Category Archives: Access and barriers to care

Feb 21 2012

How Central Massachusetts Increased Access to Oral Health Care for Low-Income Children

February is National Children’s Dental Health Month, so the Human Capital Blog reached out to John Gusha, DMD, PC, a 2003 Robert Wood Johnson Foundation (RWJF) Community Health Leader, to learn more about children’s oral health. As project director of the Central Massachusetts Oral Health Initiative, Gusha mobilized dozens of dental societies and non-profit groups to provide dental care for low-income residents of Worcester County. Although funding for the Oral Health Initiative has ended, many of the programs Gusha helped create are still in place.


Human Capital Blog: What spurred the Central Massachusetts Oral Health Initiative? What made you aware of this need for oral health care in your community?

John Gusha: There was a special legislative report in 2000 that described disparities in access to oral health care for low-income populations. It raised a lot of questions about what we could be doing in the community and in the dental society to address these gaps. We got funding from the Health Foundation of Central Massachusetts, which also saw this as a critical need for our area, to launch the initiative.

HCB: Tell us about the school-based programs you put in place.

Gusha: The decay rate in Worcester County schools was very high—more than one-third of the students had active decay in their mouths. It was especially prominent in schools with high numbers of free and reduced price lunches, where students came from low-income families that are more likely to be using Medicaid. These students didn’t have access to care and weren’t getting the preventive services they needed.

We started a school-based program that is now in place in more than 30 Worcester County schools. Dental hygiene students from a local community college provide fluoride varnishes, cleanings and other preventive services to students, and the University of Massachusetts’ Ronald McDonald “Care Mobile” visits schools to offer the same services. Community health centers also participate in these programs by adding dental to their school-based health centers. In the past you could go to schools and provide services, but Medicaid rules didn’t allow you to get reimbursed. We were able to help get those rules changed so the program could become sustainable.

HCB: You also had a role in creating a dental residency program and training primary care providers to screen for oral health needs.

Gusha: We wanted to better integrate dentistry into medicine. The University of Massachusetts was the administrator of our program, and the team there developed a dental residency program at the medical school. The University had no classes in oral health before this. The local hospitals were in desperate need of professionals with this kind of training, particularly in emergency rooms. The Medicaid population was presenting there frequently for treatment because they had nowhere else to go, and people with other issues like cardiac problems or cancer needed clearance on their oral health in order to proceed with treatment.

The residency program is still in place at our two local community health centers, and it’s grown now to include education for other disciplines.

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Oct 18 2011

The Problem of Limited Access for the Uninsured and Underinsured May Not Be So Bleak

Erica Spatz, MD, is a Robert Wood Johnson Foundation Clinical Scholar (2008-2011) at Yale University. Read more about the Project Access case study published in Health Services Research.


In many communities it is challenging to provide care for patients without insurance or with Medicaid, especially if they have complex or urgent health care needs. Getting approval for a diagnostic test or a timely appointment with a specialist - if it’s to happen at all - often requires several phone calls to empathic colleagues, cashing in on favors, and extensive coordination to make it all happen.

With a small pool of specialty physicians providing care for uninsured and underinsured adults, there is a limited capacity to provide timely care. Wait-times for appointments are long, and this often results in fragmented care plans, disease advancement and overuse of emergency departments and hospitals.

The supply-demand mismatch may get worse as strapped states cut Medicaid reimbursement levels to physicians and as the Patient Protection and Affordable Care Act takes effect, expanding Medicaid eligibility to an additional 15 million adults. In a recent New York Times guest editorial, Killing Medicaid the California Way, Bruce C. Vladeck, PhD, former assistant vice president of the Robert Wood Johnson Foundation (RWJF) and administrator of Medicare and Medicaid from 1993 to 1997, and Stephen I. Vladeck, JD, a professor of law at American University, give a grim account of the legal and political forces that may perpetuate provider shortages and ultimately threaten the equal access mandate.

But the problem of limited access for the uninsured and underinsured may not be so bleak. In 2008, six RWJF Scholars from Yale University (Erica S. Spatz, MD, MHS; Michael S. Phipps, MD, MHS; Katherine Goodrich, MD, MHS; Danil V. Makarov, MD, MHS; Kate V. Viola, MD, MHS; and Oliver J. Wang, MD, MBA, MHS) joined a local effort to bring a program called Project Access to New Haven, CT. Project Access expands the pool of providers for the uninsured by encouraging local specialty physicians and area hospitals to donate care; Project Access employs patients navigators to coordinate care and to address patient-level barriers to care delivery.

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Sep 2 2011

Nonfinancial Barriers to Care

In a new study, RWJF Clinical Scholar Jeffrey T. Kullgren, M.D., M.S., M.P.H., and colleagues find that more U.S. adults postpone or go without medical care for nonfinancial reasons than for financial reasons. These barriers, such as inability to find a primary care physician, or limited office hours, are common and limit patient access to health care.

Read the story on the Human Capital Web site, and tell us what you think by taking the poll below.

Aug 15 2011

Fifth in a Series: Advancing a Vision of Access to Quality Oral Health Care for Everyone

By David Krol, M.D., M.P.H., F.A.A.P.

RWJF Human Capital Portfolio Team Director and Senior Program Officer


“Everyone has access to quality oral health care across the life cycle.”

That was the vision formed by a varied group of individuals from dentistry, dental hygiene, medicine, public health, nursing, economics, law, social work and philanthropy as they wrote the second of the Institute of Medicine’s reports on oral health, “Improving Access to Oral Health Care for Vulnerable and Underserved Populations.” I had the privilege of being a member of that committee. Our report was released on July 13th, 2011.

Our task was an expansive one. We were asked to:

  • Assess the current U.S. oral health system of care;
  • Explore its strengths, weaknesses and future challenges for the delivery of oral health care to vulnerable and underserved populations;
  • Describe a desired vision for how oral health care for these populations should be addressed by public and private providers (including innovative programs) with a focus on safety net programs serving populations across the lifecycle and Maternal and Child Health Bureau programs serving vulnerable women and children; and
  • Recommend strategies to achieve that vision.

Piece of cake right?!

Well, as you might guess, we found numerous, persistent and systemic barriers and challenges that vulnerable and underserved populations face in accessing oral health care. Those barriers include social, cultural, economic, structural, and geographic factors. We also recognized that these barriers contribute to profound and enduring oral health disparities in the United States. Americans who are poor, minority, or have special health care needs suffer disproportionately from dental disease and receive less care than the general population. It’s a sobering reality in that many of us take oral health care for granted or don’t even think about it at all until we are forced to.

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Aug 3 2011

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.

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Jul 28 2011

Second in a Series: A Call to Action on Oral Health Care

On July 13, the Institute of Medicine released reports calling for expanded access to oral health care. Esther Lopez, D.D.S., a graduate of the Robert Wood Johnson Foundation (RWJF) Dental Pipeline program, gave the following interview to the Human Capital Blog on the reports, as part of our ongoing Voices from the Field series. Lopez is a volunteer dentist and member of the Dental Advisory Committee at Goldie’s Place, a support center for the homeless in Chicago which houses a dental clinic. See all the posts in this series.


Human Capital Blog: The IOM report recommends the integration of oral health care into overall health care by training non-dental health care professionals to screen for oral disease and administer preventive care. What do you think of this approach to reaching underserved populations?

Esther Lopez: I definitely agree with this, mostly for the obvious reason that people who are losing out in dental health care are children and the elderly. Those two populations are the ones that visit primary providers the most – for a simple cold, the flu, a slip and fall accident – so having exposure to primary providers and non-dental health care professionals would be easier and more accessible. In order for this to happen we have to have more training available for these non-dental professionals. I see a lot of patients who come to Goldie’s Place with dental abscesses and things that need to be drained, that could be drained at a hospital. They go to a hospital are told that nothing can be done for them.

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Jul 25 2011

First in a Series: A Call to Action on Oral Health Care

On July 13, the Institute of Medicine released reports calling for expanded access to oral health care. In this post, Denise Davis, Dr.P.H, M.P.A., an RWJF program officer and the guiding force behind the Robert Wood Johnson Foundation (RWJF) Dental Pipeline program, discusses the consequences of a decade of inaction, the most promising courses at this time of fiscal constraint at the federal and state levels, and invites readers to share their views. See all the posts in this series.


Ten years after the release of the Surgeon General’s report describing the oral health crisis in America, little has changed. This year, in an effort to bring this critical issue back into the spotlight for policy-makers, clinicians and the American public, the Institute of Medicine (IOM), released two reports – one in concert with the National Research Council.

These reports, Advancing Oral Health in America and Improving Access to Oral Health Care for Vulnerable and Underserved Populations, build on the Surgeon General’s report of 2000 highlighting the importance and centrality of good oral health to overall health. The former highlights the need for leadership in this area by the U.S. Department of Health and Human Services and presents a set of organized ideals for creating improvement while the latter provides a vision for oral health access and quality for all Americans.

These reports reiterate where persistent gaps in oral health access and care delivery exist and suggest what organized principles and system-level changes should be adopted to improve the current status of many underserved and vulnerable groups.

Unfortunately, progress in the area of oral health for the most vulnerable within our population is painstakingly slow, as evidenced by the previous decade of inaction. Given the current fiscal constraints at the federal and state levels, it will be critically important to give consideration to the recommendations in these reports while simultaneously looking into other approaches such as foundation studies, creative multi-stakeholder innovative demonstrations, state-level projects, etc. in order to stimulate future progress.

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Jun 29 2011

Fourth in a Series: "Nothing Has More Strength than Dire Necessity"

The AARP Solutions Forum: “Advancing Health in Rural America: Maximizing Nursing’s Impact,” was held on June 13. This post is the fourth in a series in which Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholars share their thoughts on the ideas presented. The author, Elizabeth A. Kostas-Polston, Ph.D., A.P.R.N., W.H.N.P.-B.C., is an assistant professor at Saint Louis University School of Nursing. Find out more about the forum or view the archived webcast.

Nearly one in four Americans—70 million people—live in rural America. On average, they are older, poorer, more likely to be uninsured, and suffer from higher rates of chronic health conditions.1


For the past 15 years, I have lived in south central Missouri, in a small town—population ~12,000 rural Americans. I am a nationally, board certified Women’s Health Nurse Practitioner and Colposcopist. In this role I participate by providing primary and specialty health care to rural, underserved and uninsured women who are often the target of Healthy People 2020 indicators. What’s more, the women I care for are not just faces in the crowd. They are my children’s teachers, colleagues’ wives and daughters, the lady who waits on me at the post office, the woman who rings up my groceries, my children’s friends, and my friends’ daughters—all of whom make up our community. It is no surprise, then, that the primary aim of my practice is to improve the health of women and their families. Improving the health of women and their families, in turn, positively impacts the health of our community.

As I listened to nurses such as the Honorable Mary Wakefield and Gail Finley share their thoughts regarding the challenges and opportunities that simultaneously exist as Nursing purposely and strategically moves to make its mark on the improvement of health care in rural America, I could not help but reflect on the numerous barriers which continue to interfere with my ability to practice to the full extent of my education, training, and competence.

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Jun 23 2011

Third in a Series: "Take Me Home, Country Roads to the Place Where I Belong... and Can Get the Health Care I Need!"

The AARP Solutions Forum: “Advancing Health in Rural America: Maximizing Nursing’s Impact,” was held on June 13. This post is the third in a series in which Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholars share their thoughts on the ideas presented. The author, Laurie Theeke, Ph.D., R.N., is an assistant professor of nursing at West Virginia University in Morgantown, West Virginia, and her research emphasizes the development of interventions that target loneliness as a psychosocial stressor that impacts overall health. Find out more about the forum or view the archived webcast.


I recently had the opportunity to listen to the AARP Solutions Forum, “Advancing Health in Rural America – Maximizing Nursing’s Impact.” I was thrilled to be able to hear about the continuing emphasis on rural health care. As a native of Appalachia, a long-term resident of West Virginia, and a Clinical Nurse Specialist in Gerontology, I often think about how we could better serve our older adults who are living in poverty with limited resources and complex chronic illness.

As I listened, I thought about how attached many of my patients are to rural living in Appalachia. Nearly everybody in the region knows the words to this popular song, “Take me Home, Country Roads” and I kept thinking that it would be wonderful if health care was available and affordable for all rural residents without having to take the long country road back to a more urban area, particularly in the winter months.

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Jun 21 2011

Second in a Series: What My Grandmother Taught Me

The AARP Solutions Forum: “Advancing Health in Rural America: Maximizing Nursing’s Impact,” was held on June 13. This post is the second in a series in which Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholars, who viewed the forum live, share their thoughts on the ideas presented. The author, Andrea Wallace, R.N., Ph.D., is an assistant professor at the University of Iowa College of Nursing and focuses her research on finding means of improving outcomes for those living with chronic illness, particularly for vulnerable patient populations. Find out more about the forum or view the archived webcast.


While watching last Monday’s forum, “Advancing Health in Rural America: Maximizing Nursing’s Impact,” I was forced to reflect on how my own early experiences in the frontier west shaped my current passion for quality improvement and implementation science.

At a tender age, I watched my beloved grandmother—who lived on a farm 18 miles of dirt road off a two-lane state highway, 40 miles from a town of 5,000—develop complications from a vascular condition. My family was fortunate in that it didn’t take my parents long to discover the vast differences in the quality of services available in my grandparents’ rural community, compared to those in urban Denver. So, multiple times per year, with the assistance of a large vascular center’s RN case manager, my parents would arrange for her to be seen in Denver, often driving eight hours to make it happen.

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