Jeanne Edevold Larson, Executive Director, and Clinical Team Northern Dental Access Center Dr. David Collier, DDS KOALA Dental Care Susan Voigt Medica Foundation...providing a dental home for those in need. Referral Care Coordination: Improving pediatric referral treatment completion among high risk children

Bemidji Baxter

Goal is to address “Barriers to Care” Ruby Payne- Framework for Understanding Poverty Transportation Assistance Insurance Counseling-Enrollment Navigation Chemical Use Assessments Child and Teen Check Ups Street Outreach - Homeless Primary care outreach and referral Patient Advisory Group Medical-Legal partnership Patient Advocacy….

Problem Fewer than 22% of children who were referred to pediatric care because of treatment needs beyond our capacity—were returning with their referral care complete The remaining children to return to us with even greater pain and disease (which we are unable to treat) or to the Emergency Room, where only palliative care can be provided. To avoid rampant disease and decay, these children MUST get to the pediatric clinic. KOALA Dental in Baxter faced challenges in treating low income children: Missed appointments Dentistry for children not seen as a priority Low reimbursements from Medicaid 3 rd party payers “There must be something we can do” was the plea from dental assistants.

Closest Pediatric Dentists who accept Medicaid are in Brainerd and St. Cloud. Reasons for incomplete referral treatment fall into two categories:  the complicated logistics involved in scheduling the appointments, transportation, pre-op physical, and completing extensive paperwork;  and our inability to persuade caregivers of the critical need to pursue these referrals for children, nor to provide them with health education that motivates them to make the referred treatment a priority.

Mission… The Medica Foundation funds community-based initiatives and programs that support the needs of our customers and the greater community by improving their health and removing barriers to health care services. Directing funding toward initiatives that: Are true innovations in how health care is delivered Have a high likelihood of creating sustainable, systemic change Address the social issues that drive health care costs and reduce health care disparities Build partnerships and collaborations between Medica and other community organizations MEDICA Foundation supported Northern Dental Access Center’s Pediatric Case Management Pilot because: Working successfully with Northern Dental since opening in 2009 to improve access to dental care The proposed project utilized strong partnerships and a creative delivery model to help children get the dental care they need

Myths Like many things we have learned over the years—we have to re-frame our communication with patients… Northern Dental is giving up on our child, handing us off to someone else… They are just baby teeth! They are just baby teeth! You mean I drove all the way down here JUST for an exam?? No treatment?!?

Project Design Partner with KOALA—piloted one event With this project, Northern Dental would: Take on the patient support aspect, leveraging our expertise in assuring appointment success, reduce cancelations and postponements due to insurance glitches; Provide transportation assistance; Be a trusted liaison to the pediatric office; Dedicate staff time to educate the families, and follow up with them; Schedule and follow up—a 6 month recall for each child to resume dental home preventive care and address any continued oral health habits/education that can further improve the patient’s health.

Desired Outcomes: …excerpt from pilot proposal children (and their families), between the ages of 1-12, will be provided comprehensive case management to address barriers and to assure their referred pediatric dental care is completed. Objectives: eliminating two of the three typical trips for appointments to Baxter or St. Cloud for pediatric referral care; and increasing the number of completed pediatric specialty care referrals from 22% to 50% in the pilot year.

Preparation: Northern Dental’s Practice Manager worked with the Office Manager from KOALA to ensure all children to potentially be scheduled were qualified KOALA patients. Scheduling: KOALA requested that we schedule six patients an hour confirming all patients at the top of the hour. All paper work needed by KOALA was sent out by Northern Dental to responsible parties along with an appointment preparation letter 10 days prior to their appointment. All appointments were confirmed by phone one week prior to appointment and the day before the appointment. All were offered prepaid gas cards to assist with the travel costs to the appointment. Strategies

Northern Dental provided KOALA : Two operatories for their use Up to two assistants and one patient coordinator to help with patient flow Secure Wi-fi access Instruments to use for screenings Access to digital imaging software Basic screening supplies (chair barriers, bite tabs for radiographs, barrier film, gloves, masks) Patient take home bag supplies: tooth brushes, tooth paste, flossers, stickers, tooth brushing timers, pencils, and bags.

During the first 10 Months: KOALA staff on site at Northern Dental 7 days Northern Dental Case Management Team (Patient Advocates) set up appointments and welcomed families 15 (17%) received transportation assistance to Baxter in person, all others asked for it to be mailed (all were offered) 18 (20%) received help from Patient Advocates with paperwork, scheduling appointments and pre-op exams, and treatment plan explanation ALL received reminder and follow up calls to troubleshoot obstacles 5 (6%) received insurance counseling or referrals to other community agencies

Cost $1,000 per day for KOALA expenses Miscellaneous dental screening supplies 2 Patient Advocate staff members per day $890 for patient transportation assistance 16 hours per month for patient care coordination and event preparation $ 3600 per event $50 per patient

My daughter was referred to KOALA and I was able to get all of her treatment completed thanks to the help from Northern Dental Access Center. They helped me set up an appointment with KOALA in Bemidji. That saved me a lot of driving and money. I only had to go to KOALA’s office one time for her treatment. My daughter recently had her normal checkup and did not have any cavities. She now thinks it is fun to brush her teeth and knows that if she keeps brushing like she is supposed to her teeth won’t hurt like they did when they had cavities. ~ Heather S. I have two foster children both of whom had a lot of decay. I took them to Northern Dental for a checkup only to find out that they’ve had this decay in their mouth for over six months and that both children had been referred to a pediatric dentist at their last visit. I also found out that the children had missed their appointment at that office and were not welcome there anymore. I asked the staff at Northern Dental what I was supposed to do. They helped me get both kids set up to see the pediatric dentist from KOALA that came right to Northern Dental Access Center. The dentist from KOALA was very nice and after their consult both kids were scheduled for their treatment with KOALA within a few weeks. We were able to do their follow up visits at Northern Dental. Having both of these offices work so hard to coordinate this treatment for us was amazing. ~ Linda G. Two of the children referred had outstanding referred treatment for over a year. They were newly in the care of their grandmother who was so thankful for our partnership with KOALA. By being able to complete the consult visit and post op visit at Northern Dental Access Center saved her hours of driving and the large expense of travelling. Both children were seen for a consult in May 2015 and had their treatment completed with KOALA by mid-June Patient Feedback

Lessons Learned