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Successes and Challenges of Dental Hygienists in Community Settings:Increasing Access to Oral Health Care
Part One: Bringing Oral Health Care to Your Community Through Dental Hygienists
Objectives
1. Explain the Collaborative Dental Hygiene Practice in Minnesota.
2. Discuss the integration and coordination of medical and dental health approaches to reach optimal/total health.
3. Share results of the MDH study to better understand successes, challenges and best practices at the community level.
2
3
4Image Source-MDH
Oral Health Access in Minnesota
Source-Barriers to Oral Health Care American Dental Association (2011)
Less than Half of MN Children (0-5 years) Enrolled in Medicaid Received their Recommended Annual Dental Visit
6Source: EPSDT Participation (CMS-416) Report, 2016. Lines 1b. and 12a.
39.0%
0.6%
12.6%
40.6%
0
10
20
30
40
50
60
70
80
90
100
All ages (20 and under) Less than 1 1 to 2 3 to 5
Pe
rce
nt
C&
TC e
ligib
le c
hild
ren
Age group (years)
Dental service use among Child and Teen Checkup (C&TC) eligible children by age group, federal fiscal year 2016
8Source-MDHSource-MDH
9
System Performance
Access
Inflation ACA
Population demographics
Evolving disease patterns
Advances in technology practice, and clinical practice
Unsustainable cost
De
nta
l Pre
ven
tio
n G
ap
The Iron Triangle of Health Care
Cost (Affordability/Efficiency)
Minnesota’s Collaborative Dental Hygiene Practice Authorization
Image Source-MDH
• A dental hygienist provides care that is educational, preventive, and therapeutic through observation, assessment, evaluation, counseling, and therapeutic services to establish and maintain oral health.
• A dental hygienist licensed under this limited authorization may be employed or retained by a health care facility, program, or nonprofit organization to perform the dental hygiene services in a community settings without the patient first being examined by a licensed dentist.
Overview
• Historical perspective
• Examples of other states
• Minnesota Statue
Image Source-MDH
Model
• What is a collaborative agreement? View requirements here under Minn. Statutes 150A.10 Subd.1a
• Dental Hygienist and Dentist establish a protocol (written agreement).
• The "collaborative agreement” is a formal, written document that outlines the professional practice relationship between a licensed dentist and hygienist.
• Hygienist can practice in a location remote from the collaborating dentist or a setting that is not the usual location of the dentist’s practice.
• No direct supervision required.
• The collaborating dentist has agreed to monitor treatment of patients and consult as needed.
• This may include periodically reviewing patient charts. 13
MDH Examples
• School Sealant Program
Coordinated Care
• Models of collaboration for patients with gum disease and/or heart disease at FQHCs
Co-Located Care
• Bi-directional referral model for patients with gum disease and/or diabetes
Integrated Care
14
Moving Upstream
The Prevention Parable17
Picture Source for Education Purpose Only
P R O T E C T I N G , M A I N T A I N I N G A N D I M P R O V I N G T H E H E A L T H O F A L L M I N N E S O T A N S
Laura McLain, Senior Research Analyst
Collaborative practice dental hygiene study: Results
19PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
• Workforce sets the stage for innovative models
• Need availability to implement something new
• Dentists are the foundation of the oral health workforce
• Provide complex services and lead the oral health team
• Highly paid
• Workforce challenges, especially in rural and underserved areas
Oral health workforce
Dentists24%
Dental hygenists
33%
Dental assistants
43%
Dental therapists
0.5%
206 / 1 2 / 2 0 1 9
• Dental Hygienists workforce:
• Younger
• Located throughout state
• Dental Assistants:
• Many, but hiring challenges
Oral health workforce
PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS
128
136
128
119
67
92
98
84
84
51
64
70
58
56
30
0 20 40 60 80 100 120 140
Minnesota
Urban
Micropolitan or Large Rural
Small Town/ or Small Rural
Rural or Isolated
Dentists Dental Hygienists Dental Assistants
Oral Health Professional per 100,000 population
21PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
• Dental hygienists are available to be the foundation of collaborative practice.
• A promising model barely being used
• 11% of dental hygienists have a collaborative agreement; only 5% frequently use it.
Collaborative practice and the workforce
22PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
• Qualitative study
• Better understand collaborative practice: share information and grow model
• Interviewed 22 oral health professionals including dental hygienists, dentists, and program managers in the fall of 2017.
Qualitative study
236 / 1 2 / 2 0 1 9
• Most programs are:
• Non-profits
• Serve low-income population
• Most serve children, the elderly or those in institutional settings
Regions Settings Clients
Number of locations around state
Group homes, nursing homes, schools, clinic
Special needs, elderly, children
Number of locations around the state
Schools, Head Start, Community Centers, Churches
Children
Number of locations around the state
Nursing homes Elderly
Minneapolis Schools Children
St. Paul Homeless shelter, FQHC Families, children
Northern MN School, clinic Children
Reservation Schools Children
Mankato Schools Children
Southeast MN Head Start Children
Southeast MN Community programs, schools
Adults and Children
Study participants: Diversity in programs
PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS
24PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
• Three main components from study participants:
• Working in community settings is beneficial
• The role the CPDH plays is important
• Strong partnerships are key, especially with dentists
Components
25PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
“The benefits is kids may not ever get dental services if we were not there, so that’s the biggest benefit. I think also with the presence in the schools and the community settings it opens up the public’s eye, communities’ eye and parents’ eye to the importance of oral health.”
Benefits of community setting
266 / 1 2 / 2 0 1 9
Service process in community setting
PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS
276 / 1 2 / 2 0 1 9
▪ Services vary by community partner’s needs, population, equipment and location needs, and finances.
Services provided
PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS
28PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
• Broad barrier: People are unaware of or misunderstand the program model
• Broad facilitator: Shared goals and vision
Facilitators and barriers
29PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
• Facilitators and barriers occur at three main levels:
• Organization
• Service
• Policy
Facilitators and barriers
30
Organization
6/12/2019
316 / 1 2 / 2 0 1 9
Facilitators:
Find a champion
Focus on relationship building at different stages:
Developing relationships
On-going relationship management
Clarify roles and expectations through contracts
Build oral health into regular operations
Barriers:
Not all potential partners may be willing or able to work together
Space
Lack of oral health understanding
Relationships require work/time
New = challenging
• Model doesn’t work without successful partnerships
Partner relationships
PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS
326 / 1 2 / 2 0 1 9
▪ Effective team care is necessary for the model
▪ Facilitator: Find right skill set for organization.
▪ Barrier: Confusion and inefficiency when teams aren’t functioning well.
Team care
PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS
33PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
Facilitators:
• DH are cost effective basis for a program: Prevention focus and triage patients to use dentist well
• Grants very helpful to support programs
Barriers:
• Complicated billing systems and requirements
• Grant applications and reporting can be burdensome
Financing: finding a model that works
Donations
Grants
Third party billing
Flat Fee/Sliding fee scale for patients
Medicare/MNsure/Medical Assistance
34PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
• Leader buy in and support
• Planning: focus on the details
• Right technology and equipment for services and population
• Lessons learned approach to program management
Key organization facilitators
35PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
• Most organizations created something with no model
• Focus on lessons learned along the way to make the programs successful
• Initial ideas didn’t always work: modified to be more successful
More on lessons learned
36PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
More on lessons learned
Challenges
Difficulty connecting with families
Equipment uncomfortable
Staff at parnter site see dental team as a problem
Limited space
Equipment planning and availability
Lessons Learned
Connecting with families is a group effort
Fine tuned equipment needed along with efficient maintenance
Build relationships, be flexible with partner site, find a champion at partner site
Include space in formal contract
Advance planning required for school based services
37
Service
6/12/2019
38PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
Facilitators:
• Passion and commitment
• Working at the top of license
• Flexible approach
• Provide support for dental hygienists
Key service framework facilitators and barriers
Barriers: ▪ Consent from parents
▪ Tracking information
▪ Time available from partner site staff
▪ Training staff
396 / 1 2 / 2 0 1 9
• Dental hygienist is center
• Decide roles that best fit hygienist, organization, and partners skills capacities.
• Hygienists reported enjoying having a variety of responsibilities.
Dental hygienist: service facilitator
PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS
40PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
Facilitators:
On-going treatment plans
Building relationships with dental clinics and dentists
Dentist part of program
Case management approach
Barriers:
Not all clients remain with the program to receive on-going services
Not all programs have a dentist
Transportation barriers
• Goal of collaborative practice is meeting oral health needs: more than just one-time service, including care from a dentist
Follow-up care
41
Policy
6/12/2019
42PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
• General oral health system challenges
• Billing for Medicaid complicated and not may dentists accept
• Dental services not covered by Medicare
• Patient costs of paying for services
• Lack of understanding about importance of oral health
Policy issues to address
43PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
• Financial:
• Assessment not covered by government programs
• May not be enough grants
Policy issues
▪ General CPDH issues:▪ New and different
approaches brings challenges at may levels
▪ Clarity of collaborative agreements and other legal requirements
44PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
“It’s to create more points of entry and to triage patients effectively. We are viewing each site as a population and we are wanting hundred percent access, zero disparities. That is kind of a goal. And it doesn’t make any sense to have everybody’s point of entry to be a comprehensive exam by dentist.”
45PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOT ANS6 / 1 2 / 2 0 1 9
• MDH Oral health workforce reports: https://www.health.state.mn.us/data/workforce/oral/index.html
• MDH Rural Health Advisory Committee report: https://www.health.state.mn.us/facilities/ruralhealth/rhac/docs/2018ruraloral.pdf
• Normandale 21st Century Dental Team website: http://www.normandale.edu/mndentalteam
• Legislation: https://www.revisor.mn.gov/statutes/cite/150a.10
For more information
[email protected]@state.mn.us