Midlevel Provider Models* Ben Youel, UIC ASDA President Friday, January 13 th, 2012 * Adapted from presentation given in October 2011 at ASDA Central Regional Meeting

What are we going to cover? Four Models A Spectrum: Community Dental Health Coordinator Dental Therapist (MN) Advanced Dental Therapist (MN) Dental Health Aid Therapist (AL) Advanced Dental Hygiene Practitioner

Dental Health Aid Therapist Dusty Pfundheller District 5 Trustee

What is a DHAT? “Dental Health Aid Therapist” dependent practitioner working in a satellite clinic under the general supervision by an off-site licensed dentist located at a distant regional clinic

How Were DHAT’s Created? Alaska May 2000 – Oral Health in America: A Report of the Surgeon General Alaska Native Tribal Health Consortium (ANTHC) 85,000 Alaska Native people live in rural Alaska with no road access. 5 times caries risk in children Alaska allowed high school graduates go to New Zealand for a two year program (2003 – 2005) 2004 – First DHATs began practicing In 2007 ANTHC partnered up w/ Kellogg Foundation to study at University of Washington’s Medical School - 1 year is pre-clinical, 1 year clinical.

Training for DHAT 2 yr program Must have high school diploma or equivalent & 6wk online anatomy & physiology course 1 st year = pre-clinical work & classroom setting 2 nd year = clinical experience, village practice rotations 400 clinic hours (six-month) residency program Every two years DHATs must be recertified. 24 CE credits Demonstration of ongoing clinical competency

Scope of practice Determined by the supervising dentist during the residency based on DHAT’s demonstrated clinical skills and tribal location needs Determines of clinical procedures and scope of practice Dynamic – may change periodically depending upon the maturing skills-set of the therapist. Typical DHAT may provide oral exams, preventive dental services, simple restorations, stainless steel crowns, extractions and take x-rays.

Supervision General supervision by an off-site licensed dentist located at a distant regional clinic.

Community Dental Health Coordinators Trent Lally District 6 Trustee

What is a CDHC? “Community Dental Health Coordinator” or “CDHC” Part of an ADA comprehensive effort to improve access to oral health care for underserved Americans. Promises to help Americans become better stewards of their oral health.

Is the CDHC a “mid-level provider?” No. Mid-level providers are being promoted to drill, fill, and extract. CDHC focuses on the root causes of disease – the lack of adequate prevention and oral health literacy among populations.

Background To help expand access to the same high quality dental care available to all Americans, the ADA is helping to develop a new member of the oral health team. National Coordinating and Developing Committee (NCDC) was established to create a CDHC training program. March 2009 – Pilots launched

How will the CDHC improve Access? Assist the dentist in the triage of patients Address social, environment and health literacy Educate community members Part of a comprehensive approach that also includes: Improving Medicaid reimbursement rates Placing new focus on oral health education and prevention Increasing government investments in the public health infrastructure Students in the CDHC pilot program are recruited from the communities in which they serve.

How are CDHC’s trained? Pilot Programs 18-month training program (12 months didactic + 6 months internship) University of Oklahoma Temple University A.T. Still University Arizona School of Dentistry

What is the CDHC scope? Collect information (photographs, radiographs) Screenings Fluoride treatments Sealants Temporary filings Simple teeth cleanings (gingivitis) until a patient can have a comprehensive cleaning

Where do CDHC’s work? Clinics Schools Churches Senior Citizen Centers Other public settings

Update New Mexico first state to authorize CDHC model

Advanced Dental Hygiene Practitioner (ADHP) Burton Coleman ASDA District 4 Trustee

What is it? Advanced Dental Hygiene Practitioner American Dental Hygiene Association (ADHA) proposed position in 2004 A dental hygienist who has graduated from an accredited dental hygiene program and has completed an advanced educational curriculum approved by the ADHA, which prepares the dental hygienist to provide diagnostic, preventive, restorative and therapeutic services directly to the public. Response to 2000 US Surgeon General’s Report

Where is it? Currently a proposed model public health settings schools federally qualified health centers (FQHCs) long-term care facilities hospitals nursing homes State by state, currently none in full form

Training & Curriculum Training requirements & curriculum not fully established Bachelor’s degree + 2 years = Registered Dental Hygienist RDH + 2 year Master’s level program

Scope of Practice Hygiene Dx + Perio eval, SRP, Prophy, Fluoride Tx, OHI Restorative Dx + Direct Restorations (composites, amalgams, sealants) Palliative Care Temp restorations, pre-formed crowns, pulp caps, place & remove sutures Prosthodontics Adjust & repair removable, re-cement fixed Surgery – dx, uncomplicated extractions Path – dx & refer Ortho – dx & refer Anesthesia – local & N 2 O * dentist supervision not required

The Dental Therapy Model Ben Youel District 7 Trustee

A Little History December 2006 – ADHP program approved by Board of Directors of MN State Colleges & Universities System Spring 2007 – Safety Net Coalition (SNC) convinces MN Legislative Committee on Health Care Access to recommend the creation of a dental MLP February 2008 – SNC introduces bill to create ADHP in MN Dental Practice Act

A Little More History April 2008 – Bill passes to begin creation of an “Oral Health Practitioner” April 2008 – U of MN unveiled proposed Dental Therapy program May, July & September 2008 – U of MN delegation visits Saskatchewan, New Zealand & England Early 2009 – “Dueling Bills” from U of MN/MDA & from the SNC

December 2011 – Nine students graduated with either Bachelors or Masters Degrees in Dental Therapy from U of MN May 2009 – A compromise reached: Dental Therapy (DT) & Advanced Dental Therapy (ADT) created Fall 2009 – DT program begins at U of MN & Oral Health Care Practitioner (OHCP) program at Metropolitan State University June 2011 – Seven students graduated with MS: OHCP from Metropolitan State And Finally…

Licensure Dental Therapist Graduate w/Baccalaureate or Master’s in accredited dental therapy education program Pass independent clinical competency exam Jurisprudence Exam Advanced Dental Therapist All requirements of Dental Therapist 2,000 hours of practice as DT Graduate w/Master’s in ADT Pass board-approved competency exam Apply for certification

Scope of Practice & Supervision Dental Therapist Radiographs Preventative Procedures & OHI Sealants Temporary Restorations Space Maintainers* Direct Restorations* Pre-fab Crowns* Pulpotomies (Primary teeth)* Extractions (Erupted primary teeth)* Tooth Reimplantation/Stabilization* Local Anesthesia & Nitrous Oxide Mouthguards Provide, Dispense & Administer Analgesics, Anti-Inflammatories & Antibiotics *Require Indirect Supervision All duties subject to Collaborative Management Agreement (CMA) Advanced Dental Therapist** All duties of Dental Therapist Oral Evaluations & Assessments Extraction (Periodontally involved permanent teeth) **All Require Only General Supervision

A Brief Summary of the MLPs

DHAT = Alaska (trained in University of Washington) CDHC = University of Oklahoma, Temple University, & A.T. Still University Arizona School of Dentistry; New Mexico ADHP = Nowhere Dental Therapist / Advanced Dental Therapist = Minnesota Locations

All can do: Collect information (photographs, radiographs) Screenings Fluoride treatments Sealants Temporary fillings (IRM) What can each program do?

CDHCDTDHATADHP Triage Develop and implement community education programs Direct Restorations Pre-formed crowns Primary teeth extraction Perio-involved perm teeth extraction (ADT) Pulp capping Pulpotomies Local/Nitrous Provide & administer analgesics, anti- inflammatories and antibiotics (ADT) Dx & Tx Planning (ADT) Repair removable pros Re-cement fixed pros Space maintainers Splinting Full hygiene scope Direct Restorations Pre-formed crowns Primary tooth extraction Non-surgical perm teeth extraction Pulpotomies Local Full hygiene scope Direct Restorations Pre-formed crowns “Uncomplicated extractions” Repair removable pros Re-cement fixed pros

What is the opinion of American Dental Students? ASDA C-1 Policy: Only the dentist should perform the following functions. These functions include but are not limited to: Examination, diagnosis and treatment planning Prescribing work authorizations Performing irreversible dental procedures Prescribing drugs and/or other medications ASDA C-2 Policy: ASDA is strongly opposed to independent dental hygiene practice, and favors the team approach for providing comprehensive dental care.

Resources - ASDA ADA ADHA – U of MN – Metropolitan State U – Yukon-Kuskokwim Health Corporation – W.K. Kellogg Foundation

Questions?