Third in a Series: Opportunities in Oral Health
On July 13, the Institute of Medicine released reports calling for expanded access to oral health care. In this post, Paul Glassman, D.D.S., M.A., M.B.A., a professor of dental practice and director of community oral health at the University of the Pacific, Arthur A. Dugoni School of Dentistry, discusses innovative models for improving the oral health of vulnerable and underserved populations. See all the posts in this series.
With the release of the Institute of Medicine (IOM) report on Improving Access to Oral Health Care for Vulnerable and Underserved Populations oral health is again highlighted on the national stage. This report, together with the IOM’s report on Advancing Oral Health in America released earlier this year, represent landmark calls to action on improving the oral health of the nation. I was privileged to serve on the IOM Committee on Oral Health Access to Services that produced the “Improving Access” report.
In a time when resources are dwindling, and public programs are being reduced, I find hope and opportunity for the future of oral health care for vulnerable and underserved populations. Generally in times when things are going well, people become complacent with the status quo and policy-makers are reluctant to contemplate big changes. Now, however, there is strong desire to find innovative solutions that will improve quality and lower costs.
At the highest level, the Affordable Care Act established the Center for Medicare and Medicaid Innovations (CMMI) at the Centers for Medicare and Medicaid Services (CMS). The new Center has $10 billion to “test innovative payment and service delivery models to reduce program expenditures, while preserving or enhancing the quality of care for those who get Medicare, Medicaid or CHIP (Children’s Health Insurance Program) benefits.” Oral health advocates inside and outside CMS are urging the Center to include oral health innovations in its portfolio of activities.
The IOM reports also urge expanding use of previously tested models and further testing of innovative models for improving oral health of vulnerable and underserved populations. There are a number of models that have been developed that can potentially help more people get better oral health at lower cost. In this blog posting, I’ll briefly describe several I am familiar with although there are many others that are ongoing as well.
The California Dental Pipeline Program, funded by The California Endowment, is a part of the Dental Pipeline Program, originally funded by the Robert Wood Johnson Foundation. The 23 dental schools that participated in some aspect of this program nationally increased the number of underrepresented minority and low-income students accepted to dental schools, incorporated curriculum materials and experiences to raise the level of cultural competence of dental graduates, and expanded the time dental students spend in community clinics as a part of their educational programs. These efforts all contribute to an expanded pool of culturally competent future dentists and expanded services for low-income and diverse populations seeking care in the nation’s safety net dental clinics. There are several published evaluations of the national Dental Pipeline Program.
The California Dental Pipeline was unique in that it involved all the California dental schools in a strong partnership with the California Primary Care Association (CPCA) and the California Dental Association (CDA). This collaboration, now in its ninth year, has produced a number of unique results. There are almost 50 community clinics in California where dental students rotate or where dental residents receive their education. The California schools work together to recruit underrepresented minority and low income students, and the dental schools work with CPCA and CDA on many other related activities. The California Pipeline collaboration has begun a Pipeline Learning Institute where schools, clinics and other stakeholders share lessons and best practices. There are efforts underway to expand this Pipeline Learning Institute nationally.
Another innovative model with potential to realize the vision of the IOM reports is called the Virtual Dental Home. Designed to improve oral health of vulnerable and underserved populations, this model is being demonstrated in nine sites across California. The populations being served range from children in Head Start centers and elementary schools to older or disabled adults in residential care settings and nursing homes. In this model, allied dental personnel work in community locations and collaborate with dentists who are not in these locations to form a distributed system of care. They use telehealth technology to collaborate with dentists. After consultation with the dentist, they are able to keep the majority of people in these locations healthy using health promotion and prevention education; dental disease risk assessment; preventive procedures such as application of fluoride varnish, dental sealants, dental prophylaxis and periodontal scaling; placing carious teeth in a holding pattern using interim therapeutic restorations (ITR); and tracking and supporting the individual’s need for and compliance with recommendations for additional and follow-up dental services. Placing ITRs has been approved for this project by the California Office of Statewide Health Planning and Development under the Health Workforce Pilot Project application #172.
Finally I’ll briefly mention two other activities that support the IOM vision. In one, a California demonstration project funded by First5 of San Bernardino, trains nurses and social workers to perform an oral health risk assessment for children at risk of having a developmental disability. The nurses and social workers perform the risk assessment, triage family needs, provide education and information and apply fluoride varnish for children at risk of developing dental caries. Integrating oral health activities into the professional activities of nurses and social workers could be a key to vastly increasing the number of professionals engaged in oral health activities.
The last activity I’ll mention is an effort at the Pacific Center for Special Care at the University of the Pacific School of Dentistry to develop incentive systems that can drive activities toward efforts most likely to improve the oral health of vulnerable and underserved populations. As the IOM reports indicate, incentive systems are critical components of any efforts to improve oral health and it is critical that we align these incentive systems to produce the most value in terms of oral health for vulnerable and underserved populations.
So, the good news in difficult times is that we have unprecedented opportunities to explore innovative ways to improve health and reduce the cost of health care for vulnerable and underserved populations in order to realize the vision of the IOM reports. We need to continue to support the work described here as well as other innovative solutions.