Levels of Integration

Coordinated vs. co-located vs. integrated health care models

Coordinated, co-located, and integrated oral health care delivery models and programs are emerging. These innovative models and programs move the delivery of oral health services from the traditional dental home into new settings. They focus on building collaborative relationships with dentists. They build partnerships across health professions to benefit patient populations. They aim to reduce oral health disparities by reaching underserved populations, including low-income, young children, and older adults.

SAMHSA/HRSA integration framework and the CO MDI model

The SAMHSA/HRSA-developed framework of the continuum of care provides insight into the factors that differentiate coordinated care from co-located care and integrated care.

We use this framework in our CO MDI work and typically coach clinics through the continuum, with a goal of achieving Level 6 collaboration/integration (1). The CO MDI model integrates dental hygienists as part of a medical care team. They offer up to full scope dental hygiene services as needed in the medical exam room or in a dental hygiene operatory located close to the medical exam room (not in a dental clinic). The integrated hygienist participates in team activities such as team meetings, huddles and system changes.

In a fully integrated medical-dental model, the hygienist functions as another provider. Systems that support the providers, including scheduling and billing, and coordination of referrals, also support the hygienist. Ideally, medical and dental electronic records communicate as much as possible. Integrating hygienists into medical care teams has many benefits that ultimately increase the likelihood of achieving the Triple Aim.

Using the SAMSA/HRSA framework, the following table outlines medical-dental integration on the continuum from coordinated, to co-located, to integrated care:

Standard Framework for Levels of Integrated Medical – Dental Health Care
Integration Categories	Integration Levels	Description - PCP: primary care provider\|OHP: oral health professional (hygienist/dentist)
Coordinated Care	Level 1 - Minimal Collaboration	PCP and OHP work at separate facilities with separate systems. Providers rarely communicate. Any communication is typically related to a provider’s need for specific information about a mutual patient.
Coordinated Care	Level 2 - Basic Collaboration at a Distance	PCP and OHP work at separate facilities with separate systems. Providers view each other as resources and communicate periodically about shared patients.
Co-located Care	Level 3 - Basic Collaboration On-site	PCP and OHP are co-located in the same facility but may or may not share the same practice space. Providers still use separate systems. Communication is more regular, with an occasional meeting to discuss shared patients. Movement of patients between practices is most often through a referral process. That process is more likely to be successful because the practices are in the same location. Providers may feel like they are part of a larger team, but the team and how it operates are not clearly defined. Most decisions about patient care are made by individual providers.
Co-located Care	Level 4 - Close Collaboration with Some System Integration	PCP and OHP begin to collaborate more because they are co-located in the same practice space. Integration is beginning to take shape through some shared systems. A typical model may involve a PCP setting embedding a dental hygienst or dentist. In an embedded practice, the PCP front desk schedules all appointments, and the OHP has access and enters notes in the medical record. Complex patients often drive the need for consultation, which is done through personal communication.
Integrated Care	Level 5 - Close Collaboration Approaching an Integrated Practice	There are high levels of collaboration and integration between PCP and OHP. Providers begin to function as a true team with frequent communication. The team actively seeks system solutions. Some issues, like the availability of an integrated medical and dental record, may not be easily resolved. Providers understand the different roles team members need to play and have started to change their practice and the structure of care to achieve goals.
Integrated Care	Level 6 - Full Collaboration in a Transformed/Merged Practice	There are very high levels of collaboration and integration between PCP and OHP. Providers begin to function as a true team with regular personal communication. The team actively seeks system solutions. An integrated medical-dental health record exists for ready exchange of health information. Providers understand the different roles team members need to play, and they have started to change their practice and the structure of care to achieve goals.

References/Resources

Health B WRP, Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. In: Solutions. S-HCfIH, editor.2013.