Introduction
Integrated models of care provide improved care and patient outcomes. Sydney Local Health District Oral Health Service (SLHDOHS) targets vulnerable populations with poorer social determinants of health and therefore higher dental and other social needs. To provide more holistic care, SLHDOHS has partnered with other services and developed integrated pathways for prioritising care.
Short Description of practice change implemented
Streamlined access to OHS for vulnerable patients and patients accessing other services has been developed within SLHDOHS. Patients can now access care through a single point of contact within the service, removing any barriers or the possibility of patients slipping through gaps due to lack of coordination or miscommunication. The pathways provide support services, assisting patients in keeping appointments and undertaking comprehensive care. Comprehensive care, rather than episodic care, is provided for at-risk patients, moving from a reactive to a proactive system. These pathways also provide opportunities to link patients to other health/social services.
Aim and Theory of Change
To fast-track vulnerable populations to our services and provide streamlined, holistic approaches for managing their care by removing access barriers to services.
Targeted population and stakeholders
The target population are those at risk of social exclusion, isolation, discrimination or neglect. Stakeholders include service providers across health, social services, NGOs, NFP organisations, Medical Practitioners, Child and Family Services and the Justice System.
Timeline
Pathway sustenance is a continuous process which requires consistent monitoring and evaluation. Innovations are constantly implemented based on outcomes of the initial pathway.
Highlights
SLHDOHS is transforming its services from a dental-need oriented and acute symptom-based service to a holistic patient centred model.
Large numbers of urban infield patients experience homelessness and social exclusion. SLHD also has a large urban Aboriginal population. To cater to their demands, SLHDOHS created patient-centred models of care and introduced Patient and Family Experience Officers who support patients throughout their journey.
SLHDOHS has multiple new pathways for access which include Homeless/At-Risk, Refugee/Asylum seeker programs, Young Children, Youth and Family programs, ATSI Pathways and Mental Health Pathways. We have evaluated some outcomes for patients utilising these pathways through case studies and patient journeys.
Comments on Sustainability
To ensure sustainability, SLHDOHS has embedded these pathways into practice with strong and fenced governance around them.
Comments on transferability
Pathways can be implemented in other public OHSs and with clinical justification to eligibility requirements, could be adapted by other public services.
Conclusions
The streamlined approach and collaboration between services is effective in supporting vulnerable patients’ access to comprehensive care which has a positive impact on their overall health outcomes.
Discussions
Some patient needs are more challenging and require further support from external organisations, peer support workers and social workers. Additional and continued refinements are required to engage effectively with patients and their partners in care.
Lessons Learned
Patient needs are multifaceted and require multidisciplinary approaches to provide holistic patient-centred care. Services must adapt and change to meet the needs of vulnerable populations. Existing restrictive structures of public services must evolve to bring positive change to the new frontier.

COLLABORATIVE ORAL HEALTH CARE

Introduction
‘’Oral Health is multi-faceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex’’ (FDI, 2016). Oral Health (OH) is integral to general health, well-being and quality of life (QoL).

The burden of oral disease (tooth decay, gum disease and oral cancer) is high, and is the second most costly-related disease in Australia. Some of the most common chronic diseases such as diabetes mellitus and cardiovascular disease share common risk factors with oral diseases that are lifestyle-related and preventable.

The traditional approach to dentistry has been to treat the result of disease (eg. fill holes), with little consideration for the cause of oral disease. However, evidence now exists for a preventive and minimal intervention approach to oral disease.

Aim
The North Richmond Community Health Oral Health Program (OHP) aims to improve the community’s well-being through delivery of integrated, innovative and person-centered care to large populations of high needs individuals.
Targeted Population, Stakeholders

North Richmond Community Health (NRCH) serves a diverse, culturally rich community with high care needs.

The OHP delivers collaborative OH care with other healthcare professionals such as doctors, nurses, dieticians, social workers, harm reduction workers and diabetes educators (DE).

A preventive based Model of Oral Health Care has been developed and published. Clients identified as high risk at assessment receive OH coaching around oral hygiene practices, dietary habits, smoking and other factors as required. Oral Health Educators (OHE) work closely with DEs to prioritize clients with diabetes at high risk of periodontitis to reduce disease impacts.

Dental Hygienists provide OH assessments, simple preventive treatment and oral hygiene instructions to clients within the Medically Supervised Injecting Room on site. A trauma-informed care approach assists in providing access to dental care at NRCH. The team work closely with Nurse/Care Navigators who assist and guide these clients in their care journey.
The OHP has developed outreach programs: 1) Chompers (school and pre-school children); 2) Pearly WhitesTM (residents of aged care facilities) and 3) Aboriginal Oral Health with Murray Valley Aboriginal Co-Op Health.

Impacts and Outcomes
Factors influencing access to different health providers include clients’ attendance at appointments. Clients with diabetes who completed OHE sessions demonstrate improved OH and have accessed doctors and DEs services. MSIR clients who have been assessed and received early preventive care have had managed oral lesions such as caries and reported have increased QoL.

Sustainability and Transferability
The OHP approach is to intervene early in the disease process to enable minimal intervention in the management of oral diseases. Through working with other health care professionals, OH and QoL is improved. This process has fostered change in behavior for clients and health professionals and offers models of care for other vulnerable groups.

Conclusion
Oral Health is integral to general health, well-being and QoL. OH practitioners are a part of the whole health team who together can work to improve OH.

INTRODUCTION:
Oral diseases are among the most commonly occurring costly health conditions to treat. In 2016-17, an estimated $10.2 billion was spent in Australia on oral health (OH) and treating oral diseases. About 70,200 Australians are hospitalised for dental conditions, contributing to third highest reason for acute preventable hospital admissions in Australia.
Access to public dental services is not universal. Funding levels are not enough for all eligible population to access services leading to significant OH inequalities. Activity-based commissioning of public dental services prioritises volume over value. A review of the efficiency and effectiveness of public dental services in Victoria, Australia suggested that fundamental reforms are needed to improve OH service delivery.
AIMS:
To reform the way OH services are provided, Dental Health Services Victoria (DHSV), the lead public OH agency in Victoria implemented Australia’s first Value Based Health Care (VBHC) Model for general dental services, shifting the focus from outputs to outcomes that matter to clients.
POPULATION:
Target population included people with social security concession card and their dependents, refugees and asylum seekers, Aboriginal and Torres Strait Islander people and young people in and out of home care or in youth justice custodial care.
DHSV co-designed the VBHC model with consumers and key stakeholders within government and non-governmental organisations, tertiary education, policy, research and funding sectors. A standard-set for-oral-health-outcome measures was developed in partnership with the International Consortium for Health Outcome Measures.
A six-month Proof-of-Concept commenced in October 2018 at DHSV’s Royal Dental Hospital of Melbourne. The implementation is expanding across RDHM and a subsequent state-wide-roll-out is planned.
IMPLEMENTATION HIGHLIGHTS:
DHSV’s innovative VBHC implementation is underpinned by the following core principles: improving outcomes; focus on prevention and early intervention; providing the ‘right services, by the right person, in the right place, at the right time’; enabling clinicians to work to their ‘top-of-scope’; measuring outcomes and costs for every client and reducing unwarranted variation in treatment provision.
SUSTAINABILITY & TRANSFERABILITY:
DHSV is co-designing a new funding model with key stakeholders including the development of sustainable policies supporting the scale-up of VBHC across the state, drive better health outcomes; integrate care across providers and systems; develop robust data collection systems and implement strong evaluation processes guided by knowledge-to-practice framework.
DHSV is establishing the evidence-base on VBHC in OH and is contributing to initiatives to reduce OH inequalities and improve sustainability. DHSV’s outcome benchmarking has significant research and policy implications in Australia and internationally.
FINDINGS:
Preliminary evaluation demonstrated an increase in client-engagement, evidenced by improvement in ‘failure to attend’ rates from 19.3% to 4.9% in the VBHC-model. The proportion of simple procedures being performed by dentists that can be more cost-effectively provided by other practitioners reduced from 88% to 19%.
Feedback has been overwhelmingly positive with 6-out-of-7 clients finding the coaching and collaboration useful and supportive.
Lessons Learned
The PoC provided important learnings for DHSV in the area of implementation science, integrated practice, co-design, workforce-skill-mix, interdisciplinary care, change management including implication for policy, research and practice.

Introduction
Older Australians not only suffer cognitive and physical impairments and increasingly complex medical histories, but they have increased oral health (OH) related problems. These include dry mouth, tooth loss, tooth decay, gum disease, denture-related problems and oral cancer. When OH is not considered within general care, the impact on health and quality of life includes increased health service usage and cost.
In Residential Aged Care Facilities (RACF), ensuring residents have their OH needs met is problematic. Oral healthcare for elders in RACF is an area of increasing importance to policy makers, service providers and funders.

Pearly Whites is an outreach program developed by North Richmond Community Health providing individual OH assessments, capacity building and preventive-based care to RACF within the North Western Melbourne Primary Health Network area.

Aim
Pearly Whites (PW) aims to improve OH and quality of life for residents of RACF through increasing OH knowledge and confidence for staff and residents, supporting preventive OH care and establishing referral pathways for necessary dental treatment. This enables RACF to meet their accreditation requirements and promotes sustainability.


Practice change, Targeted population, Stakeholders, Timeline
On visiting a RACF individual OH assessments are conducted for consenting residents, informing an individual report and OH care plan that is developed for each resident. An OH educational workshop is conducted with facility staff at a subsequent visit. At the third visit individual OH scores are re-assessed. OH scores are compared between first and third visits and staff OH knowledge tested through pre and post survey questionnaires.
Where dental treatment is urgent or necessary, assistance is provided by the team with referral pathways, including on-site treatment by an NRCH dentist if required. Treatment planning is based on comfort and function, with the emphasis on overall OH, rather than dental treatment, with minimal impact and disruption to RACFs.
Discussion, Lessons, Highlights, Impact, outcome
Data demonstrates an overall reduction in OH assessment scores of residents, indicating an improvement in oral hygiene following initial OH assessment, preventive care such as silver fluoride application, and care planning. Sustainability of oral hygiene practice change needs further examination. An increase in staff OH knowledge is demonstrated through surveys, indicating the importance of this education component. However, practice change for staff is a challenge and annual attendance at RACFs observe high staff turnover and stretched resources. There is a clear need for OH education to be a component of nursing and personal carer training, and continuing education.

Sustainability and transferability
The program provides early evidence of success in managing oral disease through preventive care and referral pathways. It builds capacity, increasing knowledge and confidence of staff to support residents. It is a low cost service provided by dental hygienists and OH therapists using minimal mobile equipment. Dentists are required for necessary treatment only. It provides a model for other vulnerable groups.

Conclusion
Oral health practitioners are integral to RACF health teams. They provide accessible, preventive, low cost OH care by sharing knowledge and building capacity, thus improving quality of life for older Australians.

Introduction
There is increasing evidence linking poor oral health with cardiovascular disease (CVD) and it is recommended that all cardiac care clinicians incorporate oral health into their practice. Yet, it appears oral health is not considered a priority during cardiac care in Australia and cardiovascular patients are not seeking dental care. The focus of this feasibility study was to explore the oral health perceptions, knowledge and practices of patients with CVD and cardiac care clinicians as well as their views of integrating oral health care in cardiac settings.

Methods
A mixed methods approach was undertaken involving: focus groups/phone interviews with cardiac care clinicians (n=30, mostly nurses) across Australia; interviews (n=12); and surveys (n=318) with patients with CVD across four metropolitan hospitals and outpatient cardiology clinics in Sydney. Thematic analysis, descriptive, inferential and logistic regression statistics were used to summarise the findings.

Results
Most clinicians interviewed encountered a number of patients with dental problems, yet oral health was not routinely discussed in clinical practice. Many were also unaware of the relationship between oral health and CVD and attributed this knowledge gap to lack of training. Most (82%) patients reported having at least one dental problem and around half had seen a dentist in the last 12 months. Patients had poor oral health knowledge (52%) and only 10.7% had received any information regarding oral healthcare from cardiac care clinicians. Those who received oral health information in the cardiac setting were six times more likely to have seen a dentist in the last 12 months (AOR 5.97, 95% CI: 1.91-18.74). Cardiac clinicians were receptive to the idea of promoting oral health if identified barriers such as availability of resources, training, time constraints and referral pathways were addressed. Patients were also receptive of cardiac nurses providing education (81%), performing oral health assessments (58%) and referral (82%).

Discussions
There is a high prevalence of dental problems among patients with CVD yet many have limited knowledge and awareness about the importance of oral health. There is also a lack of emphasis regarding oral health among cardiac clinicians due to various barriers. Cardiac nurses are in unique position to promote oral health and they are receptive to this idea along with patients, provided current barriers are addressed.

Conclusions
Integrating oral health into cardiac care is warranted in Australia. A new model of care is proposed where cardiac nurses are trained to promote oral health, provide risk assessment and referrals to appropriate dental services.

Lessons learned
Oral health is a neglected part of cardiac care practice in Australia and is an area that could be addressed through an interdisciplinary oral health model of care.

Limitations
The findings may not be relevant to culturally and linguistically diverse populations with CVD or those living in regional areas
Suggestions for future research.

A new model of care inclusive of a validated oral health risk assessment tool, evidence based oral health resources and training program needs to be developed and evaluated in the cardiac setting.