Referral guidelines for Tees Community Dental Service

Introduction

The North Tees and Hartlepool NHS Foundation Trust Tees Community Dental Service (Tees CDS) provides a Paediatric dental service and Adult Special Care dental service.

This guide is intended to clarify the referral process and patient acceptance criteria for General Dental Practitioners (GDPs) and other health care professionals referring individuals to this service.

Who Can Refer to the Dental Service?

Referrals are only accepted from:

• GDPs
• General Medical Practitioners (GPs) and Hospital Specialists
• Other Health & Social Care Professionals e.g. Social Services and Learning Disability Teams.

Self- referrals are not accepted.

For referrals from non-GDPs, we advise that in the first instance patients should be directed to access dental care with a ‘high street’ dentist. These dental practitioners will be able to make a referral to the Tees Community Dental Service where appropriate.

An electronic version of our GDP referral form can be found at Dental services in the community | North Tees and Hartlepool NHS Foundation Trust (Appendix 1)

Referrals from all other Health & Social Care referrers should be submitted in the form of a formal letter. The letter must include all of the information outlined in Appendix 2

Referrals are to be sent by email to [email protected]

What Geographical Area does the Dental Service Cover?

Tees CDS is commissioned to provide dental care to patients living within the county boundaries of Stockton, Hartlepool, Middlesbrough and Redcar and Cleveland. The patient’s postcode must be within this geographical area and checked prior to referral. See Appendix 3 for accepted postcodes.

Referrals are not accepted for patients who:

• Live outside this area, but whose GP is located within Stockton, Hartlepool, Middlesbrough and Redcar and Cleveland
• Patients requesting referral to this service who do not reside within Stockton, Hartlepool, Middlesbrough and Redcar and Cleveland

Referral Criteria for Adult Patients (16 years and above)

Referrals are accepted for adults with a range of complex additional needs that seriously affect the provision of dental care. Patients accepted for treatment may receive a full course of treatment or certain elements of care (e.g. extractions) in conjunction with their GDP.

The referring GDP continues to be responsible for urgent dental care, preventative advice and recall, unless otherwise agreed by Tees CDS. The majority of adult patients will be seen on a shared-care basis with the GDP.

Category and definition

Medically compromised

Patients with severely unstable medical conditions which put the patient at significant risk of adverse events and require dental care within a hospital setting (e.g. uncontrolled epilepsy, unstable angina)

Patients whose dental management requires close liaison with medical specialties, where this is not possible in primary care (e.g. patients with significant coagulopathies, patients receiving chemotherapy with acute dental problems).

Patients who are long stay in-patients within hospitals within our geographical boundaries will be provided with urgent care or one course of treatment, on request, subject to capacity.

Learning disabilities/cognitive impairment

Patients with moderate/severe learning disabilities or neuro-degenerative conditions (e.g. advanced dementia) who are not compliant for dental treatment within primary care.

Physical/mobility problems

Patients with severe physical, neurological and/or movement disabilities (e.g. Cerebral Palsy) where treatment is not possible in primary care and require specialist facilities e.g. hoist

Mental health

Patients with severe/uncontrolled mental health illness (e.g. patients hospitalised or sectioned for their mental health disorder) where treatment is not possible in primary care.

Dental anxiety

Severely dentally anxious patients with unstable ASA III or ASA IV medical conditions requiring anaesthetist led sedation and are unsuitable for Tier 1 or Tier 2 sedation services. Please include completed MDAS form with referral (Appendix 4)

Bariatric patients

Patients exceeding GDP chair weight limits. Patients will be seen for a single course of treatment only. Patients will return to their GDP for routine recall appointments. Further referrals for treatment can be sent as required. Please include a patient’s height and weight in the referral.

Referral Criteria for Paediatric Patients (Under 16 years old)

Referrals are accepted for paediatric patients with a range of complex additional needs or anxiety that seriously affect the provision of dental care. Children accepted for treatment may receive a full course of treatment or certain elements of care (e.g. extractions) in conjunction with their GDP.

The referring GDP continues to be responsible for urgent dental care, preventative advice and recall, unless directed by Tees CDS that the patient will be seen on a long-term basis. The majority of paediatric patients will be discharged back to the referring GDP after the completion of a discrete course of treatment.

Category and definition

Medical problems

Children with medical problems affecting the delivery of dental care.

Extensive dental decay

Young children under 5 years with early childhood caries unable to tolerate treatment under local anaesthetic and sedation.

Children with multiple caries in 3 or more quadrants.

Learning disability/autistic spectrum disorder

Children with a learning disability or autism where co-operation for dental examination and treatment is significantly compromised.

Anxiety/phobia

Children with dental anxiety or phobia requiring treatment after failed attempts under Tier 1 and Tier 2 sedation providers.

Please include completed MDAS form with referral (Appendix 5)

Mobility problems

Children with significant physical disability requiring specialist facilities to gain access to dental services. E.g. Hoist for transfer

Referral Exclusion Criteria

To prevent inappropriate referral of patients to Tees CDS the following table illustrates patient referrals that do not fulfil the referral criteria and will be not be accepted for care.

Patient category and referral exclusion criteria

What Information should be Included on the Referral?

The referral forms must be fully completed with as much detail as possible to aid appropriate triage. Failure to fully complete the referral form may lead to rejection of the referral or delay patient treatment.

Radiographs

High quality radiographs should be provided for all referrals. If radiographs are not included it must be indicated why they have not been provided. Original film radiographs should be sent with the referral letter and digital radiographs should be emailed to our secure email address with the patient’s name and date of birth. Emails must be sent from an nhs.net email account to ensure patient data is secure.

Secure email address: [email protected]

Printed radiographs will only be accepted if they are high quality and diagnostic. Radiographs should be less than 12 months old. All non-digital films will be returned to the referring practitioners once treatment is complete.

NHS Charges

Patients referred to Tees CDS will receive NHS treatment and will be required to pay NHS charges unless they fulfil the exemption criteria.

Where Referrals Should Be Sent?

All referrals; including continuing care and general anaesthetic referrals, should be sent by post to the address below or emailed to our secure email address:

Or emailed to our secure email address [email protected]

If you are unsure where to send the referral please phone 01642 944734 for advice.

Referral Process

Patient referrals will be triaged by an appropriate clinical member of staff. Following the triage process one of the following outcomes will result:

1. Acceptance of the referral: a letter will be sent to the patient/carer with a request to contact the department by telephone to arrange an appointment. A 2-week period is allowed for contact; after which the referral will be sent back to the referrer. The period of time that a patient will wait for an assessment appointment will be dependent on current waiting lists, but an appointment should be received within 18 weeks. Urgent general anaesthetic referrals should receive treatment within 4 weeks. Our staff will triage urgent/non urgent referrals on receipt.
2. Rejection of the referral with written letter sent to the referrer to explain why the referral was not accepted.
3. Request of missing information from the referrer e.g. radiographs. An appointment will not be sent to the patient until this information is received.

Patient Journey

Following an assessment appointment patients meeting the referral criteria will receive a treatment plan and appropriate arrangements will be made to undertake their dental care. For some patients this treatment may be for certain elements of their care only e.g. extractions, which cannot be undertaken in primary care.

The referring dental practitioner will be expected to provide urgent dental care, preventative care and recall whilst the patient is on the waiting list and receiving dental treatment from Tees CDS.

Patients found not to fulfil the criteria of Tees CDS will be discharged with a written letter to the referrer with advice on where the patient may be more appropriately referred or with a treatment plan for their GDP to provide care.

Patients who Fail To Attend Assessment Appointments

For all patients who fail to attend their assessment appointment:

• Written letter will be sent to the patient (with copy to the referrer) to notify them of their missed appointment and discharging them back to the referrer.
• Safeguarding concerns are managed in accordance with local policy.
•  To re-refer the patient a new referral letter will be required.

Discharge Process

• The majority of patients will be referred back to the referring GDP for continuing care on completion of a course of treatment. A written discharge letter will be sent to all referring GDPs.

• For patients who cannot tolerate invasive dental treatment, or it is not appropriate within primary care due to the patient’s medical status, a shared care approach will be adopted. Patients will be discharged with a letter back to their GDP once treatment has been completed for ongoing routine recall and prevention advice. As further treatment is required these patients can be referred back to Tees CDS.

For patients with significantly severe complex needs who would find it difficult to access primary care, continuing care may be offered within the Tees CDS. This would be clarified by letter to the referring practitioner stating that Tees CDS will provide all ongoing dental care.

Appendix 1: Tees CDS Referral Form for GDP’s

Our electronic referral form is available at:

• Referral document part 1
• Referral document part 2

Or by requesting a paper form from [email protected] or 01642 944734

Appendix 2: Tees CDS Referral from Other Health or Social Care Professionals

Please send a formal letter with the following information:

• Patient Details– Name, DOB, Address, Postcode, Sex, Contact telephone number.
• Carer Details (if applicable) – Parent/Guardian/Carer, contact number, relationship
• Medical History – including GP details
• Social History- including; language/interpreter required, known history of drug/alcohol misuse/dependency,
• Reason for referral – E.g.
  • Complex/unstable medical conditions (please attach a full medical history)
  • Learning disability/Autism/Cognitive impairment; with details
  • Mental Health problems; with details
  • Dental anxiety/problems with co-operation; with details
  • Looked after child/social problems; with details
  • Other; please specify
• Patient height and weight
• Dental concerns/pain
• Tolerance/Co-operation problems- are there any aspects of a dental appointment which the patient may be unable to tolerate or find distressing, resulting in unusual or challenging behaviour E.g.
  • loud noises
  • bright lighting
  • movement of dental chair
  • smells tastes textures
  • being touched
  • prolonged waiting
  • other (please specify)

Appendix 3: Tees Community Dental Service Patient Area Postcode Guidelines

Middlesbrough

Redcar & Cleveland

North Tees

Hartlepool

Appendix 4: Modified Dental Anxiety Score Questionnaire

To be completed for all patients >12 years old referred with dental anxiety and included with referral letter.

Appendix 5: Modified Dental Anxiety Score Questionnaire For Children

To be completed by children <12 years old referred with dental anxiety.

Please ask the child to point to the picture that best represents how they feel about receiving dental treatment. Circle the image selected and include completed form with patient referral.