Florida Oral Health Conference August 2012 Ron Nagel DDS MPH CAPT USPHS (ret)

Barriers to Access n Geographic (distribution) n Economic (capacity) n Cultural (social)

Dental Therapists n At least 52 countries utilize Dental Therapists – IDJ (2008) 58, n Function as part of the dental team under the supervision of a dentist n New Zealand has 90 yrs experience and Canada has over 40 n Exceptional safety record under general supervision for children and adults – Nash 2012

Dental Therapists - Scope n Clinic, Village, or School based n Provide the spectrum of health education and preventive services n Restore teeth to function utilizing amalgam and composite materials n Provide SSCs and pulp treatment for primary teeth n Extract teeth and manage dental emergencies n Screen for oral and peri-oral disease

Clinical Guidance

AFHCAN Cart Alaska Federal Health Care Access Network n Wireless Networking n Touchscreen n Mobile – Customized u Consultation u Patient education u Provider education n WWW. AFHCAN.ORG

Oversight n Educate and calibrate supervising dentists n Dental therapists are assigned to a primary supervising dentist n Supervising dentists provide patient consultations and program planning n Monitor the referral process and the scope of practice n QA: chart reviews, patient satisfaction, direct observation n Standardization of treatment to improve outcomes

n “Finally, we have pointed out the lack of published data available to serve as valid sources for comparison to assess the technical competence and practice procedures of those in the DHAT program. We have very little information about these qualities and characteristics from the practice settings in which the majority of private dentists in this country currently operate.” u Evaluation of the Dental Health Aide Therapist Workforce Model in Alaska, Final Report, October 2010, Pg. 5-9, prepared by Scott Wetterhall, MD, MPH, James D. Bader, DDS, MPH, Barri B. Burrus, PhD, Jessica Y. Lee, DDS, PhD, Daniel A. Shugars, DDS, PhD, MPH

Quality Assurance in the Alaska program n Begins with a 400+ hour directly supervised preceptorship n DHAs must demonstrate the practical professional competencies for their level of certification throughout their career n Every two years each DHA must provide evidence that they completed the CE requirements (24 hrs) n Dentists proactively monitor sentinel events and treatment outcomes n These administrative controls help to assure quality and that a single standard of care is met in tribal programs

Competency Based Credentialing n Frequent sampling of knowledge and skills over time – not a single event test n We look directly at the services that they provide day to day to achieve high predictive validity with this process n Each DHAs’ scope of practice is individually assigned based on competency through standing orders n A Federal board oversees the process

DENTEX Training Program n University of Washington MEDEX Northwest n Two year program based on NZ, Canadian, and other models n Integration into community based prevention programs throughout training n A new mix of skills that includes the behavioral and public health skills needed to affect change n The use of simulation and extensive patient contact to develop a high level of skill

Alaska DHAT training program information: First year: 40 weeks Second year: 39 weeks Total: 79 weeks (3160 hours) Curriculum Break-down first year Biological Science: 30% Social Science: 10% Pre-clinic: 40% Clinic: 20% Curriculum Break-down second year Biological Science: 15% Social Science: 7% Pre-clinic: 0% Clinic: 78% (1215 hours) Curriculum Break-down two years combined: Biological Science: 22.5% Social Science: 8.5% Pre-clinic: 20% (632 hours) Clinic: 49% (1548 hours)

n 2 year vs. 3 year combined RDH programs u Cost u Infrastructure u Career opportunities u Provider Demographics

The truth about motivation and changing behavior… Motivated by information Not going to be motivated right now Motivated by how I interact with provider over time 10 % Miller & Rollnick, Motivational Interviewing, %

Foundations for Great Primary Care Effective Relationships = Empanelment + Access + Continuity

What should new providers look like?

n Nash DA, Friedman JW, et al. Dental therapists: a global perspective. Int Dent J Apr;58(2):61-70 n McDermott, PT, Mayhall, JT, Leake, JL, Dental therapists and the delivery of dental care in Canada’s Northwest Territorties. Circumpolar Health 1990: , n Ambrose ER, Hord AB, Simpson, WJA. Quality evaluation of specific dental services provided by the Saskatchewan dental plan: final report. Regina, Saskatchewan, Canada, 1976:19 pages n Friedman JW, Ingle JI. New Zealand dental nurses. J Am Dent Assoc 1973;8:1331 n Barkley RF, Successful preventive dental practices 1972 English Book 256 p. : ill. ; Macomb, Ill. : Preventive Dentistry Press n Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med. 2005;3(2): n Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of Care: a Multidisciplinary Review. BMJ. 2003;327(7425): n Nash DA, A Review of the Global Literature on Dental Therapists: In the Context of the Movement to Add Dental Therapists to the Oral Health Workforce in the United States, Apr 2012.

"WHEN THE DENTAL HISTORY OF OUR TIME IS EVENTUALLY WRITTEN, I BELIEVE THE NEW ZEALAND DENTAL NURSE PROGRAM WILL BE CONSIDERED ONE OF THE LANDMARK DEVELOPMENTS IN THE PRACTICE OF DENTISTRY AND DENTAL PUBLIC HEALTH.“ HAROLD HILLENBRAND EXECUTIVE DIRECTOR AMERICAN DENTAL ASSOCIATION,