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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

Benefits

Source

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

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• 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

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• 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

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• 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

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• 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

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• 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

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“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

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Service process in community setting

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▪ 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

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• Broad barrier: People are unaware of or misunderstand the program model

• Broad facilitator: Shared goals and vision

Facilitators and barriers

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• Facilitators and barriers occur at three main levels:

• Organization

• Service

• Policy

Facilitators and barriers

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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

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▪ 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

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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

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• 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

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• 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

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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

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Service

6/12/2019

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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

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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

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Policy

6/12/2019

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• 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

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• 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

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“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.”

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• 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

laura.mclain@state.mn.usprasida.khanal@state.mn.us