1. Essential Elements for the State Oral Health Program Quilt Bev Isman, RDH, MPH, ELS Reg Louie, DDS, MPH UCSF Dental Public Health Seminar Series February 5, 2013 Funded by CDC Cooperative Agreement 5U58DP001695-05

2. Presentation Overview ASTDD and State Oral Health Programs Background and Purpose of Infrastructure and Capacity Enhancement Project ASTDD Resources Developed for States Research Methods, Study Findings and Lessons Learned Selected State Case Studies Recommendations & Possible “Next Steps ”

3. ASTDD A national non-profit organization representing staff of state public health agency programs for oral health. Collaborates with more than 25 organizations and federal agencies to accomplish its mission and to share best practices, evidence-based strategies and resources to support improvements in oral health programs. State members and 100+ associate members

4. State Oral Health Program (SOHP) Unit of state government, usually in the public health department Each state differs in how the program is designated, funded, and staffed and what services are provided States are charged with monitoring the health (including oral health) of its citizens and promoting proven, cost-effective ways to prevent disease Programs partner with other state and community groups to perform the 3 core public health functions of 1) assessment, 2) policy development and 3) assurance

5. Background Recognition that improved OH infrastructure is needed at national, federal, state & community levels to assure oral health for US Surgeon General’s Report: Oral Health in America Healthy People Objectives National Call to Action NIDCR study by Tomar CDC and ASTDD recognized the need to review status of SOHP Infrastructure and Capacity

6. CDC Funded Baseline Survey: 1999 Delphi Survey; 43 state responses 19% had a state-based oral health surveillance system 38% had a state oral health improvement plan 48% had an oral health advisory committee/coalition representing a broad- based constituency

7. Efforts Since 1999 ASTDD 2000 report, Building Infrastructure & Capacity in State and Territorial Oral Health Programs - 10 top infrastructure and capacity elements to address 10 Essential PH Services CDC and HRSA used the elements in their funding opportunities CDC funded ASTDD to develop resources and provide technical assistance to states

8. Definitions Infrastructure is the basic physical and organizational structure and support needed for the operation of a society, corporation or collection of people with common interests Capacity is the actual or potential ability to perform activities or withstand threats Quilt is a single piece that can be a work of art, constructed by a team following a pattern and comprised of many individual elements

9. 10 Essential PH Services for OH 10 Essential PH Services to Promote Oral Health in the US * Assessment t 1. Assess oral health status and implement an oral health surveillance system 2. Analyze determinants of oral health and respond to health hazards in the community 3. Assess public perceptions about oral health issues and educate/empower them to achieve and maintain optimal oral health** Policy Development 4. Mobilize community partners to leverage resources and advocate for/act on oral health issues 5. Develop and implement policies and systematic plans that support state and community oral health efforts Assurance 6. Review, educate about and enforce laws and regulations that promote oral health and ensure safe oral health practices 7. Reduce barriers to care and assure utilization of personal and population-based oral health services 8. Assure an adequate and competent public and private oral health workforce 9. Evaluate effectiveness, accessibility and quality of personal and population-based oral health promotion activities and oral health services 10. Conduct and review research for new insights and innovative solutions to oral health problems *

10. Guidelines for State and Territorial Oral Health Programs Key document based on 10 Essential Public Health Services to Promote Oral Health in the US and the 3 core PH functions Matrix of State Roles, Activities and Resources Used in the mentoring program; program reviews; advocacy for oral health, state program support and policy change; to develop a state oral health plan

11. Competencies for State Oral Health Programs 78 Competencies in 7 domains with progression of skill levels   Focus on Core PH Functions and Essential Services for the whole program; clinical competencies not included   Integrated into mentoring program, state OH program reviews and technical assistance (TA)   State and local health agencies use for strategic planning, to develop scopes of work, align staffing skills, advocate for additional resources to fill gaps in skills, and to create team or individual professional development plans.

12. Orientation and Mentoring Program Orientation webinars acquaint new members and associate members with ASTDD and the resources available Mentoring program pairs a new dental director with an experienced dental director to communicate via phone, email or site visits to provide guidance/peer support in developing and administering a strong state program to improve the oral health of a state’s residents Mentees note how this program increased their knowledge, confidence and skills in a variety of areas

13. State Oral Health Program Review (SOHPR) Includes a variety of self-assessment tools: SWOT analysis, core data set checklist, budget worksheet, briefing booklet Guide for states to request a comprehensive oral health program review by a team with diverse areas of expertise Reviews help with strategic planning and program prioritization, rallying support from and collaboration with multiple stakeholders, increasing program visibility and highlighting successes, identifying TA needs and need for additional resources 20 reviews since 1986, most recent in AK and MA (will discuss later)

14. Best Practices Project Purpose: Build more effective state, territorial and community oral health programs Best Practice Approach Reports: 12 with more coming State and Community Practice Examples: 200+ Most viewed portion of the ASTDD website States use to make decisions and improve programs

15. ASTDD 7 Step Model Designed to make needs assessment simpler and more manageable Step-by-step guide Can be adapted to specific community resources and objectives The process provides integrated information about health status, the existing health system and health resources

16. National Oral Health Surveillance System (NOHSS) Designed to monitor burden of oral disease, use of the oral health care delivery system, and status of community water fluoridation on a national and state level 9 indicators: 4 adult OH, 3 child OH, 1 fluoridation status, and 1 oral cancer Programs use frequently for state comparisons and in grant writing and reports to policymakers

17. Basic Screening Survey (BSS) A tool for obtaining data for an oral health surveillance system to monitor the burden of oral disease without overtaxing limited human resources in collecting data Manuals, examiner training videos, implementation packets and other associated materials are available for children (primarily 3 rd grade and preschool) and for older adults ASTDD consultants provide more than 100 hours of TA to states each year Many states have published oral disease burden documents 3 rd grade data have been submitted by 44 states to NOHSS as of 2012 Translated into Spanish and used by Children International in 11 countries last year to screen 125,610 children to triage into care

18. State Synopses of Oral Health Programs An annual report and a website contain state information useful in tracking progress toward Healthy People objectives Display trends in demographics, infrastructure, workforce, administration, budget, and programs across multiple years Programs use the information similar to how they use NOHSS; ASTDD uses for trend analysis

19. Policy Assistance

20. ASTDD Committees and Focus Areas to Help States   Best Practices   Communications   CSHCN   Data and Surveillance   Emergency Preparedness and Response   Evaluation   Fluorides   Head Start and Early Childhood   Healthy Aging   Perinatal   Policy   School and Adolescent Oral Health   State Development and Enhancement

21. ASTDD Communication Tools Annual report Quarterly newsletter Weekly News Digest Website Multiple targeted listservs Webinars Exhibit booth Annual meeting and the National Oral Health Conference in April

22. Infrastructure Enhancement Project (2010-present) CDC funded ASTDD to review current status of SOHPs and progress over the past decade Final report: State Oral Health Infrastructure and Capacity: Reflecting on Progress and Charting the Future

23. Report Methodology Reviewed and analyzed : State Synopses and other data from 2000-2010 CDC DOH-Funded States’ Evaluation Reports CDC, HRSA and ASTDD Investments in State Oral Health Programs Conducted Interviews of Collaborations between State MCH-Title V and SOHP (20 states) Conducted Interviews of SOHPs and other stakeholders (10 states)

24. Format and Content of IEP Report Identified Key Infrastructure/Capacity Elements for SOHPs IEP Study Findings: Current status and trends for SOHP structure/org placement/staffing, funding SOHP ability to perform Core Public Health Functions and 10 Essential Public Health Services Lessons Learned and Recommendations by Infrastructure/Capacity Elements Next Steps

25. State Oral Health Program Infrastructure Elements

26. IEP Overall Study Findings From 2000-10, considerable investments from Federal/state governments & others > tools, resources and funding opportunities Enhanced/broadened OH surveillance and epidemiology infrastructure, capacity, expertise > states with state oral health plans Overall increased SOHP budgets and staffing but many fluctuations and recent decreases No “ideal” staffing model > evidence-based primary prevention policies and programs

27. SOHP Placement and Authority in Health Agency Statutes in 20 states require a state oral health program in the public health agency 16 require a state dental director 13 require both organized as programs (21), offices (9), units (5), sections (5), bureaus (4); the rest are branches, divisions or service areas; these change with reorganizations in health agency

28. Dental Directors (SDD) In 2010, 7 states had SDD vacancies 21/43 SDD (48.8%) had held the position for less than five years, 13 (30.2%) for five to nine years, and 9 (20.9%) for 10-24 years 12 states had directors that had been in the position for less than one year States with a full-time director increased from 61% in 2000 to 80% in 2010 10 (19.6%) did not have a dental professional as the director; 17 states (33.3%) had a dental professional with a public health degree

29. Staffing States that provide or support clinical service programs have larger staffs, e.g. three states have 500, 120, and 63 staff States with two or fewer FTE staff has decreased from 41% in 2000 to 12% in 2010 Those with 5 to 20 staff has increased from about 20% to 41% Improved access to staff within or outside agency with specific expertise, e.g., epi, evaluation No one staffing model is appropriate for all states

30. Program Funding Concerns 21 states reported budget decreases from 2010 to 2011; one state lost their primary funding source (state general fund dollars); another state’s budget decreased from more than $3 million to less than $250,000, with corresponding elimination of programs and staff 10 states reported no budget change; 16 reported a budget increase; budgets vary widely depending on grants available 8 states received 100% of funding from one primary source 14 states receive no direct MCH Block Grant funding, while three are 100% MCH funded

31. State Oral Health Program Activities Oral health education and promotion (92%) Dental sealants (78%) Dental screening (74%) Early childhood caries prevention (74%) Access to care (64%) Fluoride varnish (62%) Programs for pregnant women (54%) Fluoride mouthrinse (50%) Abuse/neglect education or PANDA (20%) Fluoride supplements (tablets) (18%) Mouthguard/injury prevention (10%).

32. Prevention Program Successes In 2000, about 193,000 children received dental sealants through 25 state sealant programs In 2010, 40 states had a sealant program that served almost 400,000 children Fluoride varnish program increased from 23% of states in 2002 to 62% of states in 2010 Programs for pregnant women have increased from 45% in 2005 to 54% of states in 2010

33. Problems with Snapshot Reports Recent Pew Report, Falling Short. Most States Lag on Dental Sealants Examples: MO, CA Need for continued trend analysis paired with reasons for changes

34. Oral Health Needs Assessment and Planning Substantial improvement since 2000 in collecting core state OH data for N/A and planning Nine states reported improvements in OH defined as a decrease in the prevalence of untreated decay or an increase in prevalence of sealants in 3 rd graders 20 states collect OH data from their state’s PRAMS 50 states are reporting water system fluoridation status and updates, while 28 states report some level of monthly operational data to CDC’s Water Fluoridation Reporting System (WFRS) In 2010 CDHP collected state OH plans from 42 states

35. Oral Health Coalitions In 2007, an Oral Health America survey showed 41 states with a state oral health coalition As of 2011, 28 state coalitions had joined the American Network of Oral Health Coalitions (ANOHC) Children’s Dental Health Project is creating a database of OH coalitions

36. Lessons Learned – SOHP Placement and Resources Organizational placement of SOHP can be influential Diversified funding is advantageous Support for more than just the SOHP is key, e.g., support for local programs Single funding source can jeopardize a SOHP

37. Lessons Learned – Leadership, Staffing & Partnerships Successful SOHP needs a continuous, strong, credible leader to create partnerships and leverage available assets Key to address 10 Essential PH Services & SOHP Competencies SOHP need not be BIG – but need to be strong and forward thinking/visionary Need advocates/coalition/partners with financial and political clout Must take advantage of leadership/professional development opportunities

38. Lessons Learned – Surveillance Capacity Data drives decision-making and needs to be current (within 5 years) Need surveillance with sound analysis and dissemination Strategic and effective sharing of data reports promote understanding of OH and disease prevention programs and the need for and value of funding these evidence-based programs

39. Lessons Learned – State Planning & Evaluation Capacity Need current/comprehensive SOHP plan with a practical evaluation component. Allows SOHP to assess and communicate its relevance, progress, efficiency, effectiveness and impact Evaluation must engage stakeholders Evaluation can help build infrastructure and enhance sustainability when results are used to improve programs, increase program visibility and demonstrate program achievements

40. Lessons Learned – Evidence-Based Prevention & Promotion Programs & Policies States with documented improvements in OH status of residents have strong EB local programs with quality guidance/support from the SOHP Local programs without guidance/support are not always successful States with local programming limited to OH education have not seen improvements in OH status of the children they serve

41. Lessons Learned - Resiliency Resiliency of an organization relates to the ability to bounce back following some environmental, financial, political, public relations or other challenge, misfortune or disaster The ability to scale programs up and down in response to the environment, and the ability to identify and sustain core elements can help to sustain programs in challenging times

42. Key Messages from the IEP Report State oral health programs make an essential contribution to public health and must be continued and enhanced. Successful SOHPs need: diversified funding for state and local evidence-based programs a continuous, strong, credible, forward-thinking leader complement of staff, consultants and partners with proficiency in the ASTDD Competencies one or more broad-based coalitions that include partners with fiscal and political clout valid data (oral health status and other) to use for evaluation, high quality oral health surveillance, a state oral health plan with implementation strategies, and evidence-based programs and policies

43. State Case Studies from Previous UCSF Seminars North Carolina New Mexico New York California

44. Case Study: New Hampshire Leadership/staffing Use of national and regional resources Integration within Health Dept and focus of activities Planning, policies, legislation Diversified funding Links to local programs

45. Results from SOHPR - Alaska SOHPR Documents support SOHP Planning Leadership/staffing Promotion of Oral Health within Department of Public Health and focus of activities Planning, policies, legislation Importance of linkages with other programs and partners Links to local programs

46. Results from SOHPR- Massachusetts SOHPR Documents support SOHP Planning Leadership/staffing Promotion of Oral Health within Department of Public Health and focus of activities Planning, policies, legislation Importance of linkages with other programs and partners Links to local programs

47. IEP Recommendations (1) RECOMMENDATIONS (in order of the infrastructure elements as shown in Figure 3, but not prioritized) STAKEHOLDERS Federal Govern- ment ASTDD, National Organiza- tions & Partners State Public Health Agency State Oral Health Program Other State Organiza- tions & Partners Local Public Oral Health Program Other Local Organiza- tions & Partners RESOURCES 1.Provide coordinated and sustainable base funding for federal, State and local oral health programs.  2. Identify and procure diversified funding sources for state and local oral health programs.   3. Leverage resources to support oral health programs and initiatives.   4. Expand and strengthen the availability of local oral health resources to bring public oral health programs to diverse and under-served populations.  5. Promote use of current tools and technical assistance to strengthen state and local oral health programs.  6. Position public oral health programs in a prominent position within the public health agency structure. 

48. IEP Recommendations (2) RECOMMENDATIONS (in order of the infrastructure elements as shown in Figure 3, but not prioritized) STAKEHOLDERS Federal Govern- ment ASTDD, National Organiza -tions & Partners State Public Health Agency State Oral Health Program Other State Organiza -tions & Partners Local Public Oral Health Program Other Local Organiza -tions & Partners LEADERSHIP, STAFFING, PARTNERSHIPS 7. Develop and adopt a common vision and goals for oral health among federal, state and local agencies and national partners while acknowledging there are dif- ferent strategies and structures for achieving the goals.  8. Promote, provide and support leadership and professional development opportunities.   9. Staff federal, state and local oral health programs with qualified public health/oral health professionals whose skills match the job functions.   10. Strengthen State oral health leadership, consistent with the ASTDD Competencies.  11. Promote and support partnerships between the public and private sectors to improve oral health at the State and local levels.  12. Promote and support partnerships between maternal and child health, chronic disease, and other public health programs and payors to address social determinants and other factors that impact public health.  13. Increase emphasis on dental public health issues in undergraduate and graduate dental and dental hygiene programs, dental residencies, and any new specialty programs for dental hygienists. 

49. IEP Recommendations (3) RECOMMENDATIONS (in order of the infrastructure elements as shown in Figure 3, but not prioritized) STAKEHOLDERS Federal Govern- ment ASTDD, National Organiza- tions & Partners State Public Health Agency State Oral Health Program Other State Organiza- tions & Partners Local Public Oral Health Program Other Local Organiza- tions & Partners SURVEILLANCE CAPACITY 14. Ensure that there is capacity for development, implementation, and evaluation of State oral health surveillance systems; data analysis; and use of data to guide decision making and educate the public and policymakers.  15. Ensure there is high quality oral health surveillance and broad dissemination as part of overall public health surveillance.   16. Collaborate to integrate oral health data with other health survey data, e.g., height and weight.  

50. IEP Recommendations (4) RECOMMENDATIONS (in order of the infrastructure elements as shown in Figure 3, but not prioritized) STAKEHOLDERS Federal Govern- ment ASTDD, National Organiza -tions & Partners State Public Health Agency State Oral Health Program Other State Organiza -tions & Partners Local Public Oral Health Program Other Local Organiza -tions & Partners STATE PLANNING, EVALUATION CAPACITY 17. Engage in ongoing and strategic collaborative state-level oral health planning to address the oral health of the population throughout the lifespan and to promote equity among all subpopulations.  18. Develop and sustain capacity to conduct comprehensive evaluation of public oral health infrastructure and programs at all levels and use evaluation findings to guide decision making.  

51. IEP Recommendations (5) RECOMMENDATIONS (in order of the infrastructure elements as shown in Figure 3, but not prioritized) STAKEHOLDERS Federal Govern- ment ASTDD, National Organiza- tions & Partners State Public Health Agency State Oral Health Program Other State Organiza- tions & Partners Local Public Oral Health Program Other Local Organiza- tions & Partners EVIDENCE-BASED PREVENTION & PROMOTION PROGRAMS & POLICIES 19. Develop and monitor public policies that promote oral health and evaluate the impact of policy changes.  20. Assess public opinions, awareness, knowledge, and behaviors and use the data to design effective communication strategies targeted to the public and policymakers to promote oral health and the importance of oral health to the overall health of the population throughout the lifespan.   21. Promote and support the translation/transferring of research evidence into promising implementation models at State/local levels and evaluate the impact.  22.Implement culturally relevant, evidence-based programs that prevent disease and promote oral health across the lifespan.  

52. Next Steps for ASTDD and Partners Resources Leadership, Staffing and Partnerships Surveillance Capacity State Planning, Evaluation Capacity Evidence-Based Prevention & Promotion Programs & Policies

53. Key References State Oral Health Infrastructure and Capacity: Reflecting on Progress and Charting the Future : http://www.astdd.org/docs/Infrastructure_Enhance ment_Project_Feb_2012.pdf http://www.astdd.org/docs/Infrastructure_Enhance ment_Project_Feb_2012.pdf ASTDD Guidelines for SOHPs: http://www.astdd.org/state-guidelines/ http://www.astdd.org/state-guidelines/ ASTDD Competencies for SOHP and Tools for Competency Assessment: http://www.astdd.org/docs/CompetenciesandLevel sforStateOralHealthProgramsfinal.pdf http://www.astdd.org/docs/CompetenciesandLevel sforStateOralHealthProgramsfinal.pdf

54. Thank you! Questions contact: bev.isman@comcast.net reglouie@sbcglobal.net bev.isman@comcast.net reglouie@sbcglobal.net