1. Community Dental Health Coordinator (CDHC)

2. 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

3. 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

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

5. 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.

6. 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

7. 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

8. 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

9. 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

10. 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

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

13. 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.

14. 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.

15. 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

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

17. 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

18. States Sending a Letter of Interest

19. 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.

20. 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

21. 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

22. 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

23. 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

24. Population: 140,267 (2000)
Race: 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. Remote Supervision

32. 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

33. 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

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

35. 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

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