Transcript From Vision and Outcomes to Action Plans

Community Dental Health
Coordinator (CDHC)
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Amid I. Ismail
Chair, American Dental Association
CDHC Curriculum Committee
Jane Grover
Director, Center for Family Health,
Jackson, MI
December 12, 2007
National Network for Oral Health Access (NNOHA)
San Diego, CA
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Outline
• Definition of the CDHC?
• Frameworks for increasing access and reducing
oral health disparities
• Current status of the CDHC project
• Perspective of a FQHC dental director
• Outcomes and evaluation
Definition of the CDHC
Community health worker (CHWs) with
DENTAL SKILLS
CDHC
CHW
Dental Skills
Definition of Community
Health Workers
• CHWs are community members who are
– Trained to promote health, provide
leadership, peer education, and
resources to support community
empowerment.
– Trained to integrate information about
health and the health care system into
the community’s culture, language, and
value system, thus reducing many of the
barriers to health services.
CHWs Functions of the CDHC
– Coordinate and navigate dental care
– Advocate for individuals
– Motivate and assist people to
prevent dental and oral diseases
– Educate community groups and
individuals
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CHWs Functions of the CDHC
– Assist community members to enroll
in Medicaid or other programs
– Assist in reducing dental anxiety
and fatalism
– Provide social support and selfefficacy
– Advocate for oral health
– Advocate for the CHCs
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Dental Skills of the CDHC
– Screen for dental emergency and need for
urgent care
– Take of digital radiographs
– Use an interactive online database to
share information with the supervising
dentist
– Triage care based on disease and risk
status
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Dental Skills of the CDHC
• Per the instructions of the supervising
dentist, provide the following preventive
procedures
• Oral hygiene assessment and
education
• Gross scaling
• Temporary GIC restorations
• Topical fluorides
• Sealants
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Supervision of the CDHC
• The CDHC will be a salaried employee
of a community health center
• They may also be hired by dental
providers who serve low-income or
rural communities
• Geographic zones of practice will be
determined state-by-state based on
dental workforce shortages and
disease levels
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Frameworks
The CDHC model is based on extensive
experience with CHWs and expanded function
dental auxiliaries
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Effectiveness: CHWs
– Improved outcomes for
• prenatal care,
• cancer screening,
• child sick visits,
• immunizations for children,
• chronic illness care,
• maternal health,
• STD testing,
• smoking cessation, and
• mental health and outreach services.
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Effectiveness of CHWs
– Promoted weight loss and breastfeeding
among African Americans
– Reduced drug use
– Increased condom use among homeless
women,
– Increased physical activity among AfricanAmerican women with type II diabetes
– Reduced missed appointments
– Increased follow-up care.
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What about capacity?
• Triage patients based on their dental needs
• Prevention in the community
• Follow-up preventive and motivational interventions
– Reduce missed appointments
– Increase utilization
• Increase revenues for the FQHC
– Hire staff
• Community health worker functions may become
reimbursable in the near future
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Net Balance
To cover all cost in year one, the CDHC (HS
graduate) must recruit around 550 patients or 2
patients per work day.
Trainees
• DHs may be trained and certified as
CDHCs
• DAs may be trained and certified as CDHCs
• High school graduates will enroll in a 12month program
• All trainees must work as interns at a FQHC
or CHC for 6 months
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States Sending a Letter of Interest
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Site Selected For
Demonstration Projects
• Michigan
– Site director Amid Ismail, University of Michigan
– Urban site in FQHCs
• Oklahoma
– Site director Dunn Cumby, University of Oklahoma
– Rural site which may include some Native American clinics
• Native American Locations
– Site directors Nancy Reifel and Donna Kotyk, UCLA
– Using multiple sites (MT, SD, MN, and other states)
• ADA House of Delegates allocated $2 Million to cover
the cost of the demonstration projects with local
funding sources.
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Curriculum
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First draft to be completed this December
14 Modules
First 6 focus on CHW certification
7 on dental skills (screening, radiographs,
prevention of caries, periodontal disease, oral
cancer)
• 1 internship
• Unique modules: motivational interviewing;
detailed oral hygiene assessment using the
Nexo Method; oral cancer screening; tobacco
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We will not drill our way out of the
dental caries problem
We will not seal our way out of the
dental caries problem
We will not scale our way out of the
periodontal disease problem
We will not biopsy our way out of the
oral cancer problem
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Moving Forward Requires New
Models that Promote Communitybased and Individual-focused
Changes in Social, Organizational,
and Behavioral Determinants
Integrated Dental Care and Oral
Health Promotion Model
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FQHC dental director
Dr. Jane Grover
• The CDHC is at the door
– What can they do?
– Sites
– Equipment
– Supervision
– Training of clinical and other FQHC staff
– Benefits to my clinic
– Costs and risks
– Outcomes
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Population: 140,267 (2000)
Race: 88.7 Whites, 7.9
Blacks
0-19 years: 45,000
Medicaid: 14.0% (2000)
Medicaid: 16.2% (2006)
Dentists: 77 (2000)
Dental Hygienists: 117
(2000)
Preventive visits: 48.5%
FQHC: 1 (3 sites)
Dentists: 3.5 FTE
DHs: 4
DA: 7
Patients/year: 8,500
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Dental Skills
CDHC
– Screen for emergency dental needs using
questionnaires and visual inspections
– Immediate scheduling
• We will see them when we find them
– Screen for signs of caries, periodontal disease, and oral
cancer
– Take radiographs
• Enter all data in the CDHC database
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Triage patients based on urgency
Assess and improve oral hygiene practices
Map location of plaque in stagnation areas
Write oral hygiene goals card
Demonstrate how to remove plaque from stagnation 25
areas
Dental Skills
CDHC
– Apply topical fluorides
– Place sealants
– Temporize cavities to remove foci of
infection prior to application of fluorides
and sealants
– Risk-based preventive recall
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CDHC
CHW skills
• What can they do?
– Navigate dental care and referral
– Dental anxiety
– Oral health literacy
– Nutritional literacy
– Personal preventive plans
– Pregnant women
– Infant oral health
– Education of caregivers (parents)
– Oral cancer patients
– Tobacco cessation
– Coordination with medical providers
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Coordination of Dental Care
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Missed appointments
First contact in the community
Group education
Advocate on behalf of community
members
• Advocate on my behalf with
community members
• Follow-up with patients who need
referral or follow-up care
• Potential assignment sites
– Schools
– WIC/Head Start
– Neighborhoods
– Nursing homes
– Waiting rooms of medical clinics
– Emergency rooms in hospitals
– Triage the waiting list for dental care
Equipment
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Portable dental chair and light
Sealant unit (compressor, electric handpiece, air syringe, saliva ejector, high
speed suction)
Nomad
PC with wireless card
Cell phone
Instruments
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Mirror
PSR probe
Cotton pliers
Intra-oral light
Temporary restoration kits
Sundries
Autoclave (Statim)
Car (personal or FQHC owned)
Insurance
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Remote Supervision
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Training of staff who work with
CDHC
• Front desk staff who can schedule appropriately
• Dental hygienists: Coordination between hygienists
and the CDHCs to prioritize schedules based upon
needs of patients
• Dentists who will review screening records and
questionnaires recorded by the CDHC to triage care
and develop a management plan for the CDHC
• Other FQHC providers who will benefit from working
with the CDHCs (prenatal care, pre-term, diabetes,
smokers)
• Community outreach coordinators at the FQHC
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Potential Benefits
• Integrated dental care model
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Risk-based preventive care at home or community
Increased productivity
Advocate for FQHC services in the community
Disseminate accurate information regarding
locations, staff and hours of operation
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Risks
• Remote supervision
• Quality of care
• Capacity to meet increased demand
for dental care
• Turnover and cost of re-training
• Uncompensated care
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Outcomes
• Access to dental care
• Efficiency of operations (increase quantity
and quality)
• Reduction of severe disease
• Prevention of early disease
• Patient satisfaction and quality of life
• Networks with community and professional
organizations
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To move forward
Oral health Promotion, Prevention, within
an Integrated Dental Care Model
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Three demonstration projects in
2008-09
Focus on
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Integrated care
Oral health promotion
Disease prevention
Social and behavioral determinants
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