Institutionalized

A Focus on the Institutionalized Aged and Special Care Patient for Today’s Practice

Dennis M. Kalebjian, DDS, and Carole A. Murphy-Tong, DDS

Copyright 2001 Journal of the California Dental Association.

Dentists must understand the growing institutionalized-aged and special-needs population, the places wherein they reside, and the unique challenges of access that confront both the patient and dentist. This article discusses governmental regulation and legislation of long-term-care facilities and outlines professional duties and requirements of dentists who care for residents of such facilities. It will also cover the treatment needs of this population and the venues available to the hospital-trained dentist. It is Monday morning, and Dr. Treatall arrives early to prepare himself for the day ahead. Unlike the other days of the week, this is the day Dr. Treatall begins practice in his private office but completes his workday at the community hospital treating one of his "special" patients in an operating room setting. The rich aroma of Starbucks’ flavor of the day momentarily causes Dr. Treatall to think about his good fortune to be a dentist on such a magnificent day. A crisp knock on the door, however, refocuses the doctor’s eyes upon today’s rather long patient list. The receptionist half whispers, "Dr. Treatall, your first two patients have been seated." Obediently, Dr. Treatall dons his OSHA-compliant white lab coat, grabs his loupes, opens the door, and heads toward operatory 1. Though the waiting area is not in his line of sight, Dr. Treatall has sensed more than the usual motion and conversation emanating from that part of the office. The receptionist advises, "Dr. Treatall, there was a problem with transportation. Your 9:30 and 10:15 appointments have arrived early, but not to worry, the nursing home attendant will wait with them." Dr. Treatall nods his head in acknowledgment, as he begins to weigh the effect of voicing dissatisfaction. He thinks to himself "Is it purposeful to test the natural impatience of two octogenarians in the waiting room, or should daily production be sacrificed to a ‘humanitarian’ reschedule?" Indecisive, Dr. Treatall greets Mrs. Jones in operatory 1. Mrs. Jones has also noticed the congestion in the waiting area as she recounts her passage through it, employing the colorful phrase "wheelchair gauntlet." Dr. Treatall understands that Mrs. Jones means no harm, and he silently administers local anesthesia for tooth No. 30’s replacement alloy. Next, Dr. Treatall slips into operatory 2 to examine a new patient, as Peggy the hygienist stands by. He is greeted by the warm smile and wide eyes of a young man named Johnny. Johnny is a high-functioning, developmentally delayed patient with a seizure disorder, who is not at all self-conscious. Johnny is extremely friendly, eager to cooperate, though maybe a little loud. Dr. Treatall has always been committed to providing access for all patients. Having negotiated the examination, he clears Peggy to begin the scaling. Returning to check on Mrs. Jones, Dr. Treatall inquires about the profoundness of her anesthesia. He ends up asking twice so he can be heard over Johnny’s excitement of working with the hygienist next door. (If ever the annoying sound of the high-speed handpiece is welcome, it’s now.) No longer aware of the loud banter from the adjacent operatory, Dr. Treatall becomes immersed in the technical bliss of operative dentistry. Suddenly, like an alarm clock that jolts one from a restful slumber, Peggy declares her patient to be in a state of seizure, grand mal to be specific. As Dr. Treatall provides the needed emergency support, Mrs. Jones bites on an oversoaked cotton roll. As Mrs. Jones waits, she overhears the receptionist telling the doctor that one of the nursing home patients had become disruptive in the waiting room, so both were returned to the facility. "Dr. Treatall, you will now have plenty of time to complete Mrs. Jones." Mrs. Jones is silently overjoyed. Thirty minutes later, Dr. Treatall dismisses Mrs. Jones. She asks if the coast is clear as she plans her exit from the operatory; there is no answer from Dr. Treatall. With a bit less bounce in his step, Dr. Treatall retreats to his small private office only to find a note confirming his scheduled in-service at Sleepy Haven Nursing Home today at noon. Recognizing the doctor’s difficult morning, the receptionist delivers a fresh cup of coffee, while praising her employer’s willingness to treat long-term-care patients. Departing, the receptionist adds, "I get so many calls from care homes and nursing homes, you must be everybody’s favorite dentist." Somewhat worn from the morning’s events, Dr. Treatall smiles as he is satisfied with the coffee’s fine aroma.

Every community benefits from the presence of a "Dr. Treatall" who provides dental access to underserved, long-term-care populations. As depicted in the above fictional account, the commitment is not an easy one. The challenge to meet the dental treatment needs for residents of long-term-care facilities is multidimensional. Dentists are challenged to deliver care to a group of patients, many of whom have complex physical and/or mental health conditions. Sometimes the physical parameters of a private dental office cannot be overcome for such patients, making it necessary for the dentist to utilize an alternative treatment setting. Guardianship and consent issues are often burdensome and time-consuming. Remuneration for services delivered to Medicaid beneficiaries, who make up 67 percent of all California skilled nursing home residents,¹ frequently fails to cover overhead expenses. Alternatively, many long-term-care patients who receive no public funds are constrained by economic factors. Such patients frequently choose to forego needed dental care,² only to complicate any future treatment plan. Lastly, the daily oral hygiene needs of nursing home residents are often greater than the resources available to address them, especially when nursing homes must struggle to retain a skilled and knowledgeable staff.

Today’s dentist must understand the growing institutionalized aged and special needs population, the places wherein they reside, and the unique challenges of access that confront both the patient and dentist. This article identifies hospital-based general practice residency and advanced education in general dentistry programs as primary sources for training new dentists to provide access for nursing home residents. It addresses governmental regulation and legislation of long-term-care facilities and outlines professional duties and requirements of dentists who care for residents of such facilities. Lastly, this article will discuss the treatment needs of the institutionalized aged and special needs population within the context of various management strategies and treatment venues available to the hospital-trained dentist.

The Institutionalized Patient

In the care-dependent populations of the United States, geriatric, developmentally disabled, physically disabled, and cognitively impaired groups are growing. In 1995, there were approximately 1.5 million elderly residents living in nursing homes.³ This number continues to grow as more people live into their 80s and beyond, due in part to lower mortality rates from disease in older adults. Notably, the 20th century has experienced a tenfold increase in the 65 and older population, to 12.7 percent of the total population in 1998; and further acceleration of growth in the 65 and older segment is projected.⁴ By the year 2040, 21 percent of the U.S. population will be older than 65. The special care populations, including adults with cognitive disorders (e.g. Alzheimer’s dementia) and developmental disabilities (e.g., Down syndrome), will also increase.⁵ Of the 50 million people who are disabled in the United States, 10 million require assistance with basic daily living activities. By the year 2050, it is projected that 20 million people will not be able to live independently due to some form of a chronic health condition.⁶ The facilities where many members of these groups reside will similarly expand.

Patients living in institutional settings are a heterogeneous group of individuals with diverse medical conditions. They are found living in a broad variety of settings, which can be categorized according to distinctions such as facility size, level of nursing care, profitability, patient’s primary diagnosis, patient’s length of stay, etc. There are nursing homes, skilled nursing facilities, subacute facilities, Alzheimer’s centers, psychiatric hospitals, residential facilities for the developmentally disabled, and long-term-care and intermediate-care facilities; and the list continues with any combination of these distinguishing classifications. Since 1967, there has been an 85 percent decrease in the developmentally and psychologically impaired population cared for in larger state-operated facilities, as reported by the residential care industry. Underlying this decrease has been a long-standing effort to place both developmentally and psychologically disabled patients into smaller facilities and residential homes, integrating them into the community as much as possible.^7,8 As a result, in California, the average number of residents per facility was 7.4.⁹ This move away from large state-run facilities to smaller private-care facilities has left patients in a state of dental decline. Even though the intention was to improve the lives of the institutionalized, patients are no longer cared for by an institution’s staff dentist but now must rely on practitioners from within the community who are often unable or unwilling to treat them.⁸

Regardless of the facility type, the overwhelming dental needs of the institutionalized population has been thoroughly documented during the past 20 years. The 1986 California Dental Association Survey of Skilled Nursing Facilities found that 56 percent of all residents needed comprehensive oral examinations, and 17 percent needed immediate attention for acute conditions.¹ Two years later, Barnes and colleagues conducted a study that found that 31.7 percent of institutionalized adult mental patients needed emergency care and that overall 94.4 percent required some form of dental therapy.⁷ In 1993, Dolan and colleagues reported edentulism was as high as 41 percent among nursing home residents, and approximately 46 percent of those already wearing dentures needed new or relined prostheses.¹¹ Finally, the 1995 U.S. National Nursing Home Survey found that approximately 60 percent of nursing homes either have dental services on call or off site, or do not have dental services at all.³

Training to Provide Access

The outlined demographic changes and statistical projections emphasize the need to involve more dentists in the delivery of dental services for institutionalized patients.

The average general practitioner’s lack of training is central to the issue of access to care for the institutionalized dental patient.^10,12 Historically, the deficiency in training contributed to the lack of exposure to or familiarity with the population, which resulted in the inability of practitioners to include such patients within private community-based practices. In response, didactic and clinical experiences directed toward treating the functionally dependent and frail older dental patients within GPR and AEGD programs were recommended to the ADA Commission on Dental Accreditation.¹³ Underscored by the profound needs of the institutionalized population, there is dual benefit to the important role hospital-based GPR and hospital-affiliated AEGD programs now play. Not only are practitioners enriched as a result of these programs; but also, and more importantly, patients with special needs are afforded access to dental care. The treatment setting of last resort for even the most challenging institutionalized dental patient -- the hospital operating room -- is well within the capability of hospital-trained dentists.⁵

Hospital-based GPR and hospital-affiliated AEGD programs offer excellent exposure to medically compromised patients, many of whom are residents of skilled nursing or other institutionalized care facilities. GPR and AEGD programs are well-positioned to serve long-term-care populations as part of the competency-based training and assessment for dental residents.¹⁴

The ADA outlines seven goals for hospital GPR and AEGD programs:^15,16

I. The resident acts as a primary care provider for individuals and groups of patients.

II. The resident plans and provides multidisciplinary oral health care for a variety of patients, including those with special needs.

III. The resident manages the delivery of oral health care by applying concepts of patient and practice management and quality improvement that are responsive to a dynamic health care environment.
IV. The resident functions effectively within the hospital and other health care environments.

V. The resident functions effectively with interdisciplinary health care teams.

VI. The resident applies scientific principles to learning and health care. This includes critical thinking, evidence or outcomes-based clinical decision-making, and technology-based information retrieval systems.

VII. The resident utilizes the values of professional ethics, lifelong learning, patient-centered care, adaptability, and acceptance of cultural diversity in professional practice.

While the above seven goals outline the purpose of hospital-based dental graduate training, it is significant that all seven goals have specific relevance to long-term-care populations. Goal I establishes the dentist as the primary care provider -- an important distinction in settings where patients are maintained by a variety of primary and ancillary care providers. Goal II references special needs patients, who make up a segment of the long-term-care population. Goal III addresses "responsive(ness) to a dynamic health care environment." The rapid growth of the 75 and older segment of the U.S. population¹⁷ and acknowledgment of the $70 billion nursing home industry¹⁸ will demand responsive practice management measures by dentists. Goal IV speaks to the resident’s ability to function effectively at all extra-office sites. Goal V underscores the need for the resident dentist to communicate and coordinate with other professionals to manage oral care for compromised patients whose care must be multifaceted. The scientific principles referenced in Goal VI must be the foundation for the expansion of methods and techniques employed for nursing home residents. GPR and AEGD didactic training is well-suited to develop the critical-thinking skills of a new generation of dentists. Lastly, Goal VII captures the essence of what is professionally required to successfully deliver care to long-term-care residents.

Legislation and Regulation

Guidelines for dentists working within nursing homes are based upon federal and state regulations for long-term-care facilities, within the context of the dental practice acts of each state. Nursing homes with hospital affiliation are additionally influenced by standards of the Joint Commission on Accreditation of Health Care Organizations.¹⁹ For relevance to the broadest number of dentists who interact with community-based facilities within California, this paper limits discussion to the federal and state regulations and related statutes.

The Medicare/Medicaid rules of the Federal Omnibus Reconciliation Act of 1987 as well as select California statutes and regulatory codes are pertinent to California dentists. While the 1987 federal rules are most widely cited,¹⁹ the more restrictive provisions of coexisting state and federal regulations always prevail.

California Code defines dental services as "those services provided by dentists and registered dental hygienists."²⁰ Written arrangements for obtaining diagnostic and therapeutic services shall be prescribed by the attending dentist. The facility "shall assist" the patient in arranging for transportation. The advisory dentist must participate at least annually in the staff development program for all patient care personnel and approve oral hygiene policies and practices for care of patients.²¹ Dental service requires comprehensive diagnostic care for all clients and must include a complete extraoral and intraoral examination. In cases where a client has not received a dental examination within the six months prior to admission, the client’s oral condition must be evaluated by a dentist within one month following admission. Comprehensive treatment services for all clients include provision of dental treatment, annual re-examination, oral hygiene instruction, maintenance of a permanent dental record, and full-time dental emergency coverage of clients.²²

By comparison, the 1987 federal act requires skilled nursing facilities to provide or obtain routine and emergency dental services for its residents.²³ The federal regulations were designed to be the national tool requiring nursing homes to become directly responsible for the dental care of their residents. The practical application of dental care within the nursing home begins with a minimum data set assessment and care screening for the nursing facility resident. The oral-related portion of the MDS screen is usually performed by nondental personnel within 14 days of admission and repeated at least annually thereafter.²⁴ The MDS form includes two sections relevant to dentistry: "oral problems," listed under the oral/nutritional status section, is usually completed by a dietitian; and "oral status and disease prevention," listed under the oral/dental status section, is usually completed by a nurse. Positive findings from the screening mandate that a dentist be summoned for examination and comprehensive dental treatment plan within seven days.

State licensure rules generally mirror federal regulations,¹⁹ however comparison and analysis reveal unique sections of each regulation that should be integrated into a nursing home’s guidelines for resident dental care. For example, federal regulations have changed the nursing facility’s duty. Instead of merely assisting residents who seek dental services, they are directly responsible for the dental care needs of their residents. At the same time, two California regulations remain purposeful for inclusion into dental guidelines. The first issue relates to nurse’s aides, who render most of the nursing home resident’s daily care, including oral care. The California regulatory requirement for annual advisory dentist participation in a staff development program for all patient care personnel affords some remedy to the skill deficiencies and high turnover rates among nursing staff members.²⁵ The second issue concerns the fact that dentist-performed oral examinations are more consistent and thorough in identifying oral health problems than are MDS oral examinations performed by an experienced nurse.²⁶ The California regulation requiring a dentist-performed comprehensive extraoral and intraoral examination within one month following admission, may in practice be more restrictive than the federal MDS screen by nondental personnel. Examination within one month is required only when an examination has not been performed and documented within the six months prior to the resident’s nursing home admission.²²

Finally, a review of California statutes regarding dentures within the institutionalized aged population is appropriate. Dentist responsibility for labeling of new dentures began in 1983, requiring that "any dentures fabricated by, or pursuant to, an order of a dentist are to be marked with the name, initials, or social security number of the patient for identification purposes unless the patient objects."²⁷ Similarly, facilities have responsibilities relative to the theft and loss of dentures of residents living within long-term-care facilities. "The marking of a patient’s personal property, including dentures" is among the policy and procedures required for implementation by long-term-care facilities.²⁸ Facility policy regarding marking of dentures for identification purposes requires disclosure to nursing home residents and their families with no right of refusal. Advisory and provider dentists who work with nursing home residents must understand nursing home policies and procedures pursuant to relevant California statutes.

Patient Management Considerations

There are several considerations necessary to develop an effective management strategy for the delivery of dental care to institutionalized patients. The first is a strong personal commitment to the patient’s needs. It is important to build partnerships with long-term-care facilities and have open lines of communication with medical and administrative staff. This will ensure that as patients are examined and evaluated, each receives the appropriate treatment based upon factors such as cooperation level, general health status, financial resources, and severity of oral disease. An interdisciplinary approach to care is key to achieving satisfactory outcomes for all parties involved. This can be a complicated task but at a minimum should include communication with staff responsible for the patient’s daily care, the attending physician, the patient and/or patient’s family or guardian. With these combined efforts, it can be determined if the patient is a suitable candidate to receive comprehensive dentistry, maintenance care, or only limited emergency treatments.

Depending upon the scope of patient needs, the selected level of care, and equipment resources available, the dentist can determine whether to deliver dental services on site within the care facility or within the familiar confines of the traditional private office setting. Alternatively, if a patient has extensive or acute needs, has demonstrated repeated resistance to treatment due to a limited or debilitated mental state, or is unable to conform to the demands of treatment due to a physical disability, then general anesthesia may be indicated.^5,29,30 If the patient’s incapacity to cooperate compromises the quality of dentistry or endangers the patient and staff, this is a strong justification for using general anesthesia.^9,29 Another issue that must be factored into a patient management decision involving general anesthesia is the option of physical restraints. General physical restraint is inappropriate for all patients. Specific restraint to protect the patient for a short time is used only when indicated and with informed consent. Particularly when the patient is elderly or otherwise frail, physical restraint may induce serious physical or psychological trauma, possibly negating any benefit gained from the dental treatment.³¹ Whenever general anesthesia is contemplated for institutionalized patients, the increased risk for complications must be carefully weighed. Elderly nursing home patients usually are medically compromised and are therefore poorer candidates for anesthesia. By comparison, some patients with special needs, e.g., a patient with emotional disability, are not necessarily predisposed to a higher risk from anesthesia. However, it should be noted that there may be a higher incidence of medical problems common to a particular disability; therefore, pre-anesthetic evaluation is important.

Lastly, informed consent is an important moral and ethical issue faced each time the institutionalized patient is identified as needing dental services. As with any proposed treatment, caregivers are required under modern interpretation to disclose any information to patients and then allow patients to either accept or decline the proposed treatment. This means that all of the risks and benefits of the procedure must be known, appreciated, and understood as well as the risks of not having the treatment performed.³² However, with this population, many patients are not able, or are only marginally able, to make informed decisions about their care. Understanding information becomes a critical issue as it may take longer for patients to absorb and respond to treatment choices. Consent cannot be informed if patients are unable to recall what was discussed with them prior to giving consent. However, refusing treatment is allowed and in itself does not automatically mean the patient is incompetent. In most cases, competency will have already been established for institutionalized individuals because of previous medical determinations. Alternative health care decision-makers most often are the closest living relative, a court-appointed guardian, or, in the specific instance of California Regional Centers for the Developmentally Disabled, the regional center administrator or medical director. Most often, conservator information is documented in the patient’s medical or facility record, even though in some dental situations there may be insufficient time to obtain the informed consent from the person authorized to give it. In such rare cases, the treating dentist who reasonably believes that a procedure should be undertaken immediately may proceed without liability exposure for failure to obtain informed consent.³³ However, in the event that the prescribed emergency treatment requires hospital management with general anesthesia, it is prudent to document the sanction of two independent practitioners not involved in the delivery of treatment.^30,34 With regard to the comprehensive treatment needs of individuals legally incapable of giving consent, it is imperative to involve family or other responsible third parties in the consent process prior to delivery of planned dental services.³⁴

Conclusion

This article described the growing institutionalized elderly and special needs population; defined the places wherein they reside; and identified the unique challenges of access to dental care that confront both patient and doctor. Hospital-based GPR and AEGD programs were cited as primary sources for training dentists to provide access for nursing home residents. Governmental regulation and legislation relevant to long-term-care facilities were addressed, and the professional duties and requirements of dentists serving nursing home patients were reviewed. Finally, this article itemized treatment objectives within the institutionalized aged and special needs population, outlined various management strategies, discussed different treatment venues available to the hospital trained dentist, and reviewed related consent issues.

If the problems of providing access to dental care for the institutionalized population were simple, then solutions would have been implemented years ago when unmet needs were first recognized. During the past 20 years, positive efforts have been made with legislation directed to nursing homes and educational guidelines directed to postgraduate dental programs. These efforts have helped facilitate care and promote professional involvement as the aged and special needs populations significantly increase. However, for the present, it remains important for all practicing dentists to acquire the professional understanding and personal commitment required to meet the needs of our most challenging patients.

Authors

Dennis M. Kalebjian, DDS, is an assistant chief of dentistry for the General Practice Residency Program at University Medical Center in Fresno, Calif., and also has a private practice in Fresno. He currently serves as vice president of the California Dental Association.

Carole A. Murphy-Tong, DDS, is part-time faculty at the University Medical Center General Practice Residency Program in Fresno, Calif. She is also in private practice.

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15. Accreditation Standards for Advanced Education Programs in General Practice Residency, American Dental Association, 1998, effective Jan 1, 2000.

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23. 42 CFR 483.55.

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27. California Business and Professions Code, Section 1706.

28. California Health and Safety Code, Section 1418.7.

29. Solomon A, Indications for dental anesthesia. Dent Clinics N Am 32:75-9, 1987.

30. Leymann J, Mashni M, Trapp L, Anderson D, Anesthesia for the elderly and special needs patient. Dent Clin N Am 43:301-19, 1999.

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32. Surabian SR, Informed consent or refusal, J Cal Dent Assoc 24:51-4, 1996.

33. California Business and Professions Code, Section 1627.7.

34. Litch S, Liggett M, Consent for dental therapy in severely ill patients. J Dent Educ 56:298-311, 1992.

To request a printed copy of this article, please contact/Dennis M. Kalebjian, DDS, University Medical Center, Department of Dentistry, 445 S. Cedar, Fresno, CA 93703 or at dennisk@ucsfresno.edu.