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9/21/2014
1
Wel
com
e to
Lisa Greenshields, RDHAP, BS
Susan McLearan, RDHAP, MA
Sacramento Dental Hygienists’ Association
September 24, 2014
Course Objectives Be able to discuss the reasons behind the
movement to expand the dental workforce
Be able to define direct access and list four types
existing in the U.S.
Be able to discuss the most prominent workforce
models currently being tested
Be able to list the settings and scope of the
RDHAP
Be able to compare aspects of the VDH Project
with the current roles of the RDH and RDHAP
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The Surgeon General’s Report
• “Although there have been gains in oral health status for the population as a whole, they have not been evenly distributed across subpopulations.”
• Profound health disparities exist among populations including:
– Racial and ethnic minorities
– Individuals with disabilities
– Elderly individuals
– Individuals with complicated medical and social conditions and situations
Reports Dental Hygiene Workforce
Registered Dental Hygienists in California: Regional Labor Market Chart
Mertz and Bates
Center for the Health Professions
hppt://www.futurehealth.ucsf.edu
2008
Data from 2005
Reports Access, Quality Assurance, etc.
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Governor’s Report
• January 2014
• National Governor’s Association (NGA)
• Center for Best Practices Health Div.
• The Role of Dental Hygienist in Providing Access to Oral Health Care
– states can consider doing more to allow dental hygienists to fulfill these needs by freeing them to practice to the full extent
of their education and training.
UCLA Study
Friday, September 5, 2014
Preventive care outreach programs
in unorthodox settings are
successful in getting underserved
screened for health conditions…….
Total Population
281,000,000
Institutionalized
4,000,000 (1.4%)
Community Living
277,000,000 (98.6%)
Severe Medical
Co-morbidities
24,500,000 (8.7%)
Generally Healthy
252,500,000 (89.9%)
Economically
Disadvantaged
43,000,000 (15.3%)
Not Economically
Disadvantaged
209,500,000 (74.6%)
Remote
3,000,000 (1.1%)
Non-remote
40,000,000 (14.2%)
Remote
10,500,000 (3.7%)
Non-remote
199,000,000 (70.8%)
Note: The percentages are of the total population.
Source: ADA 2006 CDHC Report, 2000 Census
Population Categories
82,000,000 = 29.18% 192,000,000 = 70.8%
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70%
Well Served
30%
Underserved
Population Categories
192 million 82 million
Complex medical, physical,
and social conditions
Culturally diverse
Institutionalized
Economically disadvantaged
Rural
Children’s Use of Dental Care
in California
Among the findings:
– 24 percent of all children in California have
never visited the dentist.
– Significant racial/ethnic differences in dental visit rates exist, even among Latino and Asian subgroups.
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The Elderly
and Infirm
• Suffer disproportionately from
– Active and untreated mouth infections
– Loss of teeth
– Old and ill-fitting dentures
– Impairments in salivary and masticatory function
Source: Centers for Medicare and Medicaid Services
U.S. Dept. of Labor, Bureau of Labor Statistics: Occupational Outlook Handbook 2008-09
Projections data from the National Employment Matrix
General Dentists: http://www.bls.gov/oco/ocos072.htm#oes_links
Dental Hygienists: http://www.bls.gov/oco/ocos097.htm#projections_data
General Dentists = 9% increase, Dental Hygienists = 30% increase
136,000 149,000
167,000
217,000
0
50,000
100,000
150,000
200,000
250,000
2006 2016
Number and Projections of General Dentists and Dental Hygienists
General Dentists
Dental Hygienists
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WHAT IS
DIRECT ACCESS?
What are Workforce Models?
Direct Access –Definition ADHA
• Direct access means that the dental hygienist can initiate treatment based on his or her assessment of patient’s needs without the specific authorization of a dentist
• RDH may treat the patient without the presence of a dentist, and can maintain a provider-patient relationship
Direct Access
• One way to address the gaps in workforce vs. need
• Patient does not have see the dentist first, they can go straight to the RDH
• May mean that the RDH may bill directly for services they render
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All red states are not equal.
General Supervision
8 states
Public Health Hygienists
13 states
Collaborative Practice
12 states
Independent Practice
6 states
Direct Access
No Direct Access = 13 states
General Supervision Hygienists can initiate patient care with a dentists authorization,
in writing, such as seeing a patient of record in a nursing home
• Maryland
• New York (until 2015)
• Oklahoma
• Rhode Island
• South Carolina
• Tennessee
• Texas
• Vermont
Note that none can direct bill
for services rendered
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Public Health Hygienists Hygienists work under the supervision
of local state or federal programs
• Connecticut $
• District of Columbia
• Florida
• Iowa
• Kentucky
• Massachusetts $
• Missouri $
• Montana $
• Nebraska $
• Nevada $
• New Hampshire
• Pennsylvania
• Wisconsin $
$ = Direct billing allowed
Collaborative Practice Hygienists may provide services outside of a dental practice
according to the terms of a collaborative agreement.
Pre-diagnosis/treatment plan not required.
• Alaska
• Arkansas
• Idaho
• Kansas
• Michigan $
• Minnesota $
• New Mexico $ Rx
• New York (2015)
• Ohio
• South Dakota
• Virginia-Pilot Project
• West Virginia
Independent Practice Hygienist may practice without supervision in defined venues
and receive direct reimbursement
• Arizona $
• California $
• Colorado $ DH Diagnosis
• Maine (2014) $, no programs yet
• Oregon $ Rx
• Washington $
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Collaborative & Independent
Practice
• Some no special requirements
• Some require additional training
• Many have years of practice requirements
– Maine=Highest requirement is 6 years and 6,000 hrs
– California 3 yrs, 2,000 hours, Bachelor’s or equivalent
New(er)
Workforce Models
• Mid-level Therapist (ADHA Model 2004)
– DHAT-Alaska
– DT and ADT- Minnesota
• Collaborative Practice
• Independent Practice (RDHAPs in California)
• Public Health Hygienists
• Community Health Aids
– Promatoras
– ADA Models (create new providers) • Oral Preventive Assistant (OPA)- preventive and scaling dental assistant
• Community Dental Health Coordinator (CDHC) community based mid-
level
• Apple Tree and other Mobile Dental Models*
DHAT- Alaska
• Not ADHA’s model
• Started in 2004-began practicing in 2008
• 24 month program administered by ANTHC in partnership with the University of
Washington DENTEX program
• Remote general supervision by tele-dentistry
• DHAT providers are often Alaskan Natives
who reside or grew up in the remote villages
they serve
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DHAT- Duties
• Oral health and nutrition education
• Sealant placement
• Fluoride treatments
• Coronal polishing
• Prophylaxis
• Expose radiographs
• Restorations
• Placement of pre‐formed crowns
• Pulpotomies
• Non‐surgical
extractions
• Non‐surgical
periodontal therapy
Metropolitan State University
Advanced Dental Therapist
Apple Tree Model
• Modeled after Mayo Clinic
• 6 Free standing clinics
• Satellite site
– Equipment wheeled in
– Dental Director
– Utilize ADTs
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Apple Tree – San Mateo
Scheduled to begin satellite services in 2015
ADA’s Workforce Model
American Dental Association
“New Providers” Model
Oral Preventive Assist.
(OPA)
• Curriculum available thru ADA
• States decide duties
– Possibly sealants, fluoride and scaling Type I
• Is a certified dental assistant to work in an office or some community
Comm. Dental Health Coord.
(CDHC)
• Pilot Projects in 6 states
• New Mexico certificate program 2011
• 18 mo. program
• Can be an RDH or DA
‐ Oral health and nutrition education
Sealant placement ‐ Fluoride
treatments
Coronal polishing ‐ Scaling for Type I
Temporary fillings
Development and implementation of
community based programs
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Promotoras
CDHC
ADHP
RDHAP DHAT
Community
Oral Health Providers
RDHAP Movement in California
• 1972-73 AB 1503 creates Health Manpower Pilot Projects
• 1981 CDHA submits proposal
• 1981-86 raise money
• 1986 HMPP #139 begins was closed down in 1990
• 1990 HMPP #155 begins
• 1998 AB 560 passes after several failed attempts from initiation to legislation = 18 years (1980-1998)
• 2003 First training program WLAC
• 2004 UOP On-line training
• 2010 HWPP #172
• 2014 AB 1174
The RDHAP Model
• RDHAP – a California Workforce Model
• Not a mid-level
• Restricted practice sites/populations
• Many clients do need a DDS
• Most need prevention and case management
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RDHAP
Practice Sites
• Residences of the homebound
• Schools
• Residential facilities and other institutions
• Dental health professional shortage areas
RDHAP
Practice
This is what is seen every day
More than a perio problem
The Medical Home
• A.A. Pediatrics-1967
• Care management over time
• Patient-centered
• Comprehensive and team based
• In pediatric medical home models, there is also an emphasis on access and early intervention services
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The Dental Home The dental home is the ongoing relationship between the dentist and the
patient, inclusive of all aspects of oral health care delivered in a
comprehensive, continuously accessible, coordinated, and family-centered way
• Modeled after the medical home concept
• Articulated by the A.A. Pediatric Dentistry
“Virtual” Dental Home
• Modified from Dental Home
HWPP
# 172
California Health Workforce
Pilot Project
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HWPP #172
• Steps
– Infrastructure, training, agreements
– Expand the duties of existing providers
• x-ray decision
• “Interim Therapeutic Restorations”
– “Proof of concept” demonstration
– Measure health improvement, economic
modeling
– Advance legislation/ regulatory reform
– Stabilize and spread
The Virtual Dental Home Sites
Virtual Dental Home Sites
VDH Pilots In Training
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Quantifying and Collecting Data
Training the Virtual Workforce
Learning Laboratory
VIRTUAL DENTAL HOME
Equipment and Procedures
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Photographs-
Intra and Extra Oral Cameras
Photographs
CAMBRA Risk Assessment
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Basic Measures
Basic Measures
Performing Procedures
in the Community
• Care management over time
• Preventive education
• Prevention procedures
– Teeth cleaning
– Medical treatments
– Interim Therapeutic Restorations
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School Based
Planning
• Pre-existing • Treatment Plan
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Quick Facts
• Preliminary results indicate that the Virtual Dental Home Project can currently keep 60% of the student population healthy at the school site, providing continued hygiene care, sealants, fluoride varnish and interim therapeutic restorations (ITR).
Early Intervention
White Spot Lesions and
shallow cavitation
Prevention
• Calculus removal
• Pit/fissure sealant
• Fluoride varnish
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Radiographs
Radiographs
Intra- Oral Photographs
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Photographs
Sealants
Sealant
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Residence Based
VDH Set-Up in Activity Room
Virtual Dental Chart-X-Ray Set-Up
X-ray Set-up
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Resident with Mobile Oxygen
Interim Therapeutic Restoration
Set Up
Interim Therapeutic Restoration
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Interim Therapeutic
Restoration
Interim Therapeutic Restoration
Before
After
Glass Ionomer
I
T
R
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DDS Intervention
Results
From here To here
Prevention-More Than Restoration
Risk assessment and evaluation
Anti-bacterial regime
Maintenance
Re-Mineralization
Combating effects of xerostomia
Daily, effective oral hygiene
Case Management
Integration with medical and social services
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Caregivers, a major challenge
• Demonstrating • Pre and Post Brushing
Training the Caregivers
• Training Program • RNs, LVNs, CNAs,Others
Educator/School Staff In-service
Training Program School Nurses, Health Assistants, Teachers
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Institutionalizing
Prevention
Developing understanding and
appreciation for preventive products
Oral Chemistry
pH Testing
ATP Testing
Oral Chemistry
Fluorides Anti-microbials
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Oral Chemistry
Xylitol Ca+ Phosphates
Role of Nutrition
School Lunch SNF Snack Cart
Challenges
• Physical challenges in providing care
Operator challenges:
• Visibility
• Back support
Positioning with consideration to:
• Inability to swallow
• Head support
• Evacuation
• Fear
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Challenges
• Product delivery, use and oversight
• Patient/caregiver
• Follow-through and accountability
• General lack of experience with special populations
AB 1174
What is it?
• AB 1174 is a bill carried by Assemblymen Bocanegra and Logue intended to codify the duties proved safe by HWPP #172
• Clarifies and codifies RDAEF/RDH/AP ability to determine which x-rays to take
• Allows trained RDAEF/RDH/APs to place Interim Therapeutic Restorations (ITRs)
using glass ionomer filling material
AB 1174
Where it is now…
• AB 1174 has passed both the Assembly and the Senate (and subcommittees)
• Has been enrolled and sent to Governor Brown
• Governor Brown can sign it and it becomes
law, not sign it and it still becomes law, or veto it and it is “dead.”
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What happened…it all worked out Author’s View
• Clarified x-ray decision
• Clarified responsibility and limited number of auxiliaries supervised
• Provided additional duties for RDAEF, RDH and APs
• Set out training guidelines
• CDHAs concern of “potential misinterpretation” unjustified
CDHA View
• Did not acknowledge current RDH x-ray duty
• Added RDH supervision where there had been none
• Went over the top and did not acknowledge the role of the DHCC to develop regulations
• Various elements could be misinterpreted and
What might this mean
for dental hygiene?
• Continuing steps to increase scope of practice which can
• Lead to more opportunities and
• Utilization in alternative settings
References
Oral Health In American http://silk.nih.gov/public/[email protected], accessed September 20, 2014 Registered Dental Hygienists in California: Regional Labor Market Chart, http://futurehealth.ucsf.edu/Public/Publications-and-Resources.aspx, accessed September 20, 2014 Improving Access to Oral Health…..http://www.iom.edu/Reports/2011/Improving-Access-to-Oral-Health-Care-for-Vulnerable-and-Underserved-Populations.aspx, Accessed September 20, 2014 Oral Health In the Era of Accountability…, https://www.dentaquestinstitute.org/sites/default/files/reports/2011/12/Pacific_Center_for_Special_Care_Report.pdf The Role of the Dental Hygienist in Providing Access to Oral Health Care, http://www.nga.org/files/live/sites/NGA/files/pdf/2014/1401DentalHealthCare.pdf, accessed September 20, 2014 The Have and Have Nots…., http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/D/PDF%20DentalDisparitiesSnapshot07.pdf, Accessed September 20, 2014 Facts About California’s Elderly https://www.aging.ca.gov/Data_and_Statistics/Facts_About_Elderly/, accessed September 20, 2014
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References cont…
Direct Access Map and Chart http://www.adha.org/direct-access, accessed September 20, 2014 Alaska Dental Health Aid Therapists, http://itcaonline.com/wp-content/uploads/2013/06/Addressing-Early-Childhood-Caries-in-American-Indian-and-Alaska-Native-Communities.pdf, accessed September 20, 2014 Advanced Dental Therapy, Metropolitan State University http://www.metrostate.edu/msweb/explore/gradstudies/masters/msadt/. Accessed September 20, 2014 Apple Tree Dental http://www.appletreedental.org/, accessed September 20, 2014 Apple Tree Dental San Mateo http://www.peninsulahealthcaredistrict.org/apple-tree-center-for-dental-health/, accessed September 20, 2014 Review of Proposed Oral Health Workforce Models: Part 1, Access, August 2008, pg.21-31 Policy on the Dental Home, http://www.aapd.org/media/Policies_Guidelines/P_DentalHome.pdf, accessed September 20, 2014
References cont.
The Virtual Dental Home Policy Brief http://dental.pacific.edu/Documents/community/special_care/acrobat/VirtualDentalHome_OvierviewResults_PolicyBrief_May_2013.pdf, accessed September 20, 2014 HWPP #172 Application http://www.oshpd.ca.gov/hwdd/pdfs/HWPP/Abstract_HWPP172.pdf, accessed September 20, 2014 Basic Screening Survey Tools, http://www.astdd.org/basic-screening-survey-tool/, accessed September 20, 2014 Overcoming Obstacles To Oral Health, http://www.dental.pacific.edu/Community_Involvement/Pacific_Center_for_Special_Care_(PCSC)/Education_/Overcoming_Obstacles.html, accessed September 20, 2014