Evaluation of the DentaQuest Institute Safety Net ... · efficiency and management decision making, but also improvement in patient access to dental care, the quality of care and

Evaluation of the DentaQuest Institute Safety Net Solutions’ Practice

Management Technical Assistance Program

and

Evaluation of Dental Clinic Technical Assistance Needs Among NNOHA

Membership

A survey of health center dental clinics to assess the need for and efficacy and success of

practice management technical assistance

Prepared for the National Network for Oral Health Access (NNOHA)

October 2011

Think2 Consulting, LLC

Robin S. Koenigsberg, PhD

Aimee Pugh-Bernard, PhD

Think2 Consulting, LLC October 2011

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TABLE OF CONTENTS

Executive Summary 4

1 Introduction

1.1 Description of Study 7

1.2 Technical Assistance and Safety Net Solutions (SNS) 7

2 Survey Methodology

2.1 On-line NNOHA Technical Assistance Survey, May 2011 7

2.2 Phone Survey of SNS Clients, April 2011 8

3 General Findings as Relates to Safety Net Dental Clinics

3.1 Profile of NNOHA Technical Assistance Survey Respondents and Dental Clinics 9

3.2 Issues Affecting the Sustainability of Safety Net Dental Clinics 11

3.3 Impediments to Change 12

3.4 Technical Assistance Needs and Preferred Means of Delivery 13

3.5 Association Between Variables 14

3.6 General Impact of Technical Assistance 15

4 Analysis of SNS ‘s Technical Assistance

4.1 On-line Survey: Comparative Impact of SNS’s Technical Assistance 17

4.2 Randomized Phone Interviews with SNS Clients 17

4.3 SNS Client Satisfaction Survey 18 4.4 January 2011 Harder + Company Report 18

5 Conclusions

5.1 Overview and Summaries of Findings 19


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5.2 American Recovery and Reinvestment Act and Affordable Care Act

as Relates to Oral Health Care 22

5.3 Implications of Legislation for Community Health Center Oral Health Services 23

5.4 Recommendations 23

CHARTS AND TABLES

Chart 1: Profile Ranges of Survey Respondents by Position 9

Table 1: Profile of Survey Respondents 10

Table 2: Profile of Survey Respondents, Per Site and Per Dentist FTE 10

Table 3: Operational Problems Affecting Safety Net Dental Clinics 11

Table 4: Clinical Problems Affecting Safety Net Dental Clinics 12

Table 5: Impediments to Change 13

Table 6: Self-assessed Most Beneficial Technical Assistance Needs 14

Table 7: Number of Technical Assistance by Category 15

Table 8: Impact/Outcomes of Technical Assistance 16

APPENDICES

Appendix A Bios for R. Koenigsberg, PhD and A. Pugh-Bernard, PhD

Appendix B Acknowledgements and Sources

Appendix C States Represented Among NNOHA TA Survey Respondents

Appendix D Clinics Interested in Being Contacted by SNS


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EXECUTIVE SUMMARY

In March 2011, the National Network for Oral Health Access (NNOHA) commissioned Think2 Consulting, LLC (www.think2consulting.com) – a Colorado-based consulting team specializing in health care research, analysis, and communications – to undertake the following independent analysis:

•••• Assess the need for practice management technical assistance among the NNOHA

membership, and

•••• Provide an independent evaluation of the overall effectiveness of Safety Net

Solution’s Technical Assistance program for community health center oral health

providers.

Study Approach

In May 2011, 135 members of NNOHA participated in a survey designed to assess: (a) the

operational and clinical challenges faced by community health center dental clinics, (b) the

perceived obstacles to implement significant change, (c) the need for the various types of technical

assistance, and (d) the impact of outside technical assistance services, particularly those provided

by Safety Net Solutions (SNS). The findings from this national survey provide the most complete

picture to date of the need for technical assistance and impact of such assistance on safety net

dental clinics, generally, as well as the historical performance of SNS relative to other technical

service providers.

Our retrospective analysis of the overall effectiveness of SNS’s Technical Assistance relies on both

qualitative and quantitative information. In addition to the national survey, the report considers

the following:

•••• Telephone interviews with dental directors, clinic directors, and/or CEOs at five

randomly selected federally qualified dental clinics served by SNS (conducted by

Think2 Consulting);

•••• An internal satisfaction survey of SNS’s Technical Assistance clients; and

•••• A year-long study commissioned by the California HealthCare Foundation and the

California Pipeline Program in 2009 of the effectiveness of practice management

consulting, based on the California’s Strengthening Community Dental Practices

(SCDP) pilot project involving nine California-based safety net dental clinics.

Summary of National Findings

The majority of national survey respondents were confident their dental clinics would benefit from

receiving technical assistance services referenced in the survey. Seventy-six respondents indicated

they would like to be contacted by NNOHA’s partner, SNS, regarding technical assistance services.

The results of the survey suggest the most prevalent operational problems impacting the efficiency,

effectiveness and long-term sustainability of dental clinics are: no-show or cancellation rates,

billing and collections issues, and unsustainable patient payer mix. The inability to complete


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patient treatment plans was the most commonly sited clinical problem among safety net dental

programs.

To what extent does outside technical assistance help resolve or minimize such problems? One-

third of respondents (43 of 135) indicated their clinics had received technical assistance between

the years 2008-2011. Greater than 75 percent of survey respondents whose clinics had received

technical assistance and were far enough along in the process, in their view, to warrant judgment

(33 respondents, in all) experienced at least some improvement in net revenues, operational

efficiency and management decision making, but also improvement in patient access to dental care,

the quality of care and dental health. This preliminary evidence suggests that technical assistance

has made inroads to meeting the complex set of objectives of safety net dental clinics that span

financial viability and mission.

Nonetheless, the track record of the various technical assistance providers is imperfect and

inconsistent. In the majority of cases, technical assistance did not seem to put a dent in patient no-

show and cancellation rates or the affordability of care, at least in the first few years. Sixty percent,

or 26 of 42 respondents,1 indicated they would recommend the technical assistance provider used

by their clinic to others.

It is not entirely surprising that, in general, most clinics see some results from receiving technical

assistance but that those results vary by clinic. It may depend on a given clinic’s pre-existing

technical and physical infrastructure, the staff’s inherent capabilities, the patient population

demographics and even the particular expertise of the technical service provider. Previous studies

found that the success of technical assistance also depends on the receptivity of staff to the

prescribed measures. Regardless, such differences suggest clinics stand to benefit from networking

with other similar clinics and sharing best practices in connection with practice management.

The consensus among respondents, those that had and had not received technical assistance alike,

was that technical assistance would be of definite benefit to their clinics, in the current

environment. Remedies to the operational and clinical problems discussed above, in the form of

technical assistance or otherwise, are sometimes difficult to implement, based to our findings,

primarily because of insufficient funding. But other obstacles routinely surfaced, as well –

insufficient staff resources, a lack of a clear understanding of the value of the change among staff,

and the cost of potential remedies.

Such obstacles are likely to continue to stand in the way of increased utilization of technical

assistance and may impact the ability of dental clinics to increase their capacity to serve the

growing population of underserved insured patients under the Patient Protection and Affordable

Care Act of 2010.

Future funding of technical assistance is, at best, uncertain, as the effects of the one-time cash

infusions under the American Recovery and Reinvestment Act of 2009 begin to wane. It is possible

that there are some new community health center oral health services that will never be fully

realized because financial support for these expanded services will not be forthcoming. In FY 2009,

HRSA was unable to fund competitive oral health service expansion applications that requested

1 One of the 43 did not respond to this question.


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approximately $51.7 million. It is conceivable that the combined effect of ACA and ARRA will be

increased pressure on existing providers to improve efficiency, but also fewer resources to do just

that. This suggests there may be a need for lower-cost alternatives to individualized technical

assistance and a better means of determining where individualized services will have the most

impact per dollar expended.

Technical assistance can take a variety of forms. Overall, respondents favored, two-to-one,

technical assistance consultation related to practice-level factors (such as, patient policies,

scheduling, and billing procedures) over organizational-level factors (such as, executive leadership

and support). Other types of services of interest to a majority of the respondents were

individualized improvement plans, on-site diagnostic assessments, documented do-it-yourself

materials (sample policies, procedures, best practices, assessment strategies, and on-line

interactive materials, discussion board, webinars, etc.).

Summary of Findings Regarding SNS

Six of the 43 clinics in NNOHA’s national survey that had received technical assistance reported

partnering with SNS and all six indicated they would recommend SNS to another clinic. However

three of these clinics indicated that they were in the early stages of implementation or had yet to

begin implementation when surveyed and, thus, not in a position to provide feedback regarding the

impact of SNS’s technical assistance services. The three remaining attributed improved net

revenues, operational efficiency, and increased patient access to dental care to the technical

assistance services provided by SNS. Two of three saw improvements in patient no-show and/or

cancellation rates, management decision-making, affordability of patient care and quality of care.

We found sufficient and consistent evidence of productivity and efficiency gains among dental

clinics resulting from collaborations with SNS. The SNS model of individualized consultation and

collaboration routinely surfaces issues associated with a clinic’s fee schedules, billing practices,

patient mix, patient scheduling, and clinical policies and procedures that may undermine the long-

term viability of the clinic. Along with its core strengths in fiscal and clinical program management,

SNS has added analysis and recommendations regarding a clinic’s quality improvement program to

its technical assistance services. The magnitudes of impact of such services can and do vary among

clinics depending on baseline conditions within the clinic, buy-in from health center and dental

clinic leadership and/or staff, state regulatory constraints, etc.


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1 INTRODUCTION

1.1 Description of Study

In March 2011, the National Network for Oral Health Access (NNOHA) commissioned Think2

Consulting, LLC, a consulting firm founded by health scientist Aimee Pugh-Bernard, PhD, and

economist Robin Koenigsberg, PhD (see Appendix A for bios), to provide an independent evaluation

of the overall effectiveness of Safety Net Solution’s Technical Assistance program for safety net

dental clinics and to assess the need for practice management technical assistance among the

NNOHA membership.

The scope of work included the development of an on-line survey designed to assess the

operational and clinical challenges faced by community health center dental clinics, the perceived

obstacles to implement significant change, the need for the various types of technical assistance,

and the impact of outside technical assistance services, particularly those provided by Safety Net

Solutions (SNS). NNOHA sent out the electronic survey to its membership in May 2011. The

findings from this national survey, detailed within this report, provide the most complete picture to

date of the need and impact of technical assistance on safety net dental clinics, generally, as well as

the historical performance of SNS relative to other technical service providers. A telephone survey

of five randomly selected clinics that received assistance from SNS complimented the broader on-

line survey and provided additional support for our findings with regards to SNS.

1.2 Technical Assistance and Safety Net Solutions

Technical assistance for health care providers is a specific type of consulting service designed to

enhance practice management. Safety Net Solutions, a program of the DentaQuest Institute,

partners with safety net dental clinics to provide expert technical assistance with the goal of

improving operational efficiency, quality of care, as well as long-term growth and sustainability.

Founded in 2006, Safety Net Solutions has worked with 602 dental clinics in Federally Qualified

Health Centers (FQHCs) across the United States to improve the oral health care delivery system.

Through multiple practice analysis tools, which includes site surveys, program analysis, and the

assessment of a wide range of operational elements, Safety Net Solutions designs individualized

practice enhancement plans that are intended to fit the environment and circumstances

surrounding each safety net dental clinic evaluated.

A number of organizations and experts offer technical assistance services to healthcare facilities;

only a few, including SNS, focus on dental programs within Health Centers.

2 SURVEY METHODOLOGY

2.1 On-Line Technical Assistance Survey, May 2011

The NNOHA Technical Assistance Survey (hereafter, NNOHA TA Survey) was specifically created by

Think2 Consulting in collaboration with NNOHA’s Dental Consultant, Irene Hilton, DDS, MPH, to

2 Information provided by Dori Bingham, SNS, email dated July 11, 2011.


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assess the short- and long-term operational and clinical challenges faced by Health Center dental

clinics and identify roadblocks that stand in the way of progress. The NNOHA Technical Assistance

survey also assessed the perceived need for technical assistance as well as the consulting services

that would potentially be most beneficial to clinics. The NNOHA TA Survey was loosely modeled

after a 2010 survey commissioned by the California HealthCare Foundation with a similar goal of

assessing the need for dental clinic technical assistance within California Health Center dental

clinics (Diringer and Associates, February 2010). The NNOHA TA Survey included questions

regarding the impact and tangible outcomes of outside technical assistance services where the

clinic had utilized practice management consulting services in the past three years.

A link to the on-line survey created in Survey Monkey was distributed by NNOHA to its membership

via e-mail in May 2011.3 The survey targeted NNOHA membership at health centers with dental

programs and the list of recipients comprised a wide range of dental clinic professionals including

health care administrators, chief dentists, dental directors, dental program managers, office

managers, and other clinic professionals. Of the 3,130 survey recipients, approximately 12 percent

opened the e-mail and 5 percent submitted responses. Twenty-three of the 158 respondents

completed less than one-fourth of the questions on the survey. A total of 135 respondents, or 4.3

percent, provided sufficiently complete and valid responses. A third of these, 44 respondents,

represent clinics that have received technical assistance since 2008.

The respondents are likely to be those that have used technical assistance, are at least familiar with

technical assistance, or are most in need of such assistance; thus the data may reflect some sample

bias. Given the low response rate and lack of randomization, the information included in this paper

represents a starting point for understanding the potential value of technical assistance nationally

among safety net dental providers; the findings of this paper are instructive but cannot be

considered definitive or wholly representative of all of NNOHA’s membership. They are

nonetheless suggestive of the types of clinics that have benefitted or might benefit most from

technical assistance.

2.2 Phone Survey of SNS clients, April 2011

To further assess the overall effectiveness of the Safety Net Solutions Technical Assistance program,

Think2 Consulting interviewed dental directors, clinic directors, and/or CEOs at five federally

qualified dental clinics served by SNS. SNS provided Think2 Consulting with a list of all the clinics

that have collaborated with SNS to receive technical assistance and that were at least eighteen

months into the implementation of their practice enhancement plan. Technical assistance

improvement plans are oriented toward producing long-term, sustained effects for dental clinics.

As such, some impacts of technical assistance may not be realized or observable during the first

year.

From the list of eighteen clinics that had utilized SNS technical assistance services, five were

randomly selected by Think2 Consulting to interview via telephone.4 Effectiveness was assessed

3 Prior to dissemination, the survey was tested by four practicing dentists – Irene Hilton, Cecilia Edwards, Martin

Leiberman, Dan Watts – and then reviewed by NNOHA’s Practice Management Committee and SNS staff. 4 Each of the eighteen clinics was assigned a number (1-18) and then five numbers were selected using the random

number generator function within Excel.


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through independent interviews with CEOs, Executive Directors, and/or Dental Directors at each

clinic through several specific questions addressing: (1) the extent of provided services; (2) the

clinic’s satisfaction with provided services, including whether the clinic would recommend the

consulting services provided by SNS to other clinics; and (3) tangible outcomes as a result of the

provided services.

3 GENERAL FINDINGS AS RELATES TO SAFETY NET DENTAL CLINICS

3.1 Profile of NNOHA Technical Assistance Survey Respondents and Associated Dental

Clinics

Nearly half of the NNOHA members who responded to the TA Survey held the position of chief

dentist or dental director during the time the survey was administered. Nearly one-third of

responders were CEO, CFO, COO or CMO of the health center or dental clinic. The remaining

responses are from staff dentists, hygienists, and administrative staff, including dental program

managers and office managers.

Chart 1:

Federally qualified health centers from over 38 states and the District of Columbia responded to the

survey (See Appendix C). Dental programs responding to the survey were not required to identify

themselves by name or location, however the majority of respondents volunteered this information.

Based on these voluntary responses, we determined that at least 100 different health centers

participated in the survey.

Among survey respondents, more than 40 percent (59 respondents) indicated their facilities have

only one dental clinic site and 93 percent had five or fewer sites (see Table 1). The number of

dental operatories per site ranged from zero to 36; the median number was five (see Table 2). The

median number of Dentist full-time equivalents (FTEs) per site was two and, notably, the median

number of Dental Hygienist FTEs per Dentist FTE was only 0.5. Approximately one third of

respondents’ clinics received technical assistance between 2008 and 2011.


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Table 1. Profile of Survey Respondents, Percent by Category

Table 2. Profile of Survey Respondents, Per Site and Per Dentist FTE


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3.2 Issues Affecting the Sustainability of Safety Net Dental Clinics

Operational Issues

By far, the most prevalent operational problem affecting the efficiency, effectiveness and long-term

sustainability of dental clinics is no-show or cancellation rates. Nearly all of the respondents (123 of

135, or 91.8 percent) listed high patient no-show or cancellation rates as at least somewhat of a

problem and nearly half of all respondents indicated it was a significant problem (see Table 3

below).

Table 3. Operational Problems Affecting Safety Net Dental Clinics

Eighty percent of respondents indicated billing and collections was a problem for their dental

clinic(s). More than two-thirds of respondents also identified the following as operational

problems for their clinics: unsustainable payer mix, low FQHC reimbursement rates, and

insufficient tracking of financial and/or productivity data for the purposes management and

operational decision-making. Additionally, respondents commented that the following operational

issues pop up:

•••• Attracting new patients to fill schedule

•••• Low dental hygienist to dentist ratio

•••• Lack of electronic dental records

•••• Competition for Medicaid patients from private practices

•••• Physical space constraints

•••• Limited grant writing capabilities


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The results in Table 3 suggest that a given dental clinic is confronted by a myriad of problems and

the list of problems is likely to differ, at least by degrees, across clinics. This is discussed in further

detail in later sections.

Clinical Issues

Nearly 75 percent of respondents identified the inability to complete patient treatment plans as at

least somewhat of a problem. This suggests that the majority of clinics in this survey are falling

short of desired oral health outcomes for existing patients. For one-fifth of respondents, this posed

a significant problem.

Over half of all respondents indicated that the lack of clinical protocols and the suboptimal balance

of preventative, restorative, and surgical procedures are at least somewhat of a problem for clinics.

Just over 40 percent of all respondents indicated that inadequate patient records management and

tracking systems for the purposes of clinical decision-making was a problem.

Table 4. Clinical Problems Affecting Safety Net Dental Clinics

There was near agreement among the types of respondents (administrators, dentists, program or

office managers, etc.) regarding the operational and clinical problems discussed above with the

following exceptions: Compared with administrators, clinicians and office managers more often

identified the availability of current financial and productivity data as a problem (71 percent versus

51 percent for administrators). The same was true of outdated or poorly functioning dental

equipment and low or unsustainable clinic fee schedules.

There was a greater propensity for clinicians to cite inadequate or outdated IT infrastructure and

low FQHC reimbursement rates as at least somewhat of a problem. Administrators put greater

emphasis on inefficient scheduling processes resulting in underutilization of available operatories,

compared with clinicians, and clinicians more so than dental program and office managers.

3.3 Impediments to Change

Although the majority of health center dental clinics that participated in the survey reported the

need for technical assistance, there was universal acknowledgement of challenges that can impede

a dental clinics ability to implement significant change necessary for growth and/or sustainability.

The survey responses suggest a host – perhaps a confluence – of factors impede a clinic’s ability to

implement significant change necessary for growth and sustainability. However, the most

frequently cited impediment was insufficient funding to cover associated expenses. Over 90


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percent identified this as at least sometimes a problem; nearly half indicated this is always a

problem. The following factors also appeared to affect clinics across the board (see Table 5):

•••• Staff resources (e.g. time, know-how, expertise) (85 percent)

•••• Clear understanding of the value of the change (84 percent)

•••• Affordability of outside assistance (82 percent)

Table 5: Impediments to Change, Number of Responses

Other challenges that sometimes impede significant change included lack of staff buy-in and

accountability, leadership and/or management support of change, staff continuity during a period

of change (e.g. turnover rates). At least a few respondents commented that physical space and

equipment constraints, insufficient Medicaid benefits for adult patients, and insufficient specialty

resources (and support) play a key role, as well.

3.4 Technical Assistance Needs and Preferred Means of Delivery

Technical assistance is offered in a number of formats, ranging from general materials to

customized improvement plans. Within the various offerings of consulting services designed to

address operational, clinical and financial challenges, the technical assistance service that was

perceived as potentially being the most beneficial was consultation related to practice-level factors

(e.g. patient policies, scheduling, billing procedures) as assessed by 66 percent of the responders.

A larger share of non-executive respondents perceived leadership/management support as an

impediment to change and, consistent with this, a larger share of non-executives were interested in

consultation related to executive leadership and support.

Other services that were perceived as potentially beneficial were the use of documented ‘do-it-

yourself’ materials (e.g. sample policies and procedures, best practices, and practice strategies), the

development of an individualized improvement plan tailored to the unique qualities and


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characteristics of each clinic, on-site consultation that includes a diagnostic assessment of practice

data and a discussion of the findings with clinic staff, and on-line interactive materials (e.g.

discussion boards, webinars, and learning collaboratives). Other services that were perceived as

potentially beneficial but not as critical included on-going remote assistance with periodic site

visits, consultation related to organization-level factors (e.g. executive leadership and support), in-

person group training sessions, hard-copy printed materials, on-line self-assessments, regular

group skill-building conference calls, and linking with a mentor.

Table 6: Self-assessed Most Beneficial Technical Assistance Needs

Responses were fairly consistent regardless of respondent employment positions, with a few

exceptions:

•••• Executives and managers expressed greater interest than dentists in on-going remote

consultant assistance and less interest in hard-copy printed materials. Around 20

percent (22 executives and managers) felt on-line self-assessments would be beneficial.

•••• Chief dentists and dental directors, more often than executives and managers, showed

interest in regular group skill-building conference calls and linking with a mentor.

3.5 Association Between Variables

Differences in responses by type of respondent referenced above are likely to be due to some

combination of the following factors:

•••• Differences in first-hand knowledge and experience

•••• Concern that problem(s) might reflect poorly on their own and/or their supervisees’

work

A statistical analysis of other factors influencing responses suggests the more reported operatories

in a dental program, the less billing and collections and unsustainable patient payer mix appeared

to be a problem. It also appeared that respondents from dental programs with a greater number of


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operatories perceived technical assistance to be less of a benefit to their clinics, on average.

Economies of scale within a clinic and across affiliated clinics appear to offer notable benefits to

safety net providers, as it allows clinics to spread the costs of efficiency-creating technologies,

equipment, systems, and staff positions over more patients, more clinics, or both. Funding was

more commonly perceived to be an impediment to change necessary for growth and sustainability

by those respondents reporting fewer physical dental clinic sites and operatories.

Dental program and office managers more frequently identified scheduling as a problem than

executives. Relative to other types of respondents, executives were far less likely to identify

insufficient tracking of financial and productivity data for the purposes of management and

operational decision making as a problem. Chief dentists and dental directors were far less likely

than others to identify recruiting, retaining and training dentists and hygienists as an issue.

3.6 General Impact of Technical Assistance

Approximately one-third of survey respondents (43 of 135) indicated their clinics had received

technical assistance between the years 2008-2011. Various types of technical assistance are

offered by and through individual consultants, information technology companies offering

Electronic Dental Records systems or Practice Management software, healthcare associations,

health insurance providers, government agencies, as well as other organizations. A breakdown of

the number of technical assistance providers by category, as indicated by respondents in the

survey, is included in Table 7 below. Of those whose clinics had received technical assistance, 60

percent indicated they would recommend the technical assistance provider used in their case to

another clinic.

Table 7: Number of Technical Assistance Providers by Category

Within the context of the May 2011 ‘NNOHA Technical Assistance Services Survey’ several aspects

of the magnitude of impact were assessed to determine the overall efficacy of practice management

consulting among safety net dental clinics. Those that reported in the survey that they had received

technical assistance were asked to self-evaluate the impact or outcomes of technical assistance on

their dental clinic practice.

•••• Thirty-four percent strongly agreed improved operational efficiency had resulted and

over 75 percent at least somewhat agreed.


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•••• Twenty-seven percent strongly agreed improved patient quality of care and dental

health had resulted and over 80 percent at least somewhat agreed.

Other outcomes observed as a result of technical assistance included increased revenue and/or

decreased costs, followed by improved management decision making, increased patient access to

dental care, improved patient quality of care and dental health, and improved operational

efficiency. Notably, 59 percent of clinics did not experience a significant change in patient no-show

rates; technical assistance providers’ existing strategies are proving somewhat ineffective, implying

that alternative and perhaps more innovative approaches, such as patient-directed initiatives, need

to be examined and tested. Technical assistance also had limited impact on the affordability of

patients’ dental care.

Table 8: Impact/Outcomes of Technical Assistance

4 ANALYSIS OF SNS’S TECHNICAL ASSISTANCE

Our retrospective analysis relies on both qualitative and quantitative information available to us,

including the results of the NNOHA TA Survey, as well as the following information:

(a) Telephone interviews with dental directors, clinic directors, and/or CEOs at five randomly

selected federally qualified dental clinics served by SNS (conducted by Think2 Consulting);

(b) Interview of SNS contractor, Ellen Sachs Leicher, Principal of ESL Associates Consulting

Firm, who is responsible for evaluating clinics participating in SNS’s program and

monitoring their progress for the two years following the initiation of the technical

assistance project, for the purposes of assessing the on-going need for additional technical

assistance support services; and

(c) A year-long study commissioned by the California HealthCare Foundation and the California

Pipeline Program of the effectiveness of practice management consulting, based on a pilot

project involving nine California-based safety net dental clinics.

We sought to determine whether SNS’s technical assistance has proven valuable to clinics in terms

of financial sustainability and the quality of dental health care within the first two years of

implementation and potential benefits over the long-term. It is not within our current scope of


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work to quantify the value of contributions of technical assistance or to assess the economic

benefits relative to the costs of providing technical assistance.

4.1 On-line Survey: Comparative Impact of SNS’s Technical Assistance

The SNS model of individualized consultation and collaboration routinely addresses issues

associated with a clinic’s fee schedules, billing practices, patient mix, patient scheduling, and clinical

policies and procedures that, on the basis of the NNOHA TA Survey, appears to be undermining the

long-term sustainability and growth of safety net dental clinics.

Six of the 43 clinics received technical assistance services from SNS and all six indicated they would

recommend this practice-management consulting firm to another clinic in need of technical

assistance. However three of these clinics indicated that they were in the early stages of

implementation or had yet to begin implementation when surveyed and, thus, not in a position to

provide feedback regarding the impact of SNS’s technical assistance services. The three remaining

attributed improved net revenues, operational efficiency, and increased patient access to dental

care to the technical assistance services provided by SNS. Two of three saw improvements in

patient no-show and/or cancellation rates, management decision-making, affordability of patient

care and quality of care.

4.2 Randomized Phone Interviews with SNS Clients

In April 2011, Think2 Consulting conducted independent interviews with CEOs, Executive Directors

and/or Dental Directors at five federally qualified health centers (FQHC) that have collaborated

with SNS to receive technical assistance. To assess the overall effectiveness of the Safety Net

Solutions Technical Assistance program, five of eighteen health centers that utilized SNS technical

assistance services and were at least 18 months into the implementation of their practice

enhancement plan (as of April 2011) were randomly selected and contacted via telephone. The

interviews were conducted separate and apart from the NNOHA TA Survey conducted in May

2011.5

The effectiveness of technical assistance was assessed through independent interviews with

executives and/or dental directors at each clinic through several specific questions addressing: (1)

the extent of provided services; (2) the clinic’s satisfaction with provided services, including

whether the clinic would recommend the consulting services provided by SNS to other clinics; and

(3) tangible outcomes as a result of the provided services.

Each of the five clinics reported satisfaction with the consulting services provided by the SNS

Technical Assistance program and had observed a variety of improvements since implementing the

improvement plan created in coordination with SNS. Dr. Omar Ghoneim, the Dental Director at

Harbor Health Services in Hyannis, MA, found the recommendations provided by SNS to be

“invaluable,” affirming the priorities and goals for the Dental Departments at both sites that were

evaluated. In particular, Ghoneim found the recommendations related to billing protocols, practice

5 Two of the five centers interviewed were not NNOHA members and, thus, did not receive an invitation to take

the NNOHA TA Survey; the three centers that were NNOHA members apparently elected not to participate in the

on-line survey.


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management, scheduling, and talking points and options for incentive programs for team members

to be particularly useful. Eric Riley, the CEO of Canton Community Clinic in Canton, Ohio, was

“absolutely” satisfied with the work performed by SNS and noted that it had a “good impact on the

clinic.” Bryan Brady, the CEO of First Care Clinic in Hays, Kansas, was “very impressed with the

operational assessment” of the clinic by SNS and would “absolutely” recommend SNS to other

health center dental clinics. Janis Sunderhaus, the Executive Director for Health Partners of

Western Ohio in the town of Lima saw “significant improvement” in her clinic and was “quite

happy” with the services provided by SNS. Brian Toomey, the CEO of Piedmont Health Services in

Carrboro, North Carolina, noted that SNS performed a full review of the clinic and worked quite

well with the dental staff. He mentioned that the services provided helped to “maximize the

scheduling process and improve revenue.” Toomey stated that he would “unequivocally”

recommend SNS to other health center dental clinics. In summary, all five clinics were quite

satisfied with the work performed by SNS and would recommend SNS to other health center dental

clinics.

4.3 SNS Client Satisfaction Survey

Beginning in 2006, SNS developed its own system of evaluation of clinics participating in its

programs and that system has necessarily evolved as the number of newly participating clinics has

grown from eight in SNS’ first year to over seventeen clinics within the first six months of 2011.

Internal evaluation consists of self-reported progress reports, data analysis, and satisfaction

surveys. SNS compares net revenues, revenues and costs per visit, no show rates, number of

patient visits, and size of clinic relative to number of visits over time in an effort to quantify the

impacts of technical assistance. Data reporting by clinics is voluntary and, because FQHCs have

limited resources, the frequency and quality of reporting depend on the ease with which the

requested data can be assembled by a given clinic – in part, dependent on existing IT – and the

presence (or lack thereof) of funder incentives to collect the data. According to Ellen Sachs Leicher,

outside independent consultant to SNS, in most cases the evaluations point to notable

improvements. For those clinics surveyed to date, Leicher found all were satisfied with the services

provided by SNS and the outcomes they have experienced as a result of the provided services.

It is important to note that clinics are constrained in ways that may ultimately impact the degree to

which they might benefit from technical assistance. Relevant examples of such constraints are

Medicaid reimbursement rates, the degree of buy-in from staff and/or leadership within the clinic,

and the support of and integration with the larger health clinic. However, we could not quantify the

impact of such impediments on the effectiveness of technical assistance, given the available data.

4.4 January 2011 Harder + Company Report

A January 2011 report, “A Fine Balance: Mitigating the Financial Challenges Faced by Safety Net

Dental Clinics,” prepared by Harder+Company, attempted to quantify the benefits of technical

assistance provided by two organizations, SNS and the Pride Institute, within the scope of

California’s Strengthening Community Dental Practices (SCDP) pilot project. Although the SCDP

study was fairly narrow and only examined nine California clinics selected to participate in the

project, to date it is the most rigorous and in-depth study of the impacts of SNS’s technical

assistance program. This joint project of the California HealthCare Foundation and the California


19

Pipeline Program involved providing free individualized practice management assistance to select

safety net dental clinics within the state over a period of one year and systematically tracking and

analyzing the impacts on the short and long-term sustainability of the clinics and improvements in

connection with mission.

SNS served seven of the nine centers featured in the SCDP study. According to the Harder report,

three of these clinics achieved “high” overall success, three achieved “moderate” overall success,

and one achieved “low” overall success. Success was measured within the following four areas;

breadth of implementation, financial improvement, operational improvement, and anticipated

longevity of improvements dependent upon high clinic staff buy-in and the alignment of

improvements with clinic mission and values. Within this report, success was defined as the added

value of consulting services to clinic management and operations.

Six of the seven clinics reported that they were “very satisfied” with the technical assistance

provided by SNS, in spite of various challenges. One clinic reported being “satisfied,” and none

reported “low” overall satisfaction with consulting services received through the SCDP project.

5 CONCLUSIONS

5.1 Overview

The purpose of practice management technical assistance consulting for safety net oral health

providers is to improve clinics’ efficiency, financial and operational sustainability, and delivery of

high quality dental care. Results of the NNOHA TA Survey and this study, more broadly, shed light

on several factors surrounding practice management consulting in general, including perceived

clinical and operational problems, impediments to change that may hinder clinics’ use of technical

assistance services, and the technical assistance needs that are potentially most beneficial if

implemented. Additionally, the actual outcomes or impact of technical assistance were evaluated

along with the level of interest in and perceived effectiveness of SNS’s standardized technical

assistance consulting practices, compared to other practice management providers reported within

the survey.

5.1.1 Technical Assistance: Summary of Specific Findings Regarding SNS

We found sufficient and consistent evidence of productivity and efficiency gains among dental

clinics resulting from partnerships with SNS. The SNS model of individualized consultation and

collaboration routinely surfaces and addresses issues associated with a clinic’s fee schedules, billing

practices, patient mix, patient scheduling, and clinical policies and procedures that may undermine

the long-term viability of the clinic.

Collectively, taking into consideration the SCDP Study conducted by Harder+Company and the

NNOHA TA Survey and telephone interviews undertaken by Think2 Consulting for the purposes of

this report, we were able to independently verify the degree of effectiveness of SNS’s technical

assistance services for dental clinics at 14 different health centers. Thirteen of 14 experienced high


20

to moderate overall success, and one low success.6 Nonetheless, all fourteen indicated overall

satisfaction with SNS’s services. This represents a sample population of 23 percent of all FQHC

clients served by SNS since 2006. While not a random sample, strictly speaking, there is no obvious

systematic bias toward favorable responses within this sample.

5.1.2 Technical Assistance: Summary of General Findings

Significant Interest. There is significant interest in technical assistance among health center

dental clinics. Of health centers that participated in the NNOHA TA survey, 30 percent of the

respondents replied ‘yes’ to having received technical assistance within the last three years prior to

May 2011. Among the respondents that had not received technical assistance, 94 percent answered

that their clinic(s) would benefit from receiving outside technical assistance. This strongly suggests

that clinics are very supportive of practice management consulting and that there is a strong need

for technical assistance within the majority of health center dental clinics that participated in the

survey. Those already familiar with and interested in technical assistance are perhaps more likely

to have responded to the survey and that familiarity may translate into a favorable predisposition

toward technical assistance; thus, the sample of respondents may not necessarily represent the

needs or preferences of the larger population. But the results do suggest a sizeable demand for this

type of assistance far beyond the number that has already sought out technical assistance.

Universal Problems. Health center dental clinics face several challenges, a number of them nearly

universal, to balance mission with effective business practices to achieve sustainability. Operational

problems that impact efficiency, effectiveness and long-term sustainability include high patient no-

show or cancellation rates, followed by billing and collection problems, an unsustainable patient

payer mix, low federally qualified reimbursement rates, insufficient tracking of financial and/or

productivity data for the purposes of management and operational decision-making, and inefficient

scheduling processes resulting in the underutilization of operatories or staff. Clinical problems are

primarily due to an inability to complete patient treatment plans and a lack of clinical protocols to

standardize dental services.

Of the operational issues targeted by technical assistance, patient policies, scheduling and billing

procedures are among the most significant for those that responded to the survey. Technical

assistance directly targets such issues, although it has been relatively less effective, thus far, as a

tool in lowering patient no-show rates.

Balanced and Measurable Outcomes. A study by Paul Glassman on technical assistance suggests

magnitudes of impact can and do vary among clinics depending on baseline conditions within the

clinic, buy-in from health center and dental clinic leadership and/or staff, state regulatory

constraints, etc.7 Nonetheless, the NNOHA TA findings presented above and the SCDP study8

6 Clinicas de Salud del Pueblo noted “frustration with the scheduling practices” and “high anxiety in a tough

economy.” 7 Paul Glassman, DDS, MA, MBA, PowerPoint presentation, “Improving Community Heath Center Operations:

Lessons from Financial Analysis, Technical Assistance and Delivery Systems,” presented on Wednesday, October

27, 2010 at the NNOHA National Primary Oral Health Conference (NPOHC). 8 “A Fine Balance: Mitigating the Financial Challenges Faced by Safety Net Dental Clinics,” Harder+Company,

January 2011.


21

provide at least preliminary qualitative and quantitative evidence, respectively, that quality

improvements, greater patient access and equity, and improved oral health outcomes among safety

net dental clinics can be achieved in conjunction with, and often as a result of, increased operational

and clinical efficiency and that such results are not the exception.

Variable Methods of Service Delivery. Technical assistance can take a variety of forms. Overall,

respondents favored two-to-one technical assistance consultation related to practice-level factors

targeting the needs mentioned above over organizational-level factors focused on executive

leadership and support.

Other types of services of interest to a majority of the respondents were:

•••• Individualized improvement plan

•••• On-site diagnostic assessment

•••• Documented do-it-yourself materials

•••• On-line interactive materials, discussion board, webinars, etc.

Assessment of Technical Assistance - Strengths, Challenges, and Limitations

The underlying question that was the major catalyst for the NNOHA Technical Assistance Survey

was two-fold: What are the current needs for technical assistance services within its membership

and to what extent does outside technical assistance help resolve or minimize existing operational

and clinical problems? The consensus among respondents, those that had and had not received

technical assistance alike, was that technical assistance would be of definite benefit to their clinics,

in the current environment. One-third of the survey respondents (43 of 135) reported that their

clinics had received technical assistance between the years 2008-2011. Of those respondents,

greater than 75 percent were far enough along in the process, in their view, to warrant judgment

(33 respondents, in all) and had experienced at least some improvement in net revenues,

operational efficiency and management decision making, but also improvement in patient access to

dental care, the quality of care and dental health. This preliminary evidence suggests that technical

assistance has made inroads to meeting the complex set of objectives of safety net dental clinics.

Nonetheless, the track record of the various technical assistance providers is imperfect and

inconsistent. In the majority of cases, technical assistance did not seem to put a dent in patient no-

show and cancellation rates or the affordability of care, at least in the first few years. And just 60

percent, or 26 of 42 respondents (one of the 43 did not respond to this question), indicated they

would recommend the technical assistance provider used by their clinic to others.

It is not surprising that, in general, most clinics benefitted in some way from receiving technical

assistance and that the ways in which they benefitted varied by clinic. Technical assistance

recommendations are typically tailored to the clinic and attempt to address the highest priority

issues afflicting that clinic. But results may also depend on a given clinic’s pre-existing technical

and physical infrastructure, the staff’s inherent capabilities, the patient population demographics

and even the particular expertise of the technical assistance provider. Previous studies found that

the success of technical assistance depends on the receptivity of staff to the prescribed measures.

While the majority of respondents acknowledged that there are real obstacles to change most

indicated such challenges were sometimes, rather than always, a problem suggesting that while

these problems are real, they are not insurmountable.


22

Remedies to the operational and clinical problems discussed above in the form of technical

assistance or otherwise are sometimes difficult to implement primarily because of insufficient

funding. The significance of this and other findings included in this report can be better understood

in the context of the partially enacted Patient Protection and Affordable Care Act of 2010 and the

American Recovery and Reinvestment Act of 2009.

5.2 ARRA and ACA as Relates to Oral Health Care

Passage of the Patient Protection and Affordable Care Act of 2010, often referred to as the ACA,

holds the promise of vastly expanded oral health care, particularly within the context of Health

Centers. This law, coupled with the enactment of the American Recovery and Reinvestment Act of

2009 (ARRA), provides Health Centers and migrant and homeless health care programs with

options for growth in the coming years.

As President Obama and his Administration looked for areas to invest funds as part of the ARRA,

Health Centers emerged as key recipients for federal dollars. This law provided $2 billion for

Health Centers nationwide, in an effort to serve more patients, stimulate new jobs, and meet the

needs for healthcare among our nation’s medically uninsured and underinsured populations.

The ARRA provided for Health Centers:

•••• $851 million for Capital Improvement Projects. As of July 2011, a total of 2,617

projects have received a total of $342 million.

•••• In March 2009, the Department of Health and Human Services released $338 million

in ARRA funds to expand services at Health Centers. These funding opportunities are

known as Increased Demand for Health Center Services (IDS) grants.

•••• In May 2009, the President announced release of $155 million as part of ARRA to

support 126 Health Centers through the New Access Points. The intention of the New

Access Points grants was to extend Health Center services to 750,000 Americans and

create 5,500 jobs.

•••• Finally, in December 2009 roughly $600 million was announced to support the

Facilities Investment Program at health centers. Use of this funding can be used to

expand health information technology.

As passed and signed into law, the Affordable Care Act provides $11 billion to bolster and expand

community health centers over the next 5 years, which should expand the oral health services that

these centers provide. The ACA authorizes $1.5 billion to support major construction and

renovation projects at existing Health Centers nationwide and $9.5 billion to create new community

health center sites in medically underserved areas. These new centers are expected to provide

some form of oral health services. The rationale for expanding capacity in Health Centers is, in part,

due to the expected increase in the number of previously uninsured children who will be able to

obtain coverage through expansion of the Medicaid/S-CHIP program. Health Centers have

traditionally been an access point for populations with public insurance programs.


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5.3 Implications of Legislation for Health Center Oral Health Services

The ACA has the potential to vastly expand the number of Americans eligible for medical services in

Community Health Centers through New Access Points. National healthcare reform, if fully funded

and implemented, will require that Health Centers reach out to a larger segment of the newly

insured population. NNOHA’s overarching goal of expanding oral health services will depend upon

the increased capacity at existing clinics and expansion via new clinics at health community centers.

Yet, funds and support for increased capacity is, at best, uncertain, as the effects of the one-time

cash infusions under the American Recovery and Reinvestment Act of 2009 begin to wane, the

American economic recovery creeps along, and the political jockeying over the fate of the ACA

continues. It is conceivable that the combined effect will be increased pressure on existing clinics

and operatories to improve efficiency, but also fewer resources to do so.

All of this presents both challenges and opportunities for technical assistance as a resource for

dental clinics focused on underserved populations. Regardless of the ultimate evolution of ACA and

ARRA programs and funding, the key message is that existing Health Center dental programs,

through a combination of expansion opportunities and increased efficiency, will have to increase

capacity in the most cost effective way to meet the oral health needs of new Health Center patients.

This creates countless technical assistance opportunities to help dental programs achieve these

efficiencies and meet these needs.

5.4 Final Recommendations

As ascertained in this report, a variety of technical assistance tools and services exist to serve the

needs of health center dental clinics and the most desired among them are practice level

management, individualized improvement plans, on-site diagnostic assessment, documented do-it-

yourself materials, on-line interactive materials, discussion boards, and webinars.

Given SNS’s standardized approach to and experience with offering technical assistance, the

organization is well positioned to cost-effectively expand its capacity to serve the growing need for

such services. And, based on the findings of this report, SNS has proven itself to be a valuable and

effective technical assistance resource, particularly for those clinics that require individualized

consultation and on-going expert guidance. NNOHA should work with SNS to follow up with the

seventy-six clinics that asked to be contacted by SNS.

NNOHA is in a unique position to (further) educate its members about technical assistance, provide

objective evidence regarding its effectiveness, and help interested clinics determine which types of

technical assistance, if any, are likely to be most beneficial to them. In response to the findings of

NNOHA’s national survey on technical assistance, they might also begin to facilitate the sharing of

resources and experiences between dental clinics within its membership to allow for the exchange

of critical information to further facilitate improvements in practice management and ultimately

the operational and clinical success of dental clinics in health centers across the country. The

findings also suggest the need for greater funding/grant research assistance and a dynamic arsenal

of technical assistance offerings to include various levels of service, different corresponding prices,


24

a la carte options or ‘packages’ of service, and variable types of delivery options to accommodate

the need for technical assistance that is more accessible in the context of financial constraints.

Think2 Conulting, LLC

Appendices to SNS TA White Paper August 2011

1

Appendix A

Robin Koenigsberg, PhD

Dr. Koenisgberg is an Associate Professor of Economics at Regis University, where

she has taught economics, with an emphasis on topics in public finance and public

policy, for seven years. Prior to entering academia, Dr. Koenigsberg worked as a

senior associate and economist at a variety of national economic consulting firms;

National Economic Research Associates in Washington, DC, Charles River Associates

in Boston, MA, and Analysis Group Economics in Denver, CO. She specialized in

healthcare and pharmaceuticals, analyzing within these sectors market dynamics,

market outcomes, prices and the impacts of government regulations and policies.

Dr. Koenigsberg provided consulting services to the Colorado Health Institute,

which included a study of Colorado's shift from a no-fault to tort auto insurance

system and a presentation of the findings to a panel of over twenty industry experts

and state policy makers. A key component of her research included analyzing the

potential impacts of this change on state premiums and coverage, and on the cost

and accessibility of health care services for those critically injured in auto accidents.

Dr. Koenigsberg earned a Ph.D. in Public Economics at the University of Colorado,

Boulder; a M.A. in International Trade and Economic Development at the University

of Reading, Reading, England; and a B.S. in Journalism at the University of Maryland.

She currently serves on the Board of Directors of the John J. Sullivan Program at

Regis University and recently served on the Board of Directors of the Montessori

Academy of Colorado between the fall of 2008 and 2010.

Aimee Pugh-Bernard, PhD

Dr. Pugh-Bernard is a Senior Instructor of Biology at the University of Colorado

Denver, where she has taught immunology, virology, molecular biology, and

genetics since the fall of 2007. Prior to entering academia, Dr. Pugh-Bernard was

trained in and acquired extensive research experience in the fields of immunology,

molecular biology, and developmental biology. Throughout her career, Dr. Pugh-

Bernard has been dedicated to obtaining biological knowledge that directly

translates into relevant findings in human diseases.

As a post-doctoral fellow at the Barbara Davis Center for Childhood Diabetes she

characterized and studied the developmental regulation of the gastrointestinal tract

and pancreas in a mouse model of diabetes. As a post-doctoral fellow at National

Jewish Health she studied signaling of human immune system cells in health and

disease, particularly related to autoimmune disorders. This work extended from her

doctoral thesis describing cellular abnormalities in the B cells of patients with the

autoimmune disorder Systemic Lupus Erythematosus. Between college and

graduate school she analyzed the efficacy of several immune-based therapies for the

treatment of human childhood cancers at the University of Minnesota in the

Biotherapy and Radiation-Oncology Department. Dr. Pugh-Bernard has published

her findings in several prestigious scientific journals including the Journal of Clinical

Investigation, Proceedings of the National Academy of Sciences of the United States of



2

America, and the Journal of Immunology. Dr. Pugh-Bernard recently won the 2010

‘Excellence in Teaching’ award for the College of Liberal Arts and Sciences at the

University of Colorado Denver and was selected to attend the Howard Hughes

Medical Institute and National Academies of Sciences Mountain West Summer

Institute on Undergraduate Education in Biology in August 2011.

Dr. Pugh-Bernard earned a Ph.D. in Immunology, Microbiology and Vaccine Biology

from the University of Rochester in Rochester, NY and graduated cum laude with a

B.A. in Biology from Gustavus Adolphus College in Saint Peter, MN. She served on

the executive committee for the Board of Directors of the Montessori Academy of

Colorado between the fall of 2008 and 2010.



3

Appendix B

Acknowledgements

• Irene Hilton, DDS and NNOHA Dental Consultant

• Ellen Sachs Leicher, Principal of ESL Associates and outside independent

consultant for Safety Net Solutions

• Dori Bingham, Project Manager at Safety Net Solutions

• Cecilia Edwards, Dental Director for Salud Clinic in Fort Lupton, CO

• California HealthCare Foundation (survey)

• Paul Glassman, DDS, MA, MBA, Professor of Dentistry at University of the

Pacific

• Five clinics in telephone survey1:

1. Canton Community Clinics, Inc. in Canton, OH – Eric Riley, CEO

2. First Care Clinic in Hays, KS – Bryan Brady, CEO

3. Health Partners of Western Ohio in Lima, OH – Janis Sunderhaus,

Executive Director

4. Piedmont Health Services in Carrboro, NC – Brian Toomey, CEO

5. Harbor Health Services in Hyannis, MA - Omar Ghoneim, DDS and Dental

Director

Complete List of Sources

• A year-long study commissioned by the California HealthCare Foundation

and the California Pipeline Program of the effectiveness of practice management

consulting based on a pilot project involving nine California-based safety net

dental clinics (Harder+Company, January 2011).

• A survey commissioned by the California HealthCare Foundation to assess

the need for dental clinic technical assistance within California community health

center dental clinics (Diringer and Associates, February 2010).

• Paul Glassman, DDS, MA, MBA PowerPoint presentation, “Improving

Community Heath Center Operations: Lessons from Financial Analysis, Technical

Assistance and Delivery Systems,” presented on Wednesday, October 27, 2010 at

the NNOHA National Primary Oral Health Conference (NPOHC); Paul is currently

Professor of Dental Practice and Director of Community Oral Health and Director

of the Pacific Center for Special Care (PCSC) at the University of the Pacific Arthur

A. Dugoni School of Dentistry in San Francisco (Pacific).

1 Holyoke Health Center in Holyoke, MA – Jay Breines, CEO – several attempts were

made to connect with the CEO, ultimately with no response



4

• Personal communication with Ellen Sachs Leicher, Principal of ESL

Associates Consulting Firm and outside independent SNS contractor responsible

for evaluating clinics participating in SNS’s TA program and monitoring their

progress for the two years following the initiation of the TA project.

• Telephone interviews with dental directors, clinic directors, and/or CEOs at

five federally qualified dental clinics served by SNS conducted by Think2

Consulting, LLC. Dori Bingham, Project Manager for SNS, provided Think2

Consulting with a list of eighteen clinics that had utilized practice management

consulting services from SNS for a minimum of eighteen months. From that list of

eighteen clinics, five were randomly selected to interview via telephone to assess

the overall effectiveness of the Safety Net Solutions Technical Assistance program.

• Consulting Dentists:

o Irene Hilton, D.D.S., M.P.H., Southeast Health Center, San Francisco,

CA; former NNOHA Board Member

o Cecilia Edwards, D.D.S., Salud Family Health Center, Fort Lupton, CO

o Martin Lieberman, D.D.S., Neighborcare Health, Seattle, WA;

Organizational Member of the NNOHA Board

o Dan Watts, D.D.S., Dental Director at Terry Reilly Health Services,

Nampa, ID



5

Appendix C

Documents

Evaluation of the DentaQuest Institute Safety Net ... · efficiency and management decision making, but also improvement in patient access to dental care, the quality of care and