implementing a community-based oral health care program: lessons learned

240 Journal of Public Health Dentistry

Implementing a Community-based Oral Health Care Program: Lessons Learned

Richard Diamond, DMD, MPH; Eugene Litwak, PhD; Stephen Marshall, DDS, MPH; Alexis Diamond, MA

Abstract Objectives: The objective of this paper is to report key findings of a process

evaluation that may be useful to other institutions seeking to implement a community-based oral health care program primarily targeting children in dentally underserved communities. By partnering with community-based organizations, public schools, and community health care providers, the Columbia University School of Oral and Dental Surgery (SDOS) established the Community DentCare Network (Dentcare) in the Harlem and Washington Heights/lnwood neighborhoods of northern Manhattan. These low-income neighborhoods are charac- terized by poor oral health and have been designated by the federal government as health professions shortage areas. Methods: The method used in the process evaluation was open-ended qualitative interviewing by a sociologist with extensive experience in this methodology aided by a participant-observer within the DentCare program. Results: The heterogeneity of the two communities required different strategies and resources to gain trust and acceptance. Fundamental changes were required of SDOS over a 7 O-year period, beginning with prioritizing community service into a primary mission. Collaborating with medical clinics facilitated the implementation of the network when the partners shared the same philosophical goals. Faculty and staff with different skills were needed during the start-up and the sustained development phases of the program. [J Public Health Dent 2003;63(4):240-431.

Key Words: school health services, community dentistry, community networks, Hispanic Americans, blacks, dental care, health services accessibility.

Inequity in access to dental care is one of the most pressing public health dental problems facing the United States today. According to the Sur- geon General’s year 2000 report, Oral Health in America: “There are profound and consequential oral health dispari- ties within the US population, and safe and effective measures exist to pre- vent the most common dental dis- eases-dental caries and periodontal disease” (1).

Columbia University’s School of Oral and Dental Surgery (SDOS) is 10- cated in northern Manhattan. Neigh- boring communities are Washington Heights/Inwood (WH/I), a predominantly Hispanic community, and Har- lem, a predominantly African-Ameri- can community. Both WH/I and Har- lem are customarily classified as poor

urban communities. According to the year 2000 US Census, among families with related children younger than 18 years of age, 29.5 percent in WH/I and 31.4 percent in Harlem were below the poverty level (2). According to WH/I and Harlem school principals interviewed as part of the process evaluation, more than 80 percent of students were eligible for free school lunch program and Medicaid.

The Kellogg Foundation funded Dentcare’s start-up and requested that a process evaluation be per- formed. This type of evaluation is commonly used to ascertain if a program is functioning according to its design. Other oral health promotion programs have undertaken process evaluations to review and refine their activities (3). A process evaluation also

can study problems in implementing new programs: ”The critical points in implementation need to be identified, solutions to managerial problems out- lined, quahfications of successful program personnel documented ... The results of program monitoring at the developmental stage can be profitably used in the diffusion of effective and efficient programs” (4). The purpose of this paper is to share key findings of the process evaluation that would be useful to other institutions seeking to implement dental service programs in dentally underserved communities.

Specifically, the process evaluation identified four key findings:

1. the heterogeneity of the two low-income communities served by the program;

2. the changes in SDOS necessary to engage successfully in the DentCare program;

3. the importance of partnering with medical facilities; and

4. the utility of defining the program in multiple phases of implementation.

Program Description. DentCare was established by partnering with community organizations (Figure 1). School-aged children in the New York City (NYC) neighborhoods of Harlem and WH/I were the initial target populations. DentCare’s goal was to shift primary care services from NY Presbyterian Hospital and SDOS to neighborhood settings with emphasis in providing preventive care in NYC public schools.

The first dental clinics were established in five NYC schools. Intermedi- ate schools IS 52 and 164 are in WH/I, and IS 136 and P911M are in Harlem. Preventive services provided in these schools included oral examinations, prophylaxis, scaling, fluoride, sealants, and patient education in

Send correspondence and reprint requests to Dr. Diamond, Columbia University School of Dental and Oral Surgery, Division of Community Health, 630 West 168th Street, New York, NY 10032. E-mail: [email protected]. Dr. Litwak is with Columbia University Departments of Sociomedical Sciences and Sociology. Dr. A. Diamond is affiliated with the John F. Kennedy School of Government, Harvard University. Dr. Marshall is associate dean of Columbia University School of Dental and Oral Surgery. Manuscript received: 6/4/02; returned to authors for revision: 7/26/02; final version accepted for publication: 1/22/03.

Vol. 63, No. 4, Fall 2003 241

home care procedures. IS-143 is in WH/I and provides basic restorative treatment and simple extractions, as well as preventive treatment.

Assessment of Need. Preliminary data collected on the first 556 children examined in the DentCare program suggest that intermediate schoolchildren in WH/I and Harlem have more untreated dental disease than children with similar dentition across the coun- try as reported in the Third National Health and Nutritional Examination Survey (NHANES 111). Mitchell’s analysis of these data indicates that for children aged 12 to 17 years, the mean number of decayed, missing, or filled teeth in the DentCare population was 3.36, compared to 2.53 in the NHANES I11 survey, and untreated dental disease in the DentCare population was 36 percent compared to 13 percent in NHANES 111 (5).

These results were not surprising, given that Hispanic and African- American communities have more unmet dental needs than white communities (6-ll), and WH/I and Harlem were designated health professions shortage areas by the federal government. Residents in a recent survey of Harlem households cited oral health care as their number one health problem (Zabos G. Identifying unmet needs in oral health research. Pre- sented at the American Public Health Association meeting, April 2000). In- termediate school IS 52 in WH/I was the first DentCare clinic established, and information from demographic questionnaires, dental histories, and dental examinations all confirmed the need for oral healthcare interventions.

FIGURE 1 Providers-Communities-Policy Makers

Local School Districts/ School-Based Clinics

I

\ / r 1 I Local Churches I

of Public Health Community DentCare Network \

Health Center

Dental Service

‘Alianza Dominicana: Dominican community-based organization. tACNC: Ambulatory Care network Corporation, NY Presbyterian Medical Center.

Methods The process evaluation utilized

open-ended qualitative interviewing to trace the steps taken by SDOS and its community partners to establish DentCare. Interviews were conducted by a sociologist with extensive experience in this methodology, aided by a participant-observer within the DentCare program. Researchers jointly conducted 27 interviews. Inter- views were conducted with people by their affiliation in one of four catego- ries: public schools, community leaders, Columbia University, and DentCare. Some of these people worked exclusively in WH/I, some exclusively in Harlem, and the rest worked in both communities (Table 1).

Key questions were asked of all interviewees. A sample of key questions were: Would you describe your back-

TABLE 1 Interviewees by Location and Affiliation

ground and how you became involved with the community DentCare program? How would you describe WH/I as compared to Harlem? What were the problems in implementing the program? Do you or your staff live in the neighborhood? Was finding space for the clinics a problem? Did establishing community clinics re- quire different organizational strategies in the WH/I and Harlem communities? Why did you decide to go with Dentcare?

Results Heterogeneity. As noted by Peter-

son, many people think that all communities with dense pockets of poverty are the same (13). The pkocess evaluation suggests that WH/I and Harlem are two very distinct poor urban communities. WH/I represents a

Public Community Columbia Univ. DentCare Location Schools* Leaderst Administrators$ Staff Total

Harlem 2 4 0 2 8 W H / I ~ 2 1 0 5 8 Harlem & WH/I 2 1 6 2 11 Total 6 6 6 9 27

Twenty-seven people were interviewed. Some worked only in Harlem, some only in WH/I, and some worked in both locations. *Interviewees from public schools included four principals, one vice-principal, and one teacher. tHarlem community leaders represented diverse groups, in contrast to a single umbrella community group in W / I . Columbia University interviewees were from the School of Dental and Oral Surgery and the School of Public Health.

h H / I Washington Heights and Inwood. WH/I and Harlem are innorthem Manhatten bordering Columbia University School of Dental and Oral Surgery.

242

Phase I Start-up

* Creative administrators

Motivation, vision & networking skills

9 Goal-oriented staff

Ability to adapt and overcome obstacles

Grant funding

Journal of Public Health Dentistry

Phase II: Sustainable Development

Efficient administrators

Leadership, organizational, and communication skills

Rules-oriented staff II,

Ability to follow standardized quality assurance procedures

Patient revenue

relatively optimistic immigrant community, whereas Harlem represents the “truly disadvantaged community” discussed by Wilson (14). The process evaluation determined that different strategies were used to establish DentCare in the two communities due to qualitative differences in c o m u - nity structure.

We found that parent-teacher asso- ciations (PTAs) were an important ve- hicle for reaching and involving the parents of schoolchildren in the WH/I schools. The process evaluation determined that parental cooperation was essential to ensure that students fol- lowed through on referrals, brushed regularly at home, and provided insurance information for billing pur- poses. Only the WH/I public schools had active PTAs; thus, it was easier to gain parental cooperation in WH/I than in Harlem. PTAs were not the only institutional resources available for mobilizing community support. The director of the DentCare program in WH/I gained community support by engaging an existing community umbrella organization, whereas the director of the Harlem program gained community support by form- ing a working group of community leaders composed of dedicated mid- dle class professionals and clergy.

Fundamental Changes Required by SDOS. We found that SDOS modi- fied its mission in the early 1990s (15). Previously, the SDOS mission was primarily the education of dental students and research on oral health issues. Dental services provided to the patients were a secondary benefit. Raising community service to the same priority as education and research helped gain faculty and community support.

There were five major modifications a t SDOS required to make DentCare work the establishment of a patient- centered education curriculum, the creation of an onsite SDOS faculty practice, the creation of offsite dental clinics, the hiring of faculty with public health expertise, and the establishment of a postgraduate curriculum in community dental services.

Collaboration with Medical Clin- ics. DentCare’s first collaboration was as a participant in NY Presbyterian Hospital’s effort to establish five offsite community-based medical clinics, part of the hospital’s Ambulatory Care Network Clinics (ACNC). The first

ACNC clinic was established with a dental unit. The hospital then decided that this dental unit was not profitable enough to merit an expansion. Plans for the four additional oral health clinics were canceled.

The second collaboration was with a community health center in Harlem. This health center shared DentCare’s goal of creating access for the greatest possible number of people rather than maximizing profits. The third collaboration was with the Columbia Univer- sity Mailman School of Public Health’s school-based medical clinics in the five schools previously noted in the program description. These school-based medical clinics had a similar preven- tion orientation and mission as DentCare. In this collaboration, DentCare was a full partner, not a sub- ordinate as it had been with the hospital and community health center.

Phases of Implementation. The process evaluation identified two distinct phases in the establishment of DentCare (Figure 2). These two phases were the start-up phase and the sustainable development phase. During the start-up phase, it was very important to have staff who were predominantly goal oriented. If students were scheduled to come to the clinic and failed to make their appointment, a goal-oriented staff member would go to the classroom and find out why the students did not show up in order to minimize the reoccurrence and, if necessary, find substitutes.

Discussion Heterogeneity. WH/I is a growing,

dynamic, predominantly Dominican immigrant community. This community is relatively receptive to outside agencies, as evident by the fact that a

non-Latino dentist was able to elicit support for DentCare by attending community meetings over three years. The process evaluation confirmed that it was easier for DentCare to gain the trust of the WH/I community than the Harlem community.

It was the unanimous opinion of the interviewees that the population of Harlem had a deep suspicion of outside agencies due to a long history of racism and exploitation. Gaining support for the DentCare program was not easy, even for an African-Ameri- can dentist who had lived in Harlem for seven years. Ultimately, this dentist needed the endorsement of an- other African-American Harlem resi- dent, who was the director of the Har- lem Hospital Dental Service and a long-standing, widely known, and re- spected community leader.

Parental cooperation was essential for children who required dental treatment not provided at the preventive clinics. DentCare staff found it more difficult to follow up on dental referrals in the two Harlem schools without active PTAs than in WH/I schools with active ITAs. Parental cooperation also was required for the financial success of the school-based clinics because preventive services were offered regardless of ability to pay, insurance coverage, or citizenship status, and program revenues depended on Medicaid and the New York State Child Health Insurance Program (CHI‘). DentCare administrators esti- mated that more than 80 percent of the children were eligible for either Medi- caid or CHP. Only 3 0 4 0 percent of parents provided the Medicaid or CHP information needed by DentCare to receive funds. Of those not providing this information, some had no cov-

Vol. 63, No. 4, Fall 2003 243

erage; an outreach program was im- plemented to enroll these families, im- proving the ratio of payers to nonpay- ers.

Fundamental Changes Required by SDOS. The faculty had little incen- tive to elevate its community service program into a primary mission for the school because the structure of the university promotes and rewards faculty on the basis of teaching and research. The dean of SDOS, however, was strongly committed to DentCare and gained faculty support by replac- ing dwindling state and federal funding with grants for community services and fees from the redesigned dental clinics.

The dean had to take direct admin- istrative control because the financial resources involved were substantial. In the start-up phase, much was ac- complished in an ad hoc and flexible manner under the leadership and in- tuition of a highly regarded leader, rather than strict adherence to a formal business plan. It took approximately 10 years for the dean to make all the changes necessary to institute DentCare.

Collaboration with Medical Clin- ics. Had Dentcare’s collaboration with the hospital been successful, it would have allowed SDOS to launch its program very rapidly. The failure of this collaboration challenged SDOS to develop its own linkages with the community. Dentcare’s partnership with the community health center worked well because institutional goals were closely aligned.

When a dental unit joins with a medical facility, it must do so from a position of strength. DentCare had the complete support of the dean of SDOS, Columbia University, and over a 10- year period had gained the support of most of the SDOS faculty. Affiliation with SDOS enhanced DentCare affili- ates’ images and improved their ability to apply for and receive grants. With each successful year of operation the network expanded, community trust of SDOS increased, and its bar- gaining position strengthened.

In the public schools, partnering closely with the School of Public Health’s medical clinics proved essential. The School of Public Health helped reduce Dentcare’s start-up costs by sharing its facilities until sepa- rate dental clu-tics were opened. With- out the endorsement of the existing

general health clinics, it would have been extremely difficult for DentCare to gain entry into the public schools.

Phases of Implementation. During the start-up phase, funding was less problematic thanks to a grant from the Kellogg Foundation. In this phase, Dentcare’s main goal was to start the clinic treatment program. Faculty members with public health and community organizing skills were essential in this phase. Public health dentists were primarily responsible for plan- ning and implementation. It was necessary for the dentists to have good communication skills, be culturally sensitive, and have an understanding of public health issues when t a h g to principals, community leaders, and school boards.

The crucial aspect of phase 11, the sustainable development phase, was to assure long-term economic stability by increasing the number of patient visits per day and shifting funding sources from grants to patient revenue. In phase 11, scheduling and billing procedures were made more efficient, allowing more time for treating patients. DentCare changed its examination form from a lengthy research-oriented form to one that is shorter and clinically oriented, collecting all perti- nent data and reducing the time required for the examination and data entry.

Lessons Learned All low-income neighborhoods are

not identical, and each requires dis- tinctive strategies and resources. Den- tal schools that are developing community-based programs should make community service its primary mission. If this requires a change in the school’s mission, it will take several years and must have the support and oversight of a committed dean. Col- laborating from a position of strength with existing medical clinics that share the dental school’s goals is a win-win situation, especially for the patients. The start-up phase requires goal-oriented staff who can overcome unex- pected obstacles. Once the program is up and running, it is important to have standardized procedures and staff who can maintain a financially self- supporting operation. Dental schools partnering with community service programs may provide a partial solu- tion to the lack of access to dental care within their cities and neighborhoods.

Acknowledements The authors wish to thank Dr. M a n For-

micola, dean of SDOS, for his encouragement and guidance; and Dr. Burton Edelstein, director, Division of Community Health of SDOS, for his editorial assistance in the writ- ing of this article.

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