Midlevel Dental Providers One Approach to Expanding Access to Care

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Poll

How informed are you on midlevel dental providers?

1. Very informed

2. Somewhat informed

3. Not very informed

4. Not informed at all

Overview: Midlevel Dental Providers

Andrew Peters

The Pew Charitable Trusts

apeters@pewtrusts.org

4

Objectives 1. Access: Understand the factors driving the dental

care access problem in the U.S.

2. Midlevel Dental Provider Models: Understand the four models being used in different parts of the country to expand access to care for the underserved.

3. State Activity: Learn about current state laws and legislative interest in authorizing midlevel dental providers.

The Problem: Access to Care

• Many Americans lack dental insurance

• Maldistribution of dentists

• Few dentists accept Medicaid

• Too few children on Medicaid get dental care

Mission of Mercy clinic in Cape Girardeau, Missouri on May 3, 2013. People camped out in line for two days to receive free dental care.

6

7

Few Dentists Accept Medicaid 2012 survey of 33 states

Less than

30% of dentists

Filed

50

claims or more

8

9

10

One Solution to Improve Access: Midlevel Dental Providers

11

What are mid-level providers?

• They fill roles similar to nurse practitioners or physician’s assistants in medicine

• Scope of practice: preventive and routine restorative care

• Models vary by scope of practice, settings for practice and supervision requirements

12

Why employ midlevels?

1. Extend reach of dental practices to underserved people

2. Make it economically viable for dental practices to treat more Medicaid patients

3. Improve efficiency and economic bottom line

13

14

Evidence on safety of dental therapists

Review of 1,100 studies show that dental therapists deliver safe, effective care

15

Nurse Practitioner Workforce Growth

Source: Unpublished data from the National Organization of Nurse Practitioners Faculties; Analysis by the Center for Health Professions, UCSF, 2004. 16

State Legislative Activity: Mid-Level Dental Providers

NH

MA

ME

NJ

CT RI

DE

VT

NY

MD

NC

PA

VA WV

FL

GA

SC

KY

IN OH

MI

TN

MS AL

MO

IL

IA

MN

WI

LA

AR OK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AK

AZ

NM

ID OR

WA

NV

CA

4 states authorizing new providers

15 states considering new providers

Models Examined

• Dental therapist (hygiene based)

• Dental Therapist (non-hygiene based)

• Community Dental Health Coordinator

• Hygienists with additional training to provide atraumatic restorative treatment

18

2003: Began practicing on Alaska tribal lands 2009: authorized in Minnesota

Dental Therapy without a dental hygiene degree

19

Model (Location) Supervision Education Allowable Procedures (not a complete list)

Dental Health Aide Therapist (Alaska tribal lands)

Can work without a dentist in the same location, performing procedures based on standing orders issued by supervising dentist.

Certificate program (20 months + 400 clinical practice hours under dentist direct supervision)

• Perform exams • Take X-rays • Conduct cleanings • Apply fluoride varnish and sealants • Prepare and restore decayed primary

and permanent teeth • Place pre-formed crowns • Perform pulpotomies • Extract (non-surgically) primary and

permanent teeth

Dental Therapist (Minnesota)

Some procedures (preparing cavities and restoring and extracting teeth) require a dentist in the office; others (X-rays , fluoride varnish) do not.

Bachelor’s degree (28-month post-high- school program; requires 10 prerequisite courses)

• Take X-rays • Apply fluoride varnish and sealants • Prepare and restore decayed primary

and permanent teeth • Place temporary and preformed

crowns • Perform primary tooth pulpotomies • Extract primary teeth

Dental Therapists (non-hygiene based)

20

2009: Advanced dental therapists authorized in Minnesota.

2014: Dental hygiene therapists authorized in Maine

Dental Therapy with a dental hygiene degree

21

Dental Therapists (hygiene based) Model Supervision Education Allowable Procedures (not a complete list)

Advanced Dental Therapist (Minnesota)

Can work without a dentist in the same location, performing procedures according to standing orders issued by the supervising dentist.

Master’s degree (26 month degree; prerequisite bachelor’s degree in dental hygiene) + 2,000 clinical practice hours

All dental therapy procedures, plus: • Take X-rays • Apply fluoride varnish and sealants • Prepare and restore decayed primary and

permanent teeth • Place temporary and preformed crowns • Perform primary tooth pulpotomies • Extract primary teeth, perform simple extractions

of permanent teeth • Complete an oral evaluation and create a

treatment plan

Dental Hygiene Therapists (Maine)

Must be supervised by a dentist in the same office.

4 years (or 2 years in addition to a hygiene degree)*

All dental hygiene procedures, plus: • Perform oral health assessments • Take X-rays • Apply fluoride varnish and sealants • Prepare and restore decayed primary and

permanent teeth • Place pre-formed crowns • Perform primary tooth pulpotomies • Extract (non-surgically) primary and uncomplicated

permanent teeth

*Legislation was passed in Maine in April 2014. Regulations and training programs are still being developed.

22

Community Dental Health Coordinators

• Offer oral health education to underserved communities and link residents to dentists in their communities.

• 2011: New Mexico authorizes CDHCs

23

Community Dental Health Coordinators

Supervision Education Allowable Procedures (not a complete list)

Can work without a dentist in the same location, performing procedures authorized by a supervising dentist.

18 months (12 months online and 6 month internship)

• Take X-rays • Apply fluoride varnish and

sealants • Perform coronal polishing • Prepare teeth for temporary

restorations • Place temporary restorations,

including Interim Therapeutic Restorations

24

Dental Hygienists with Restorative Duties

Current Status:

Numerous states allow hygienists to perform restorative duties using a hand piece but not a drill.

Examples: Virtual Dental Home demonstration, California; ForsythKids Program, Massachusetts

25

Dental Hygienists with Restorative Duties

Supervision Education Training Allowable Procedures (not a complete list)

Typically direct or general, although some states allow for public health supervision or independent practice

Varies, typically through a certificate course

Varies Expanded functions vary state by state, but may include: • Apply cavity liner/base • Place (and also carve and finish) amalgam

restoration • Place and finish composite restoration • Place and/or remove temporary fillings,

which may include Interim Therapeutic Restorations

• Place and/or remove temporary crown • Fabricate temporary crown

26

Registered Dental Hygienist with restorative

duties

Community Dental Health Coordinator

Dental Health Aide Therapist

(AK)

Dental Therapist (MN)

Advanced Dental

Therapist (MN)

Dental Hygiene Therapist (ME)

Dentist

Preventive Services

Full Routine Routine Routine Full Full Full

Restorative Services

Very few Very few Routine Routine Routine Routine Full

Prescribing Rights

No No No No No No Yes

Practice w/out dentist on site

In some states Yes Yes No Yes No n/a

Independent Practice

(supervision requirements)

In some states (varies)

No (general) No (general) No (indirect or

general) No (general) No (direct) Yes

Understanding Scope of Practice

27

Length of Training (Post High School): US and International Dental Providers

28

0

1

2

3

4

5

6

7

8

9Assistants &

CDHC

Hygienists Therapists Hygiene- Therapists

Dentist

Midlevel Dental

Providers in Practice: 5 Examples

29

2012 (DTs first year at practice)

Patients DT saw: 241

DT’s procedure volume: 972

DT’s procedure mix:

Mostly

composite

restorations

Main Street Dental Care, Solo Dental Practice (Minnesota) 1

30

A dental therapist at Battlefords Dental Group (Saskatchewan)

2

31

Patients: 637

Procedures: 2622

Patients: 715

Procedures: 4,734

Dental Health Aide Therapists (Alaska)

3

32

A dental therapist at the People’s Center Health Services (Minneapolis)

4

33

Dental Hygienists with expanded restorative skills at the Virtual Dental Home

(California)

5

34

New Findings: Economics of Midlevel Dental Providers

35

Total cost of employment $90,700

Increase in Medicaid

patients served 50%

Additional revenue to

practice $23,000

Main Street Dental Care (Minnesota)

36

Total Therapy Collections in 2012:

$529,000 Profit

$217,000

Commissions paid: $192,032

Overhead: $120,000

Battlefords Dental Group (Saskatchewan)

37

Total Revenue Generated by Advanced Dental Therapists and Dental Therapists in Minnesota (in green) and Dental Health Aide Therapists in Alaska (in blue)

http://www.communitycatalyst.org/doc_store/publications/economic-viability-dental-therapists.pdf; Report conducted by Dr. Frances M. Kim, May 2013

Dental therapists cost their employers less than 30 cents for every dollar of revenue they generate.

38

Dental Health Aide Therapists (Alaska)

39

Annual billing per DHAT:

$150,000 - $250,000 above employment costs

Annual savings in patient travel per DHAT:

Over $40,000

Cost to employ: $136,000

Medicaid revenue:$167,000

Medicaid revenue exceeds costs

by over $30,000

A dental therapist at the People’s Center Health Services (Minneapolis)

40

Virtual Dental Home (California)

Costs: $115 $99

Revenue: $61 $112

California vs. National average per visit

41

For Additional Information

Andrew Peters

The Pew Charitable Trusts

apeters@pewtrusts.org

http://www.pewtrusts.org/en/research-and-analysis/reports/2014/06/30/expanding-the-dental-team

http://www.pewtrusts.org/en/projects/childrens-dental-policy

42

AK DHAT Educational Program-

Education and Practice Basics

Mary E. Williard, DDS

Midlevel Dental Providers: One Approach to Expanding

Access to Care

Webinar, June 30, 2015

The

American

Academy

of Dental

Therapy,

2011

History of Dental Caries in Alaska

Native People

1984

1925

Archeological records

show caries rate of ~1%

1928 – 1930’s

Studies show lowest

caries rate in the world

Improved air transportation and dietary changes

Prevalence of

dental caries in

children 2x same

aged U.S. children

1999

Vast majority

of children

have dental

caries

Price, WA. 1939. Nutrition and Physical

Degeneration. 8th ed. Lemon Grove, CA.

1921

NZ Dental

Nurse

2003

AK students

to NZ

Dental Therapists: A Definition

• Primary oral health care professionals • Basic clinical dental treatment

and preventive services

• Multidisciplinary team members

• Advocate for the needs of clients

• Refer for services beyond the scope of the dental therapist’s practice.*

*SASKATCHEWAN DENTAL THERAPISTS ASSOCIATION

There Was Opposition

The Fight is Winnable and Worth It

Conan Murat, DHAT, standing his ground

“A Review of the Global Literature

on Dental Therapists”*

http://www.wkkf.org/news-and-media/article/2012/04/nash-report-is-evidence-that-dental-therapists-expand-access

*Prepared by: David A. Nash, Jay W. Friedman, Kavita R. Mathu-Muju, Peter G. Robinson, Julie Satur, Susan Moffat,

Rosemary Kardos, Edward C.M. Lo, Anthony H.H. Wong, Nasruddin Jaafar, Jos van den Heuvel, Prathip Phantumvanit,

Eu Oy Chu, Rahul Naidu, Lesley Naidoo, Irving McKenzie and Eshani Fernando

Supported by the W.K. Kellogg Foundation

Dental Therapists:

• Decrease cost of care

• Improve access to care

• Provide care safely

• Public values the role of

dental therapists

• Traditionally 2 years

education

The Journal of Public Health Dentistry, Special Issue:

Workforce Development in Dentistry: Addressing

Access to Care

Spring 2011 Volume 71, Issue Supplement S2

American Association of Public Health Dentistry

• 11-person academic panel

• Model curriculum

• Two-year, post-secondary

• Open access online:

• http://onlinelibrary.wiley.com/doi/10.

1111/jphd.2011.71.issue-s2/issuetoc

Curriculum

DHAT curriculum adapted by AAPHD panel

DHAT Education by Hours First year: 40 weeks

Second year: 39 weeks

Total: 79 weeks (3160 hours)

Curriculum Break-down year 1

Biological Science: 30%

Social Science: 10%

Pre-clinic: 40%

Clinic: 20%

Curriculum Break-down year 2

Biological Science: 15%

Social Science: 7%

Pre-clinic: 0%

Clinic: 78% (1215 hours)

Curriculum Break-down both years

combined:

Biological Science: 22.5%

Social Science: 8.5%

Pre-clinic: 20% (632 hours)

Clinic: 49% (1548 hours)

Different

Providers

Different

Education

DHAT

NEED TO KNOW

Limited scope, 46 procedures

Supervised

Prevention oriented team approach

Accessible to students in target populations

Culturally competent

Patient centered

DENTIST

NEED to know+ nice to know

Large scope, 500+

Team leader

Surgically oriented

Education is difficult to access, especially for minorities

Struggling to address cultural competency

Practice centered

Prevention and Promotion

The Heart of DHAT

DHAT students doing screenings and

fluoride applications at a Head Start

From ANTHC Consultant Survey of AK

Tribal Dental Directors

Each DHAT team on average,

provides care to 830 patients during

approximately 1200 patient

encounters (or visits) each year.

700 visits

500 visits

Scott and Co. Consulting

Improved Access and Quality

• 25 certified DHAT

• 81 communities in rural AK

• Over 40,000 people have access

• Continuity of care

• Higher level of care possible

• Dentist working up to their licensure

DHAT Aurora Johnson,

NZ Educated

Keys to DHAT Success • Not Mini Dentists

• Part of a dentist led team

• 2 Year Education

• Competency based

• Accessible to non-traditional

students

• Cultural Competence

• General Supervision

• Appropriate Scope:

• Diagnosis and Treatment

Planning

• Extractions

• Certification/ Recertification

• Community-based Trisha Patton, DHAT student, taking x-rays

DHAT Educational Program

Mary E. Williard, DDS 907-729-5600

4200 Lake Otis Parkway, Ste. 204

Anchorage, AK 99508

DHAT training is ANTHCsmile

on Facebook

website:

http://anthcoralhealth.org

Division of Community Health Services

Utilization of a Dental Therapist

in a FQHC

Eric Elmquist D.D.S.

Overview

• Background on Dental Therapist in MN

• My Process in hiring a Dental Therapist

• How was the Dental Therapist utilized in our clinic

• What worked, what didn’t

• Future

Legislation Enacted 2009

• MN Created both Dental Therapists and Advanced Dental

Therapists

• DTs/ADTs work under a written collaborative management

agreement with a MN licensed dentist

• The purpose of this provider is to extend dental care to

underserved communities

Lake Superior Community

Health Center- Clinic Background • FQHC

• Health Center established 1973

• Superior Site – 8 Dental Chairs, Established 2005

• Duluth Site – 11 Dental Chairs, Established 2007

• Minnesota and Wisconsin offer MA Reimbursement for

Adult Preventative, Restorative and Emergency Services

• Clinic increasing depended on Oral Health Program

financially

Transitions at LSCHC

• Started rebranding and extensive promotion

campaign for first time since opening of

dental clinic

• Dental Staffing Changes

• Dental Program Expansion

Care Delivery Challenges

2013 greatest number of encounters seen in our dental clinic

• Increased wait time for routine appointments

• Hard to keep both sites open 5 days a week

• Dentist seeing more ER patients Everyday

• DDS Scheduling causing FD nightmare

Were we meeting the needs of our Patient population?

Staffing Options

• Dentist

• Dental Students

• Dental Therapist

• Restorative Functions Dental Assistant

Developing the Dental

Therapist Program

• Needed to educate the dental staff about the

position.

• Needed to education patient population.

• What was the goal for the Dental Therapist?

Dental Therapist in Action

Dental Therapist Started November 2013

• Production expectation 1.1 patients per hour

• Quality Assurance the same as any new provider

• Majority of Patients was adult restorative

Clinic Production 2014

Clinic Production

Other things helping production:

• Hired Temporary Dentist

• Hired Permanent Dentist

• Stricter failed appointment policy

• Increased use of Restorative Functions Dental

Assistants

• Staff was great

Production and Scheduling

Considerations

Patient Population:

• DT seeing an Adult population

• Longer appointments

• More complex procedures

• More procedures per appointment

• Decreased Production- Was this a

problem?

Other Benefits of Dental Therapist

• Improve the Morale, Communication and

Collaboration. The Dental staff was working as

a Team.

• Increase Patient Satisfaction - we were being

responsive to their needs

• Made our Clinic more Visible

• Provided Same Quality Care to More Patients

If I Knew Now… • Formal Utilization and Scheduling Plan for

Position

• More Education of Entire Clinic

• One Dentist as Point Person

• Used State and Community Resources

• Set Realistic Expectations

Conclusions

• Did the DT increase access?

• Was the DT position successful in our clinic?

• Did the DT solve our access needs?

Future of Program

Contact

Eric Elmquist, D.D.S.

Access Community Health Center

elmquisteric@gmail.com

Q & A

Contact us!

National Network for Oral Health Access Jodi Padilla, MBA NNOHA Policy Analyst 303-957-0635 x1 jodi@nnoha.org www.nnoha.org