Community Dental Health Coordinator (CDHC)

Chair, American Dental Association CDHC Curriculum Committee Amid I. Ismail Chair, American Dental Association CDHC Curriculum Committee Jane Grover Director, Center for Family Health, Jackson, MI December 12, 2007 National Network for Oral Health Access (NNOHA) San Diego, CA

Outline Definition of the CDHC? Frameworks for increasing access and reducing oral health disparities Current status of the CDHC project Perspective of a FQHC dental director Outcomes and evaluation

Community health worker (CHWs) with Definition of the CDHC Community health worker (CHWs) with DENTAL SKILLS

Definition of Community Health Workers CHWs are community members who are Trained to promote health, provide leadership, peer education, and resources to support community empowerment. Trained to integrate information about health and the health care system into the community’s culture, language, and value system, thus reducing many of the barriers to health services.

CHWs Functions of the CDHC Coordinate and navigate dental care Advocate for individuals Motivate and assist people to prevent dental and oral diseases Educate community groups and individuals

CHWs Functions of the CDHC Assist community members to enroll in Medicaid or other programs Assist in reducing dental anxiety and fatalism Provide social support and self-efficacy Advocate for oral health Advocate for the CHCs

Dental Skills of the CDHC Screen for dental emergency and need for urgent care Take of digital radiographs Use an interactive online database to share information with the supervising dentist Triage care based on disease and risk status

Dental Skills of the CDHC Per the instructions of the supervising dentist, provide the following preventive procedures Oral hygiene assessment and education Gross scaling Temporary GIC restorations Topical fluorides Sealants

Supervision of the CDHC The CDHC will be a salaried employee of a community health center They may also be hired by dental providers who serve low-income or rural communities Geographic zones of practice will be determined state-by-state based on dental workforce shortages and disease levels

Frameworks The CDHC model is based on extensive experience with CHWs and expanded function dental auxiliaries

Effectiveness: CHWs Improved outcomes for prenatal care, cancer screening, child sick visits, immunizations for children, chronic illness care, maternal health, STD testing, smoking cessation, and mental health and outreach services.

Effectiveness of CHWs Promoted weight loss and breastfeeding among African Americans Reduced drug use Increased condom use among homeless women, Increased physical activity among African-American women with type II diabetes Reduced missed appointments Increased follow-up care.

What about capacity? Triage patients based on their dental needs Prevention in the community Follow-up preventive and motivational interventions Reduce missed appointments Increase utilization Increase revenues for the FQHC Hire staff Community health worker functions may become reimbursable in the near future

Net Balance To cover all cost in year one, the CDHC (HS graduate) must recruit around 550 patients or 2 patients per work day.

Trainees DHs may be trained and certified as CDHCs DAs may be trained and certified as CDHCs High school graduates will enroll in a 12-month program All trainees must work as interns at a FQHC or CHC for 6 months

States Sending a Letter of Interest

Site Selected For Demonstration Projects Michigan Site director Amid Ismail, University of Michigan Urban site in FQHCs Oklahoma Site director Dunn Cumby, University of Oklahoma Rural site which may include some Native American clinics Native American Locations Site directors Nancy Reifel and Donna Kotyk, UCLA Using multiple sites (MT, SD, MN, and other states) ADA House of Delegates allocated $2 Million to cover the cost of the demonstration projects with local funding sources.

Curriculum First draft to be completed this December 14 Modules First 6 focus on CHW certification 7 on dental skills (screening, radiographs, prevention of caries, periodontal disease, oral cancer) 1 internship Unique modules: motivational interviewing; detailed oral hygiene assessment using the Nexo Method; oral cancer screening; tobacco cessation

We will not drill our way out of the dental caries problem We will not seal our way out of the dental caries problem We will not scale our way out of the periodontal disease problem We will not biopsy our way out of the oral cancer problem

Moving Forward Requires New Models that Promote Community-based and Individual-focused Changes in Social, Organizational, and Behavioral Determinants Integrated Dental Care and Oral Health Promotion Model

FQHC dental director Dr. Jane Grover The CDHC is at the door What can they do? Sites Equipment Supervision Training of clinical and other FQHC staff Benefits to my clinic Costs and risks Outcomes

Population: 140,267 (2000) Race: 88.7 Whites, 7.9 Blacks 0-19 years: 45,000 Medicaid: 14.0% (2000) Medicaid: 16.2% (2006) Dentists: 77 (2000) Dental Hygienists: 117 (2000) Preventive visits: 48.5% FQHC: 1 (3 sites) Dentists: 3.5 FTE DHs: 4 DA: 7 Patients/year: 8,500

Dental Skills CDHC Screen for emergency dental needs using questionnaires and visual inspections Immediate scheduling We will see them when we find them Screen for signs of caries, periodontal disease, and oral cancer Take radiographs Enter all data in the CDHC database Triage patients based on urgency Assess and improve oral hygiene practices Map location of plaque in stagnation areas Write oral hygiene goals card Demonstrate how to remove plaque from stagnation areas

Dental Skills CDHC Apply topical fluorides Place sealants Temporize cavities to remove foci of infection prior to application of fluorides and sealants Risk-based preventive recall

CDHC CHW skills What can they do? Navigate dental care and referral Dental anxiety Oral health literacy Nutritional literacy Personal preventive plans Pregnant women Infant oral health Education of caregivers (parents) Oral cancer patients Tobacco cessation Coordination with medical providers

Coordination of Dental Care Missed appointments First contact in the community Group education Advocate on behalf of community members Advocate on my behalf with community members Follow-up with patients who need referral or follow-up care

Potential assignment sites Schools WIC/Head Start Neighborhoods Nursing homes Waiting rooms of medical clinics Emergency rooms in hospitals Triage the waiting list for dental care

Equipment Portable dental chair and light Sealant unit (compressor, electric handpiece, air syringe, saliva ejector, high speed suction) Nomad PC with wireless card Cell phone Instruments Mirror PSR probe Cotton pliers Intra-oral light Temporary restoration kits Sundries Autoclave (Statim) Car (personal or FQHC owned) Insurance

Remote Supervision

Training of staff who work with CDHC Front desk staff who can schedule appropriately Dental hygienists: Coordination between hygienists and the CDHCs to prioritize schedules based upon needs of patients Dentists who will review screening records and questionnaires recorded by the CDHC to triage care and develop a management plan for the CDHC Other FQHC providers who will benefit from working with the CDHCs (prenatal care, pre-term, diabetes, smokers) Community outreach coordinators at the FQHC

Potential Benefits Integrated dental care model Risk-based preventive care at home or community Increased productivity Advocate for FQHC services in the community Disseminate accurate information regarding locations, staff and hours of operation

Risks Remote supervision Quality of care Capacity to meet increased demand for dental care Turnover and cost of re-training Uncompensated care

Outcomes Access to dental care Efficiency of operations (increase quantity and quality) Reduction of severe disease Prevention of early disease Patient satisfaction and quality of life Networks with community and professional organizations

To move forward Oral health Promotion, Prevention, within an Integrated Dental Care Model Three demonstration projects in 2008-09 Focus on Integrated care Oral health promotion Disease prevention Social and behavioral determinants