Education and Referral Program for Inpatient Engagement in Dental Care

ABSTRACT

Objectives: Previous research suggests that many hospitalized adults have unmet oral health needs and could benefit from discharge planning that includes linkage to dental care. This study protocol describes the planned implementation and evaluation of a study to develop and implement a system for referral to community dental providers with the goal of improving dental care utilization after hospitalization.

Study Design: A preexperimental research design will be utilized to evaluate the feasibility of recruiting hospital inpatients for a program to improve their basic oral health knowledge and assist them in selecting a community dental provider within a newly established network and making an appointment to receive dental care.

Methods: This study will be implemented within the general medicine service in a metropolitan medical center for adult inpatients (≥ 18 years) who have dental insurance coverage but report having not seen a dental provider in the past year. The study aims to recruit at least 60 hospitalized patients and identify at least 10 local dental providers to create a referral network. Local dental providers will be identified via online internet searches, referrals from hospital community partners, and word of mouth, and invited for participation. Improvements in oral health knowledge will be measured by a simple pre-/posttest. Patients will be recruited while hospitalized through a large, preexisting, and ongoing hospital-based longitudinal study.

Results: The expected outcomes for this study are (1) improved knowledge about oral health care and (2) attendance of dental appointments by study enrollees.

Conclusions: This study will provide evidence regarding the feasibility of implementing a hospital-based referral program to increase patient oral health knowledge and engagement with routine dental care after hospitalization.

Am J Manag Care. 2026;32(3):e92-e96. https://doi.org/10.37765/ajmc.2026.89901

Takeaway Points

• Many hospitalized patients have unmet oral health needs.
• Hospitalized patients represent a captive audience for care coordination and health education.
• Oral health care is an important but often overlooked component of systemic health and chronic disease management.

Oral health is an essential component of overall health and well-being. Even so, oral health care needs are often undertreated. Poor oral health practices and lack of routine dental check-ups and professional cleaning are associated with higher risks of chronic health conditions such as diabetes, lung disease, and cardiovascular disease, as well as low birth weight in newborns.¹ More than 35% of adults have not had a dental exam or cleaning in the past year.² Even for individuals with dental insurance, there are often barriers to accessing dental services. In a survey completed by the American Dental Association, 59% of adults did not access dental services due to cost, 19% could not find a convenient time or location, and 15% reported trouble finding a dentist even when they had dental insurance.³

The literature has demonstrated a strong relationship among individuals’ health literacy, health behaviors, and health outcomes.⁴ Poor oral health is associated with limited or inaccurate oral health knowledge.⁵ Specifically, poor oral health literacy has also been linked to missed dental appointments, poor adherence to medical instructions, and poor self-management skills.⁶ Given the impact of poor health literacy, improving oral health literacy is a priority for promoting improvement in medical adherence and oral health outcomes.⁷ Furthermore, evidence suggests that educational interventions can improve health literacy and have a significant impact on health-promoting behaviors.⁸

Given the relationships among chronic health conditions, socioeconomic status, race, and oral health, hospitals serving large numbers of vulnerable populations may be in an ideal position to intervene and improve oral health outcomes.^9-12 Hospitals often play an important role in coordinating care by providing referrals to outpatient services. In addition, the hospitalized population for this study has a demonstrated need. A forthcoming publication will present findings from an investigation in this health care system revealing that approximately 57% of hospitalized adults had not seen a dentist in the past year.In addition, providing education to patients about practicing oral health may improve oral health literacy, which is significantly associated with dental health service utilization.¹³ Thus, a study was developed to implement a program to educate and refer hospitalized patients to dental providers to determine the acceptability of a hospital-based program to improve patient engagement with oral service post discharge.

METHODS

Study Design

This hospital-based education and referral program aims to leverage a hospitalization episode to facilitate patient engagement with routine dental care after hospital discharge. A preexperimental research design will be utilized to evaluate the feasibility of recruiting hospital inpatients for a program to assist them in identifying a community dental provider within an established network and making an appointment to receive dental care. The expected outcomes for this study are (1) improved knowledge about oral health care and (2) attendance of dental appointments by study enrollees.

Study Setting and Participants

Study recruitment will include at least 60 patients receiving care on a general medicine service at the University of Chicago in a metropolitan academic medical center located in Chicago, Illinois. This sample size was chosen based on retrospective analysis of the number of eligible hospital patients in a 6-month time period in 2024 and the availability of study staff for recruitment. From May 1 to October 31, 2025, 781 unique patients reported having dental insurance and had not seen a dentist in the past year. The patient recruitment period for this study is anticipated to last approximately 3 months, from July 15 to October 15, 2025. The inclusion criteria are (1) adult inpatients, (2) 18 years or older, (3) who report not having seen a dental provider in the last 12 months, and (4) who state that they have dental insurance. Dental insurance is defined as a source of insurance coverage, including publicly funded programs such as Medicaid. This study will be conducted in English. Patients will be excluded from study enrollment if they score 3 or higher on the Short Portable Mental Status Questionnaire (SPMSQ), indicating cognitive impairment.

Intervention

Development of the referral network. Dental providers will be identified through several modalities. Providers for the referral network will be found from existing dental resource guides currently available through 2 other university research initiatives. Internet searches for dental offices and reviews of their care will also be conducted. In addition, during participant enrollment, it is anticipated that the provider list will expand on an ongoing basis through word-of-mouth recommendations from study participants and oral health resource organizations. Providers may request to be removed from the list. Study staff will remove providers from the list if it is determined that the provider’s ability to adequately contribute to participants’ care is insufficient—for example, if the wait time for new patient appointments is excessively long or study enrollees report consistent issues with their dental experience.

Study staff will contact providers by phone for an initial phone screening (see eAppendix A [eAppendices available at ajmc.com]). In-person assessment of the facility will be completed for providers who pass the initial screening and consent to further evaluation. In-person evaluation will include whether the provider is accepting new patients, the projected length of wait times to schedule appointments and be seen by providers, what types of dental services are offered, the types of dental specialists available onsite, what forms of dental insurance or other payment are accepted, and an additional evaluation regarding quality of patient care and provider facilities. Quality-of-care measures will include observing proper hygiene procedures, availability of office staff, and helpfulness and friendliness of staff. The site evaluation will be completed by 2 of the study team members, including a licensed general dentist.

To preserve the referral network, ongoing engagement with dental offices will include monthly calls by study staff. Calls to provider offices and oral health resource organizations will encourage input and feedback on the program from participating dental providers. Monthly and as-needed communication will continue for 3 months following the end of the participant recruitment stage.

Patient recruitment and study enrollment. This study will build on recruitment, assessment, and follow-up procedures already created and utilized by a longitudinal study that has been ongoing at the University of Chicago since 1997.¹⁴ The existing study procedures include utilizing a team of research coordinators and assistants for study recruitment and routine follow-up assessments. The SPMSQ is administered as part of the screening process for this study. In addition, the initial study assessment asks patients when they last had a dental appointment. Patients who have not seen a provider in a year or more will automatically be included in an electronic recruitment roster for the dental referral study. A dental referral study team member will approach the patient while they are still hospitalized. Patients will be screened for inclusion and exclusion criteria, and if they are interested in study enrollment, they will be assisted in completing the consent process.

Implementation plan. Participant study involvement will entail completing the consent process, signing the written consent document (see eAppendix B), completing an oral health knowledge pre-/posttest, receiving oral health education, completing 3 brief validated survey instruments related to oral health, selecting a dental provider from the referral list and scheduling an appointment, and receiving follow-up calls from study staff. Participants who are approached for study recruitment but decline enrollment will be asked to share their reason for declining, including possible reasons they may not want to schedule a dental appointment. In this way, the study tracks the number of participants approached for recruitment and, in addition to those who consent, gains more information regarding the acceptability of the program. Effectiveness of the oral health navigator will be evaluated by (1) the number of patients who are successfully enrolled in the study and (2) the percentage of patients who complete their scheduled dental appointment in the follow-up period. Participant-facing interactions will be managed by the study’s oral health navigator. The navigator has previous experience with care coordination and case management. In addition to standardized institutional research coordinator training, which includes human participants research and Collaborative Institutional Training Initiative Program training, the oral health navigator will receive additional guidance about oral health and dental care practices directly from the study’s licensed general dentist team member. Oral health and dental care practice training will focus on oral anatomy, common dental and oral health interventions, and proper hygiene and sterilization procedures for dental practices. Specific oral health and dental care practices will include regular tooth brushing, flossing, the use of oral rinse, routine changing of toothbrushes, and completing regular dental appointments. The oral health navigator’s approach will focus on one-on-one meetings with patients, using culturally competent and clear communication strategies and the appropriate reading level for both written and verbal communication. A standardized script will be used by the study navigator to ensure intervention fidelity across patient encounters (see eAppendix C).

Oral health education, pre-/posttest. The study’s oral health navigator will assist patients in completing a simple 10-item, pre-/posttest questionnaire (eAppendix D) to assess their knowledge of basic oral health information. Participants who are unable or unwilling to read the pre-/posttest questions may have the document read aloud. The navigator will provide clarifying information if participants have questions regarding any test questions. Next, the navigator will present the patient with approximately 10 minutes of educational information regarding the importance of routine dental care. The pre-/posttest questionnaire and educational information will be gathered through resources provided and validated by the American Dental Association. Test questions and presentation information include terminology related to oral health, evidence-based self-care interventions promoting improved oral health, and 1 question regarding dental anxiety. The oral health navigator will present information verbally, using visual aids (eg, photos, diagrams) to help patients understand select topics. Once participants have completed the education portion and have been allowed to ask any questions, they will immediately complete the pre-/posttest questionnaire a second time. The oral health navigator will record enrollees’ responses in the study’s electronic database. Responses will be reviewed for correctness, and incorrect responses will be shared and reviewed with the participant to reinforce the health information provided during the 10-minute education presentation.

Next, participants will be introduced to the dental provider referral list, which includes information on location, services provided, payment options, and availability for accepting new patients. Patients will select a provider, and study staff will assist them in scheduling an appointment. The study staff will note the participant’s appointment information and provide an appointment reminder card with the dental provider’s information. Follow-up calls will be made to remind the patient of their appointment and confirm the participant’s attendance at their scheduled visit. The provided appointment reminder card will also include information on how to contact study staff for any questions or concerns they may have.

Intervention Outcomes

Effectiveness outcomes will include (1) meeting the study’s recruitment goals, (2) participants’ increase in oral health knowledge, (3) participant dental appointment attendance following hospital discharge, and (4) retention of dental providers in the referral network. Of note, the study team will also record patients’ dental appointment attendance regardless of whether the provider is within the study’s referral network. Outcomes will be evaluated at the end of the study period, 3 months following the end of the patient recruitment period.

Data Collection

Patients. Descriptive statistics will be obtained by accessing the hospital’s electronic health record and the existing longitudinal study’s database. During hospitalization, all enrolled participants will be asked to answer the following self-reported questionnaires: Modified Dental Anxiety Scale (MDAS), Self-Reported Oral Health Questionnaire (SROH), and Oral Health Impact Profile-14 (OHIP-14). These questionnaires were incorporated to better describe participants’ fear related to specific dental interventions, their perceived oral health state, and how their oral health impacts their well-being. Following discharge, study participants will be contacted by phone or email at 2, 4, 8, and 12 weeks following hospital discharge and asked to self-report whether dental appointments have been completed and, if so, what treatments have been completed or recommended.

Instruments. Impacts of dental-related anxiety include avoidant behavior (canceling or failing to appear for scheduled dental appointments), which could lead to poorer dental health.¹⁵ The MDAS is used to measure participants’ anxiety related to dental interventions. The MDAS takes minimal time to complete, scoring is straightforward, and it has been determined to have good psychometric properties.¹⁶ Individual scores range from 5 to 25, with a cutoff value of 19 or greater indicating high dental anxiety, potentially requiring additional attention by dental personnel.¹⁷

The SROH questionnaire is an 8-item survey used to measure how an individual perceives their oral health. The SROH is derived from the extensive National Health and Nutrition Examination Survey (NHANES). The NHANES has been used since the early 1960s to assess the health and nutrition status of adults and children in the US.¹⁸

OHIP-14 is a self-report measure used to assess the impact of oral health on quality of life in the context of an individual’s ability to speak, chew food, and socialize, among other daily activities. The psychometric properties of the OHIP-14 have been demonstrated in a variety of contexts, including 36 languages and cultural contexts, among both dental and nondental patients.^19,20

Data Analysis

Demographics will be obtained from the hospital’s electronic health record system as well as the existing longitudinal study. Basic descriptive statistics will be used to analyze demographic data. An exploration of variables to compare participants who attend their dental appointments vs those who do not will be completed using 2-sample t tests. Data analysis will characterize patients based on their responses to the MDAS, SROH, and OHIP-14 questionnaires. The Stata statistical program will be used for data analysis.

DISCUSSION

Expected Impact/Significance

Many hospitalized patients have unmet oral health needs, the consequences of which may affect their systemic health and overall well-being. A number of barriers prevent individuals from seeking dental care, including cost, available time, convenient location, and finding a provider. Although it is common for hospital patients with medically complex conditions to receive referrals from hospital teams to other health care specialists, postdischarge referral to dental providers is not common practice. Therefore, there is a paucity of data on how dental referrals for hospitalized patients may affect their engagement with oral health services after being discharged from the hospital. This novel study will be the first to explore the feasibility of linking hospitalized patients to community dental providers. The study will use research staff to help patients engage with dental providers by scheduling postdischarge dental appointments. The effectiveness of this study’s intervention will be measured based on the ability to meet the anticipated recruitment of 60 hospitalized patients and successful attendance at their scheduled dental appointments after leaving the hospital. Although this is a preliminary study, its outcomes could support the implementation of larger, more involved studies that would further demonstrate the application of utilizing existing hospital infrastructure to identify patients with unmet dental needs and facilitate dental provider engagement for patients being discharged from the inpatient setting.

Limitations

Due to several factors, the results of this study may not be generalizable to other populations, such as those with greater financial resources, hospitals without available support staff, those without dental insurance coverage, or those in nonurban settings. Of note, complex, chronically ill patients may wait longer to schedule or attend dental appointments due to competing needs from other postdischarge referrals. One limitation of this study is patient follow-up time; due to time and grant funding constraints, follow-up time is limited to 3 months. Given the short duration available for patient follow-up, the study might not capture some patients’ dental appointment attendance. In addition, the study will rely on patient self-reports to determine whether they attended their appointments and what dental interventions or treatments were recommended or completed. This was done to limit participant burden and to avoid reducing recruitment by having patients and dental providers complete a Health Insurance Portability and Accountability Act component. Another study limitation is that limited information will be collected from the patient participants. Better insight into the patient population and the acceptability of a referral program could be gained from qualitative work, and this will be considered for future exploration. Lastly, due to the small sample size, this preliminary study is underpowered.

CONCLUSIONS

The goal of this study is to determine the feasibility of developing and implementing a hospital-based referral and education program to facilitate patient engagement with dental care providers after hospital discharge. The utilization of a local network of community dental providers for hospitalized patients is an innovative and timely intervention to facilitate patient engagement with needed dental care services. The results could be generalized to other hospital settings, as care coordination and referrals for other chronic disease management are common practice. Adaptations for patients’ individual health and socioeconomic challenges, as well as hospital-specific resource limitations, should be considered when translating information from this study. Lessons learned from this study could add to the literature on chronic disease management and the impact of outpatient referrals on postdischarge engagement with care. The results of this proposed study could substantiate the claim that care coordination efforts within the hospital setting can be utilized to further optimize patients’ overall health by promoting dental care referrals post discharge. 

Author Affiliations: Center for Health and the Social Sciences, University of Chicago (MM, DOM), Chicago, IL; Section of Geriatrics and Palliative Medicine (KT) and Section of General Internal Medicine (NL), Department of Medicine, University of Chicago, Chicago, IL; Department of Psychiatry and Behavioral Neuroscience, University of Chicago (NL), Chicago, IL.

Source of Funding: RBH Endowment Fund.

Author Disclosures: Dr Laiteerapong reports receiving grants from the National Institutes of Health (NIH) and Health Resources and Services Administration, a pending NIH grant about posttraumatic stress disorder, and honoraria for the Diabetes Care editorial board. Dr Meltzer reports receiving grant funding from the Richmond Foundation. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MM, KT, DOM); acquisition of data (MM, DOM); analysis and interpretation of data (MM, KT, NL); drafting of the manuscript (MM, KT); critical revision of the manuscript for important intellectual content (MM, KT, NL); provision of patients or study materials (MM, DOM); obtaining funding (MM, DOM); administrative, technical, or logistic support (MM, DOM); and supervision (MM, KT, NL, DOM).

Address Correspondence to: Marissa Mackiewicz, PhD, Center for Health and the Social Sciences, University of Chicago, 5841 S Maryland Ave, MC 1005, Chicago, IL 60637. Email: Marissa.mackiewicz@bsd.uchicago.edu.

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