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Streamlined Oral Health Pathway for People Living with a Mental Illness

Sydney Local Health District
Project Added:
19 October 2016
Last updated:
2 November 2016

Streamlined Oral Health Pathway for People Living with a Mental Illness


Sydney Local Health District (SLHD) developed an electronic oral health (OH) assessment form that provides appropriate information to the OH clinician, as well as a comprehensive summary that can be easily understood by the participant, their carer and general practitioner (GP).


To improve the quality of OH assessments for participants in the Living Well, Living Longer (LWLL) program, by implementing a standardised OH assessment form across all sites and reducing the number of missing OH assessment forms by 50% within six months.


  • Improves the oral health of people living with a mental illness.
  • Standardises OH assessments across all sites and improves the quality of these assessments.
  • Improves collaboration between healthcare services and teams.
  • Ensures OH information is available to clinicians, participants, carers and general practitioners.
  • Provides OH teams with the information they need to provide appropriate OH treatment and care.
  • Provides a central database of OH information that can be collected, stored and transferred electronically.
  • Reduces the time and costs associated with duplication of OH assessments and looking for missing records.
  • Improves the participant experience and provides them with a streamlined care pathway.


SLHD is working to improve access to appropriate healthcare, quality of life and health outcomes for people living with severe mental illness. These people have a life expectancy up to 25 years less than the general population. Reasons for their poor health are complex and include low socio-economic status, poor motivation and diagnostic overshadowing. Major contributors to the mortality of this group include a high risk of diabetes, dyslipidemia, hypertension and obesity, as well as lifestyle risk factors such as smoking, poor diet and sedentary behaviour.

Despite their increased need for healthcare services, people living with mental illness are less likely to receive appropriate care, even when attending clinical services. Poor OH is widely recognised as a major health problem in this group, as it has a significant impact on wellbeing and is a key risk factor for cardiovascular disease.

The LWLL program aims to integrate appropriate healthcare services into routine services for people living with mental illness1. As part of this program, the Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHiP) and Cardiometabolic Clinics based at the Charles Perkins Centre and Concord Hospital, provide a multidisciplinary consultation service that involves a matrix of assessments and interventions. It has a focus on cardiovascular and metabolic risk factors in people with severe mental illness, including an OH assessment.

Despite these assessments, audits showed that the pathway to providing appropriate OH care was lacking. It was determined that improving the quality of OH referrals and assessments would streamline the healthcare journey of people living with mental illness and improve the OH outcomes of this group.


  • Missing OH assessment records were collected from ccCHiP and the patients’ dentist. These were added to a central LWLL database.
  • A new electronic OH assessment form was developed, in consultation with the LWLL program team and clinicians, to standardise information and eliminate duplication. The new form allows relevant information to be collected, stored and transferred electronically to clinicians, patients, carers and GPs.
  • A laptop was provided to the OH team, making it easier for them to keep OH assessments accurate and up to date.
  • Mental Health identifiers were added to the Information System for Oral Health (ISOH), with a drop-down list including LWLL and ccCHiP. This identifies patients in each program, so reports (such as number treated, types of treatments, failure to attend) can easily be generated from the ISOH.
  • Dentists, oral health therapists and dental assistants who provide initial OH assessments were trained in the use of the new form, including how to identify participants correctly in the ISOH and generate detailed reports for ccCHiP and clinical records. This training was delivered in a face-to-face group session, followed by individual feedback sessions with clinicians. Barriers to using the form and difficulties in providing the OH assessment were noted and changes made to improve the process.

Project status

Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Key dates

November 2015 – July 2016

Implementation sites

  • The Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHiP) at Concord Hospital,  Sydney Local Health District
  • Cardiometabolic Clinics at Charles Perkins Centre, University of Sydney



  • 82 missing assessment records were collected and added to the LWLL database.
  • The number of missing records reduced from 82 in December 2015 to 13 in July 2016.
  • The new electronic OH assessment form was implemented across all sites participating in the LWLL program, by July 2016.
  • OH assessments were conducted live on the electronic database from July 2016, eliminating the risk of missing OH records in the future.

Lessons learnt

  • Teamwork and stakeholder engagement is important for achieving success in any project.
  • Communication between teams through regular meetings is essential for resolving any existing problems and preventing new ones.
  • Projects often take longer than planned, so motivating team members to continue their hard work is key to any successful project.


  1. Duffy L, McDonald A, Lambert T et al. Living Well, Living Longer: Working together for better health in people with mental illness. International Journal of Integrated Care 2014; 14(9). DOI: 10.5334/ijic.1888.

Further reading

  • Hennekens CH, Hennekens AR, Hollar D et al. Schizophrenia and increased risks of cardiovascular disease. American Heart Journal 2005; 150(6): 1115-1121.
  • Newcomer JW. Antipsychotic medications: metabolic and cardiovascular risk. Journal of Clinical Psychiatry 2007; 68(Suppl 4): 8-13.


Dr Shilpi Ajwani
Head of Oral Health Promotion & Research
SLHD Oral Health Services and Sydney Dental Hospital
Sydney Local Health District
Phone: 02 9293 3466

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