaceutical knowledge and developing tools as being the most commonly mentioned.Conclusions: Optimising medication use of the aged requires new systemic solutions within and between different system levels. The main challenges can be solved by clarifying responsibilities, enhancing communication and applying operational models that involve pharmacists and the use of information technology in medication management.KEY POINTSAn interprofessional team approach has been suggested as a solution to promote rational medicine use among the aged.Fragmented health care system and lack of coordinated patient care are reasons for medication related problems of the aged.Challenges in the implementation of interprofessional collaboration in medication management appear in legislation, information systems, operational models and individuals’ attitudes.Optimising medications requires better interprofessional networking and new systemic solutions within and between macro, meso and micro levels.

BackgroundThere is a need to strengthen interprofessional collaborative practice (IPCP) through interprofessional education (IPE) to improve patient outcomes. To contextualise IPE in primary care, there is a need to understand the factors associated with IPE. This study aims to identify the perceived enablers and barriers of IPE, taking diabetes care as an example, among practising professionals, educators, and institution leaders in primary care.MethodsA qualitative study was conducted in primary care clinics in Singapore. The maximum variation purposive sampling approach was employed and a total of 20 participants were recruited, comprising of 14 healthcare professionals (HCPs), 3 educators, and 3 leaders. Basic demographics data were collected followed by individual semi-structured interviews using a topic guide. Conceptual framework by D'amour and Oandasan was adopted as the underpinning framework to evaluate factors associated to micro (learners and educators), meso (instituitions) and macro (policy and professional bodies) level. Thematic analysis method was adopted for data analysis.ResultsTen themes were identified in this study. For HCPs at the micro level, the themes illustrated interprofessional interactions influenced by learning and work environments, and receptiveness towards IPE shaped by HCPs' attitudes. Additionally, interprofessional collaboration was enhanced through increased interprofessional knowledgeability and overcoming interprofessional hierarchy, while effective communication was fostered by establishing trust, respect, and overcoming psychological barriers. For educators at the micro level, the key themes included the attitudes of educators and the importance of professional development, as well as curriculum development. At the meso level, institutions focused on themes such as resource allocation, system changes, and outcome measurements in the implementation of the IPE programme, along with leadership support for IPE. At the macro level, the emphases were on the roles of policymakers in funding and defining national strategy, as well as the roles of professional bodies in providing educational resources.ConclusionsThis study demonstrated the complexity and interrelation of the factors associated with IPE in primary care. A multi-pronged approach needs to be adopted to address all the barriers in the future implementation of the IPE model in primary care and to design an IPE curriculum that integrates well with clinical practice.Clinical Trial NumberNot Applicable.

IntroductionGoal setting (GS) is an important aspect of initial spinal cord injury/ disorder (SCI/D) rehabilitation. However, because expected outcomes are individual and often difficult to determine, GS is not straightforward. The aim of this study was to explore the health care professionals' (HCP's) experiences with and perspectives on the goal-setting process (GSP) during initial SCI/D rehabilitation.MethodFive semi-structured focus groups (FG) (22 purposively sampled HCP, mostly in leadership positions, six different professions). The FG were transcribed verbatim. We analyzed the transcripts for qualitative content analysis following Braun and Clarke (2013).ResultsHCP described GS-influencing aspects at the macro, meso and micro levels. At the macro level, participants spoke about restrictions imposed by health insurers or difficulties in planning the post-inpatient setting. Regarding the meso level, HCP spoke of institutional structures and culture that facilitated the GSP. At the micro level, knowledge of the diagnosis, expected outcomes, and individual patient characteristics were mentioned as important to the rehabilitation process. It was important for HCP to be patient and empathetic, to endure negative emotions, to accept that patients need time to adjust to their new situation, and to ensure that they do not lose hope. Open communication and interprofessional collaboration helped overcome barriers in the GSP.DiscussionThis paper shows the complex relationship between external (e.g., health insurers), emotional, and communication aspects. It calls for a comprehensive approach to optimizing the GSP, so that patients' experiences can be fully considered as a basis to identify the most appropriate care pathway.

To assess whether, and if so, which oral health care services for community-dwelling older people with dementia are available. Oral health in people with dementia is poor compared with people without dementia. Although multiple oral health care interventions have previously been studied for older people living in nursing homes, little is known about interventions or services for community-dwelling older people with dementia. A literature search was performed in the databases Pubmed, Embase and CINAHL. The following search terms were used: "Dementia", "Oral health", "Dental health services" and "Older person". The term "dental health services" was intended to be an as broad as possible construct because limited search results were expected. The search generated 1624 unique references, of which seven studies were eligible for inclusion (four cohort studies, one cross-sectional study, and two qualitative studies). The included studies described two actual oral health care services: a telephone help line on oral health and dementia, and a mobile geriatric dental programme in adult day health centres. A need was found for services and strategies specific to community-dwelling older people with dementia. One identified solution was an intervention with individually tailored daily oral hygiene self-care supported by the informal caregiver. Furthermore, increasing accessibility of oral health care professionals with treatment at other locations than their own practices, better collaboration between health care professionals and preventive oral health care are highly necessary. There is limited evidence on the availability of oral health care services for community-dwelling older people with dementia, while a need was found for oral health care services that focus on good accessibility, oral hygiene self-care, preventive strategies and collaboration among health care professionals.