avenues to access a primer in initial development of a dental safety net system

Avenues to Access

A Primer in

Initial Development of a

Dental Safety Net System

© 2012 American Dental Association, All Rights Reserved

In the Beginning:

• Someone, somewhere has decided to look into access to oral health in a particular area.

• If the leader is new to the public health arena, it can be a little overwhelming.


“Expert” Advice:

“You got to be careful if you don’t know where you’re going, because you might not get there.”

Yogi Berra


What is the purpose of this presentation?

The most important need on this trip is to figure out where you would like to this journey to end.

This is best accomplished with a few simple, though time-consuming steps.


Where does one begin?

Just like eating an elephant, the job is best accomplished through small bites!


What This Presentation CANNOT Do:

• Answer all of the questions.• Provide anything more than a starting point

for a community discussion on how to best provide services for unmet oral health care needs.

• Pick the delivery method that will work best for a particular area.


What This Presentation CAN Do:

• Provide a very basic overview of different ways to create access to dental care.

• Spell out the common acronyms.• Raise a few points to consider as one is

developing a safety net system.• Provide some links to additional information

on many of the ideas introduced.


Overview

1. Do a quick assessment to get a sense of need.

2. Develop a team.

3. Investigate more deeply the existing conditions/resources and their growth potential, as well as the actual numbers and characteristics of those in need.

4. Understand the options available.

5. Create a plan: What will best address the needs the team have identified as top priority?


Quick Assessment: What?

• Gather and assess basic information that is readily available including:– Population– Overview of needs– Number of existing providers


Quick Assessment: Why?

– Go beyond anecdotal.– Helps in recruiting team.– Requires little time and effort.


Quick Assessment: How?

• U.S. Census Data available at www.census.gov• Health Resources and Services Administration (HRSA)

– Medically Underserved Area (MUA) Data– Medically Underserved Population (MUP) Data– bhpr.hrsa.gov/shortage/

• State Department of Public Health– Association of State and Territorial Dental Directors

(ASTDD) has links to all state programs– www.astdd.org/state-programs/

• County/Municipal Health Department• State licensing agency quantity of providers in area

http://ww.census.gov/

http://bhpr.hrsa.gov/shortage/

http://www.astdd.org/state-programs/


Developing a Team: Why?

– Gain a better understanding of the needs and resources within the community.

– Promotes buy-in, lends legitimacy.

– Share the workload.

– Sustain the operation over time.


Developing a Team

Who should be on board?

Think of all the necessary aspects of bringing such a project to completion.


Team Members: Who?

– Provider Network

– Governmental Units

– Finance People

– Social Services

– Patient Representatives


Team: How to Invite Onboard

• A personal invitation is best.

• Now is the time to share a story, some enthusiasm and define the problem as you see it.

• Discuss why they’ve been included; why their view matters.

• Be honest about the duration of commitment you expect at that point.


Team: Provider Network

• There MUST be a local dentist onboard:– Knowledge of

community, delivery systems and a great resource for potential collaborative efforts

– Serves as a conduit to the local dental society for information/idea exchange as well as a referral source



• There SHOULD be a member of the County or Municipal Public Health Department:

– Knowledge of the community and patient populations

– Awareness of existing sources of care

– Awareness of funding sources



• If a local hospital exists, consider inviting the administrator or the ER supervisor to join. Urgent care clinic folks also have good information:– Great source of statistics for

community need– Possible funding source– Familiar with many aspects of

healthcare delivery, from governmental regulations on through inventory supply systems



• Local dental schools and hygiene or assisting programs

• Hygiene society

• Community health workers

• School Nurses


Team: Governmental Representatives

• State and local officials

• County or municipal Board of Health

• State dental director


Team: Finance People

• Foundations• Charitable civic

organizations

• Corporate donors

• Bankers

• Grant writers


Team: Social Services

1. Agencies that work with special populations groups• Homeless• Aging• Children (Head Start, WIC, school systems)• Individuals with disabilities

2. Clergy

3. Other social service agencies (county, municipal, hospital)


Team: Patient Representatives

• Advocates for the homeless

• Local AARP representative

• Shelter residents

• Uninsured “working poor”


Investigate Existing Conditions/Resources

How do you know what you

NEED

when you don’t know what you

HAVE?


Investigate Existing Resources

• Look at existing safety net resources: – How many and who are

they serving now?– Can they/will they grow? • Look at the

unserved population:– Demographically– Geographically



• Health Professional Shortage Area (HPSA)Designation?– Incentives (loan forgiveness) in recruiting

providers.– HPSA determination: hpsafind.hrsa.gov

• Other “scholarship” type incentives for providers in underserved areas– As an example, Illinois has “Bridge to Healthy

Smiles”: www.bridgetohealthysmiles.com/

http://hpsafind.hrsa.gov/

http://www.bridgetohealthysmiles.com/



• Clinics

• Mobile Units• School Programs

• Hospitals

• Private Dentists Accepting Medicaid

• Nursing Homes• Professional

Schools



• Land• Buildings/Clinics with extra space• Nearby Federally Qualified Health Center

(FQHC)—possibility of satellite?• Unused equipment or potential corporate

donations of same• New school being built?



• Ask your team and Use your team!• Where does the county refer patients?• Does the hospital have a referral base?• Current Provider Data:

– CMS provides database of current Medicaid providers: www.insurekidsnow.gov/

– FreeDental.org is a searchable database that provides a breakdown of providers of free or sliding-scale care by state: www.freedental.org/

– Identify low-cost/free care providers by zip code: www.1dental.com/free-dental/

http://www.insurekidsnow.gov/

http://www.freedental.org/

http://www.freedental.org/

http://www.1dental.com/free-dental/

http://www.1dental.com/free-dental/



• Geographical Information Systems (GIS) mapping– More accurate than “by county” analysis– See Kansas study data available at

www.kdheks.gov.ohi/index.html

• Hospitals: emergency room data• School Nurses: oral health-related

absences

http://www.kdheks.gov.ohi/index.html



• From census data:– Age– Ethnicity– Location

• Languages spoken• Special Needs Populations


Existing Conditions: Helpful Resources

• “A Guide for Developing and Enhancing Community Oral Health Programs,” National Maternal and Oral Health Resources, Available at www.aacdp.com/Guide/

• “Assessing Oral Health Needs: ASTDD Seven-Step Model” The Association of State and Territorial Dental Directors, Available at www.astdd.org/index.php?template=sevensteps.html

http://www.aacdp.com/Guide/

http://www.astdd.org/index.php?template=sevensteps.html

http://www.astdd.org/index.php?template=sevensteps.html


Systems Check

1. You’ve established need.

2. You’ve put together a team.

3. You assessed your existing resources.

4. You have taken a deeper look at your unserved population in order to better understand them.

5. What next?


Congratulations!!

If your existing

resources

fulfill your existing

needs:


However:

IT SEEMS MORE LIKELY THAT THE NEED WILL OUTWEIGH THE EXISTING NUMBER OF CAREGIVERS!

(The team needs to keep going.)


Options to Address Needs

• Bricks and mortar clinic– FQHC and

“Lookalike” Clinic– Local Public Health

Clinic– Hospital Clinic

• Mobile Clinic• Portable Dental Unit

• School-based Program

• “Temporary” Fixes:– Mission of Mercy– Give Kids a Smile– Donated Dental

Services• Indian Health Service


FQHC and “Lookalikes”

• WHAT are they?

• HOW do they work?

• WHOM do they serve?

• WHY or why not?FQHC

Madison, WI


FQHC: What are they?

• Federally Qualified Health Centers• Nonprofit healthcare centers located in a high

need or high-risk area (most provide some dental care).

• Provide comprehensive primary care to all.– Exceptions exist for FQHCs that target specific

populations, such as the homeless or migrant farmworker communities.

• Provide support/enabling services for patients.


FQHC: What are they? (continued)

• Governing board of community members with at least 51% of its members coming from within the patient ranks.

• Meet other requirements regarding administrative, clinical and financial operations.

• “Lookalikes” are much the same, except they do not receive federal funding from Section 330 grants nor do they qualify for malpractice protection under the Federal Tort Claims Act (FTCA).


FQHC: How do they work?

• Made possible under Authorizing Legislation of the Health Center Program – Section 330 of the Public Health Service Act; – bphc.hrsa.gov/about/legislation/section330.htm

• Partially funded by Sec. 330 grants, estimated by Cong. Research Center to cover 20% of cost (lookalikes do not get this grant money)– “Federal Health Centers,” Elaine J. Heisler,

Congressional Research Service, March 21,2012, p.2. Available at www.fas.org/sgp/crs/misc/R42433.pdf

http://bphc.hrsa.gov/about/legislation/section330.htm

http://www.fas.org/sgp/crs/misc/R42433.pdf


FQHC: How do they work? (continued)

• Many other grant sources can be tapped for funding. For example:– Ryan White HIV/AIDS– Healthy Start program– State and local grants– Health Professional Shortage Area (HPSA)

designation • Can help qualify for financial help by providing loan

forgiveness assistance for providers; hpsafind.hrsa.gov/• Can hire staff through Nat’l. Health Service Corp

http://hpsafind.hrsa.gov/



• Medicare, Medicaid, private pay and insurance also accepted

• Federal Poverty Level = $22,350/family of four and is used as determinant in fees owed

• Patients above 200% of the FPL pay a fee set by board to align with local prevailing fees.

• A family at or below 200% of FPL is subject to sliding scale, though none refused if unable to pay.

• Private or corporate funding also accepted



• Can elect to receive funding through a Prospective Payment System (PPS).– Per visit payment rate determined by baseline

rate/visit from previous years, with Medicare Economic Index adjustments.

– Helps FQHC determine budget.– Quadrant dentistry is performance goal; want to

avoid practice of “churning.”

• Other Alternative Payment Methodologies (APM) exist.


FQHC: Whom do they serve?

• Designed to serve the community, absent of regard for personal resources (or lack thereof) with “required primary health services.”

• By statute must provide “dental screenings for children” and “preventive dental services” as part of requirements.– “Preventive dental services” are defined in regulations to mean oral

hygiene instruction, cleanings, topical fluoride and/or fluoride prescriptions.

– If FQHC does not provide dental, must make these services available by referral or contracting with providers.

– See 42 U.S.C. Sec. 254b(b)(1)(A)(i)(III)(ff) & (hh)


FQHC: Whom do they serve? (continued)

• May get approval to extend services beyond those provided as primary.– Health and Human Services gives approval for

supplementing services.– See 42 C.F.R. Sec. 51c(102)(j)(6).

• If so, then must offer this additional care to all residents of service area that fit the parameters defined.


FQHC: Why or why not?

• If an FQHC exists somewhere “in the area” consider a satellite office.

• Access to medical staff within system.• Federal Tort Claims Act (FTCA): Centers are

considered Federal employees and thus covered in malpractice lawsuits: bphc.hrsa.gov/policiesregulations/policies/pin201101.html (click on policy manual link)

• FQHC can contract with private dentists in providing care.

• A little more difficult to share space.

http://bphc.hrsa.gov/policiesregulations/policies/pin201101.html




FQHC: Helpful Resources

• “Operations Manual for Health Center Oral Health Programs” National Network for Oral Health Access. Available at www.nnoha.org/practicemanagement/manual.html

• “So You Want to Start A Health Center. . .? A Practical Guide to Starting a Federally Qualified Health Center” National Association of Community Health Centers. Available at www.nachc.com/hc-growth-development.cfm

• “Safety Net Dental Clinic Manual” National Maternal and Child Oral Health Resource Center, available at www.dentalclinicmanual.com/

• “Increasing Access to Dental Care through Public Private Partnerships: Contracting between Private Dentists and FQHC” Children’s Dental Health Project. Available at www.cdhp.org/resource/FQHC_Handbook

http://www.nnoha.org/practicemanagement/manual.html

http://www.nachc.com/hc-growth-development.cfm

http://www.dentalclinicmanual.com/

http://www.cdhp.org/resource/FQHC_Handbook


Local Public Health Clinic (LPHC)

Northern Dental Access Center

Bemidji, Minnesota


LPHC: What are they?

• Includes many county, municipal and foundation-based facilities that provide services

• Regulation of each entity dependent on governing body—usually a board-type governance structure


LPHC: How do they work?

• Very broad spectrum of operational plans exist.

• Funding sources:– Grants/donations: private, corporate and

nonprofit– Governmental funding (but not Sec. 330 dollars)– Private pay, insurance, Medicaid– Donations of services often help defray costs


LPHC: Whom do they serve?

• The parameters for each individual clinic are defined when they are established: – Subject to modification by board– Subject to modification by county/municipal ruling– Subject to modification by supporting

organization

• Often see a combination of programs run under one umbrella: e.g. a school-based sealant program with a local clinic or local private dentist providing restorative.


LPHC: Why or Why not?

• Can be less regulated than a federal clinic.• Can make excellent use of shared facilities

and/or community partnerships.• Have a great deal of flexibility for structure.• Mission can be altered a little more readily

than federal clinic.• Easier for dentists to volunteer.• Do not qualify for federal Sec. 330 funds or

malpractice protection under FTCA.


LPHC: Helpful Resources

• Talk to state dental director for referral and/or mentoring advice from some of the state’s best practice examples.

• “Guide for Developing and Enhancing Oral Health Programs” American Assoc. for Community Dental Programs. Available at www.aacdp.com/Guide/

• “Proven and Promising Best Practices for State and Community Oral Health Programs” American Society of State and Territorial Dental Directors. Available at www.astdd.org/best-practices/

http://www.aacdp.com/Guide/

http://www.astdd.org/best-practices/


Hospital Clinics

Dental Clinic Children’s Hospital of

WisconsinMilwaukee, WI


Hospital Clinics: What are they?

• Located on-site or near the hospital with whom they are affiliated.

• Can range from limited services (emergency only, oral surgery only) to full-blown care.

• Hospital may elect not to build own clinic, but rather to contribute funding to some other safety net entity to whom referrals may be made.


Hospital Clinics: How do they work?

• Can choose from many options, based on mission/vision

• Often incorporate graduate programs:– Specialty– General Practice Residency

• Funding from parent hospital, grants, Medicaid, Medicare, private pay, insurance


Hospital Clinics: Whom do they serve?

• The parent hospital sets parameters for patient base as well as care offered:– Emergency care– In-patient care– Medically necessary care– Graduate programs

• Lose flexibility and control over definition of care if elect to contribute funds to some other entity to provide safety net services.


Hospital Clinics: Why or why not?

• Better service for oral pain patients in ER• Better expenditure of dollars• Can benefit from purchasing power of

hospital for supplies and equipment• Support of medical staff in-house for

consultation on medically compromised patients


Hospital Clinics: Helpful Resources

• “Emergency Department Visits for Dental Conditions,” Romesh P. Nalliah, BDS and Veerasathpurush Allareddy, BDS, PhD; March 19, 2012; available at www.medscape.com/viewarticle/760206

• “Dental Treatment in Florida’s Hospital Emergency Rooms,” an overview which illustrates the issue for one state, available at apha.confex.com/apha/140am/webprogram/Paper257408.html

http://www.medscape.com/viewarticle/760206

https://apha.confex.com/apha/140am/webprogram/Paper257408.html






Mobile Clinic

DuPage County, IL “Smile Squad” Dental Care Van


Mobile Clinics: What are they?

• Self-contained mobile dental treatment facilities.– Vans or trailers retrofitted with total care units.– Completely self-contained water system,

vacuum, compressor and (often) sterilization located within.

• Can be moved wherever desired to serve population.


Mobile Clinics: How do they work?

• Start-up funding through grants, corporate/private donations, fundraising.

• Continued support through much of the same, along with gov’t. funding, private pay and insurance.

• Services may be provided on a volunteer basis by local providers.


Mobile Clinics: Whom do they serve?

• Often used in conjunction with service provision to patients with limited access to transportation—homebound, school children, geriatric patients.– For example, Ronald McDonald Care van only

available to children in specific service areas.

• May be limited in scope by grant parameters initially, but then may be expanded once grant requirements met.


Mobile Clinics: Why or why not?

• Work well to reach those with limited access to transportation.

• Introduce host of other issues:– Maintenance of vehicle– Driver: additional costs, background check, etc.– Need place to park:

• Possible access to electricity, water– Insurance on vehicle– Access for disabled patients


Portable Dental Unit


Portable Dental Unit: What is it?

• Discrete movable dental module that generally consists of a chair, light and self-contained treatment center with handpiece and suction hookups, compressor

• For transportation purposes is disassembled into pieces– Chair~30 lbs– Units range~30-50 lbs

• Easily reassembled on site


Portable Dental Unit: How does it work?

• All equipment can be wheeled/carried into the selected treatment area and assembled there.

• Unit has self-contained water supply and suction tanks, as well as compressor.

• Only requirement of host facility is power source and space.

• Operator and assisting stools also available.


Portable Unit: Whom Do They Serve?

• Nursing homes• Senior centers• Schools• Homebound patients• Remote access areas• “MASH-style” charitable operations• Just about anyone treated anywhere!


Portable Unit: Why or Why Not?

• Extremely adaptable for many delivery situations

• Sometimes a bit challenging for some special needs populations:– Chairs not as stable, so transfers over can be

difficult– Weight limit on chairs (~350 lbs.)

• Ergonomically can be difficult for provider long-term


Mobile/Portable Care: Helpful Resource

“Mobile/Portable Dental Manual” Association of State and Territorial Dental Directors. Available

at http://www.mobile-portabledentalmanual.com/

http://www.mobile-portabledentalmanual.com/


Charitable/Free Care

Mission of Mercy

June 8-9, 2012Grayslake, IL


Charitable Care: What is it?

• Endless list of services fall into this category, the common factor being that the care is provided free of charge.

• Can be provided in one’s own office or local clinic.

• May be offered in a temporarily established clinic.

• Generally offers basic preventive and extractions, as well as basic restorative treatment; variations occur.


Charitable Care: How does it work?

• For in-office treatment: dentist and staff commit to providing care either for a particular patient, a particular day or for a particular service

• Larger scale mobile clinics involve more planning: fundraising, donations, recruitment of volunteers, planning for follow-up care where needed and arranging for patients’ needs (lab services, transportation, pharmaceutical support, etc.)


Charitable Care: Whom does it serve?

• Planners set protocol.• Some examples:

– Give Kids A Smile: limited to pediatric patients– Mission of Mercy: open to all– Veteran’s Day: open to any former service man

or woman– Donated Dental Services: patients prescreened

to demonstrate need—financial and otherwise (disabled, elderly, medically compromised)


Charitable Care: Why or Why Not?

• Provides a lot of care that might otherwise be left untouched.

• Capable of serving huge numbers of patients in short amount of time.

• Often fails to establish dental home.• Does not address long-term solutions.• Can be used to dramatically illustrate vast

unmet needs in area: speaks to policy makers.


Charitable Care: Helpful Resources

• America’s Dentists Care Foundation Missions of Mercy: www.adcfmom.org/

• National Foundation of Dentistry for the Handicapped, Donated Dental Services: nfdh.org/donated-dental-services-dds

• Dentistry from the Heart: dentistryfromtheheart.org/

http://www.adcfmom.org/

http://nfdh.org/donated-dental-services-dds

http://nfdh.org/donated-dental-services-dds

http://dentistryfromtheheart.org/


School-Based Programs

School-Based ProgramPhoto courtesy of Dr. Martin MacIntyre


School Program: What is it?

• Usually means in-school delivery of care• May incorporate off-site treatment, which may

then be called “school-linked program”• Often includes referral to private partners for

follow-up• May be limited to screenings, sealants,

fluoride, oral hygiene instructions, but strive to identify options for needed restorative work:– Goal with prevention-based programs is to reduce

incidence of disease, not prevalence


School Program: How does it work?

• Target school district is identified• Verify unmet need• Obtain permission from parent/guardian• Obtain financial support

– Children’s Health Insurance (CHIP)– Grants, donations

• Delivery most likely through portable or mobile units


School Program: Whom do they serve?

• Generally target students with no access to care otherwise– Identify potential patients via percent of children

eligible for free/reduced lunch

• “Good” programs validate that patient does not have access to care otherwise:– Done via parent/guardian information provided– Generally accepted as no dental care/visit within

last 12 months


School Program: Why or why not?

• Excellent way to reach target population effectively.

• Reduces out of school time for children.• Easy way for parents to access care for their

children.• Difficulty is often in linking up with follow-up

care, so need to establish system for that.• If new school being built, good time to ask for

dedicated space.


School Program: Helpful Resources

• School-Based Dental Sealant Programs; CDC available at www.cdc.gov/print.do?url=http%3A%2F%2Fwww.cdc.gov%2Foralhealth%2Ftopics%2Fdental_sealant_programs.htm

• School-Based Sealant Programs Introduction; Assoc. of State and Territorial Dental Directors (ASTDD), available at www.astdd.org/school-based-dental-sealant-programs-introduction/

http://www.cdc.gov/print.do?url=http://www.cdc.gov/oralhealth/topics/dental_sealant_programs.htm



http://www.astdd.org/school-based-dental-sealant-programs-introduction/

http://www.astdd.org/school-based-dental-sealant-programs-introduction/


Indian Health Service (I.H.S.)

Fort Defiance Indian HospitalWindow Rock, Arizona

Houses a 24 chair dental clinic


I.H.S.: What is it?

• The Indian Health Service is an agency within the Health and Human Service (H.H.S.) that is established to provide care for American Indians and Alaskan Natives.

• May be operated as an FQHC in some instances, but often run solely as a tribal unit.

• Often a physical clinic exists, but remote locations may be served by portable equipment.


I.H.S.: How does it work?

• Funding is provided through H.H.S., either paid directly in response to care or given to the tribe so that they may elect more specifically how to utilize their available healthcare monies.– This latter method is called “638 contracting” as it is made

possible under the Indian Self Determination Act, see www.doi.gov/ost/information/tribal/contracting.html

• Monies may also be funded through grants, donations and third-party payments.

• Providers are either Civil Servants, members of the Commissioned Corp of the U.S. Public Health Service or direct tribal hires, along with some volunteers.

http://www.doi.gov/ost/information/tribal/contracting.html


I.H.S.: Whom do they serve?

Care is limited to the two targeted populations of American Indians and Alaskan Natives.

– Given budget restraints, all facilities are not operated the same

– Some elect to focus most care on children, pregnant patients and those with diabetes

– Some provide basic care to all


I.H.S.: Why or Why Not?

• Need for provision of services determined by I.H.S.– Resource Requirement Methodology (RRM)

used to determine needs and provide data for Congressional Appropriation hearings

– Tribal input– Bureau of Indian Affairs


I.H.S.: Helpful Resources

• I.H.S. Oral Health Program Guide, available at www.ihs.gov/doh/clinicmanagement/ohpg/ohpg.pdf

• Indian Health Service, available at www.ihs.gov/• I.H.S./RRM planning worksheet available at

www.ihs.gov/PlanningEvaluation/• “Safety Net Dental Clinic Manual” National Maternal

and Child Oral Health Resource Center, available at www.dentalclinicmanual.com/

http://www.ihs.gov/doh/clinicmanagement/ohpg/ohpg.pdf



http://www.ihs.gov/

http://www.ihs.gov/PlanningEvaluation/




Next Steps?


Create a Plan:

• The committee will look at all the information gathered:– Population in need– Available resources– Options to provide care

• Engage in healthy debate and decision-making.

• And set goals for which road it wishes to travel!


Next Steps: Helpful Hints

• Respect the differences of opinion among the team.

• Be good listeners.• Creatively seek mutually acceptable

solutions.• Remember that the project can be done

incrementally.• Focus on the mutual commitment to

helping those in need!


Questions?

Dr. Steven P. Geiermann

Sr. Manager

Council on Access, Prevention and Interprofessional Relations

[email protected]

312-440-2667

Dr. Elizabeth “Betsy” Shapiro

ADA 2011-2012 Hillenbrand Fellow

[email protected]

312-440-7729

mailto:[email protected]

mailto:[email protected]

avenues to access a primer in initial development of a dental safety net system

Documents

american dental association

dental care

rights reserved overview

rights reserved team

area slide

dental safety net system

local dental society

referral source slide