A Community Participatory Model to Address Oral Health and Healthcare in HIV-positive Families in NYC Kavita P. Ahluwalia, DDS, MPH 1, Luarnie Bermudo, MPH, BS 2, Emma Roberts, BSc 3, Athenesios Zavras, DDS, MS, DrMSc 1, Burton L. Edelstein, DDS, MPH 1 1 Columbia University College of Dental Medicine 2 Dominican Sisters Family Health Services, Inc 3 Harlem United Community AIDS Center, Inc

HIV/AIDS in NYC “NYC remains the epicenter of HIV/AIDS in the US. More that 107,000 New Yorkers are living with HIV and thousands more don’t know they’re infected. NYC’s AIDS case rate is almost 3 times the U.S. average, and HIV is the third leading cause of death for New York City residents aged 35 to 54”. -- NYC Department of Health and Mental Hygiene, 2014

Community-Based Dental Partnership Program HRSA-funded collaboration between Columbia University College of Dental Medicine (CDM) and Harlem United Community AIDS Center, Inc (Harlem United). Goals: Increase access to comprehensive and culturally appropriate care for People Living With and those at risk for HIV/AIDS Improve dental residents’ and students’ understanding and treatment of HIV positive people with chronic medical psychological and social conditions

Target Population West Harlem and the South Bronx are “hot spots” for HIV infection Hard-to reach for healthcare systems – Minority and vulnerable populations – Multiple social and economic vulnerabilities Homelessness, drug use, low SES – Multiple medical co-morbidities – Only one Hospital and 2 FQHCs provide dental services

Harlem United Community AIDS Center, Inc Founded in 1988 as the Upper Room AIDS Ministry – Community-based movement to care for people living with HIV/AIDS in West Harlem, NYC – Address personal, social and institutional barriers to care Homeless, mental illness, substance use, social stigma – Renamed Harlem United Community AIDS Center, Inc. in 1995

Community-Based Dental Partnership Program 2002: Co-located dental services – Served Adult Day Health Care clients – Clinical services provided by AEGD fellows; patients referred to CDM for comprehensive services – Supervised by CDM faculty 2003: Full service dental clinic – Clinical services provided by AEGD fellows and DDS/MPH students – Supervised by HU staff dentist Community Advisory Board oversees the program 2012: Mobile van (HU funded by HRSA) – Clinical services provided by HU staff dentist 2013: Expansion of services to the South Bronx – New partner and new model

Expansion of Services to South Bronx Use a community-participatory approach to: Deliver relevant primary oral health services to medically underserved adults and families living with HIV/AIDS in the South Bronx Train dental public health residents to develop an understanding of the roles played by social, environmental and medical co-morbidities in oral health disparities

Dominican Sisters Family Health Services, Inc. Faith-Based CBO Founded in 1826 by the Dominican Sisters of the Sick Poor---South Bronx, Westchester, and East Hampton Mission to serve the vulnerable and marginalized Funded by Ryan White Part D in 1993 Services expanded to meet the needs of the community

South Bronx, NYC Poorest congressional district in the U.S. – 37.4% of NY’s 16th District lives below the poverty line Population: 1.4 Million Mostly African-Americans and Latinos – 43.0% Black or African American – 52.0% Latino 3,809 newly diagnosed HIV cases in NYC 838 newly diagnosed HIV cases in the – Bronx 64% Male (537) 36% Female (301) Dental safety net providers are not easily accessible

Map of South Bronx

DS Case management CDM Screening & Education HU Primary dental services Access to population/home visitation Referral, intake, appointments Appointment facilitation Dental Services Partnership Model CAG &CQI

Partnership Model Two community-based, one academic partners Dominican Sisters (DS) – Case management and linkages Home visit appointments Escorting to dental visit Harlem United (HU) – Primary dental services (bi-monthly) College of Dental Medicine (CDM) – Screening, Education, Referral and Appointments (weekly) Home visits by Dental Public Health Residents (N=2) – Intake, referral, appointments – Data collection and reporting

Process: Service Delivery DS Social Worker CDM DPH Resident (N=2) 0.5 day/week HU DDS (N=1) 2 days/month Screening Appointment Screening, OHI, OH Aides, Intake Data, Dental Appointment Dental Services

Preliminary Outcomes Screening and outreach (Dec 12, 2014 – March 10, 2014) DPH Residents have made 11 visits – Total number of clients screened: 19 – Total number of clients received OHI and OHI kits: 19 – Total number of clients referred: 17 Dental Services (Jan 27, 2014 – March 10, 2014) Mobile van has made three visits – Total number of patients scheduled: 21 – Total number of patients received dental services: 8 – No show rate: 62% Continuous Quality Improvement Oral health has been included in DS’ CQI process; HU and CDM representation

Resident (N=3) Training and Evaluation Understanding the role of social, medical, economic and geographic disparities on oral health outcomes – Orientation – Home visits with social workers – Oral and Medical Screening and OHI Evaluation through weekly meetings with faculty and written reflection Dominican Sisters approved as “field experience” site by CODA (March 2014)

Resident Reflection “This experience affords opportunity for me to see homes and gives me insight into the economic social and oral health problems of an HIV positive patient.” “In most of the cases the consequences to their general health are directly related to their oral health.” “…when I had the opportunity to go for home visits to HIV+ patients, I realized that there are more aspects and barriers to achieve oral health for these patients…I realized that for some of them with their complicated health problems as well as their housing insecurity it is very hard to comply with oral hygiene instructions.” “When they are in the comfort of their own home they are more prone to tell me about their life experiences, their health status, socio-economic status, family issues, and a lot of other details that could not be possible to tell in a dental office.”

Collaboration Benefits CDM Expansion of CBDPP program – Geographic location and population – Resident training and home visits HU Expansion of mobile dental services program – Geographic location – Appointments (making and facilitation) DS Expansion of services offered – On-site dental services – Oral health education and outreach by social workers

Challenges Geographic location – Meetings/trouble shooting – Resident travel time (to DS and between home visits) Screening and outreach – Privacy concerns – Case workers (competing priorities/overburdened) – Multiple schedules and travel time Dental Services – Screening visit time (intake) – Multiple providers (?trust) Data Sharing and Reporting – Privacy and data safety High No-show rate – ?Perceived need – ?Multiple providers/trust – Weather

Lessons Learned Time – Develop and partnerships – Workplans and processes Equal partnership – Competing priorities/needs and stakeholders – But, all working towards a healthier community – Money, data, dissemination Stakeholder and consumer buy-in at all levels is vital