Taking a Bite out of Dental Caries_BOH Presentation

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JCPH Cavity Free at Three presentation

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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 our service delivery model using the nursing process.
  • What is Cavity Free at Three?
    A coalition engaged in a three-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.
    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.
  • Dr. Johnson strongly suggested we write a grant, so Amy Guccione did.
  • The on-site education included
    Linda Reiner, Dr. Dennis Lewis, and Diane Brunson from the CF3 technical assistance team, 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.
    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.
  • 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 for prevention which reduces costs for Medicaid and CHP+
  • 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
    In January of this year, we signed contracts with three independent registered dental hygienists who had attended the November CF3 training; Havens Guenthner, Debbie McMahon, and Cora Sexton Wheeler.
  • 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)
  • Timely and appropriate referrals are provided using the following case management guidelines:
    **READ SLIDE**
    So far, the program coordinator has managed four 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.
  • 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.
    Maximizing their incentives and minimizing their costs to participate became a priority when we discovered that their billable rates turned out to be much less than anticipated. They were only being reimbursed for approximately 40% of clients and many of those were partial reimbursements. This has not deterred participation, however, as we are still working with all three dental hygienists and expect to continue the relationship into next year with a renewed contract.
    Finally, capacity building activities regarding changes in billing law and re-orienting WIC staff are conducted as needed.
  • We also track the number of screenings performed each month as an indication of the program’s success.
    As you can see….
  • 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 $3,000-$5,000 per year on supplies for an anticipated 2,000 screenings.
    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.
    The RDHs and CF3 technical advisor Diane Brunson determined that it would be best to buy less expensive toothbrushes,
    replace the disposable mouth mirrors with autoclavable ones to be reused,
    and purchase xtra application brushes to allow using one adult dose for two children.
    This last savings allowed us to upgrade to a non-staining, better tasting and more easily spread fluoride varnish which has been a hit with everyone. Mellon is our clients’ flavor of choice, just so you know 
  • 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.
  • Taking a Bite out of Dental Caries_BOH Presentation

    1. 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 December, 2009
    2. 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. 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. 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. 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. 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. 7. • Each grant is valued at $50,000 and includes: – On-site education on the infant oral health protocol – Help in developing systems for infant oral care – Provider and patient information and education – Provider infant oral care kits for the infant oral care exam – Evaluation of the implementation of the infant oral care model and – Funding to help off-set costs of staff working to implement the model Program Catalyst: Cavity Free at Three How?
    8. 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 1. Community Assessment 2. Community Oriented Nursing Diagnosis 3. Program Planning 4. Program Implementation 5. Evaluating the Program 6. Sustaining the Program
    9. 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. 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. 11. Nursing Process Phase 3: Program Design Ideal Service Providers 1. RDH: Registered Dental Hygienist 2. Independent: Owns dental hygiene business 3. Medicaid/CHP+ Providers
    12. 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. 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. 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. 15. Nursing Process Phase 5: Evaluation Measuring Impact • Oral health screening from completed for every client encounter • Basic data recorded in electronic medical record • Case Studies
    16. 16. Nursing Process Phase 5: Evaluation Ongoing Evaluation • Periodic meetings with stakeholders • Monitor and maximize provider incentives • Capacity building activities as needed
    17. 17. Tracking Screenings February 55 March 266 April 162 May-July 150-200 August 100 (Vacations) Screenings to date Over 1,100
    18. 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. 19. Conclusion Linking for Synergy JCPH CHS Staff CF3 Service Providers JCPH EPSDT Insurance Providers Local Dental Home JCPH WIC Staff Target Population Program Coordinator

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