Overview
Initiative type
Service Improvement
Status
Deliver
Published
June 2026
Summary
The General Practice Oral Health Service (GPOHS) VPP demonstrates a strong commitment to equity and high-quality care by proactively identifying and supporting vulnerable members of our community
Dates: January 2024 - December 2025
Implementation sites: Metro North Hospital and Health Service
Parternships: TPCH Mental Health Unit, Kallangur Satellite Oral Health Service
This was a Poster presentation at CEQ Showcase 2026 (PDF 1.1MB)
Aim
By prioritising patients over 90, TPCH mental health inpatients, people with complex medical needs and those experiencing social disadvantage, the VPP ensures respectful, compassionate, & person centred access to care. Targeted outreach and collaborative care pathways have enabled earlier intervention.
Outcomes
The outcomes of these initiatives reflect a culture of teamwork, integrity, and high performance. Older adults in the Kallangur catchment aged over 90 are now routinely reviewed every six months, ensuring continuity of care and early management of their oral health concerns.
The service has also supported 24 mental health in patient referrals from TPCH, strengthening partnerships across teams and improving patient outcomes. In addition, the expansion of Specialist Special Needs Dentistry staffing has enhanced our ability to provide comprehensive care for individuals with significant clinical complexity, contributing to a measurable reduction in waiting times for this vulnerable group.
Background
Gap in accessible, equitable and appropriate interventive services tailored to the needs of priority populations including the frail and elderly, the poor and socially disadvantaged, the complex medically and psychosocial patient and those with different levels of health literacy to reduce oral health inequality among these VPP. Proportional universalism with a risk stratified approach to target VPP was needed to ensure oral health care is provided to these groups across their oral health journey.
To recognise the strong interplay between oral health and overall health to highlight that oral health is considered an integral part of health care and not a separate entity. Many of the common risk factors for general health are applicable to oral health and need to be considered within the broader socio-environmental context. To target those populations most at risk of oral disease a pointed and collaborative care pathways needed to be established to mitigate the two year waiting period for general public dental care and emergent care presentations that often resulted in the loss of preventive option for care As part of the Vulnerable Peoples Program (VPP), General Practice Oral Health Services (GPOHS) are currently delivering targeted oral health services to vulnerable and high needs populations, and specifically the elderly, through the following initiatives:
Methods
- Cooinda House (Redcliffe): GPOHS has implemented a comprehensive oral health care model at Cooinda House, focusing on residents who have provided consent for dental services. All consenting patients have been triaged to identify their individual oral health needs and appropriate pathways of care. This approach ensures timely intervention, reduces the risk of oral health deterioration, and supports improved comfort, function, and overall quality of life for residents.
- Kallangur Satellite Health Centre – 90 Plus Program (90PP): GPOHS currently operates the 90 Plus Program (90PP) at the Kallangur Satellite Health Centre. This program targets patients aged over 90 years who are on general or priority public dental waiting lists. Patients are placed on a structured six monthly recall schedule. This model supports ongoing maintenance of oral health, reduces emergency presentations, and promotes continuity of care for a highly vulnerable ageing population.
- Homeless and Socially Disadvantaged Engagement: The GPOHS engages quarterly with the homeless and socially disadvantaged at Redcliffe and Sandgate community services offering basic oral hygiene products and connection to public oral health services. This reach of oral health services to the homeless and socially disadvantaged provides the vulnerable with direct contact and triaging with GPOHS and mitigates delay of care to emergent services only. This outreach approach of the GPOHS embeds this vulnerable cohort into the system for ongoing care.
- Oral Health Outreach Screenings: The GPOHS has actively collaborated with its School Dental Peers offering support and
oral health screening to Aboriginal and Torres Strait Island peoples once a term at Koobara Kindy. The GPOHS has also provided screening services at the Spring Hill emergency hostel housing for Aboriginal and Torres Strait Island peoples. This successful outreach
screening service provided a pathway into oral health services for community and established trust and connection for this important group.
Discussion
The Vulnerable Peoples Program (VPP) succeeded because it operated in an environment that prioritised equity, partnership, and flexible service design. Metro North Health’s commitment to person centred care created the conditions for innovative oral health models tailored to frail older adults, mental health inpatients, people experiencing homelessness, and Aboriginal and Torres Strait Islander communities. Strong relationships with TPCH Mental Health, Kallangur Satellite Health Centre, Cooinda House, the School Dental Service, enabled proactive outreach, triage, and earlier intervention for groups who would otherwise wait up to two years for care.
Key lessons included the value of a structured recall systems, consistent on site presence, and trust building through culturally safe engagement. Early intervention reduced emergency presentations and prevented deterioration.
Limitations centred on workforce capacity, challenges in coordinating care for medically complex patients, and inconsistencies in data capture across outreach settings.
Strengths of the program included its risk stratified approach, strong interdisciplinary collaboration, and expansion of the Special Needs Dentistry capability. Weaknesses involved limited specialist resources and challenges scaling outreach without sustained workforce investment.
Opportunities exist to standardise preventive programs across all GPOHS clinics, extend oral health screening in mental health and aged care settings, and formalise integrated care pathways with primary care and Aboriginal health services. If repeated, the project would benefit from earlier workforce expansion, a more robust evaluation framework, and co design with vulnerable communities to strengthen cultural and practical relevance. This model could succeed across Queensland Health in areas with large ageing populations, long dental waitlists, mental health inpatient units, community outreach programs, and settings serving Aboriginal and Torres Strait Islander families. Next steps include implementing planned workforce enhancements, expanding the 90 Plus Program service wide, strengthening data systems, and embedding sustained outreach and culturally safe care practices to ensure long term equity and improved oral health outcomes for vulnerable Queenslanders
References
Queensland Statewide Oral Health Service Plan
Key contact
Dr Chris Butson
Director, General Practice Oral Health Service
Community and Oral Health
Metro North Health Service