John McFarland DDS President The National Primary Oral Health Care Conference San Diego 2007 Welcome Everyone National Network for Oral Health Access (NNOHA) Because of the myriad of issues we deal with as safety nets, we felt it was important to explore partnerships to enhance our ability to meet the needs of the underserved. John McFarland DDS President

NNOHA National Network for Oral Health Access The organization of Migrant, Homeless, and Community Health Center dental providers

Why NNOHA From 1985 to 1990 CHC’s lost 75 dental programs. In 1985 there were 250 CHC’s with dental. By 1990 there were 175. NNOHA was formed as an organization to stop the continuing loss of CHC dental programs and start building new dental programs NNOHA is the only organization of CHC dentists and hygienists, by us, for us.

NNOHA NNOHA needs your support, and quite frankly You need NNOHA Please join by requesting an application form from us here in Atlanta, or Please join by requesting an application form on the list serve or here in San Diego. $25.00 per dentist or hygienist, $250.00 per Health Center

NNOHA List Serve Send an e-mail to: majordomo@ohsu.edu Place nothing anywhere except in the message area. In the message area place the following: Subscribe nnoha@ohsu.edu

MISSION The mission of the National Network for Oral Health Access (NNOHA) is to improve the oral health status of the underserved through advocacy and support for Health Centers

Strategic Perspective We must work to insure that oral health services, including prevention and treatment, must be an integral component of primary health care and defined as such in legislation and regulation.

Strategic Perspective Start new dental programs in CHC’s that do not have dental

Strategic Perspective Expand dental programs to sites in CHC’s with multiple sites that do not have dental.

Strategic Perspective Expand existing sites which do have dental to meet the oral health needs of the patients served by that site within the CHC

Strategic Perspective Build NNOHA infrastructure at the local level through local dental entities within primary care associations.

Strategic Perspective Provide a forum for CHC dentists and hygienists.

Strategic Perspective Provide guidance to CHC dental providers in managing and operating their programs.

Strategic Perspective Provide input from CHC dentist’s in the development of HRSA’s dental clinical measures.

NNOHA ACTIVITIES 2007 Substantial funding through a cooperative agreement with HRSA Creation of NNOHA Advisory Committee NNOHA Website www.nnoha.org NNOHA Listserve Annual Conference Oral Health Pilot Collaborative

Why Is Oral Health Important 95% of all Americans are afflicted by oral disease Oral cancer is more common than leukemia, melanoma of the skin, Hodgkins disease, and cancers of the brain, liver, bone, stomach, thyroid gland, ovaries, or cervix. Each year over 164 million hours are missed from work and 52 million hours from school due to dental problems.

Why Is Oral Health Important Dental related illness accounts for 6.1 million days of bed disability and 12.7 million days of restricted activity annually Lost work due to dental problems equates to 164,000 American workers off the job for the entire year Populations served by health centers are particularly at risk for oral disease and have the highest disease level. Safety net clinicians practice in a non-traditional model. We frequently use a multidisciplinary approach. Unlike private practice, our focus is the community rather than solely the patients who come for care. Community-oriented prevention must be part of our practice. Dental disease, in the populations we serve, is significant in all categories (caries, perio, cancer, and trauma). This is due to a number of factors including poor dental education, neglect, lack of access and socio-economic factors. Our training did not focus on the balance between what is ideal for each tooth versus what is ideal for each patient’s condition and resources. For example, a crown may be the ideal restoration for a broken tooth, but in light of stretched fiscal and personnel resources, a cusp-protected amalgam may be functional and very appropriate. We must look beyond the individual tooth to the individual. Health centers care for unique populations, as well as individual patients. We must be as concerned about community water fluoride levels as we are about individual patient health status. To maximize our effectiveness, we utilize outreach, transportation, translation and social work services whenever appropriate when caring for these patients, as well as getting intimately involved in those BPHC sponsored "Collaboratives" which have an oral health component. Safety net providers need to interface with the social needs of their patient population. This means frequently addressing compliance issues that are commonly less burdensome in other health delivery systems.

Why Is Oral Health Care Important 82% of those in poverty will require a dental visit in the near future 33% of those in poverty saw a dentist in a given year versus 61% of those not in poverty Prevalence of dental disease in the uninsured / underinsured population is 3 times the national average These issues represent challenges to the organizational system that, when successfully addressed, bring order to chaos and make efficient use of limited resources. Often, these challenges are not given sufficient attention. Many clinicians in safety nets feel that such "system issues" are given too little attention resulting in their day-to-day worklife including a higher degree of disorder than they prefer. This perceived higher level of chaos existing within many safety nets is of interest. Does it derive partially from the nature of the patient populations we serve; many of whom have a high degree of uncertainly and chaos in their daily lives regarding housing, employment, and obtaining the basic necessities of life. This uncertainty can be compounded when coupled with poverty, single parent families, domestic violence, and substance abuse. Regardless, this realization does not negate our need to address these challenges to the organizational system regularly through quality and utilization management with a realistic goal of maintaining and improving them. Consistency within the health center is one less demand upon our patients.

Why Is Oral Health Care Important 12% of those in poverty had significant dental findings versus 5% of the non poverty population 97% of homeless population need dental care Migrant populations have 3 times the incidence of dental decay than the average population

Percentage of Adults With Untreated Caries by Family Income (GAO 2000)

Why Is Oral Health Care Important Particularly To Children Tooth decay is the single most common chronic disease of childhood Almost half of US children age 5-17 have experienced tooth decay in their permanent teeth. 25% of children and adolescents (typically from families with low incomes and minority populations) experience 80% of all dental decay occurring in permanent teeth Here is a list of a few of the things we have to deal with on a daily basis.

Why Is Oral Health Care Important Particularly To Children 1% of child patients suffer from Early Childhood Caries (Baby Bottle Tooth Decay) by age 5 and are from families typically seen by health centers Children ages 2-5 and between 100% and 200% of poverty quidelines have 4.5 times the rate of dental disease than the national average

Why Is Oral Health Care Important Particularly to Children Among migrant children age 10-14, dental is the most common health problem, and age 15-19, it is the second most common health problem

Percentage of Children With Untreated Caries by Family Income (GAO 2000)

Is There An Oral Health Access Problem (Or Crisis) One in ten children aged 5-11 years has never visited a dentist within the past 12 months. 43% of Americans age 2 and older have not visited a dentist within the past 12 months 50% of homebound elderly have not seen a dentist in ten years

Percentage of Population Who Made a Dental Visit in the Preceding Year (GAO 2000)

Is There An Oral Health Access Problem (Or Crisis) Dentist per population ratio is decreasing from 60 dentists per 100,000 population in 1991 to 57 dentists per 100,000 population in 2000 (and projections are to 53 dentists per 100,000 in 2020). Number of students graduating from dental schools has decreased from 5,765 in 1982 to 4041 in 1998 We must set budget priorities and budget development (system, equipment, personnel). Keep an updated Wish List for those unexpected occasions when unallocated resources are uncovered and must be spent within a day. Have the purchase orders ready for signatures within the hour!

Is There An Oral Health Access Problem (Or Crisis) Only 25% of Medicaid eligible children actually receive oral health services Only 71% of Community Health Centers have dental programs (678/952) and health centers are only able to treat 2.34 million patients per year

Is There A Funding Problem in Dental Care 120 million Americans do not have dental insurance as opposed to 43 million without medical insurance Upon retiring, 85% of Americans have no dental insurance There are no dental benefits under Medicare Develop clinical outcome measurements that allow assessment of progress in meeting health center and community needs assessments. Develop chart and clinical outcome reviews to insure that all charting is done in a systematic, risk avoidance manner yielding and documenting positive outcomes. Conduct ongoing chart review that is not limited to outcomes documentation; insure that all dentists, hygienists, and expanded function assistants participate. Take the lead in oversight activities. Share results and information. In collaboration with staff, formulate necessary action plans and agree to implement within a timely manner. Nothing is sacred. When new models are found and proven more efficient, make changes. Serve as primary reviewer for dental incident reports. Act as advisor to the personnel department. Take a lead role when disciplinary action is necessary. Participate in patient satisfaction activities and align programs with results. By doing all this, you are continuously preparing for your JCAHO/Primary Care Effectiveness Review (PCER).

Is There A Funding Problem in Dental Care There are limited dental benefits for adults under Medicaid Uninsured patients must pay out-of-pocket, and for low income patients the expense of dental care is generally prohibitive

Three Main Dental Issues Lack of access to dental care Inadequate funding for oral health especially in unserved and underserved populations Declining provider pool We develop and suggest new strategies to reach our communities’ vision of oral health. Consider financial implications of all new strategies and programs Seek grants and research possibilities to fund new programs. Rigorously evaluate new programs. Collaborate whenever possible. Expand your network.

Solutions CONTINUE TO EXPAND DENTAL PROGRAMS IN COMMUNITY HEALTH CENTERS Increase the number of Centers with dental programs to increase from 58% in 1998 to 90% in 2010. Expand existing dental programs in health centers We frequently work with our Board of Directors and the community to develop a periodic community dental needs assessment that is integrated and coordinated with the overall health center needs assessment . How many of us monitor and update our dental health professional shortage area designation?

Solutions Increase funding to the National Health Service Corp loan repayment and scholarship programs to enable health centers to compete for a shrinking supply of dentists and hygienists Increase or initiate state loan repayment programs for dentists and hygienists

Solutions Strengthen Medicaid and CHIP revenues which are vital revenue streams for health center dental programs and other providers treating underserved populations Collaborations principally between local, county, and state initiatives with private and public entities

Status of Health Center Dental Programs Nationally 963 dentists in health centers 2000 280 hygienists in health centers 2000 1,300,000 dental patients 2000 3,000,000 dental visits 2000 450 centers out of 731 have dental 2000

Status of Health Center Dental Programs Nationally 1,230 dentists in health centers 2002 383 hygienists in health centers 2002 1,644,917 dental patients 2002 3,787,923 dental visits 2002 539 centers out of 843 have dental 2002

Status of Health Center Dental Programs Nationally 1,416 dentists in health centers 2003 477 hygienists in health centers 2003 1,885,359 dental patients 2003 4,460,429 dental visits 2003 572 centers out of 890 have dental 2003

Status of Health Center Dental Programs Nationally 1,586 dentists in health centers 2004 547 hygienists in health centers 2004 2,150,664 dental patients 2004 5,126,657 dental visits 2004 603 centers out of 914 have dental 2004

Status of Health Center Dental Programs Nationally 1,739 dentists in health centers 2005 643 hygienists in health centers 2005 2,340,710 dental patients 2005 5,562,632 dental visits 2005 678 centers out of 952 have dental 2005

Status of Health Center Dental Programs Nationally 1,911 dentists in health centers 2006 714 hygienists in health centers 2006 2,557,003 dental patients 2006 6,149,694 dental visits 2006 698 centers out of 1002 have dental 2006

Status of Health Center Dental Programs Nationally Continued 2,702 Encounters per dentist 2006 1,379 Encounters per hygienist 2006 2,711 Encounters per dental team 2006 2.380 Encounters per dental user 2006 $138.64 per dental encounter 2006 $333.43 per dental user 2006 Source www.bphc.hrsa.gov/uds

NNOHA Thank you

Functional Statement A significant documented disparity exists between the oral health status of those individuals who have ready access to oral health care services and those who do not. It is the intent of this organization to reduce or eliminate this disparity through establishment of an effective network of dental clinical leaders in community, migrant , and homeless health programs. Strategies will be developed to ameliorate these differences and enhance the quality of life.

Requests for NNOHA What are salaries for dentists, hygienists, and dental assistants What are the productivity expectations for dentists, hygienists I need a Policy and Procedure Manual Continuous Quality Improvement Manual Protocol Manual

Requests for NNOHA Salaries Dentists – From Ken Bolin, CCHN, Others – Mean $86,400 Salaries Dental Directors – Approximately $10,000 higher than dentist salaries Salaries Dental Hygienists – Mean $54,000 Salaries Dental Assistants - Mean $22,600

Requests for NNOHA Productivity Expectation Dentist Regional Program Guidance Memorandum 87-8 2300 encounters per year Productivity Expectation Hygienist Regional Program Guidance Memorandum 87-8 1400 encounters per year

Requests for NNOHA MANUALS Request manuals on NNOHA list serve Oral Health Clinical Resources go to www.cchn.org