HCM 491 Module 4 Project One Example

Milestone One: Building a Dental Bridge From Marlow Regional Hospital's Emergency Department

[Student Name]

Southern New Hampshire University

HCM 491: Health Sciences Capstone

Project One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone One: Building a Dental Bridge From Marlow Regional Hospital's Emergency Department

This milestone brings together the problem analysis from Modules Two and Three and proposes a solution for Marlow Regional Hospital's board and emergency department leaders to consider. It summarizes the problem and its causes, describes the organizations involved, sets objectives, presents a pathway called Dental Bridge, explains how each part addresses a cause and why the evidence supports it and compares the proposal with alternatives.

The Problem in Brief

Last fiscal year, Marlow's ED treated 1,452 patients for toothaches, abscesses and other nontraumatic dental problems, 3.1% of all visits. Nearly two-thirds were uninsured or on Medicaid, more than half arrived when dental offices were closed and about 36% came back with a dental problem within a year. A group of 112 frequent visitors accounted for 410 visits. The hospital spent about $840,000 in direct costs on these visits and admissions and recovered roughly 38%. The central cause is a missing link: patients leave with advice to see a dentist but no appointment, no clinic name and often no way to afford one.

Organizational Context

Marlow is a 180-bed nonprofit hospital whose mission commits it to improving the health of its county, and its community health needs assessment lists oral health among the top five local concerns. The partner, Riverside Community Health, is a federally qualified health center six miles away with a four-dentist clinic that charges on a sliding scale by income. Riverside's new-patient wait is two to three weeks, but its director has offered to reserve urgent slots for hospital referrals if the hospital helps cover staffing, because unfilled reserved slots cost the clinic money.

Goal and Objectives

The goal is to connect ED dental patients with definitive dental care and reduce repeat ED dental visits. Each objective below carries a number, a baseline and a deadline. Within twelve months of launch: 60% of eligible adult dental patients seen during navigator hours leave with a booked dental appointment; 50% of those booked attend within seven days; the twelve-month repeat dental visit rate falls from 36% to 25%; and local anesthetic nerve block use rises from 6% to 30% of dental visits. By the end of year two, total ED dental visits fall by 20%, to about 1,160.

The Dental Bridge Pathway

Dental Bridge has six parts. First, a full-time community health worker serves as dental navigator from 2 PM to 10:30 PM on weekdays, covering the busiest hours, and books appointments before patients leave. Second, Riverside reserves twelve urgent slots a week for Dental Bridge referrals. Third, the ED adopts a dental pain protocol extending its opioid guideline to include nerve blocks, antibiotics only when infection is present and a discharge packet naming Riverside with a map and the patient's appointment time. Fourth, the 112 frequent visitors receive proactive outreach. Fifth, the navigator calls each referred patient 48 hours before the appointment. Sixth, Marlow passes summary figures to its statewide hospital group to back the case for fuller adult dental coverage in Medicaid.

After-Hours and Weekend Patients

Because more than half of dental patients arrive outside navigator hours, the pathway needs a way to reach them. Overnight and weekend staff will give these patients the discharge packet and ask permission for a callback. Each morning, the navigator will review the previous night's dental visits and call patients to book appointments. Patients who cannot be reached will receive a text with the clinic's direct scheduling number.

Linking Components to Causes

Each part of Dental Bridge targets a cause identified in the fishbone analysis. Table 1 shows the links. The only major cause the hospital cannot directly change is Medicaid policy, which the sixth component addresses through advocacy.

Table 1. Root Causes and Dental Bridge Components

Note. Mapping by the author from the Module Two fishbone analysis.

Evidence Behind the Design

The navigator follows the model evaluated by Jiang et al. (2022), whose ED navigation program reduced return visits and increased follow-up appointment adherence. Sun et al. (2015) found that patients and community leaders themselves proposed care coordination as a solution. The pain protocol builds on Fox et al. (2013), whose prescribing guideline reduced opioid use for ED dental pain, and on Marlow's own guideline results. The advocacy component rests on Elani et al. (2020), who found that ED dental visits fell where Medicaid expansion came with adult dental benefits.

Alternatives Considered

Four alternatives were weighed. An on-site dental clinic within the ED would offer immediate treatment but would cost more than $600,000 a year and duplicate Riverside's services. Teledentistry consultations from the ED could improve triage but cannot provide fillings or extractions. Vouchers for private dentists would be costly and depend on dentists accepting them. Keeping the status quo would leave costs and repeat visits unchanged. Table 2 compares them with Dental Bridge.

Table 2. Alternatives Compared

Note. Cost estimates are preliminary and will be refined in Module Six.

Why Dental Bridge

Dental Bridge offers the best balance of cost, feasibility and impact on root causes. It uses an existing community resource instead of building a new one, it targets the missing link the analysis identified and its components can be tested and adjusted one at a time. It also fits Marlow's nonprofit mission and community benefit obligations, since oral health is already a stated local priority.

Assumptions and Constraints

The proposal assumes Riverside can sustain twelve urgent slots a week, that the hospital can hire a community health worker within three months and that ED clinicians will accept nerve block training. It is constrained by the state's limited Medicaid coverage, which means some patients will still face costs at Riverside, and by the navigator's single shift, which leaves overnight patients dependent on callbacks. These assumptions will be tested with stakeholders in Module Five.

Next Steps

Module Five will map stakeholders, including ED physicians and nurses, Riverside's dentists, hospital finance and patients, and plan how to engage them. Module Six will refine the budget, estimate savings and design an evaluation using plan-do-study-act cycles. The final proposal in Module Seven will combine these pieces into a complete plan for the board.

Conclusion

Marlow's ED cannot fix teeth, but it can make sure patients leave with a path to someone who can. Dental Bridge links each part of the solution to a documented cause, draws on the best available evidence and costs a fraction of the alternatives that would treat patients directly. With stakeholder support and a careful evaluation, it can reduce repeat visits and give patients the care the ED cannot.

References

Elani, H. W., Kawachi, I., & Sommers, B. D. (2020). Changes in emergency department dental visits after Medicaid expansion. Health Services Research, 55(3), 367-374. https://doi.org/10.1111/1475-6773.13261

Fox, T. R., Li, J., Stevens, S., & Tippie, T. (2013). A performance improvement prescribing guideline reduces opioid prescriptions for emergency department dental pain patients. Annals of Emergency Medicine, 62(3), 237-240. https://doi.org/10.1016/j.annemergmed.2012.11.020

Jiang, L. G., Zhang, Y., Greca, E., Bodnar, D., Gogia, K., Wang, Y., Peretz, P., & Steel, P. A. (2022). Emergency department patient navigator program demonstrates reduction in emergency department return visits and increase in follow-up appointment adherence. The American Journal of Emergency Medicine, 53, 173-179. https://doi.org/10.1016/j.ajem.2022.01.009

Sun, B. C., Chi, D. L., Schwarz, E., Milgrom, P., Yagapen, A., Malveau, S., Chen, Z., Chan, B., Danner, S., Owen, E., Morton, V., & Lowe, R. A. (2015). Emergency department visits for nontraumatic dental problems: A mixed-methods study. American Journal of Public Health, 105(5), 947-955. https://doi.org/10.2105/AJPH.2014.302398