Thank you to Dr. Sheila Semler, Michigan Oral Health Program Director, who provided much of the context for this presentation
Community water fluoridation: Only Michigan and GA and AL meet the HP2010 Objectives for community water fluoridation. CDC considers community water fluoridation as one of the top ten greatest achievements in public health of the 20 th century. Two studies conducted by CDC examined the cost-effectiveness of community water fluoridation and the wide benefit of fluoridated water in states that are highly fluoridated to those people living in nonfluoridated communities. Together, the studies continue to show that widespread community water fluoridation prevents cavities and saves money, both for families and the health care system Produced in conjunction with the release of Oral Health in America: A Report of the Surgeon General (May 2000), this fact sheet describes community water fluoridation as an effective, safe, and inexpensive way to prevent tooth decay. This method of fluoride delivery benefits Americans of all ages and socioeconomic status. Most water supplies contain trace amounts of fluoride. Water systems are considered naturally fluoridated when the natural level of fluoride is greater than 0.7 parts per million (ppm). When a water system adjusts the level of fluoride to 0.7–1.2 ppm it is referred to as community water fluoridation. In 1945, Grand Rapids, Michigan, adjusted the fluoride content of their water supply to 1 ppm and became the first city to implement community water fluoridation. Today, approximately 67.3 percent of the U.S. population on public water supplies has access to fluoridated water.
Hispanic National Health and Nutrition Examination Survey Dentistry in Mexico is much different than the U.S. Cultural differences and the regard for dental health are much different.
Anecdotal evidence supplied over nearly four decades by a legion of health care providers and analysts, point to a series of problems which combine to exclude migrant workers from dental and health care. Some of the programs are present among many low-income populations excluded from Medicaid, but what is stiking is how migratory farmwork serves to elevate and intensify their effect, while adding other attributable barriers created by legal status and frequent changes in state residence. In short, classic Medicaid eligibility and enrollment barriers appear to combine with particular force in the case of migrant and seasonal farmworkers. Financial Eligibility Barriers: States have considerable discretion in how they define and count income and resources. Use of monthly budgeting rules and restrictive asset tests are financial eligibility rules that tend to penalize itinerant and fluctuating work income (relatively high in relation to Medicaid eligibility rules one month, and then extremely low in the next month) and that fail to recognize work implements (I.e. tools, a truck) as a permissible asset. Application and enrollment barriers: Inaccessible site locations, long application forms, extensive verification requirements, and limited to no language assistance. Residency barriers: Medicaid is a state based program; state residency requirements, coupled with the problems describe above can lead to nearly insurmountable Medicaid access problems for farmworkers.
An understanding of the of the essential circumstances created by the culture of agricultural labor is critical. For example, the recommended practice to prevent baby bottle tooth decay is to give the baby only water in the bottle, or preferably, to wean the child from the bottle completely. It is often assumed by practitioners that parents fully understand the benefit to the long-term health of the child will offset the days or weeks of crying of an angry baby not willing to give up the bottle. It is important here to have an understanding that practical necessity and cultural expectations may make it either impractical or undesirable for families to comply with the advice of the health care practitioner. Example: Texas – extended family.
Utilization use in one study demonstrated 51% of those surveyed had not sought oral health care in the previous year, citing absence of pain and discomfort as the primary reason. 41% reported seeking oral health care on a yearly basis, while 42% only sought care when in pain. Of this population: 50% reporting bleeding gums; swollen or tender gingiva by 37%, and tooth loss by 49%.
Produced by Migrant Health Promotion
209 full time, part time, seasonal, and mobile sites This slide only shows the “permanent sites.”
Telamon Corporation. Head Start requires that every child have a dental exam with 60 days of intake, a requirement very hard for many Head Start Centers to achieve. Migrant and Seasonal Farmworker (MSFW)
Organized dentistry’s unwillingness to allow dental hygienists the professional freedom to treat patients when, where and how it is needed contributes significantly to the access crises. PA 161 ( Explain and state it is not working) (need dentist supervision, can’t directly bill Medicaid, few DDS take Medicaid, DDS do not want the liability , Similar issue to those faced by nursing; Public Health Certificate Model, CDHT (ADA model for community dental health therapist) Medicaid reimbursement does not cover the costs associated with either program. Varnish reimbursement: NV $50, WI $19-24, MI $9. For preventive programs to have sustainability they must be funded at adequate levels. Varnish- Delta Dental $250,000
Health Profession Shortage Areas MI dental licensing survey of 2006 demonstrates that MI will loose over 50% of the dentist work force within 10 years due to retirement or moving out of state. Of those remaining near retirement age, it is expected that the days practicing will be significantly reduced. Preventing Dental Caries Through Community Programs Describes the reduction in tooth decay attributed to community water fluoridation and school-based dental sealant programs and provides examples of states that have implemented effective prevention strategies
Improving Oral Health Access Migrant and Seasonal Workers
Cover page Improving Oral Health Access for migrant farmworkers Michigan Primary Care Association July 29, 2008 The mission of the Michigan Primary Care Association is to promote, support, and develop comprehensive, accessible, and affordable quality community-based primary care services to everyone in Michigan.
<ul><li>Since the early 1970s, the cases of dental caries in permanent teeth have declined dramatically among school-aged children. (CDC, 2000) </li></ul><ul><li>This decline is the result of various preventive regimens such as community water fluoridation and increased use of toothpastes and rinses that contain fluoride. </li></ul><ul><li>Dental caries, however, remains a significant problem in some populations, particularly certain racial and ethnic groups and poor children. </li></ul>
31 42 32 41 19 9 30 17 Migration Pattern and State Fluoridation Ranks
Migrant Oral Health <ul><li>Dental disease ranks as one of the top 5 health problems for farmworkers aged 5 - 29 and among the top 20 health problems for farmworkers of other ages. </li></ul><ul><li>For children ages 10-19, dental disease is their chief complaint. </li></ul><ul><li>Only about 50% of Caucasian children, 39% of African American children, and 32% of Mexican American children have dental insurance. </li></ul><ul><ul><ul><ul><ul><li>Source: National Center for Farmworker Health, Inc. </li></ul></ul></ul></ul></ul>
<ul><li>In the 2005/2006 Count Your Smiles Screening , completed by the MDCH, parents of children who had not had a dental visit within the last 12 months were asked why they were unable to get care. Of the parents surveyed, 50.7% reported lack of insurance, 36.3% reported they couldn’t afford it, and 13.7% reported that they couldn’t find a dentist willing to take their insurance . (MDCH, June 2005) </li></ul>
Barriers to Care <ul><li>A NHANES (Hispanic National Health and Nutrition Examination Survey) listed the barriers to care for migrant families as: </li></ul><ul><ul><li>Cost. </li></ul></ul><ul><ul><li>Time factors. </li></ul></ul><ul><ul><li>Perceptions that diagnosis and treatment would be ineffective. </li></ul></ul>
Barriers to Care <ul><li>Categorical eligibility for certain groups of low-income people, in particular, childless working-age adults without disabilities. </li></ul><ul><li>Financial eligibility barriers. </li></ul><ul><li>Legal status requirements. </li></ul><ul><li>Application and enrollment barriers. </li></ul><ul><li>Barriers related to lack of state (and county) residency. </li></ul>
Barriers to Care <ul><li>Access along is not enough, health care provider must be able to understand the farmworker’s language, as well as the cultural assumptions and practical circumstances that influence their worldview and the actions they choose to take. </li></ul>
Barriers to Care <ul><li>A study at a Southern Illinois Migrant Health Center revealed the following barriers to oral health care: </li></ul><ul><li>limited clinic hours (57%) </li></ul><ul><li>high fees (33%) </li></ul><ul><li>lack of transportation (17%) </li></ul><ul><li>Source: Oral health issues among migrant farmworkers, Department of Health Care Professions, College of Applied Sciences and Arts, Southern Illinois University, Carbondale, Illinois, USA. </li></ul>
Migrant and Seasonal Farm workers <ul><li>Michigan has 5 organizations designated as Migrant Health Centers (MHC). </li></ul><ul><li>A total of 20,550 MSFW were seen in centers in 2006 </li></ul><ul><ul><li>23% of MSFW in the State </li></ul></ul><ul><li>15,809 were in MHC </li></ul><ul><li>4,741 were in Community Health Centers </li></ul>
Role of Health Centers <ul><li>Since 1962, federally-funded Migrant Health and Community Centers have served farmworkers. However, only 15 to 20 percent of farmworkers utilize these services. </li></ul><ul><li>Follow-up and continuity of care present additional challenges; many farmworkers relocate several times each year and do not maintain permanent addresses or phone numbers. </li></ul><ul><li>Source: Migrant Health Promotion </li></ul>
<ul><ul><ul><ul><ul><li>According to 2004 MDCH dental licensing information, Michigan has 6,366 licensed dentists for an overall population to dentist ratio of 1561 to 1. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>The overall population to dentists ratio is based on dentists licensed to practice in Michigan and is not adjusted for those who are not currently practicing in the state or who are working part time. </li></ul></ul></ul></ul></ul>Oral Health Workforce
<ul><li>There is a shortage of providers willing to serve low-income populations. According to the Michigan Department of Community health, 8% of Michigan counties (7 out of 83 counties) have zero enrolled Medicaid dentists (MDCH CDC, 2004). </li></ul><ul><li>43% (36 out of 83) of the counties have only one enrolled Medicaid dentist with paid claims above $10,000 per year. </li></ul><ul><li>Sixty-five out of 83 counties were designated in 2005 as a full or partial county Dental Health Professional Shortage Area (HPSA) for low income and Medicaid populations . </li></ul>Oral Health Workforce
Role of Community Health Workers <ul><li>Outreach and enrollment </li></ul><ul><li>Navigation </li></ul><ul><li>Member of care delivery team </li></ul><ul><li>Screening and health education </li></ul><ul><li>Cultural and social understanding </li></ul>
University of Michigan - 2008 <ul><li>Partnership with NWMHS </li></ul><ul><li>Annual program – June 30-July 25. </li></ul><ul><li>16 Dental students provide free services. </li></ul><ul><li>Services to be provided to migrant workers and families at the Suttons Bay Elementary School </li></ul><ul><li>Portable equipment. </li></ul><ul><li>In 2007 – 320 children and adults received services ranging from screenings to x-rays, extractions and fillings. </li></ul>
What More Can Be Done? <ul><li>New models of care </li></ul><ul><ul><li>Allow dental hygienists to deliver preventive oral health care </li></ul></ul><ul><ul><li>PA 161, CDHC, PH Certificate, ADHA Model </li></ul></ul><ul><li>Increase Medicaid funding for preventive services and restorative services </li></ul><ul><ul><li>School-based/school-linked dental sealant program </li></ul></ul><ul><ul><li>Fluoride varnish program for Early Head Start and Head Start </li></ul></ul>
What More Can Be Done? <ul><li>Encourage screening and application of fluoride varnish by non-dental professionals. </li></ul><ul><li>Fee reimbursement for preventive services provided by non-dental professionals. </li></ul><ul><li>Encourage local dental hygiene and dental schools to increase outreach dental programs. </li></ul><ul><li>Expand innovative public-private relationships that may involve private practitioners collaborating with FQHCs, local health departments and academic centers. </li></ul>
What More Can Be Done? <ul><li>Legislation. </li></ul><ul><ul><li>Dental care delivery models.-(current CDHC Legislation pending) </li></ul></ul><ul><li>Recruit dentists. </li></ul><ul><ul><li>Michigan State Loan Repayment Program. </li></ul></ul><ul><ul><li>HPSA designation. </li></ul></ul><ul><li>Fund Oral Health Program to allow for Migrant dental programs and organization of existing programs. </li></ul><ul><ul><li>Prevent dental caries through community programs (i.e. sealants and varnish). </li></ul></ul>
For More Information <ul><li>Dr . Sheila Semler, Oral Health Director </li></ul><ul><ul><li>517-335-8388 </li></ul></ul><ul><ul><li>[email_address] </li></ul></ul><ul><ul><li>Rebecca Cienki, Michigan Primary Care Association </li></ul></ul><ul><ul><li>(517) 381-8000 ext 223 </li></ul></ul><ul><ul><li>[email_address] </li></ul></ul><ul><li>Michigan Oral Health Coalition </li></ul><ul><ul><li>http://www.mohc.org </li></ul></ul>