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Taking a Bite Out of Dental Caries - Integrating Cavity Prevention with WIC Nutrition Services

Taking a Bite Out of Dental Caries - Integrating Cavity Prevention with WIC Nutrition Services

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  • Our presentation has two main goals. First, we will outline the statewide Cavity Free at Three (CF3) grant and clinical model . Next, we’ll show how public health nurses at Jefferson County Public Health (JCPH) designed and implemented our service delivery model
  • What is Cavity Free at Three? A coalition engaged in a t hree-year statewide effort to prevent oral disease in young children. It does so by involving multiple disciplines in prevention and early detection. Engages dentists, physicians, nurses, dental hygienists, public health practitioners and early childhood educators in the prevention and early detection of oral disease in pregnant women, infants, and toddlers And teaches a new clinical model to screen, educate, and apply fluoride varnish in medical and public health settings. Ex rural peds
  • Why invest in preventing dental caries in the young? Dental caries is the most common chronic childhood disease; --5 times as common as asthma; --7 times as common as hay fever. Eighty percent of the disease is in twenty percent of the population. --It is largely a disease of poverty. Poor children have nearly 12x more restricted activity days because of dental related illness than fo children from higher income families. And most significantly, dental disease causes pain, and affects children's ability to eat properly, grow, attend school and learn. Most common childhood disease
  • Many partners came together to create this new clinical model with a goal of having Colorado children cavity free at three. These organizations created grant funding opportunities for local public health and other agencies.
  • The on-site education provided an onsite eight hour training for our public health nurses (PHN), WIC managers, and community dental hygienists.
  • Once we had received the grant money and training we were a little stymied as to how to effectively and efficiently deliver this clinical model to the target population. Used the nursing process was used to assist us with developing a service delivery model for an oral health promotion and screenings program.
  • Quantify target population members in existing programs NFP (130) Maternal-Child Programs (80) Immunization Program (1,000) WIC Program (8,000) Percentage of Medicaid/CHP+ children belonging to a dental home Human and material resources available to implement program In order to maximize our limited implementation resources, we had to find the best program for service integration. We found that working with WIC program clients would offer the most bang for the buck. The majority of its 8,000 clients are in our target population. All are low income, encounter barriers to accessing dental care, and regularly attend WIC appointments to meet family nutrition needs. Child Health Plan Plus ( CHP+ ) is low-cost health insurance for Colorado's uninsured children and pregnant women. CHP+ is public health insurance for children and pregnant women who earn too much to qualify for Medicaid, but cannot afford private health insurance
  • During the program phase A literature search was conducted to find evidence-based service delivery programs that would work for our organization and clients. We found no program directly prescribing how to deliver CF3 services in county health department settings because the CF3 clinical model is new and county health departments traditionally do not address caries prevention without a dental program and its associated costs Informative patterns did arise, however, in the use of registered dental hygienists as prevention service providers for clients in a variety of county-based programs. In fall 2008 when this program was being designed, the Texas Head Start program’s use of RDHs to provide preventive oral hygiene services was being widely reviewed. They hired the RDHs on staff, but this prompted our exploration of recruiting independent RDHs to deliver services and bill Medicaid/CHP+.
  • Now that we knew where to deliver services, we had to decide who would be best to deliver those services. we felt that compensated providers would be more easily retained than volunteers, yet we had no budget to pay them. So our best option for service providers was to contract with independent RDHs who we pay nothing, but would be compensated by billing Medicaid and CHP+ through their own practices. We would require that they would also see uninsured clients in exchange for paying no rent or supply fees. RDHs are ideal because they are the public health arm of dentistry, and have specialized oral health knowledge. Independent business owners are preferred because they have the skills and knowledge to act with minimal supervision and no support staff, and in Colorado, can bill Medicaid and CHP+ through their own business. Finally, we chose Medicaid and CHP+ Providers because they desire to work with the target population and can be compensated using existing public insurance resources .
  • Before our chosen service providers could begin delivering CF3 services to WIC clients, we had to develop a non-fiscal contract with them. Highlights of the contract include: READ SLIDE Currently have three RDH”S and working on adding another.
  • The CF3 clinical model focuses on caries prevention. However, we needed to be prepared to find problems requiring treatment beyond our scope. So we developed a local referral network by: (read slide) Also linking the uninsured children into HCA, to apply for insurance.
  • Timely and appropriate referrals are provided using the following case management guidelines: **READ SLIDE** So far, the program coordinator has managed six cases needing urgent treatment which ultimately resulted in full mouth restorations or pulling of all primary teeth. These clients and their families had significant socioeconomic challenges including being homeless and genocide survivors. In addressing their more immediate needs of finding food and shelter, the child’s oral health was not a priority. WICs partnership at CF3 allows us to catch and find treatment for these rare but extreme cases.
  • Think about evaluation from the beginning Our CF3 grant provided us with an oral health screening form to be completed for every client encounter. Our donors were sent copies at the end of our one-year grant cycle. We also recorded each encounter in our electronic medical record. This record included client ID, date of encounter, service provider, risk assessment score, and whether the encounter was initial or repeat. Case study files are also kept to ensure that urgent cases are properly followed. Show Screening Form
  • Ongoing evaluation includes a collection of informal tools and meetings developed and used as needed. Periodic meetings with stakeholders identify problems and allow for trouble shooting. Monitoring provider incentives allows us to encourage provider retention by identifying problems early on. Each provider has her own set of needs to make working with us feasible.
  • Jefferson County Head start-400 Lakewood Head Start -138
  • Also need to think about sustainability The key to sustaining our program amidst financial constraints is, not surprisingly, maintaining a negligible cost to JCPH Currently, we have exhausted our kits and education hand outs supplied by the grant, and have begun spending approximately $1,600 per year on supplies for an anticipated 800 screenings. Average Cost per Child for services and Supplies, 2009 2009 Total Supply Costs$2,716PHN program time (Salary and benefits) $14,081Indirect costs$9,271Total estimated costs$26,067Total number of children screened1,316Average cost per child$19.81 As mentioned earlier, we need to maximize incentives and minimize costs for service providers to ensure their long term participation. Allowing rent free exam space, easy access to our clients, and providing supplies is currently sufficient to reward their seeing so many clients pro bono. And finally, we minimized supply costs by assembling kits ourselves and going to several different vendors for lowest-cost supplies.
  • In summary, you can see that the essential public health function we employ is LINKING. We link clients with CF3 RDHs, community dental homes, and insurance providers. Linking is the method of choice when you have limited new resources and must maximize what you already have. The synergies we achieved through linking include: Connecting our insured and uninsured clients with dental hygienists and dental homes to prevent dental caries And by connecting Medicaid and CHP+ children with providers before caries develop, Valuable public dollars are shifted towards less expensive preventive care In short, each stakeholder benefits from these links which require few resources to establish and maintain. As a spin off we have re-employed the nursing process to design a second service delivery model for HeadStart. Beginning October 1st, our dental hygienists will offer all 406 county head start children free CF3 screenings and fluoride varnish applications this school year. This program costs us nothing and the Head Start program will pay only $600.00 for supplies.
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Transcript

  • 1. Taking a Bite Out of Dental Caries Integrating Cavity Prevention with WIC Nutrition Services Presented by: Susan Moyer, RN, MSN, CNSPH Jefferson County Public Health Community Health Services September, 2010
  • 2. Presentation Goals
    • Outline the statewide Cavity Free at Three (CF3) grant and clinical model
    • Show how Jefferson County Public Health (JCPH) designed its service delivery model
  • 3.
    • Three-year statewide effort to prevent oral disease in young children
    • Engages multiple disciplines in prevention and early detection
    • Teaches a new clinical model to screen, educate, and apply fluoride varnish in medical and public health settings
    Program Catalyst: Cavity Free at Three What is Cavity Free at Three?
  • 4. Program Catalyst: Cavity Free at Three Why?
    • Dental caries is the most common chronic childhood disease
    • 80% of the disease is in 20% of the population
    • Dental disease causes pain and affects children's ability to eat properly, grow, attend school and learn
  • 5. Program Catalyst: Cavity Free at Three Who?
    • Technical Assistance Team: leading dentists, physicians and dental hygienists
    • Funding Agencies: Caring for Colorado Foundation, The Colorado Health Foundation, The Colorado Trust, Delta Dental of Colorado Foundation, Kaiser Permanente and Rose Community Foundation.
    • Implementing Agencies: Caring for Colorado Foundation (first year), then University of Colorado Denver School of Medicine, Department of Family Medicine and the University of Colorado Denver School of Dental Medicine
  • 6.
    • Three annual grant cycles occurring between Fall 2008 and 2011
    • JCPH Awarded CF3 grant in Fall 2008
    Program Catalyst: Cavity Free at Three When?
  • 7.
    • $10,000 awarded
    • On-site education/training on the infant oral health protocol
    • Infant oral care kits for the oral care exam
    • Provider and patient information and education tools
    • Evaluation of the implementation of the infant oral care model and
    • Technical assistance
      • Each grant is valued at $50,000
    Program Catalyst: Cavity Free at Three How?
  • 8. Cavity Free at Three Grantee: Designing a Service Delivery Model
    • Public Health Nurses used the nursing process to design the most efficient and effective service delivery model
      • Community Assessment
      • Community Oriented Nursing Diagnosis
      • Program Planning
      • Program Implementation
      • Evaluating the Program
      • Sustaining the Program
  • 9. Nursing Process Phase 1: Assessment Identify Communities
    • Target Population: WIC Program Pregnant women and children
      • Low income
      • Multiple barriers to accessing preventive care (time, cost, travel)
      • Regularly attend WIC appointments to meet family nutrition needs
  • 10. Nursing Process Phase 3: Program Design Evidence-Based Program Design
    • Research proven service delivery models
      • Texas Head Start uses RDHs to provide preventive oral hygiene services
  • 11. Nursing Process Phase 3: Program Design Ideal Service Providers
    • RDH: Registered Dental Hygienist
    • Independent: Owns dental hygiene business
    • Medicaid/CHP+ Providers
  • 12. Nursing Process Phase 3: Program Design Provider Non-Fiscal Contract
    • Adhere to CF3 clinical model
    • Must see all uninsured clients pro bono in exchange for paying no office rent or supply fees
    • Bill Medicaid/CHP+ for eligible clients as part of own independent practice
  • 13. Nursing Process Phase 3: Program Design Developing a Local Referral Network
    • Visit community providers on list generated during community assessment phase
    • Inform about CF3 Program
    • Ask to include on referral list
    • List Includes
      • Medicaid/CHP+ providers who also offer discounted services for the uninsured (both pediatric and adult)
  • 14. Nursing Process Phase 3: Program Design Case Management Guidelines
    • Encourage all clients to establish a dental home
    • Recommend that all clients obtain dental insurance when possible
    • Refer clients with non-urgent problems to providers on list
    • Refer clients with urgent problems to local provider immediately and program coordinator for case management
  • 15. Nursing Process Phase 5: Evaluation Measuring Impact
    • Oral health screening form completed for every client encounter
    • Basic data recorded in electronic medical record
    • Case Studies
  • 16. Nursing Process Phase 5: Evaluation Ongoing Evaluation
    • Periodic meetings with stakeholders
    • Monitor and maximize provider incentives
    • Capacity building activities as needed
  • 17. Tracking Screenings
    • Began screenings February of 2009
      • 1,521 screenings completed as of June 30, 2010
      • 87.5% High Caries Risk assessment
    • Additional Screenings
      • 500 with Head Start
  • 18. Nursing Process Phase 6: Sustaining Benefits Keys to Sustainability
    • Negligible cost to JCPH
    • Maximizing Incentives for Service Providers
    • Minimizing Costs of Participation for Service Providers
    • Minimizing Supply Costs
  • 19. Conclusion Linking for Synergy Healthcare Access JCPH CHS Staff CF3 Service Providers JCPH EPSDT Insurance Providers Local Dental Home JCPH WIC Staff Target Population Program Coordinator
  • 20.  
  • 21.  
  • 22. Contact Information
    • Susan Moyer RN MSN CNSPH
    • Public Health Nurse Supervisor
    • Jefferson County Public Health
    • Lakewood, Colorado
    • [email_address]
    • 303-239-7045
    • http://jeffco.us/health/
    • http://www.cavityfreeatthree.org/