CROC: Taking a Bite Out of Early Childhood Cavities on the Eastern Shore National Primary Oral Health Care Conference December 9-13, 2007 San Diego, CA Scott Wolpin, DMD

Where is the Eastern Shore of Maryland??

CROC Children's Regional Oral health Consortium

Collaboration: the Stakeholders Eastern Shore Area Health Education Center University of Maryland Dental School Choptank Community Health System Three Lower Counties Community Services Shore Health System (DGH, EMH)

How does a community raise a CROC? In 2004, a 1 year HRSA Planning Grant was used to set the table Eastern Shore Oral Health Action Network (ESOHAN) assembled In 2005, a 3 year HRSA Rural Health Outreach Grant proposal is submitted/funded

Community Responsiveness The hope is for Medicaid-insured children to access primary and specialty dental services closer to home, to give every child on the Shore a healthy start…

Innovation: CROC’s Charge Develop a dental home for Medicaid and uninsured children of Dorchester County Develop a regional hospital-based pediatric dental program for children requiring GA Develop clinical and community-based education training opportunities for dental hygiene students

Dorchester County – the heart of a CROC

Dorchester County Top 4 of Maryland’s 24 counties with worst child health indicators Half of all children in the area are eligible for Medical Assistance No dental home for Medicaid-insured or uninsured children

Target Population All low income children in Dorchester County – uninsured or enrolled in MA Immigrant and migrant worker’s children

Oral Health

Water Fluoridation* * Determined by the difference between Public Water Systems with Fluoride > 0.8ppm and total population, for each county

Medicaid-insured Children in Maryland The percentage of Maryland school children with decay is 60%. The national average is 50%. 75% of the decay is found in 25% of the children (MA) Children who are eligible for Medicaid, Free or reduced lunch programs have over 30% more cavities than the state average All children who receive Medical Assistance have 70% of their cavities untreated, whereas children who pay for dental services through insurance or out-of-pocket average 50% untreated disease Only one-third of medical Assistance eligible children see a dentist every 6 months. The state average is 48%.

Oral Health Mouth of a two year old child

Maryland’s Medicaid Reform Program: HealthChoice Initially there were 7 dental Managed Care Organizations (MCO) but he State is now hoping to move to a single vendor On the Eastern Shore, less than ten percent of the 160 practicing dentists accept Medicaid-insured patients In Dorchester County, there are no dentists accepting Medicaid-insured patients

Workforce Disparities There are three training programs for dental hygienists in Maryland, however, none are located on the Eastern Shore Not only is there a shortage of hygienists on the Eastern Shore, less than ten percent of the dental hygienists work with the target population

Integration: Public Health Initiatives Pediatric Dental Fellows Satellite Dental Hygiene Training Program

“Titanic Approach” Until a complete oral health team network can be established and/or CCHS expands services, the following guidelines were developed to provide oral health services: Patients must reside within Caroline, Dorchester or Talbot Counties Services will be targeted to children who are uninsured or enrolled in HealthChoice/MA Services for adult patients will be targeted to those with emergencies or are referred by medical providers for chronic illness (i.e. HIV, diabetes, etc.) or pregnancy

Lack of Specialty Care No services were available on the Eastern Shore for children who require oral rehabilitation under general anesthesia prior to CCHS’s hospital-based pediatric dental program To accommodate the surgical and restorative needs of young children locally, the existing hospital-based dental services will need to be increased to at least one day per week.

Building a Regional Referral System

CROC/DGH Provider Staff

Why are we still seeing so much disease? “Decay will happen anyway” “Baby teeth are not important” “The bottle keeps my baby quiet”

Measurable Outcomes By 2008, at least 50 percent of low-income children in Dorchester County will have received preventive dental service during the past year. Baseline: 36.7 % in 2003Healthy People 2010 Goal: 57% By 2010, reduce the proportion of untreated dental decay in 6 to 8 year old children on the Eastern Shore to no more than 40 percent. Baseline: 72 % in 2001Healthy People 2010 Goal: 21%

So how are we doing?? A dental home has been built and 663 children have visited for 1143 visits (91%MA) The hospital-based dental program has now added a second full day in the OR each month and over 40 children have received dental surgery at DGH A dental hygienist/oral health educator has provided ECC prevention in-services to medical providers in three of our health center’s primary care offices, established many community linkages and assembled a referral tool box

Replication Stakeholders need to be identified (some are not traditional) Meetings must be well attended – have food! Strong partnerships must be cultivated then nurtured Substantial data must be collected Determine what health needs are a priority to the community HRSA does not have a plethora of evaluation data, so we think CROC data will be welcome

CCHS’s application to the Maryland Community Health Resources Commission was awarded These monies will be used to expand our Cambridge dental office from three to seven treatment rooms and recruit a case worker to optimize OR utilization Sustainability

Scott Wolpin, DMD Chief Dental Officer Choptank Community Health System Federalsburg, Maryland