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    Oral Health Collaborations in the United States, 2000-2008 ... Oral Health Collaborations in the United States, 2000-2008 ... Document Transcript

    • Oral Health Collaborations in the United States, 2000-2008 Elizabeth L. Rogers Director of Communications Oral Health America
    • The need to work in partnership to advance oral health is undeniable, in part because thedelivery and payment of most oral health care in the United States has historically been separatefrom general healthcare, but also because for those experiencing barriers to care, the reasons aremutli-faceted and complex. A collaborative approach has the best chance of bringing newopportunities to an oral health care delivery system that is designed primarily for those that havedental insurance or can pay out of pocket. Moreover, targeted oral health education and diseaseprevention services can play a key role in reducing oral disease. Reaching out to families thatare outside the traditional oral care setting requires connecting with new partners, a strategy theoral health community appears to be embracing as evidenced by the many promisingpartnerships that have come about in the past decade. Oral Health in America: A Report of the Surgeon General and the subsequent NationalCall to Action to Promote Oral Health (SGROH) provided a platform for multiple entities toshape programs, policies and communications in ways that engaged new partners. In OralHealth in America, then Surgeon General Dr. David Satcher highlighted the need for individuals,communities, health professions, business leaders, decision makers, and others to work togetherto improve oral health. 1 This approach informed the design of The Face of the Child: SurgeonGeneral’s Conference on Children and Oral Health, held immediately after the release of theSGROH. 2 Two years later, at regional meetings organized for public input into the developmentof A National Call to Action to Promote Oral Health, people expressed that they care about theiroral health, are able to articulate the problems they face, and can create solutions to resolvethem—often, as the Call to Action notes—through creative partnerships. 3 At Oral Health America (OHA), collaboration is both a choice and a necessity. OurSmiles Across America (SAA) program supports infrastructure development for school oralhealth care in eight regions of the country, and is funded by an array of foundations andbusinesses, including Ronald McDonald House Charities, Trident, Patterson Dental, 3M ESPE,Aetna Dental, Delta Dental of Minnesota, Northeast Delta Dental, Dr. Scholl Foundation,Stephen and Tabitha King Foundation, Simmons Foundation and others. SAA regional programpartners enable the provision of treatment and education in schools. They range from DirectRelief International and the Santa Barbara/Ventura County Dental Health Foundation inCalifornia, to United Way of the Greater Twin Cities and Children’s Dental Services inMinnesota, to the Chicago Department of Public Health and Chicago Public Schools, and KidsSmiles, Inc. in Philadelphia. Partnerships define our programs and bring them to life. In fact, collaborative efforts to improve oral health are happening almost everywhere inAmerica. The Maine Oral Health Funders, a group that includes public and private regionalfoundations, meet several times a year to ensure a strategic approach to grantmaking and recentlyhired a consultant to advance a collaborative oral health agenda. Leaders from the Maine OralHealth Funders participate in a National Oral Health Policy Group, which includes leaders fromthe Oral Health Foundation (MA), Washington Dental Service Foundation, and UnitedMethodist Health Ministry Fund (KS)—collaborative funding leaders from other regions of thecountry. Oral health information, science, communications strategies, and “best practices” areshared at numerous national meetings, and disseminated and utilized at the state and local level.The Internet has played an increasing role in linking individuals and programs and fosteringcommunication. Listservs exist for many oral health groups including a dental public healthlistserv, children’s oral health listserv, state and territorial dental directors listserv, and a state 2
    • oral health coalitions listserv, to name a few. The annual National Oral Health Conference, itselfa collaboration between the Association of State and Territorial Dental Directors (ASTDD) andAmerican Association of Public Health Dentistry (AAPHD) has steadily grown in size, from 400attendees in 2001 to 765 attendees in 2007. ASTDD’s Best Practices Project 4 promotes bestpractices for state, territorial and community oral health programs, including collaborativeprogramming and planning. Collaborations with communities and other institutions have been key to mounting newinitiatives in dental education. Drawing on models of community-based dental education,Arizona’s School of Dentistry and Oral Health welcomed its first class of students in 2003,emphasizing community-based clinical care in communities of need. At about the same time theRobert Wood Johnson Pipeline, Profession & Practice: Community-Based Dental Educationwas funded (augmented by dollars from the Kellogg Foundation and California Endowment),providing sixteen dental schools with funds to implement community-based training to enhancedental students’ experiences with underserved populations. Based on models originallydeveloped at the University of Colorado and Columbia University, these grantees were alsofunded to improve the pipeline of under-represented minorities into dental education, a factorassociated with improved access to care for communities in need. The University of Washington School of Dentistry launched its RIDE (RegionalInitiatives in Dental Education) program with a first class of students in 2008. Started initiallywith a planning grant from the American Dental Association Foundation, the program wassubsequently funded by the Washington State Legislature. The RIDE program combinesextensive community-based training in underserved and rural communities in easternWashington with interprofessional education with medical and dental hygiene students. TheRIDE program is a collaboration between the University of Washington Schools of Dentistry andMedicine, Washington State University and Eastern Washington University. New dental schoolsincluding one at East Carolina University and a dental school in preliminary exploring stages atthe University of New England will also require that students spend significant amounts of timein community clinic rotations. New York University College of Dentistry recently formed analliance with the College of Nursing with the intention of expanding access to care for needypopulations and increasing interprofessional experiences Most states now have some form of statewide oral health coalition that has been inexistence for one to five years, focusing on access, disparities in care, dental sealants, andcommunity water fluoridation. 5 At least twelve of these coalitions are funded and staffed. TheCenters for Disease Control and Prevention has supported the development of state oral healthcoalitions, in addition to providing funding and technical assistance to build strong state oralhealth programs. Success in advancing oral health, including through Medicaid reform in states such asMichigan, Tennessee, and Alabama, has not come without significant collaboration. TheSurgeon General’s report on oral health recognized that previous victories were built on theefforts of many, working together. The following examples underscore the importance of partnerships and collaboration inexpanding oral health care and oral health education to new populations. 3
    • CITIZEN’S WATCH FOR ORAL HEALTH AND ABCD Citizen’s Watch for Oral Health, 6 is an outgrowth of the Watch Your Mouth campaignwhich was initiated in Washington State after the release of the Surgeon General’s report. TheCitizens’ Watch campaign raises awareness of oral health issues affecting all age groups, and isfounded on the belief that in order to benefit large numbers of people with long-term sustainablesolutions, it is necessary to shape public policies that will change or create systems to improveoral health. Led by the Washington Dental Service (WDS) Foundation, Citizen’s Watch includes paidand earned media, a policy agenda, and a broad-based coalition to help create a constituency fororal health to build a supportive climate for policy proposals. The coalition’s partners includethe Association of Washington Business, Washington Roundtable, Washington State LaborCouncil, Washington State PTA, Office of Superintendent of Public Instruction, Head Stateprograms and the Washington State Head Start Association, School Nurse Association ofWashington, Washington Academy of Family Physicians, Washington State HospitalAssociation, and the Community Health Network of Washington, among many others. Since 2001, Citizen’s Watch has increased the profile of oral health as an importanthealth issue and shifted the public dialogue from recognizing a problem to identifying solutions.The campaign and associated advocacy efforts have achieved a number of policy successes.Those directly impacting children’s oral health are 1) expanded reimbursement to primary caremedical providers for delivering dental disease prevention services to young Medicaid-eligiblechildren, 2) the defeat of anti-fluoridation legislation, and 3) the expansion of the Access to Babyand Child Dentistry (ABCD) [2] program, which increases access to dental care for youngchildren in Washington state by providing dental services—both preventive and restorative—toMedicaid-enrolled children up through age five. The ABCD program is a collaborative success story, with the engagement of local dentalsocieties, public health agencies, Washington State Medicaid, University of Washington Schoolof Dentistry, WDS Foundation, and others. Since the inception of ABCD, Medicaid utilizationrates have increased substantially: children under age six receiving dental services increasedfrom 21.1 percent in 1997 to 36.8 percent in 2007. Thirty counties have implemented ABCDprograms across the state. Evaluation has shown that the ABCD program is a cost-effectivemodel for improving the oral health of young Medicaid-enrolled children.HEALTHY KIDS DENTAL PROGRAM The Delta Dental Plans Association (DDPA), Delta Dental member companies and theiremployees are involved in numerous programs to enrich and improve the communities theyserve. These programs provide oral health care to children, support community waterfluoridation, educate families, and prevent child abuse and neglect. One of many notable DeltaDental partnerships, Michigan’s Medicaid Healthy Kids Dental Program (HKD), a collaborationbetween the Michigan Department of Community Health, Michigan Dental Association, andDelta Dental of Michigan was been cited by Michigan Governor Jennifer Granholm as “one ofthe nation’s most effective public-private partnerships in delivering care to some of the state’smost vulnerable residents.” Eighty-seven percent of Michigan dentists participate in HKD,which serves Medicaid-eligible children under the age of 21. 4
    • ORAL HEALTH KANSAS With a mission to increase oral health through advocacy, public awareness, andeducation, Oral Health Kansas, Inc. (OHK) 7 represents a broad base of over 200 members withfrom around the state. Launched in 2003 by a group of interested stakeholders, OHK isdedicated to influencing policy changes that will improve the oral health status of all Kansans.The organization’s key efforts target policymakers at the local, state, and federal levels—and theconstituents who influence them. OHK’s programs include the “Dental Champions” leadership training program,developing state level leaders to advance a progressive oral health vision; a program to expandthe utilization of the new Extended Care Permit for dental hygienists; the Kansas CoordinatedSchool Oral Health guidelines; and proactive strategies to engage the media on oral healthissues. A grant to OHK from the Kansas Council on Developmental Disabilities enables theorganization to arrange training of dental professionals in treating populations withdevelopmental disabilities, and assist consumers in utilizing the Medicaid dental servicesavailable to them. OHK’s public policy agenda includes expansion of adult Medicaid dentalbenefits, increased Medicaid dental reimbursement rates, strategies to expand the Medicaiddental provider network as well as many other prevention and early intervention initiatives. “These programs are not only developed through a collaborative process, they also fostercollaboration in the field,” says Teresa Schwab, LMSW, Executive Director of Oral HealthKansas.FIRST SMILES California’s “First Smiles” education and training project funded by First 5 California,was co-implemented by the California Dental Association Foundation (CDAF) and the DentalHealth Foundation (DHF) in 2004-2008. The long-term goal of this workforce initiativeinvestment was to create greater access statewide to preventive oral health services for childrenaged 0-5, including children with disabilities and other special needs, by training more dental andprimary care professionals and staff from community agencies that typically serve families withhighest risk for oral disease. Multiple partnerships informed a scientific advisory council, including oral health expertsfrom public health, private practice and academia, represented by dentists, physicians (includingpediatricians), dental hygienists, and dental assistants. Partnerships also defined an oversightcommittee of the California First 5 County Commissions, California Diversity Council, First 5California Special Needs Project and the scientific advisory council, and major involvement bythe Alameda County Department of Public Health, Anderson Center for Dental Care, BarbaraAved and Associates, California Women, Infant and Children (WIC) Association, CaliforniaHead Start Association, California Dental Hygienists’ Association, Contra Costa Department ofPublic Health, Dental Assisting Association, Healthy Smiles for Children of Orange County,local dental societies, Molina Health Care, University of California at San Francisco School ofDentistry, University of the Pacific School of Dentistry, and University of Southern CaliforniaSchool of Dentistry. As of February 2008, a total of 15,230 (90 percent of the overall goal) of Californiadental and medical providers attended a First Smiles training, and 883 staff members fromcommunity service organizations received training in children’s oral health. In assessing change,dental and medical providers indicated the highest self-perceived increase in skill level in their 5
    • ability to communicate with parents and provide education and anticipatory guidance. Sixmonths after the training, 16 percent of a sample group of general dentists said they were seeingmore children aged 0-5 in their practices, and close to 80 percent reported having the capacity toaccommodate requests for appointments for this age group. According to Wynne Grossman, Executive Director of the Dental Health Foundation, theproject would not have been possible without multiple collaborations at the state and local level.In a state as large and diverse as California, the primary partnership between the DHF and CDAFwas a launch for outreach to local dental societies and California First 5s. The program used a“train-the-trainer” approach to expand the number of links to target groups. First Smiles led DHF to think differently about incorporating oral health into otherinitiatives such as nutrition, and the organization is now building on the relationship that theyestablished with the WIC Nutrition Program to integrate dental visits at WIC centers, usingproviders trained through the First Smiles program. DHF is also working with the CaliforniaAssociation of Pediatrics in exploring the next steps to ensuring that fluoride varnish is a corepediatric service. “A stand-alone approach to oral health care for young children just doesn’t make sense,”says Grossman.INTO THE MOUTHS OF BABES A number of organizations in North Carolina have been involved for almost a decade inaggressively and collaboratively trying to resolve high rates of tooth decay and barriers to oralhealth care for young children. North Carolina Medicaid’s Into the Mouths of Babes (IMB), 8which began as a successful pilot, and expanded state-wide in 2001, is the joint effort of theNorth Carolina Academy of Family Physicians, North Carolina Pediatric Society, North CarolinaDivision of Medical Assistance, Oral Health Section of the Division of Public Health, Universityof North Carolina School of Dentistry and University of North Carolina School of Public Health. Initial funding for IMB was provided by the Centers for Medicare and Medicaid Services,Health Resources and Services Administration, and the Centers for Disease Control andPrevention. The goals of the IMB program are to 1) increase access to preventive dental care forlow income children 0 to 3 years of age, 2) reduce the prevalence of early childhood caries(ECC) in low-income children, and 3) reduce the burden of treatment needs on a dental caresystem “stretched beyond its capacity to serve young children.” The program engages primarycare medical providers and physicians, nurses and other healthcare providers to increasescreening and risk assessments, preventive care (including fluoride varnish applications), andparent education. Providers participate in a Continuing Medical Education Program and to date, more than3,000 healthcare professionals have been trained. Extensive evaluation of IMB shows that theprogram has led to a substantial increase to the number of children receiving preventive dentalcare and the use of restorative services, and that by four years of age, the estimated cumulativereduction in the number of restorative treatments was 39% for anterior teeth. 9 In the thirdquarter of 2007 alone, the most recent quarter for which information is available, more than26,000 visits occurred in medical offices in which these oral health services were provided. 10“Diagnostic/preventive treatment, namely fluoride varnish application, in the medical setting,can lead to statistically significant caries reduction,” states Mark Casey DDS, MPH, DentalDirector, North Carolina Division of Medical Assistance. 6
    • FORSYTHKIDS ForsythKids in Boston is a school oral health program notable in its focus on outcomevariables and assessments to determine improvements in oral health. The program stands out asa collaborative program of the Forsyth Institute, which revolutionized the oral health professionin the mid 1900s with the discovery of the connections between dental decay and bacteria.Program partners include the Massachusetts Department of Public Health, local departments ofpublic health, elementary schools in Boston, Lynn and Hyannis, oral health coalitions, healthcenters, and state legislators. The program intends to expand partnerships with local dentists andthe Massachusetts Dental Society to provide more options for referrals and a continuum ofrestorative care. ForsythKids sends dentists and dental hygienists into schools to provide oral exams,treatment plans, oral health education, and preventive care including teeth cleanings, fluoridevarnish treatments and dental sealants. With a focus on optimal comprehensive preventive care,children are seen every six months. Forsyth has found that one round of prevention, measured atsix months, resulted in a significant reduction in new decay for both baby teeth and permanentteeth of 52% and 32% respectively. Children enrolled in the Forsyth program are virtually freeof new tooth decay. 11 The Forsyth Institute’s capacity for data analysis and evaluation, and theprogram’s ability to track improvements due to regular preventive care makes ForsythKids avaluable model for policymakers, oral health advocates, and decision makers seeking to addressoral disease.NATIONAL ORAL HEALTH POLICY CENTER The Childrens Dental Health Project (CDHP) in collaboration with the Association ofMaternal and Child Health Programs (AMCHP), Association of State and Territorial DentalDirectors (ASTDD), Medicaid/SCHIP Dental Association (MSDA), and National Academy forState Health Policy (NASHP), was awarded a three-year cooperative agreement on June 9, 2008,from the federal Maternal and Child Health Bureau, Department of Health and Human Servicesto launch a National Oral Health Policy Center. The new National Oral Health Policy Center at CDHP will work jointly with AMCHP,ASTDD, MSDA and NASHP to promote a better understanding of effective policy options toaddress disparities in children’s oral health. The Policy Center intends to publish policy trendreports; train policymakers on how to address oral health; and expand and diversity the audienceengaged in promoting children’s oral health.ENDING CARIES IN LA COUNTY The Annenberg Foundation is leading a bold collaborative effort to significantly reducecaries among children aged 0 to 18 in Los Angeles County. Recognizing that caries is easilypreventable, but occurring at epidemic proportions in the region, program officers at TheAnnenberg Foundation sought out key stakeholders to participate in developing a comprehensivestrategy to address oral disease, and change the behaviors of families and care providers. Thesestakeholder conversations, which included members of the Los Angeles County Children’s OralHealth Collaborative, highlighted the need for a better understanding of where oral disease ismost prevalent, and where services are being provided. The Collaborative decided to conduct a“cavity count,” including social and geographic determinants, and a “dentist count,” to determinewhere dentists are currently located and the services they provide. 7
    • The Annenberg Foundation was joined by Los Angeles County First 5, CaliforniaEndowment, Los Angeles Children’s Trust, Callifornia Wellness Foundation, Richard AtlasFoundation, and the James Collings Foundation in providing a grant to the University ofSouthern California (USC) as the clinical organization for the project, in partnership with theUniversity of California at Los Angeles (UCLA) School of Dentistry. Over 100 agencies andorganizations, including the Los Angeles County School District, Los Angeles County HealthDepartment, Head Start, public health clinics, and elected officials are participating in the 18-month study, which will tap preschools, WIC centers, Head Starts, and schools to assess the oralhealth status of children from three age groups up to 18 years of age. This unprecedented projectwill provide a baseline for future efforts to educate targeted populations and increase capacity forpreventive and restorative services.ALASKA DENTAL HEALTH AID THERAPIST PROGRAM The ability to obtain dental care is an ongoing challenge for more than 200 Nativevillages located in remote sections of Alaska. There have never been enough dentists, either asvisitors or residents, to fill the need for preventive and restorative services in rural Alaskancommunities. Recognizing the opportunities presented by a new model for care, the AlaskaNative Tribal Health Consortium (ANTHC) determined to incorporate Dental Health AidTherapists (DHATs) into the context of its healthcare delivery system, the Community HealthAide Program, authorized by a federal statute in which Tribes provide primary health carethroughout Alaska. Since 2004, ten DHATs have completed a 2-year training program and are serving 42villages. These new health team members are providing basic dental care, including routinetooth extractions and cavity fillings to thousands of individuals, primarily children. Dentistssupervise the therapists, both on-site, and through the rural Alaska telemedicine network. A2006 study of the program by the Baylor College of Dentistry found that the proceduresperformed by the DHATs were of equal quality to that of dentists. The first cohorts of DHATs were trained in New Zealand, which has utilized dentaltherapists since the 1920s. A new DHAT training program was launched in Anchorage in 2007through a partnership between the ANTHC and the University of Washington, with funding fromthe W.K. Kellogg Foundation, Rasmussen Foundation, Bethel Community Services Foundation,and M.J. Murdock Charitable Trust. Alaskan tribal organizations sponsor the DHAT students inAnchorage for the program, which requires a high school degree. Of 18 recent candidates for theprogram, seven were accepted. Program funders are collaborating on an extensive evaluation of the program.CHICAGO’S SCHOOL ORAL HEALTH PROGRAM The City of Chicago’s ambitious School Oral Health Program is the largest in thecountry, serving all children in Chicago Public Schools from pre-Kindergarten through eighthgrade. Directed and administered by the Chicago Department of Public Health (CDPH) througha strong working partnership with the Chicago Public Schools (CPS), the program allows forcontract dentists and staff to visit schools and provide preventive care (dental sealants, fluoridevarnish treatments, oral exams, and cleanings). CDPH provides oversight of the program, linksthe dentists to the schools, collects data, and serves as a referral mechanism for children whoneed further treatment. 8
    • In CPS, the majority of the 408,601 children are African American (46.5 percent) andLatino (39.1 percent). Over 84 percent of CPS students are from low-income families, and closeto 19 percent are limited-English-proficient. 1 Dentists working in CPS through contracts with CDPH are required to treat all childrenwho return a consent form, whether or not they have insurance. Launched as a pilot program in7 schools in 2000, the program expanded to 126 schools in 2004, with the support of a grantfrom the Michael Reese Health Trust to Oral Health America. These funds supported servicesto uninsured children, thereby increasing the likelihood that participating dentists would visitschools with low Medicaid rates. Funding to the program has continued, through Oral HealthAmerica grants from Ronald McDonald House Charities, Patterson Foundation, Dr. SchollFoundation, Eisenberg Foundation for Charities, and Trident. During the 2007-08 school year,the program served approximately 501 elementary schools, and provided oral disease preventionservices (including close to 225,00 dental sealants) to almost 61,000 children in 2007-08. Apreliminary review of records from 15 schools shows a 10 percent decrease in referrals forextended care. The school oral health program has received accolades from the Lieutenant Governor, theMayor’s office, CPS and CDPH leadership, school reform advocates, and prompted outreachwith the Illinois Maternal and Child Health Coalition to schools to increase “AllKid” enrollment.The presence of the program and the numbers of children who are receiving dental sealantsthrough the program are recognized as a significant outcome of the Illinois Oral Health Plan,developed by IFLOSS, the state’s oral health coalition.Conclusion A look at the many partnerships that have developed since the release of Oral Health inAmerica to improve children’s oral health is cause for celebration. Particularly exciting areefforts to increase the oral health skills, competence, and networks of those who are in regularcontact with families and children, so that oral disease can be identified and addressed. There isno turning back from here: despite national and state budget shortfalls, a remarkable amount ofwork is happening to ensure that oral health and oral health care are an expected part ofchildren’s services. With healthcare reform only a matter of time, partnerships will also ensurethat oral health is represented by multiple stakeholders as new legislation is crafted and signedinto law.ACKNOWLEDGEMENTS Oral Health America receives funding from sources listed in this document, includingRonald McDonald House Charities, Centers for Disease Control and Prevention, Aetna Dental,Patterson Dental, Trident, Northeast Delta Dental, Delta Dental of Minnesota, Dr. SchollFoundation, 3M ESPE, Simmons Foundation, Stephen and Tabitha King Foundation, andPhillips Sonicare.1 http://www.cps.k12.il.us/AtAGlance.html 9
    • REFERENCES1 U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General.Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and CraniofacialResearch, National Institutes of Health, 2000.2 http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/Conference/ConferenceChildrenOralHealth/3 U.S. Department of Health and Human Services. A National Call to Action to Promote Oral Health. Rockville,MD: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control andPrevention and the National Institutes of Health, National Institute of Dental and Craniofacial Research. NIHPublication No. 03-5303, May 2003.4 The purpose of the Best Practices Project. http://www.astdd.org/index.php?template=bestpractices.html. AccessedJune 19, 2008.5 Oral Health America. Report on the findings from the Year 3 Coalition Survey. Cooperative Agreement #04135with the Centers for Disease Control and Prevention. November 2007.6 The website of Citizen’s Watch. http://www.kidsoralhealth.org/index.html. Accessed June 19, 2008.7 The website of Oral Health Kansas. http://www.oralhealthkansas.org. Accessed June 19, 2008.8 An overview of Into the Mouths of Babes.http://www.communityhealth.dhhs.state.nc.us/dental/Into_the_Mouths_of_Babes.htm. Accessed June 19, 2008.9 Rozier G, Stearns S, Pahel B, Quinonez R. Research Brief: Evaluation of Into the Mouths of Babes Program.School of Public Health, Department of Health Policy and Administration, The University of North Carolina atChapel Hill. June 2007.10 Communication with Mark Casey, DDS, MPH, Dental Director, North Carolina Division of Medical Assistance.11 ForsythKids Analysis, The Forsyth Institute. http://www.forsyth.org/kids/analysis.html. Accessed June 17, 2008. 10