Interprofessional education and experiential learning: The nurse practitioner–dentist collaborative practice model

In 1840, when the first dental school was established separately from a university's medical school, this initiated a schism between medicine and dentistry in the United States.1 Since then, ever-increasing evidence has demonstrated the interweaving of oral health, overall health, and quality of life2; integrating oral and systemic health improves health outcomes, facilitates access to care, and decreases healthcare costs.3 As less than two in five Americans have both a dental and medical visit each year, and 29.5 million individuals had a dental but no medical visit,4 offering a broader array of services and entry points into the primary care system through a dental visit is opportune to facilitating holistic care. This knowledge has motivated academic institutions5, 6 to incorporate medical–dental integration in their curricula and implement models that will hopefully inform future standards of practice. At the Harvard School of Dental Medicine (HSDM), the Nurse Practitioner–Dentist (NPD) Model was first applied in 2015 to HSDM's academic dental practice environment to integrate preventive primary care services by a nurse practitioner (NP) and promote value-based health care (VBHC).7 The Model's second phase, implemented from September 2023 through April 2024, tested operating and financial systems and determined the feasibility of billing and reimbursement for medical services provided in the dental office (Figure 1). These efforts were buoyed by collaboration between the NPs, dental students and faculty, staff, and HSDM's mission to foster a community “dedicated to improving human health by integrating dentistry and medicine,”8 which helped to address challenges experienced during implementation (Table 1). This piece provides perspectives on the most recent phase of the NPD Model in the context of the four established Interprofessional Education Collaborative (IPEC) Core Competencies for Interprofessional Collaborative Practice.9 This effort promoted a collaborative practice environment with experiential learning opportunities. Established in 2009, the IPEC represents many national health professional educational programs. The IPEC established four core competencies with the aim to prepare “learners to engage in lifelong learning and collaboration to improve both person/client care and population health outcomes.” Those are divided into the following areas: Roles and Responsibilities, Teams and Teamwork, Values and Ethics, and Communication.9 To evaluate the NPD Model's interprofessional foundation, interviews were conducted to gain participant insights. The core competencies provide a framework to evaluate their unique perspectives on experiential learning practicing medical–dental integration. Participants represented the program's patients, NPs, dental students, and staff. In every health practice, each person is expected to understand their unique roles and responsibilities and carry out their tasks to the best of their ability. IPEC defines this competency as “using the knowledge of one's own role and team members’ expertise to address individual and population health outcomes.”9 This includes leveraging expertise, differentiating roles, collaboration, and practicing humility. The NPD Model's central care team is composed of NPs, dental students, and staff. NPs provide primary care, educate patients on optimizing health and the oral–systemic link, and connect patients with a dentist if necessary. Dental students render oral care, educate on oral health and the oral–systemic connection, and connect patients with resources to establish a primary care provider (PCP) if needed. Staff members connect patients lacking established PCPs with NP services, ensure patients receive needed medical and dental appointments, and collect critical information to facilitate medical coding, billing, and reimbursement. The NPs and dental students’ roles and responsibilities are especially complementary in emphasizing the link between oral and systemic health from different viewpoints. This collaboration is crucial in emphasizing the interconnectedness of dentistry and primary care. Dental students often focus on bidirectional relationships between oral health and chronic conditions, and NPs can bring a unique perspective by initially considering a person's overall systemic health, including nutrition, lifestyle, and social determinants. This positions NPs to provide essential counseling on the associations between chronic disease, dental disease, and therapeutic lifestyle changes. Understanding and appreciating the impact of medical–dental integration is essential for both parties. In an interview, a NP shared how her experience transformed her approach to patient care: “As primary care providers, we often overlook the importance of examining the oral cavity and considering oral health. Many diseases manifest in the mouth.” Similarly, a dental student noted, “Through our collaboration, I had the opportunity to educate the NP about the oral health implications of diabetes, particularly its association with periodontal disease” (Table 2). “How great is it to have dental and medical care on the same day and in the same place? This will help those with limited access to healthcare. Working together, dental and medical providers can offer routine care.”a “When a patient with hypertension visits the dentist, they can be referred immediately for appropriate medical care.” “By integrating [a NP] into our patient's care journey, we've been able to readily coordinate follow-up appointments and ensure continuity of care between dental visits and medical consultations.” “After her appointment, [the NP] and I met to discuss the patient. She added depth to the patient's narrative, shedding light on the challenges the patient faced in managing her medical conditions.” “[Before staff were fully onboarded], scheduling was challenging, and there were different issues at the front desk.”a “This concept—I want to share it with where I work at [health center]. I will tell them how important it is to take a few minutes and ask when the last time [the patient] saw the dentist and looked inside the mouth.” While defined roles and responsibilities are important, overlapping functions also promote patient-centered care. It has been argued that blurred provider roles and culture represents the pinnacle of medical–dental integration, which is well demonstrated in the model developed by the Substance Abuse and Mental Health Services Administration (SAMHSA)-Health Resources and Services Administration (HRSA) Center for Integrated Health Solutions. They describe this as “Full Collaboration in a Transformed/Merged Integrated Practice.”10 The NPD Model exemplifies the idea that it takes a team to support a patient from disease to health. The IPEC defines this core competency as “the application of values and principles of the science of teamwork to adapt one's own role in a variety of team settings.”9 The NPD Model team includes medical and dental providers, students, faculty, supporting staff, a network of referral sites, patients, and the patients’ support systems. As dental students preparing for the workforce, it is imperative to develop skills in interprofessional collaboration, and academic settings provide crucial opportunities for experiential learning. Through this program, providers directly collaborate on complex cases, such as that of Patient A, who had previously undiagnosed diabetes for most of her adult life, which resulted in severe oral and systemic complications. Patient A shared that she experienced numerous barriers to care, including limited access to childhood dental care, unemployment, and reliance on family members for transportation. To address this patient's complex medical, dental, behavioral, and social needs, it was critical for the patient's student dental provider to actively collaborate with the NP to adapt their roles as part of a patient care team. This facilitated development and implementation of optimal care plan. In her interview, a NP remarked, “How great is it to have dental and medical care on the same day and in the same place? This will help those with limited access to healthcare. Working together, dental and medical providers can offer routine care.” Likewise, a dental student noted the “exchange of knowledge and expertise felt like a true partnership aimed at optimizing the patient's health outcomes while deepening our understanding of holistic healthcare” (Table 2). These interdisciplinary partnerships facilitate both enhanced care for patients and long-term practice changes by learners and providers. Values and ethics are fundamental in healthcare and serve as a foundation for medical–dental integration. IPEC describes this competency as “working with team members to maintain a climate of shared values, ethical conduct, and mutual respect.”9 In the NPD Model, this competency models the synergetic relationship between all four competencies. Reflected in interviews, mutual respect between the collaborating providers and patients was achieved, facilitated by establishing responsibilities, teamwork, and communication. This was shown to be an integral part of the NPD model, creating an environment prioritizing person-centered care, where patients felt genuinely supported for by their care team. This was well described by Patient A, who remarked how “much more comfortable” she felt while receiving coordinated, thoughtful care from her medical and dental providers at HSDM (Table 2). While stubborn, systems-level divisions often persist between medical and dental care, mutual respect and shared fundamental values facilitated integration of oral and systemic health in the model medicine under a common goal. With the respect for each other professions, the dental and medical provider defined roles, used teamwork, and promoted communication to provide holistic care. Patient A stated that her mouth bled less, had diminished pain, and noted improved control of her diabetes (reflected in her HbA1c 4 months after beginning treatment). Additionally, she reported feeling hopeful about improving her health and endorsed improved self-esteem. Through respectful, collaborative efforts, the team addressed several concerns simultaneously to achieve a common goal: optimizing patients’ overall health and well-being. IPEC defines this competency as “communicating in a responsive, responsible, respectful, and compassionate manner with team members.”9 The NPD Model itself relies on open, receptive communication. There were many pathways of communication, including between the patient and dental student provider, the patient and NP, the dental student and NP, and staff and patient. Communication between a student dentist and NP demonstrates medical–dental integration in action for patients. That was apparent for Patient B, who presented with hypertension, endorsed smoking one pack of cigarettes daily, and consumed a half-dozen alcoholic beverages nightly. The providers collaborated to treat Patient B's hypertension and periodontal disease, aware of the association between the conditions and common risk factors of tobacco and alcohol. The NP prescribed a nicotine patch; after multiple visits, Patient B reported a decrease to six cigarettes per day and intended to further reduce his substance use. As a student stated, “By integrating [a NP] into our patient's care journey, we've been able to readily coordinate follow-up appointments and ensure continuity of care between dental visits and medical consultations” (Table 2). With the NP's recommendations, Patient B implemented at-home blood pressure monitoring, regular exercise, and an improved diet. Using direct communication skills such as motivational interviewing, empathy, and counseling, the dental student and NP educated and motivated patients while reinforcing how intercommunication benefits patient care. This was also demonstrated in Patient A's statement how she was not aware of the mouth–body connection “until I came to Harvard and talked to the nurse who said that my diabetes can affect my gums” (Table 2). Additionally, a staff member was the center of all communication in patient recruitment, managing information, and communicating program details. Before staff were fully onboarded, the NP remarked how “Scheduling was challenging, and there were different issues at the front desk” (Table 2). After onboarding, Staff Member A identified an initial challenge with patient recruitment, which used the electronic dental record (EDR) to determine patients lacking a PCP. Although the team anticipated this process to be straightforward, communication between students and staff was lacking, as the EDR was often outdated in this question. This resulted in Staff Member A spending valuable time reaching out to potential patients who already had medical care. Lack of this competency created systematic issues including preventing patients in need from receiving information about primary care services at HSDM. In assessing his overall experiences of communicating with patients, Staff Member A reported, “The patients said they were happy. Having a dentist and NP at the same place was convenient for them. We got great comments once they came in to see the nurse practitioner” (Table 2). The collaborative NPD Model is an innovative approach to experiential learning in medical–dental integration that can be adapted and replicated. It facilitates person-centered care and may be especially impactful for patients with chronic conditions and oral needs. Thoughtful interactions with NPs and dental students significantly shifted patient perceptions of dentists as essential members of a comprehensive healthcare team, and many patients were pleasantly surprised by this innovative approach. This commentary illustrates multiple perspectives on integrated patient care encounters and provides motivation for other academic practices to adopt the model. The four IPEC competencies of Roles and Responsibilities, Teams and Teamwork, Values and Ethics, and Communication provided a template to analyze the NPD Model. The HSDM team found that it is critical to achieve a balance between defining roles and responsibilities and unifying these roles in teamwork. Practicing consistent values and ethics in clinical encounters directly translates to positive patient experiences. However, lacking just in one competency, which was communication, led to upstream issues. Therefore, it is key to address all competencies to successfully apply the NPD Model, especially given existing facilitators and barriers to this model (Table 1). With ever-increasing evidence supporting the bidirectional link between oral and systemic health, there is overwhelming support for medical–dental integration. In practice, this addresses gaps in care by expanding the range of available services during a patient encounter, facilitating overall health and well-being. The model also increases value for providers as it allows for a more thorough patient assessment and interaction with other members of the healthcare team, enhancing providers’ ability to deliver patient-centered, holistic care. Student and practicing clinician learning also is enhanced with experiencing team members collaboratively caring for patients, exchanging information, and evaluating metrics pertaining to health and social determinants that might not be typical in a dental practice. While providing a way to analyze the NPD model at HSDM, the four competencies provide a framework in incorporating similar models at other institutions. The successes and lessons learned in this model at the HSDM support a strong case for integrated care delivery and can be leveraged as an example for other dental schools and practice settings to implement the NPD Model. The authors gratefully acknowledge the patients who participated in the NPD Model, especially Patients A and B; Maria Dolce, PhD, RN, CNE; John Da Silva, DMD, MPH, ScM; Robert Allison; Harvard School of Dental Medicine leadership; Harvard Dental Center management and staff supporting this project; and Shehreen Zakir. Phase 2 of the NPD Model was funded by CareQuest Institute for Oral Health (Project #G-1905-15121). Phase 1 of the project was funded by the Health Resources and Services Administration (HRSA; UD7HP28534). The authors declare no conflicts of interest.