A Review of the Revised Head Start Program Performance Standards Relevant to Oral Health November 18, 2016 Presented by: Marco Beltran, Dr.P.H., and Harry Goodman, D.M.D., M.P.H Moderated by: Michelle Landrum, RDH, MEd

General Reminders This webinar will be recorded and archived on the ASTDD website Questions will be addressed after the speakers are finished. Please click on the icon at the top of your screen that looks like a person with their hand in the air. The moderator will recognize and “un-mute” you so you can ask your question.

Learning Objectives Value the significance of the revised Head Start Program Performance Standards (HSPPS) Understand the expanded visibility of oral health in the revised HSPPS Understand the changes in the revised HSPPS as they relate to oral health Understanding of the current Head Start Program Information Report (PIR) oral health elements as they relate to oral health

Important Reminder! DHLs should not provide direct guidance on or interpretation of the HSPPS to HS programs or staff The Office of Head start would like to respond to questions through the Contact Us link (https://eclkc.ohs.acf.hhs.gov/hslc/hs/contact) on the ECLKC website to maintain consistency DHLs role is to provide support and evidence-based resources to programs so they can make informed decisions e.g., providing information on the benefits and appropriate use of fluoride, or assisting programs find dental providers in their area that will provide age 1 dental exams

Overview of Head Start Program Performance Standards Final Rule Presented by: Marco Beltran

Office of Head Start Administration for Children and Families Head Start Program Performance Standards Final RULE ______________________ An Overview

Paradigm Shift Focusing on outcomes over processes and plans Eliminating Head Start-specific requirements where government- or HHS-wide procedures exist Giving grantees more flexibility in how to meet the requirements Increasing transparency with simplified and streamlined standards Reduced the prior Head Start regulations by 30%

Guiding Principles The new Head Start Program Performance Standards: Provide research-based program service requirements. Are written in plain language and presented clearly to support better program delivery for current and prospective grantees. Strengthen Education requirements and ensure all children will get the exposure to early learning they need to leave Head Start ready for school.

Guiding Principles The new Head Start Program Performance Standards: Maintain core Head Start principles, including comprehensive services, parent engagement, enrolling the highest need children and valuing diversity. Requires using data for continuous quality improvement.

Major Changes in Response to Comments The NPRM proposed specific requirements for length of day and year, for all programs by 2017. The final rule sets an annual hour requirement for duration and phases the requirement in over five years (by 2021). The NPRM proposed to eliminate home-based as a standard option for preschoolers. The final rule allows home-based as a standard option as long as it isn’t the only option available to preschoolers. The NPRM proposed to eliminate the requirement for parent committees and articulated impasse procedures that could become imbalanced. The final rule retains the parent committee requirement and ensures impasse procedures lead to an equitable process for both parties.

Overall Structure of the HSPPS The new HSPPS has five clearly defined parts: Program Governance (1301) Program Operations (1302) Administrative & Financial Requirements (1303) Federal Administrative Procedures (1304) Definitions (1305)

Questions about the HSPPS? All questions should be sent to ECLKC -Contact Us OHS staff will be answering the questions based on the following: Reflect the Standard Paradigm Shift Clarification of Intent Deferred for Future Answer Implementation Tips

Supporting implementation Resources and supports will be provided, including: OHS Webinar series every third Wednesday! The Performance Standards Showcase- a series of videos that examine highlights and major changes to the regulations and standards. https://eclkc.ohs.acf.hhs.gov/policy/showcase Federal Sessions at national and regional events Region 9 conference in Hawaii CHSA conferences Cluster meetings Training by National Centers and Regional TTA OHS Birth to Five Leadership Institute Spring 2017

Head Start Program Performance Relevant to Oral Health Presented by: Harry Goodman

Relevant Revised Head Start Program Performance Standards Themes The core health services from the previous program performance standards were maintained Strengthened requirements with an emphasis on oral health and parent education in health issues Updated mental health requirements Streamlined program performance standards

HSPPS Sections of Importance to Oral Health Five (5) Revisions of Note 1302.40 In general—Revision 1302.41 Collaboration and communication with parents 1302.42 Child health status and care—Revision (3) 1302.43 Oral Health practices—Revision 1302.44 Child nutrition (changes of note with indirect impact on oral health) 1302.45 Child mental health and social and emotional well-being 1302.46 Family support services for health, nutrition, and mental health 1302.47 Safety practices (changes of note with indirect impact on oral health) 1302.53 Community partnerships and coordination with other early childhood and education programs 1302.80 Enrolled pregnant women 1302.81 Prenatal and postpartum information, education, and services

Sections of Importance for Oral Health 1302.40 In General Goal of the health section is to ensure programs provide high-quality health, oral health, mental health, and nutrition services that support each child’s growth and school readiness

Sections of Importance for Oral Health 1302.40 In General The term “oral” replaced the term “dental” throughout the revised regulation (REVISED) Rationale Reflects current scientific and clinical terminology Agreement oral health is an important element of overall health If it had remained as “dental” health, it might not automatically have been recognized by programs as included under health

Sections of Importance for Oral Health 1302 Sections of Importance for Oral Health 1302.42 Child Health Status and Care Determine children’s source of care Support parents in ensuring children are up-to-date and ensure children receive ongoing necessary care Determine if children have health insurance and support families in accessing health insurance if they do not Requirements for extended follow-up care and clarifies use of program funds for medical and oral health services Use of funds for the provision of diapers and formula

HSPPS: Oral Health 1302.42 Child Health Status and Care Now includes “oral health care professional” in addition to “health care professional” throughout the regulation (REVISED) Rationale Needed clarity about the meaning of “health care professional” as it relates to oral health since previously confusing Now specifies “oral health care professional” Doesn’t specify the qualifications of oral health care professionals leaving it instead to individual states

HSPPS: Oral Health 1302.42 Child Health Status and Care Now includes the language “…dental periodicity schedule as prescribed by the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program of the Medicaid agency of the state in which they operate” (REVISED) Rationale Needed more clarity to ensure that being “up to date” on health care services included oral health care services This now clarifies that programs must determine whether the child is up-to-date on both medical health and oral health care

HSPPS: Oral Health 1302.42 Child Health Status and Care Key points regarding the revised reference to the “dental periodicity schedule”: Not every state Medicaid program has a specific “dental periodicity schedule” While all states are required to submit “dental periodicity schedules” to the Centers for Medicare and Medicaid Services (CMS), not all have done so to-date

EPSDT Dental Periodicity Schedules References http://www.aapd.org/policy_center/state_dental_periodicity_schedules/. EPSDT Dental Periodicity Schedules References American Academy of Pediatric Dentistry (AAPD) States with EPSDT Dental Periodicity Schedules http://www.aapd.org/policy_center/state_dental_periodicit y_schedules/ Hom JM, Lee JY, Silverman J, Casamassimo PS. State Medicaid Early and Periodic Screening, Diagnosis, and Treatment guidelines: adherence to professionally recommended best oral health practices. J Am Dent Assoc; 2013 Mar 144(3): 297- 305 Discussion of EPSDT Dental Periodicity Schedules https://www.ncbi.nlm.nih.gov/pubmed/23449906 I am not sure I did justice to explaining EPSDT and the implications for 1) states that do not have yet dental periodicity schedules; 2) states that use different resources and guidelines to determine their dental schedule. It is really a topic that we could devote its own session to. But to drill this down to a few simple statements, you will need to 1) refer to a state’s Medicaid program to determine what source is used for their EPSDT periodicity schedule, whether they have a dental periodicity schedule or not; and essentially what it covers and at what age does it provide these services. And 2) be familiar with a state’s dental practice act, which I am sure most of you are, to determine the extent to what a dental hygienist can do by law in a Head Start program’s compliance with EPSDT. But let me say this about the latter point – and something I have said ever since I got involved with Head Start – regardless of whether a dental hygienist can legally do an exam and bill for it, there is so much dental hygienists can still do for HS programs. Of course, provide needed anticipatory guidance and preventive services but even doing a simple assessment that, depending on your state, may not count toward a program’s PIR can still go so far in giving the HS program an idea of how many children and who are at high risk for oral disease. And of course, you as our Dental Hygienist Liaisons on a more global scale do so much, through your knowledge, experience and local contacts, in helping HS kids find dental homes.

Additional Key Points Regarding State EPSDT Schedules: State Medicaid programs use different sources to determine their EPSDT schedules (e.g., AAP’s “Bright Futures”, AAPD Guidelines, other) Refer to individual state’s Medicaid program for the source The EPSDT periodicity schedule impacts the following oral health services/actions, among others: Oral health risk assessment/screening by health care professional Clinical oral examination by an oral health care professional Referral to a dental home Prevention services such as prophylaxis and fluoride treatment Anticipatory guidance State EPSDT schedules still depend on state dental practice acts regardless of the existence of a state dental periodicity schedule or from where it is derived

HSPPS: Oral Health 1302.42(a) Child Health Status and Care Ongoing care “Program must facilitate and monitor necessary oral health preventive care, treatment and follow-up, including topical fluoride treatments. In communities where there is a lack of adequate fluoride available through the water supply and for every child with moderate to severe tooth decay, a program must also facilitate fluoride supplements and other necessary preventive measures, and further oral health treatment as recommended by the oral health professional” (REVISED) Rationale Programs must provide preventive oral health care for all children including, access to topical fluoride treatments (in areas with and without fluoridated water systems) and, as indicated, where there is a lack of a fluoridated water system, facilitate the provision of fluoride supplements

Sections of Importance for Oral Health 1302.43 Oral Health Practices Promote effective oral health hygiene with daily tooth brushing More direct/clear from previous instruction where we said that staff must promote effective dental hygiene among children in conjunction with meals

Sections of Importance for Oral Health 1302.43 Oral Health Practices The title of this section has been changed from “toothbrushing” to “oral health practices” (REVISED) Rationale Better reflects the connection between toothbrushing and overall oral health status Titling a section as “toothbrushing” was too limiting and tended to undermine the importance of overall evidenced-based oral health practice Clarifies the requirement that all children with teeth have their teeth brushed at least once per day with toothpaste that contains fluoride to better reflect scientific evidence

Sections of Importance for Oral Health 1302.44 Nutrition A program must: Serve 3 to 5 year-olds meals and snacks that conform to USDA requirements Meals and snacks must be high in nutrients and low in fat, sugar, and salt Ensure bottle-fed infants are never laid down to sleep with a bottle Make safe drinking water available to children during the program day

Sections of Importance for Oral Health: 1302.44 Nutrition A new requirement to “make safe drinking water available to children during the program day” was added Rationale An indirect revision relevant to oral health While not specifically mentioned since Head Start programs already comply with Child and Adult Food Care Program guidelines, consuming safe drinking water during the day may make children less likely to consume large amounts of sugar-sweetened beverages

Sections of Importance for Oral Health: 1302.47 Safety All staff systematically and routinely implement hygiene practices that at a minimum ensure exposure to blood and body fluids are handled consistent with standards of the Occupational Safety Health Administration

Sections of Importance for Oral Health 1302.47 Safety Language changed in hygiene practices from “spills of bodily fluids” to “exposure to blood and bodily fluids” Rationale An indirect revision relative to oral health given oral disease prevention practice is a component of “hygiene practices” Language more aligned with language used by OSHA, CDC, and other agencies that address infection control for employees and patients

What is the Head Start Program Information Report? The PIR provides comprehensive data on the services, staff, children, and families served by Early Head Start/Head Start programs nationwide All grantees and delegates are required to submit PIR reports to the Office of Head Start annually Self-reported data PIR data are compiled for use at the federal, regional, state, and local levels eclkc.ohs.acf.hhs.gov/hslc/mr/pir

What is the Impact of the HSPPS Changes on the PIR? There are NO changes on the 2016-2017 PIR Unlike the Program Performance Standards, PIR is NOT federal law/regulations New monitoring guidelines will be forthcoming eclkc.ohs.acf.hhs.gov/hslc/data/pir/2016-2017-pdf/2016-2017-hs-pir-form.pdf

Current PIR Oral Health Requirements PIR #C.17 The number of children with continuous, accessible dental care provided by a dentist: # at enrollment # at the end of enrollment year Dental home (as defined in the PIR): An ongoing source of continuous, accessible dental care provided by a dentist PIR #C.18 The number of children who received preventive care since last year’s PIR was reported: Preventive care (as defined in the PIR): Includes fluoride application, cleaning, sealant application, etc.

Current PIR Oral Health Requirements PIR #C.19: The number of children…who have completed a professional dental exam since last year’s PIR was reported: # at the end of enrollment year Professional dental exam (as defined in the Program Performance Standards) Must incorporate the requirements for a schedule of well child care utilized by the EPSDT program of the Medicaid agency of the State in which they operate

Current PIR Oral Health Requirements PIR #C.19.a.: Of the number of children in C.19, the number of children diagnosed as needing dental treatment since last year’s PIR was reported; and, of these children the number who received or are receiving dental treatment: # at the end of enrollment year Dental treatment (as defined by PIR) Includes restoration, pulp therapy, or extraction Does not include fluoride application or cleaning

Current Early Head Start PIR Oral Health Requirements Infant & toddlers PIR #C.20: Number of all children who are up-to-date on a schedule of age-appropriate preventive and primary oral health care according to the relevant state’s EPSDT schedule at the end of the enrollment year Pregnant women PIR #C.21: Number of all pregnant women who received a professional dental examination(s) and/or treatment since last year’s PIR was reported # of pregnant women

Important Reminders for DHLs Quarterly reports Thanks to all the DHLs that completed their quarterly reports in October! It is very important that we receive reports from all DHLs each quarter. The deadlines are: January 7 (Quarter 1) April 7 (Quarter 2) July 7 (Quarter 3) October 7 (Quarter 4)

Important Reminders for DHLs (con’t) New DHL orientation PPT now available! Posted on the DHL webpage right under the DHL contact list Good review for even “seasoned” DHLs Make sure to read the notes section on each slide If you have any questions, please ask your RDHL or Michelle Landrum

Presenters’ Contact Information Marco Beltran: marco.beltran@acf.hhs.gov Harry Goodman: harrygoodman2307@gmail.com Michelle Landrum: michellelandrum@yahoo.com

National Center on Early Childhood Health and Wellness Toll-Free: (866) 763-6481 Email: health@ecetta.info Website: http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/health/center

Questions? Please click on the icon at the top of your screen that looks like a person with their hand in the air. The moderator will recognize and “un-mute” you so you can ask your question.