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Oral Health Florida

Leadership Council Meeting Thursday, December 5, 2013; 8:00 am – 4:00 pm

In Attendance Leadership Council Voting Members Philippe Bilger, County Health Department Dental Programs Donna Solovan-Gleason, Department of Health Public Health Dental Program Charles Hoffman, Florida Dental Association (for Rick Stevenson) Tami Miller, OHF Co-chair, Florida Dental Hygiene Association Roderick King, Florida Public Health Institute Nancy Zinser, Palm Beach County Oral Health Coalition Frank Catalanotto, OHF Chair, University of Florida College of Dentistry Lilli Copp, Head Start State Collaboration Office Nancy Sawyer, Special Olympics Ann Papadelias, Escambia Community Clinic Leadership Council Non-voting Members Cathy Cabanzon, Florida Board of Dentistry Erica Floyd-Thomas, Agency for Health Care Administration (for Beth Kidder) Action Team Leads Sean Isaac, Fluoridation Action Team Chair Karen Pesce, Medical-Dental Collaboration Action Team Co-chair Kim Herremans, Sealant Action Team Co-chair Additional Participants Edward Zapert, Florida Department of Health State Dental Director Deitre Epps, Trainer/Facilitator, Results Leadership Group Cristy Kovach Hom, Project Manager/Administrative Support Florida Public Health Institute

Meeting Results By the end of the meeting participants will:

Build upon their current work in developing a statewide oral health plan

Decide upon final OHF result and focus areas

Select headline indicators for Improved Access to Quality Oral Health Care

Identify existing performance measures data for current strategies

Use data-driven decision making to develop and select statewide strategies

Meeting Decisions 1. The plan will remain at population level and not include performance measures. 2. The plan will be used as a tool to rally influential people and to present/propose strategies to improve oral health in

Florida. 3. The focus area of Untreated Decay will fall under Improved Access to Quality Oral Health Care and untreated decay

indicators will be combined with Improved Access to Quality Oral Health Care indicators. 4. The group confirmed use of the Florida Medicaid – CMS data –as the lead headline indicator.

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5. The group decided to measure any dental service as an indicator (currently 22%) and not just preventive dental service which is currently 18%.

6. The Improved Access to Quality Oral Health Care work group revised strategy language developed earlier in the session to change language and context around “billing” to reimbursement for all.

7. Group will include a headline indicator for Improved Access to Quality Oral Health Care to include ED/ER – visits and costs for total population. Associated indicators will include by payer class; age groupings; county of origin of patient (not hospital).

8. Access numbers per percentage below poverty line as reported by county health departments will remain on the Data Development Agenda

Meeting Notes Welcome, Purpose and Introductions – Dr. Frank Catalanotto, OHF Chair:

The group reviewed and confirmed contents of notes from August 9 meeting.

Dr. Catalanotto welcomed the group and stated that the goal for day was to focus on the result: All people in Florida have optimal oral health and well-being. To support this result, members were encouraged to: o Increase individual and organizational ownership of strategies o Identify additional partners

Planning Process Overview of Florida’s Roadmap for Oral Health: A Results Based Strategic Plan – Dr. Roderick King, FPHI Executive Director Dr. King welcomed the group and presented the following timeline:

Time Activity

December 2013 – February 2014 The next two face to face meetings (the present day’s meeting and February meeting) will be critical to the development of the strategic plan/roadmap.

January – March 2014 The plan/roadmap will be drafted.

February 2014 The draft plan will be presented at the next face to face Leadership Council meeting. This plan will be a result of combining multiple plans to have one for the state.

March 2014 Using the RBA framework, once the plan has been pulled together, it can be shared with stakeholders. The plan will include narrowly defined results and will be sharp, clear and focused in order to help turn the curve on oral health.

Dr. King noted that a culmination of events is pushing oral health to forefront: o Surgeon general has made oral health a top priority for Florida. o Deans of medical schools are interested in addressing oral health. o CMS is focusing on Florida oral health outcomes as a result of poor results for Medicaid children. o Foundations are showing more interest in oral health.

The day’s focus will be to solidify specific results, measures and indicators. The existing draft taken from work completed in August will be shared. Contents were dropped into the RBA framework.

Purpose – Deitre Epps, Results Leadership Group Facilitator

Deitre Epps reviewed meeting results and the purpose of the meeting.

Please see PowerPoint presentation which was used as a guide for the meeting’s discussion. Additional notes are as follows:

Today – consider two questions: 1. At the state level: Are we doing the right things? Do we have the right strategies in place? 2. Are we doing those things right? What data do we have to show effectiveness and what can we put in place to

have rigor around measuring success for strategies?

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3. Deitre recommended including plans to develop data at the performance accountability level. As well as at the population indicator level.

Population indicators were distinguished from performance measures and noted that this meeting will address population indicators only. Population indicators can be tracked and compared to national indicators.

Deitre stressed the importance of separating performance measures from population indicators. The current format has the two combined. Her recommendation is that the plan address results at the population level only. The group agreed.

What programs do we have that are working? Include in the plan: “These program strategies have worked and can be replicated.”

Two points of view exist: evidence-based vs. innovative promising practices with no data. Evidence-base is a good benchmark but there should be a balance with promising practices/common sense interventions. Collect data on promising practice/common sense interventions; ex: barber shop outreach.

If status quo strategy is not working, first collect data to prove it is not working before eliminating it. Review of roadmap/plan to date – Tami Miller, Chair of Data Action Team, OHF Co-chair

Tami reviewed the method of creating the plan using existing planning work and using the template from the Children’s Trust. It leads into a way to take the words we all know and put them into action – and using data to measure. This gives a format to look at the data in the state and develop it.

Using the principles of collective impact, the group should ask: What is our part? How can we work together? How will we all do our own projects with our own performance measures with the goal of achieving collective impact?

OHF data committee has been collecting data, evaluating needs. Tami explained the plan’s format and data appendix which includes data collected over the last two years.

This is an example of what plan can look like. Using the Children’s Trust plan as template, this is a concrete example of what the group has completed to date.

This document is not ready to be shared. Selecting Indicators – Deitre Epps, Results Leadership Group Facilitator

Deitre reviewed the indicators that were chosen for focus areas at the last meeting. Those rated as HIGH made it into the plan as headline indicators.

She distinguished between indicators and performance measures, considering what programs are in place and what performance measures can be tracked. State partners should be asked to use the same measurement.

She reiterated the importance of headline indicators – “Everything we do will correlate to the headline indicators. The indicator drives strategies you select to improve the indicator.”

Improved Access to Oral Health Care indicator could be reworded to the number of visits for dental-specific needs – not services provided.

A headline indicator needs to use a specific measure such as # or % or $.

Group will include a headline indicator to include ED/ER – visits and costs for total population

Associated indicators – by payer class; age groupings; county of origin of patient (not hospital) Community Water Fluoridation Indicators - Sean Isaac, Community Water Fluoridation Action Team Chair

Community Water Fluoridation Indicator: Percentage of people on fluoridated water/per total population

Sean shared that this can be calculated for each county by combining communities/municipalities. The current information measured is community specific – by water system. Information not available includes: what steps were taken to institute fluoridation and cause the increase? The story behind the data may be the strategy that needs to be employed. (Data Development Agenda can include county-level data collection).

Research agenda would be to learn the story behind the fluoridation data. (This can be added to the plan). Finalizing Headline State Indicators

The group reviewed Choosing Best Data Indicators Worksheet for Improved Access to Quality Oral Health Care.

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The group confirmed use of the Florida Medicaid CMS data as the lead headline indicator.

CMS measures are 1. Any preventive dental service, ages 0-20 (actually a performance measure but can be used as a headline

indicator. (Note: CHIP population at 45% (national is 42%) but Medicaid is only 18%). 2. Sealants age 6-9 (Adult Florida Medicaid utilization report exists).

There was a recommendation to consolidate Head Start data.

Dental Quality Alliance released pediatric performance measures to assist with verbiage and measures. This is a nice tool to use. Deitre suggested entitling headline indicators the same as the national data.

Possible future indicator: Increasing eligibility for children for Medicaid. o Percentages work better than numbers. o CMS is now 18% preventive service - goal for 2015 = 28%. Group discussed and decided to measure any service

which is currently 22%.

DOH reports PHDP by county and reports both access at 100% poverty and 200% poverty levels. Dr. Bilger recommended keeping this differentiation as it will incorporate more services (measures all dental services and measures poverty levels, beyond those covered by Medicaid). Dr. Bilger proposed keeping it because it covers more people and will provide access for more people. (This is county health department data).

Tami proposed that it remain on data development agenda. (If it is HMS data – it is limited). FQHC data is segregated from county health department data.

The Untreated Decay work group proposed to the full group that it fold under access to care. Untreated decay could become an indicator to measure access to care. The group came to consensus.

Since the last meeting, Tami added sealant program data – slide 22.

Sealant measure is now the number of schools covered not the county. Sealant programs are per high need schools. Including statewide (not Medicaid only) sealant data is a recommendation for the data development agenda.

Strategy Development through Data-driven Decision Making: Turn the Curve: Improved Access to Quality Oral Health Care (full group) The full group engaged in the Turn the Curve exercise using CMS data trend. (See updated Turn the Curve sheets at the end of this document. Group decided to measure any dental service as an indicator (currently this is 22%) and not just preventive service 18%. However, it is better practice to consider story behind the data first. Reviewing and Prioritizing Factors

Deitre stated that the first thing to do at any meeting is to check for:

o Changes/updates to data o Updates to the story behind the data

Add to Story Behind the Data from August: 1) Reimbursement rates rose in 2011

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2) The health access law was passed in 2011 Other story changes:

CMS, prepaid dental has had a greater impact on preventive services.

New/additional children added should increase the numbers. (They are at 45% as their parents take them – higher value of dental).

An additional indicator could include BSS data which reaches beyond Medicaid eligible children.

(BSS is a random sample population. Hygienist will tell if the child has had sealant, restoration, decay. It gives a snapshot and will link to other data in other states).

As a note, in the group process, there will be tension between the data the group wants to include and available data. It is important to note and capture this within data development. This is an indicator conversation.

“Data driven decision making requires us to look with laser focus at that indicator and strategies to move that indicator.”

Baseline:

Forecast by asking: In next 3-5 years, regarding the 22%, if everything stays the same will there be an increase or decrease? Factors include: o Changes in the system - the move to managed care o The number of dental providers per people is projected to decline because of lower reimbursement rates. (Story

behind 2013 data will include managed care raising reimbursement for few months at the end of the year). AHCA will have 2013 data in April 2014.

o If we do nothing differently, by 2015, only __% will receive services and is that okay? If not, what will we do to turn the curve? This is ROI.

o Bureaucratic red tape exists for dentists.

Once factors are listed, there is a need to choose prioritized factors.

Raised reimbursement rates are a factor. The group chose the following top prioritized factors:

1. Lack of full implementation of 409 2. In 2008, executive rule that medical providers reimbursed for early childhood caries prevention in Medicaid

patients 3. Lack of oral health literacy – pending – needs to be researched 4. Lack of value oral health 5. Lack of providers due to low reimbursement 6. Lack of providers due to bureaucracy 7. Lack of integration – oral health with primary care

This list of factors was consolidated by the small Improved Access to Quality Oral Health Care group. See below. Recommending new strategies

What works to address the strategies which are already in place and have worked?

Include concrete strategies to improve the data: collection of coherent set of actions: specific/concise.

Please see next page.

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Strategy Development Part II – Small Group Meetings

Improved Access to Quality Oral Health Care Group Prioritizing Factors

Prioritized Factors All partners for every factor

1) Lack of full implementation of 409

Florida Association of Community Health Centers Agency for Health Care Administration Florida Department of Health Florida Chapter of the AAP Florida Department of Education Florida CHAIN Community Catalyst Florida Legal Services Office of the Governor State Legislature Human Services Organizations Area Agencies on Aging Managed care plans Community Health Workers Social Workers Group dental practices Insurance groups/managed care Hospitals Primary care professionals School districts Early childhood coalitions Legislators Lobbyists Florida Head Start State Collaboration Office Special Olympics Florida

2) In 2008, executive rule that medical providers reimbursed for early childhood caries prevention in Medicaid patients

3) Lack of oral health literacy – pending – needs to be researched

4) Lack of value oral health

5) Lack of providers due to low reimbursement

6) Lack of providers due to bureaucracy

Strategy Development Meeting – Rating the Strategies Group suggested that a timeline be developed.

Prioritized factors Strategies to address each factor Action Steps

New language was developed: 1) Lack of billing component to fully

implement health access law Factor would include: lack of preventive services due to underutilization of dental hygiene workforce

1) Work with FDA to support upcoming legislation to fully implementation health access setting legislation. (Changing the billing glitch of 409).

H/M/H/H

2) Lack of integration of oral health into primary care

2a) Increase awareness and education among medical providers to increase the value of oral health as a part of general health. Examples: H/H/H/H 2b) Expand focus of school health

1) Make referrals to dental providers

2) Assist medical patients to establish a dental home

(As a state they are discussing replacing scoliosis screening

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programs to include BSS oral health screenings and prevention services that can be provided by school nurses H/H/H/H

with oral health screening).

3) Lack of value oral health – messaging/oral health literacy as evidence based

3a) Increase knowledge and broaden and leverage partnerships (revised) – culturally sensitive messages H/H/H/H 3b) Increase knowledge and information and broaden partnership on the value of oral health H/H/H/H 3c) New strategy: Increase broad based support from other organizations affiliated with children’s health (PTAs, PCP, head start, CMS) H/H/H/H

1) Identify effective messaging campaigns

2) Engage dental product corporations

4) Lack of providers due to low reimbursement; Lack of providers due to bureaucracy

5) Promote increased participation of dental providers in managed care programs to improve access to care

H/H/H/H

1) Support a common provider application for credentialing for managed care organization

2) Encourage AHCA to develop a customized participation program for Medicaid dentists (TX model)

3) Organize groups/stakeholders to create broad coalition support to increase utilization and therefore drive demand for increased reimbursement to providers

4) Encourage AHCA (or directly encourage managed care companies) to require managed care companies to decrease bureaucracy and increase percentage of claims that are reimbursed to providers via specific performance measures

Additional comments:

Donna Solovan-Gleason shared that there are consistent questions surfacing around the plan – is it a plan from the state? (See decisions above).

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She also suggested that the group change language and context around “billing” to reimbursement for all. (A decision was made to shift the language.

Encourage “push back” – asking- how is this really going to improve? Community Water Fluoridation Group Strategies Indicator: Percentage of population receiving fluoridated water One prioritized factor: Insufficient funds in state and local budgets to support fluoridation

Strategies Action Steps Partners

1) Maintain and secure funding for CWF (block grant decreased from 150,000 in 2008 to 35,000 this year)

H/H/H/M

1) OHF support continued funding via public testimony and LOS

2) Recruit OHF members – especially LC - onto advisory council

3) Increase OHF fluoridation action team participation

FDOH FDA FDHA UF Nova FL League of Cities FL Assoc. of Counties

2) Build and mobilize local coalitions to advocate for CWF (This has been very successful).

1) Increase # of members in OHF Fluoridation work group

2) Link FPHI’s coalition-building with fluoridation effort

3) Prioritize largest water systems not fluoridated

4) Show ROI for CWF 5) Advocate for statewide law – long

range planning

Water operators Dental Schools Dental Hygiene Schools Engineers

3) Reward best practice examples in CWF in state using ASTDD awards, OHF, FDOH awards by end of 2014

H/H/H/H

ASTDD CDC ADA FDOH OHF Local coalitions, City/county officials CHDs

OHF Decision-making and Next Steps Additional partners to engage

1. School nurses – Florida Association of School Nurses and Florida School Health Association; National Association of School Based Health Centers/Florida Coalition

2. Medical association 3. CMS 4. Migrant health 5. ARC 6. AARP 7. Area Agency on Aging 8. Developmental Disability council (APD) 9. Florida legal services 10. Community health workers 11. Day care centers 12. Florida Association of Education of Young Children 13. Media

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Individual Commitments to Action Who will do what? When will it be completed? What is my role? Community Water Fluoridation work group

Deadline Activity Person Responsible

December 2013 – January 8, 2014 Turn the Curve(TTC) sheets completed Conference call to discuss and review strategies and action steps

Sean Isaac, Fluoridation Action Team Chair/work group lead, schedule and lead conference call

January 8, 2014 Call with full Community Water Fluoridation work group Present to group information from series of conference calls – provide information to action team and solicit input

Sean Isaac

January 8, 2014 – February 1, 2014 Email additional strategies to fluoridation action team and solicit additional comments and input from team

Sean Isaac

February 13, 2014 Report final strategies and action steps to OHF Leadership Council

Sean Isaac

Improved Access to Quality Oral Health Care work group

Deadline Activity Person Responsible

January 31, 2014 Turn the Curve(TTC) sheets completed Tami Miller, Access to Oral Health Care work group lead

January 31, 2014

ER costs – TTC with small group Ann Papadelias schedule and lead

January 31, 2014 ER visits –TTC with small group Ann Papadelias schedule and lead

January 31, 2014 Sealants –TTC with small group

Kim Herremans and Dr. Elizabeth Orr schedule and lead

Week of February 3, 2014 Call with full Access to Quality Oral Health Care work group

Tami Miller schedule and lead

December 20, 2013 Cristy send one-hour TTC handout to leads

Cristy Hom

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TURN THE CURVE (A collation of all strategic planning sessions) Focus Area: Community Water Fluoridation

Indicator: Percentage of population on community water systems with fluoridated water One prioritized factor: Insufficient funds in state and local budgets to support fluoridation Story behind the baseline What positive factors have contributed to the baseline? 1) Team approach of stakeholders (FDA, FDHA, OHF, FDOH, UFCD, local coalitions) 2) State and local legislative policies: Surgeon General, 3) Local budgets for fluoridation systems (resources) 4) Advocacy/PR/media: Public hearings, articles, speakers, education materials

5) Research to offset anti-fluoridation (CDC, ADA) What negative factors have contributed to the baseline? 1) Anti-fluoridationists giving false information about fluoride chemical

Generates confusion/fear/doubt/lack of trust

Lack of information, common language and health literacy 2) Economics

Municipal budgets decree

Easy to cut fluoride budget

Optional service - not a high priority

Don’t understand ROI

Fluoridation Turn the Curve Report - Summary Current: No change – 77% Goal: Healthy People 2020 79.6%

Story behind the baseline:

Stakeholder team approach

Legislation

Resources

Advocacy – PR/media

Research to offset anti-fluoridation

Reasons for decrease in fluoridation trend:

Anti-fluoridationists

Economics – insufficient funds

Fluoridation partners:

Association of Counties

Consumers

Water operators

Local dental groups

Dental insurance companies

What works:

Increase information distribution

Advocacy and political involvement (support a fluoridation candidate)

Word of mouth, a no cost idea

State mandate, and “off the wall” idea

Focus on large water systems

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Community Water Fluoridation Group Strategies Strategies Action Steps Partners

Maintain and secure funding for CWF (block grant decreased from 150,000 in 2008 to 35,000 this year) H/H/H/M

OHF support continued funding via public testimony and LOS

Recruit OHF members – especially LC - onto advisory council

Increase OHF fluoridation action team participation

FDOH FDA FDHA UF Nova FL League of Cities FL Assoc. of Counties

Build and mobilize local coalitions to advocate for CWF (This has been very successful).

Increase # of members in OHF Fluoridation work group

Link FPHI’s coalition-building with fluoridation effort

Prioritize largest water systems not fluoridated

Show ROI for CWF

Advocate for statewide law – long range planning

Water operators Dental Schools Dental Hygiene Schools Engineers

Reward best practice examples in CWF in state using ASTDD awards, OHF, FDOH awards by end of 2014 H/H/H/H

ASTDD CDC ADA FDOH OHF Local coalitions, City/county officials CHDs

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TURN THE CURVE Focus Area: Improved Access to Quality Oral Health Care Indicator: Total number of Medicaid eligible children age birth – 20 who are receiving any dental service Current: 22% Story behind the baseline What positive factors have contributed to the baseline? 1) Access to care legislation – sealant program

More children receive sealants through funded, implemented programs

National publicity exists for programs. Florida’s bad publicity created embarrassment. 2) Fluoride-varnish program out of “traditional dental home” – health access settings

More people providing varnish increases workforce

Services reimbursed

Publicity for program

Advancements in research trends for service

Improved technology for procedure creates easier application process

Increased parental acceptance 3) Link between oral health and primary care

Better understanding of prevention; industry is behind it

Revenue generation

Research strongly supports link between mouth and body

National publicity increased use of spokespersons

4) CMS, prepaid dental has had a greater impact on preventive services. 5) Changes in the system - the move to managed care What negative factors have contributed to the baseline? 1) Lack of funding/reimbursement for oral health programs (Medicaid)

Legislature doesn’t place enough value on oral health

Lack of strong, unified advocacy voice/message due to competing and misaligned priorities* (*How to better align priorities/how to get legislature to support oral health priorities – messaging of data to legislature – how to best craft message – and who is best messenger? Patient? Provider?)

2). Negative image of dentists

Fear/pain leads to not accessing care

3). Parents do not value/buy into child’s oral health.

Lack of knowledge of importance of oral health; school-based programs don’t explain available programs to parents; cultural issues

Decreasing school programs and health education stems from a lack of regulation/mandate for routine dental screening prior to school enrollment

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4). Lack of providers available for population

Poor reimbursement for health access setting procedures/treatment and providers leads to underutilization of current workforce

Lack of preventive services due to underutilization of dental hygiene workforce

The number of dental providers per people is projected to decline because of lower reimbursement rates. (Story behind 2013 data will include managed care raising reimbursement for few months at the end of the year). AHCA will have 2013 data in April 2014.

Bureaucratic red tape exists for dentists.

Social stigma associated with being a Medicaid provider

5). Focus on acute care – prevention not valued 6). Dental is segregated from “health care”

Insurance is separate

New/additional children added should increase the numbers. (They are at 45% as their parents take them – higher value of dental).

Story behind the baseline: Prioritized factors

Lack of billing component to fully implement health access law

Lack of integration of oral health into primary care

Lack of value oral health – messaging/oral health literacy as evidence based

Lack of providers due to low reimbursement; Lack of providers due to bureaucracy Access to Care Partners

Agency for Health Care Administration (AHCA)

Florida Department of Health

Pediatricians – Florida Chapter of American Academy of Pediatrics

Community Catalyst

Florida Legal Services

Parents – PTAs

Human services organizations

Area Agencies on Aging

Managed care plans

Primary care professionals

School districts

Early childhood coalitions

Lobbyists

Florida Head Start State Collaboration Office

Social workers (NASW-FL)

Florida Association of Community Health Centers

Agency for Health Care Administration

Florida Chapter of the AAP

Florida Department of Education

Florida CHAIN

Office of the Governor

State Legislature

Legislative champs: Negron, Gaetz, Gardner, Hudson, D. Grimsley

Community Health Workers

Group dental practices

Insurance groups/managed care

Hospitals

Special Olympics Florida

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Improved Access to Quality Oral Health Care Prioritized Factors, Strategies and Action Steps Prioritized factors Strategies to address each factor Action Steps

Lack of billing component to fully implement health access law

Work with FDA to support upcoming legislation to fully implementation health access setting legislation. (Changing the billing glitch of 409).

H/M/H/H

Lack of integration of oral health into primary care

Increase awareness and education among medical providers to increase the value of oral health as a part of general health. Examples:

H/H/H/H

Expand focus of school health programs to include BSS oral health screenings and prevention services that can be provided by school nurses

H/H/H/H

Make referrals to dental providers

Assist medical patients to establish a dental home

(As a state they are discussing replacing scoliosis screening with oral health screening).

Lack of value oral health – messaging/oral health literacy as evidence based

Increase knowledge and broaden and leverage partnerships (revised) – culturally sensitive messages

H/H/H/H

Increase knowledge and information and broaden partnership on the value of oral health

H/H/H/H

New strategy: Increase broad based support from other organizations affiliated with children’s health(PTAs, PCP, head start, CMS)

H/H/H/H

Identify effective messaging campaigns

Engage dental product corporations

Lack of providers due to low reimbursement; Lack of providers due to bureaucracy

Promote increased participation of dental providers in managed care programs to improve access to care

H/H/H/H

Support a common provider application for credentialing for managed care organization

Encourage AHCA to develop a customized participation program for Medicaid dentists (TX model)

Organize groups/stakeholders to create broad coalition support to increase utilization and therefore drive demand for increased reimbursement to providers

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Encourage AHCA (or directly encourage managed care companies) to require managed care companies to decrease bureaucracy and increase percentage of claims that are reimbursed to providers via specific performance measures