The 2000 Surgeon General’s Report established that the mouth is a mirror to the rest of the body. “The mouth shows you what's going on, sometimes before we would even know from any other manifestation,” explains Michelle Baxter, a nurse practitioner (NP) and assistant professor at the University of Louisville (UofL) School of Dentistry. “Diabetes, hypertension, cancers and various other systemic disease processes that you wouldn't normally think would have an oral manifestation, its all connected.”
This concept of oral-systemic health has long been an area of interest for Dr. Whitney Nash, associate dean of practice at UofL School of Nursing and assistant vice-president of interprofessional practice partnerships. In 2012, Nash received a grant to help teach oral-systemic health to nursing and dental students as an interprofessional project. As Nash recalls, “We wanted to help dental students and even faculty understand and appreciate the role of a nurse practitioner, how the physical piece intertwines with dentistry. In the past 8-10 years, we have made extraordinary headway in establishing an interprofessional collaboration between the schools of dentistry and nursing, which is not so common in traditional medical programs.”
This relationship laid the groundwork for what became UofL Care Partners in 2017, a primary care clinic in the dental school. Patients coming for dental services many times find themselves not meeting the criteria for treatment for various reasons, including uncontrolled diabetes or high blood pressure, says Nash. In 2016, the School of Dentistry wrote over 940 medical consults for patients who needed medical follow-ups before receiving dental treatment but more than 40 percent of those patients failed to return. “The idea was to have a nurse practitioner there to provide that service at the point of care.”
Nash recruited Baxter, who in her faculty role was helping dental students understand that medical aspects were an important element of dental care, to set up the clinic with Dr. Beverly Williams Coleman, a nurse practitioner in family practice and assistant professor in the School of Nursing.
Coleman who had previously worked as a nurse practitioner in neurosurgery says throughout her career she kept running into those chronic issues that were causing problems—diabetes, hypertension, COPD—and that brought her to family practice. “In family practice, I found where I needed to be, to be able to address those chronic issues, and that was life-changing,” says Coleman. “When I found out that they were looking for someone to open this clinic in the dental school, I thought, wow I can use my previous experience to develop this clinic.”
From finding office space and construction details to establishing the patient flow and setting up billing processes, it took a good year for Nash, Baxter and Coleman to get UofL Care Partners up and running.
The dental school is open to both insured and uninsured patients. “We are a referral center throughout the community. We have patients that drive two and three hours to come see us from rural communities, some rural counties in Kentucky do not have a dental provider,” says Baxter.
“We have patients who say, ‘I am completely well,’ and we take their blood pressure and it's through the roof,” she adds. “The reason they think they're well is they haven't seen a doctor in 10 years or don't have a primary care provider. UofL Care Partners is like one stop shopping, having primary care right there with their dental provider. Managing medical needs like getting their labs taken right there allows them to proceed with dental treatment.”
And then, COVID-19 hit and brought things to a screeching halt.
The dental clinic shut down from March-August last year, and Coleman relocated to another UofL connected primary care practice down the street. Now Baxter refers patients needing medical attention to Coleman’s current practice. UofL Care Partners is not seeing patients in the way it was originally set up, with dental and primary care services side-by-side, and plans are to re-evaluate in the fall. While Coleman is not physically back at UofL Care Partners, this current arrangement is making sure patients do not fall through the cracks and that they don’t delay care, says Baxter.
There is a movement afoot to set up similar relationships in other academic settings, and this model is garnering interest even in private practice, says Nash, adding that a former student recently contacted her about hiring a nurse practitioner for his dental practice. “He sees patients who are sicker than they realize who need to address their medical issues and lots of times they won’t come back. He hates to lose those patients, so while it is certainly altruistic and a good patient care model, there is also a financial incentive.”
The Importance of Leadership Development for Nurse Practitioners
Nash, Baxter and Coleman are also alums of the Duke-Johnson & Johnson Nurse Leadership Program. Nash who graduated from the program in 2015 encouraged Baxter to apply and she joined the 2018 cohort followed by Coleman in 2019.
“I had done some leadership development before but it was geared towards nurse executives in a hospital setting and it didn’t really fit,” says Nash. “Having a program for advanced nurse practitioners was a wonderful experience. In particular, it was such a great networking opportunity to see what other people were doing—you see a different staffing model that is amazing or you learn how to better mentor someone or remediate something. The collegiality that was developed, these are people I still reach out to if I am stuck with some particular problem.”
Baxter remembers asking Nash about the program, and her response was: “Just do it, it will be good for you.” She attended the program in the midst of organizing and building UofL Care Partners and credits the presentation about UofL Care Partners at the end of the program for opening many opportunities including being able to join the American Academy of Oral Medicine as an Affiliate Fellow, the only non-dental provider to do so. Additionally, the Dean of the University of North Carolina (UNC) School of Dentistry who saw her presentation sent his team to Louisville to learn how they could set up a similar program at UNC.
“I received my DNP (Doctor of Nursing Practice) and was getting ready to put my training into real practice,” adds Coleman, who joined the next cohort after she kept hearing about the program from Baxter. “We really had no model for UofL Care Partners, we were creating our own model. The program gave me the leadership skills to get something up and running, and also gave me the skills as a leader to be able to say, okay this isn't working, we need to back up and look at this again.”
With so many changes in the past year, those leadership skills came in handy, Nash agrees. “When things are going great, that's fine. But we also have look for opportunities when you hit a roadblock. You have to regroup and figure out what to do next. How we have adapted over the last year with patient care during the pandemic is also an example of how nimble nurse practitioners can be.”
Nash’s advice for all nurses is to seek out such opportunities. “The earlier, the better. These are great opportunities to draw from each other. Seek out those mentors, seek out those opportunities to do professional development.”
Baxter, who will receive her DNP in August, is starting a PhD program with Coleman in the fall. “I love what I do. I love interprofessional practice working with dental students and dentists and coming to a decision together on how to best manage a patient.”
Having partnered with the dental school since creating UofL Care Partners, all kinds of light bulbs have gone off in other areas of research, says Coleman, and that’s what she plans to explore in her PhD. “We’re in the center of downtown Louisville, and this is an area with a lot of needs. Unfortunately, there is also mistrust among some of the populations we serve and I often hear, 'why do you care about my health?' And I tell them, ‘well, first I want you to care about your health.’ Education is a huge piece of what I do, I try to get people to advocate for themselves and to not be afraid to ask questions.”
The three women reiterate how important it has been to be part of a community that is supportive of each other, to be able to have each other to bounce ideas off of. “I have about 18 NPs I am responsible for, and I can’t tell you how blessed I am to have just an amazing group of people that that just are incredibly committed to our community,” says Nash. She is exploring how they can better serve the diverse population of students, faculty and community especially in the city’s urban areas and to develop new access points for patients to receive care.
“One of the greatest, most affirming things about my position is being able to see how willing nurse practitioners are to step outside the box and meet people where they are,” adds Nash. “Whether it's in a dental clinic or in a homeless shelter or on the side of the street or in another country, if I need somebody, I can pick up the phone and its absolutely, tell me where to be, tell me what I need to do, what I need to bring, and I'll be there.”