The U.S. Oral Health Workforce in the Coming Decade: Workshop Summary (2009)

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10 Workforce Strategies for Improving Access A panel of experts presented examples of established and evolving models of care that aim to increase access to oral health services through workforce strategies in the United States. community dental health coordinator Jane S. Grover, D.D.S., M.P.H. Center for Family Health and American Dental Association Today, many children are not having their oral health needs met. As the number of oral health programs in community health centers increases, there is a corresponding increase in demand for efficient strategies to maxi- mize the use of the existing infrastructure of these centers. Various types of community health workers are already prevalent in many health centers. These individuals are valuable because they work within the community to provide leadership and peer education; to integrate health information into the community’s culture, language, and value system; and to promote oral health literacy to facilitate decision making. The American Dental Association (ADA) has developed a model for oral health care that envisions oral health assessment in an integrated care system centered on improving access to dental services and reducing oral health disparities. The workforce team has the dentist at the head of a team of workers, including lab technicians, office support staff, dental hygien- 81 

82 THE U.S. ORAL HEALTH WORKFORCE ists, dental assistants, and a new member of the dental team known as the community dental health coordinator (CDHC). The CDHC is located in various community locales (e.g., schools, Head Start programs, nursing homes, walk-in clinics) working under the remote supervision of a dentist. The CDHC focuses on health promotion and ­ behavioral change including clinical duties such as risk assessment, education, and radiographic and photographic screening, when needed. Assuming an electronic dental record, the entire team may access this infor- mation to determine the level of care needed. In addition, the CDHC could place sealants and temporary restorations (in preparation for permanent restoration by a dentist). The ADA has funded the development of a new curriculum to train the CDHC, consisting of a number of modules, many of which may be com- pleted online (e.g., advocacy, communication, effective interviewing skills, teaching skills). The curriculum also includes dental skills modules (e.g., introduction to dentistry, screening, and classification) and a ­community- based internship. Potential sources of CDHCs include people who are already members of the local community. CDHCs must be high school graduates and may already be oral health professionals or acting as a gen- eral community health worker, providing assistance with health education, translation, and transportation. As the CDHC model enters pilot testing, outcomes will need to be evaluated, such as how often patients follow through on referrals by the CDHC, improvements in untreated disease among CDHC patients, and increases in the number of patients seen in clinics by CDHCs. Other con- siderations include evaluation of the costs and benefits when using CDHCs as well as their patients’ satisfaction with their services. Conclusions The CDHC curriculum has been developed and funded, and the pilot projects are currently being tested. The ADA is looking to the CDHC to act as a community-based link to the dentist and to expand and increase the efficiency of the existing community health center infrastructure. The educa- tional component of the CDHC will strive to elevate the public’s oral health literacy and help ensure oral health integration into total patient care. dentex: the dental health aide therapist in alaska Ruth Ballweg, M.P.A., PA-C MEDEX Northwest, University of Washington The DENTEX project in Alaska is a partnership between the Alaskan Native Tribal Health Consortium, MEDEX Northwest of the University of 

WORKFORCE STRATEGIES FOR IMPROVING ACCESS 83 Washington (a physician assistant program), and the Yuut Dental Training Clinic in Bethel, Alaska. A large group of philanthropies have come ­together to fund the project, which aims to create a new profession, the dental health aide therapist (DHAT). DHATs are a part of the Community Health Aide Program which was originally established in the 1950s to serve remote Alaskan bush communities. DHATs are at highest level of dental providers in the health aide system; along with prevention-based dental health aides, they provide a range of oral health services. To create a new profession, one needs to concentrate on creating a collaborative model rather than just focusing on the training program. The training should be based on competency wherein you first determine what you want the practitioners to do and work backwards to develop the pro- gram. In that same vein, accreditation, licensing, evaluation, and reimburse- ment of the new profession needs to be determined first. Models for new types of practitioners should focus on community-specific recruitment and structured deployment to facilitate retention. Finally, other pro­fessionals that will be working with these new practitioners need to be involved in training and supervision. Special Needs of Alaska Natives Special concerns exist for the oral health of Alaska Natives. There is a subsistence lifestyle with low socioeconomic status. Transportation is difficult due to high costs and widely dispersed villages (many of which are off the road system). Tribal systems are divided into Native Health Corporations that provide care, each with its own administration, budget, and advisory board. Due to its extreme rural characteristics, Alaska is in many ways like a developing country. Therefore, the format for health care should look different, and duplication of services is not going to work. For example, years ago, villages picked one individual responsible for the daily disbursement of tuberculosis medicines, forming the model for the modern community health worker. Finally, Alaska Natives suffer from caries rates that are several times higher than the national average and, largely due to the geographic concerns described, it is difficult to have dentists or dental hygienists visit each village at the necessary intervals. Training Program and Practice Model Dental therapy models have a long-standing history worldwide and an exceptional safety record; the DENTEX training program is based on those models. The 2-year certificate program is specifically designed to prepare professionals to treat rural populations in bush Alaska. Therefore, the pro- gram focuses on dental disease prevention and preparing practitioners to provide competent care under remote dental supervision in rural practice 

84 THE U.S. ORAL HEALTH WORKFORCE locations. To apply for the program, individuals must have at least a high school education and have the support of their tribal group. Prior medi- cal or dental experience is preferred. The DENTEX curriculum overall is intended to be culturally respectful and sensitive and focused on prevention strategies, including behavior change, motivational interviewing, risk assess­ ment, and triage. The first year (in Anchorage, Alaska) concentrates on general science and basic skills, including modules of lectures from faculty of multiple dental schools; the second year (in Bethel, Alaska) increases clinical instruction and includes rotations in various villages. Ultimately, the DHAT practice model involves an individual who lives and practices in a village (or several small villages), working regionally with all members of the health care team (e.g., dentists, dental hygienists, nurse practitioners, physician assistants) to provide continuity of care. The legal basis for the accreditation and practice of the DHAT falls under the rules and regulations of the federally recognized and funded Community Health Aide Program. Under these regulations, DHATs must complete preceptor- ships with the dentists they will work with, and their scopes of practice will be based on their skill level as well as the individual village’s needs. Conclusions The community basis of the DHAT is essential—it is about recruiting students from specific communities who will return to these villages to practice. Second, concerns about supervision need to be allayed. Instead, supervision should be considered as in the physician assistant profession— supervision should occur prospectively (e.g., discussing treatment plans in advance), concurrently (e.g., direct observation), and retrospectively (e.g., chart review). Finally, as seen in other midlevel models, these types of pro- fessionals have economic benefit, are adaptable, and have strong patient acceptance. oral health practitioner Colleen M. Brickle, Ed.D., RDH Normandale Community College and Metropolitan State University In Minnesota, there has been increased interest in examining oral health workforce needs. Challenges related to access to dentists include inadequate numbers, lack of presence in rural areas and community centers, and the aging of current professionals. 

WORKFORCE STRATEGIES FOR IMPROVING ACCESS 85 Defining the Oral Health Practitioner In 2008, the Minnesota legislature passed a statute recommending the exploration of a new type of professional, the oral health practitioner (OHP). The resultant statutory language authorized licensure qualifications and conditions, including a collaborative management agreement with a dentist and completion of an accredited OHP educational program. To prepare for proposed 2009 legislation, the statute charged the formation of a workgroup to provide evidence-based recommendations for strategies to improve access to care, to preserve quality of care, and to protect patients from harm. The workgroup came to many conclusions regarding the recommended practice of an OHP (Minnesota Department of Health and Minnesota Board of Dentistry, 2009). They stated that OHP practice should be limited to underserved populations including low-income populations, uninsured populations, and residents of dental health professional shortage areas. Currently, dental hygienists in Minnesota, under a collaborative agreement with a dentist, may practice in community settings such as hospitals, nurs- ing homes, and Head Start schools. OHPs are also proposed to practice in these and other community settings, including assisted living facilities, Veterans Administration settings, patient homes, and certain clinics. When considering scope of practice, the workgroup considered many different services in the realms of prevention, primary diagnosis, education, pal- liation, therapy, and restoration. The workgroup considered each service individually, including the level of supervision, and based recommendations on the majority vote for each service. Overall, the workgroup recommended maintenance of the collaborative agreement with a dentist. The final report details 20 components of the collaborative management agreement, includ- ing protocols for standing orders, referral pathways, specialty care, and the documentation of professional liability for both practitioners. For purposes of evaluation, the workgroup’s final report identified that the Minnesota Department of Health and the Minnesota Board of Dentistry would examine data such as the number of new patients served, the types of services provided, and the impact on emergency room visits. The edu- cational programs will also be evaluated to ensure graduates meet the out- lined competencies and to improve the educational programs themselves. Two educational programs have arisen—one resulting from a collaboration b ­ etween the Metropolitan State University and the Normandale Community College and another with the University of Minnesota School of Dentistry. These programs have some differences; for example, the Metropolitan State University requires applicants to be registered dental hygienists. The success of the OHP will be challenged by several factors. First, like many other states, Minnesota is facing an economic climate of cost 

86 THE U.S. ORAL HEALTH WORKFORCE c ­ ontainment—state residents are losing jobs, becoming uninsured, and straining the safety net clinics. Second, this new type of practitioner and model of care may not be accepted by current dental professionals. In addition, educational institutions need to form partnerships to create cost-­effective programs. Finally, new payment mechanisms are needed to recognize and pay for these new professionals. Conclusions Solutions to oral health access problems need to focus on the patients, especially those people who are underserved. Solutions need to rely on an evidence base of research and experience. Finally, the key to overcoming many barriers include education and communication with all stakeholders, funding support for students and educational programs, and continuous communication, education, and collaboration. registered dental hygienists in alternative practice and virtual dental homes Paul Glassman, D.D.S., M.A., M.B.A. University of the Pacific School of Dentistry In this country, resources need to be aligned with health promotion and disease prevention. As seen in Figure 10-1, public health factors such as health behavior patterns and social circumstances have greater impact on early death in the United States than shortfalls in medical care. In addi- tion, a large number of populations (e.g., diverse populations, those with complex medical and social situations, economically disadvantaged popula- tions) are not well served currently. Also, traditional dental offices are not designed for and do not operate under an economic model that supports health promotion activities. In California, two different models seek to overcome some of the barriers patients face in accessing dental services: the Registered Dental Hygienist in Alternative Practice (RDHAP) and the Virtual Dental Home. Registered Dental Hygienists in Alternative Practice The RDHAP model began in California in the 1980s with the Health Manpower Pilot Project (now the Health Workforce Pilot Project). How- ever, the California legislature did not delineate requirements for a RDHAP license until 1997. In addition, the first license was not issued until 2003 due to the lack of a dental board-approved curriculum, a requirement of licensure. Training programs to allow individuals to meet the requirements 

WORKFORCE STRATEGIES FOR IMPROVING ACCESS 87 Health care procedures 10% Health behaviors Social circumstances 40% and environment 20% Genetics 30% FIGURE 10-1  Population-based determinants of early death. SOURCE: McGinnis et al., 2002. for licensure began in 2003 and currently, there are over 200 RDHAPs Figure 10-2, fully editable in California. Under California law, requirements for licensure include a bachelor’s degree (or equivalent); 2,000 hours of clinical practice in the imme­diately preceding 36 months; a current California dental hygiene license; and the completion of a 150-hour dental board-approved course. RDHAPs may work in patients’ homes, schools, residential facilities and other institutions, and dental health professional shortage areas. The use of RDHAPs has special importance to communities. Oral health services in this country are primarily delivered in dental offices, safety net clinics, and hospitals. To better accommodate all members of society, services need to be delivered in community locations where people work, live, play, and attend school. Delivery of many oral health services do not require a fully equipped dental operatory such as screening, triage, preventive education, and the application of sealants and fluoride varnish. Even minor dental procedures can be done in community settings. Virtual Dental Home Community-based case management models have had much success, often through integration of dental hygienists and dental assistants with social service agencies to provide health promotion, triage, and referral    California Business and Professions Code, Section 1774, 1775. 

88 THE U.S. ORAL HEALTH WORKFORCE services in local communities. The evolution of direct access dental hygiene practice has contributed to the success of community-based care manage- ment, although fragmented care still exists and much more collaboration is needed. As technology has advanced, the idea arose to use teledentistry to foster this needed collaboration between community-based oral health professionals and dentists in dental offices and clinics. Simultaneously, the concept of the medical home model (or health home model) has focused attention on care management over time; health promotion; access to com- plex services when needed; and, for pediatric models, early intervention. Together, these developments led to the development of the virtual dental home. Currently, if a community-based oral health professional such as an RDHAP is cleaning a patient’s teeth at home, he or she cannot address more complex problems that are identified. Under the proposed virtual dental home model, the RDHAP can collect a full set of digital records including X-rays and other information and enter these into an electronic medical record that can be examined by a dentist remotely. This dentist may then make a diagnosis and create a treatment plan in consultation with the ­community-based oral health professional who is familiar with the patient, their health history, consent information, and resources and may help ­coordinate needed services. A demonstration of the virtual dental home model is currently funded, and the infrastructure is being built, including the establishment of train- ing systems and agreements with community-based settings. This year will involve a proof of concept demonstration. Future work will allow for long- term assessment of health improvement, economic modeling, and regula- tory reform to enable widespread adoption. Conclusions Many things can be done in the community setting including care management over time, preventive education, teeth cleaning, medical model prevention treatments, and minor dental procedures. Because of this, many more people will be able to remain healthy in community-based settings without the need to visit a dental office. And, when more complex ser- vices are needed, the referral is much more likely to be successful due to the community oral health professional’s familiarity with the patient and coordinating role over time as well as the dentist’s virtual familiarity with the patient. While many different models are being proposed, there is not enough information at this time to predict which models will work best in which situations, and so a lot of experimentation is necessary. In fact, mul- tiple models and collaborative agreements are likely needed due to the dif- fering needs of various locations and populations. As new types of ­workers 

WORKFORCE STRATEGIES FOR IMPROVING ACCESS 89 are developed, consideration is needed for how those professionals will fit into a broader health care system that is integrated with social service and general health systems. oral health impact project Lawrence B. Caplin, D.M.D., CCHP Oral Health Impact Project The Oral Health Impact Project (OHIP) is a patient-focused, self- sustaining public health care model that focuses on perpetual practitioner development. Today there are three main barriers to accessing oral health care services: transportation, education (both of children and parents), and access to quality professionals (the willingness of practitioners themselves to care for populations in need). In light of this, the OHIP model was d ­ esigned to overcome all of these barriers and is based in part on a project done in the 1970s wherein the K–6 school curriculum was infused with oral health education and mobile vans were used to bring services to the children in need. As a result, disease was eradicated, all children were treated, and the children changed their behaviors through curricula changes. Families became more engaged as the families of the children in the project had an increase in oral health service utilization. An unexpected result of the project was that a disproportionate number of children in the project went into careers in oral health. Designing the OHIP Model Several necessary characteristics were identified in the process of design­ ing the OHIP model: it had to be self-sustaining, comprehensive, compas- sionate, and culturally sensitive. In addition, it needed to be coordinated and continuously accessible with data to track the results, so a compre- hensive digital record with digital radiography is used that allows for a centralization of the patient records that are retrievable from any location. This record also allows for epidemiological data collection to facilitate the measurement of services provided, evaluation of outcomes, and longitudi- nal tracking of children even when they change schools. OHIP addressed the educational barrier by changing the curriculum within the school dis- tricts of Philadelphia to include early and positively reinforced oral health education. In addition, every time a child is seen, the professionals deliver needed services and also discuss careers in oral health care to plant the seeds for careers in oral health care. 

90 THE U.S. ORAL HEALTH WORKFORCE Encouraging Careers in Oral Health In the city of Philadelphia, OHIP created an Oral Health Academy in conjunction with the school district of Philadelphia. This is a 4-year, merit- based program beginning in September 2009. The program will include 24 children of various backgrounds who will spend all 4 years of high school involved in oral health care, including exposure to all career options. Upon graduation from the academy and high school, the participants will have a certificate in dental assistance. Most of the participants will be from minority populations, which will help address some of the disparities cur- rently seen in our oral health workforce. OHIP is currently approaching universities about the possibilities of the students doing their basic science courses at the universities through dual-enrollment. This will increase their exposure to and comfort with college settings while attaining up to 20 col- lege credit hours during their high school years. In addition, there are two dental schools in Philadelphia, and OHIP is working to create a mentor- ship program with dental students and various internships and externships programs throughout the entire city. As a part of the larger project, CF Charities, a not-for-profit organiza- tion, was established to provide scholarships for graduates who want to pursue higher or continued education for any career in oral health. These scholarships require the students to perform public health dentistry upon graduation by providing care in the military, the Public Health Service, the Indian Health Service, in a federally qualified health center, or in the school-based program. This will foster the repopulation of our public health professionals pool and reintroduce a new set of mentors and leaders in oral health. Conclusions OHIP is a 20-year commitment to these children from age 5 through age 25. At ages 5–9, children are getting clinical care, oral health education, nutrition education, and instruction in oral hygiene. From ages 10–13, the care and education continues. In high school, 14–18, the care continues and the students may also apply to enroll in the Oral Health Academy, which provides leadership skills and exposure to all oral health careers in the frame of public health dentistry. The economic support through CF Charities for higher education from 19–25 continues the commitment and initiates the graduate’s commitment to public health dentistry. Instead of just focusing on getting care services to people, OHIP is a model for trans- forming the lives of youth by changing their expectations for their own oral health care, and their career opportunities. It is getting people interested in providing care where it is needed most. 

WORKFORCE STRATEGIES FOR IMPROVING ACCESS 91 health commons Daniel Derksen, M.D. University of New Mexico The health commons model in New Mexico is a medical home that emphasizes the importance of an interdisciplinary team that brings ­together oral health, behavioral health, and physical health with necessary social services that address social determinants. Health commons may also ­include other special services to address the needs of the specific populations served. In times of scarce resources, health commons provides a compre- hensive model for bringing together the needs of a population in a single c ­ ommunity-based setting. New Mexico’s Unique Challenges New Mexico has unique health care challenges because of its rural nature and prevalence of medically underserved areas. New Mexico has a population of approximately 2 million and ranks 43rd of the 50 states in income (U.S. Census Bureau, 2007a) and has the second highest rate of uninsurance (Kaiser Family Foundation, 2007). In total, more than half of the population is either on Medicare or Medicaid or is uninsured (Kaiser Family Foundation, 2007). New Mexico’s population is 44 percent Hispanic and 10 percent Native American (U.S. Census Bureau, 2007c) and the population density is the sixth lowest in the country (U.S. Census Bureau, 2000). Virtually all of the counties in New Mexico are designated as health professional shortage areas for primary care, dental care, and mental health. In fact, New Mexico ranks 49th of the 50 states in per capita dentists (HRSA, 2000), in part due to the lack of a dental school in the state. In spite of raised Medicaid payments, too few of the existing dentists participate in the Medicaid program. Health Professions’ Training It is difficult to convince the state legislature to spend more on health professions since three-quarters of the medical school graduates leave New Mexico. However, decentralized residency programs have had better suc- cess in the retention of graduates. In family medicine, the model includes having the first year spent at an urban tertiary facility (e.g., University of New Mexico at Albuquerque) with the second and third years being spent largely in community-based settings like community health centers. In dentistry, residents participate in community-based rotations around the state. As a result of these types of programs, more than half of the ­residents 

92 THE U.S. ORAL HEALTH WORKFORCE end up staying to practice in New Mexico. In addition, more than half of the dental resident graduates are from underrepresented minority groups. D ­ ental residents are trained alongside other practitioners in training, includ­ ing family medicine residents, nurse practitioners, social workers, and pharmacy students. South Valley Health Commons Derksen noted his employment at the South Valley Health Commons, which he described as a 40,000-square-foot facility that provides com- prehensive health care services with some wrap-around social services. In terms of oral health, he said this particular facility has 5 dentists, 1 dental resident, 3 dental hygienists, 14 dental assistants, and 16 operatories. Last month, he said, they had 1,500 visits and have an annual goal of 16,000 visits. Derksen noted that New Mexico’s Medicaid program pays about 85 percent of the usual and customary fee, so it generates a significant amount of revenue that helps cross-subsidize other services that enable the care to be affordable, coordinated, and comprehensive, including behavioral health and social work services. The design of the facility itself and schedul- ing encourages interaction among the different types of professionals. Conclusions One of the biggest barriers to providing health care services to under- served populations results from the pipeline of professionals. Statistically, both family medicine and dental residents who grew up in rural areas or are from underrepresented minorities are more likely to serve those popula- tions in the future. The health commons model provides a unique solution to providing comprehensive care to underserved communities, especially due to its physical design that facilitates interdisciplinary care and pipeline in the training of many types of professionals. pediatric oral health educator Burton L. Edelstein, D.D.S., M.P.H. Columbia University Oral health, as opposed to dental health, is acquired primarily through health behavior change. In part, the difficulty may be in the attempt to tie these principles to the delivery of dental treatment services. By the time    The Pediatric Oral Health Educator is a theoretical model and has not been developed into practice. 

WORKFORCE STRATEGIES FOR IMPROVING ACCESS 93 many children are seen for the first time, they already have an active caries process. Therefore, behaviors need to be addressed even before these chil- dren ever reach a dental office. The theoretical concept of a pediatric oral health educator (POHE) targets parents with young children who already have an active disease process for early childhood caries. This model is distinctively different from a public health intervention such as education, community water fluoridation, or a new attempt to deliver oral health ser- vices, as those services address the entire community. The POHE focuses on disease management, which is distinctly dif- ferent than prevention because it focuses on what you have to do after the disease is already present. True disease management is an individual patient intervention based on the chronic disease model. The POHE could be integrated with traditional oral health care professionals, either through colocation or referrals. Disease management is important because once the disease process is arrested, traditional dental repair will be more likely to succeed. The POHE model is based on four concepts: (1) the nature of the disease itself, (2) lessons from medical care, (3) biobehavioral approaches, and (4) wellness management. First, a distinction needs to be made between the underlying disease process itself (caries) and the holes in the teeth (cavities) that the dis- ease causes. This disease is established very early in life and is chronic, p ­ rogressive, diet dependent, and is either exacerbating or correcting itself. However, traditional dental treatment is surgical and instructive rather than engaging families in health behavior changes. This approach is costly and ineffective in both the short term (e.g., high rates of recurrence) and long term (e.g., early childhood caries is the best predictor of long-term disease). Instead, the disease process must be addressed first. The second key concept is to look at lessons learned from medicine. In many medical disciplines, different practitioners manage the medical and surgical aspects of care (e.g., cardiologist and cardiac surgeon). In this same manner, the POHE could provide individualized medical management of pediatric caries disease while the pediatric dentist provides the treatment intervention. In addition, medicine has successfully developed and utilized the certified diabetes educator, a licensed professional (e.g., nurse, dieti- tian, physicians assistant) with specific training and certification in disease management to work directly with patients and their families to address the diabetes disease process at its root causes. The POHE could operate in a similar manner. However, currently we have neither the skills to engage families nor the protocols to deal with oral disease in a way that will turn it off. In conclusion, the POHE has the potential to fulfill many roles in the care of the pediatric population including 

94 THE U.S. ORAL HEALTH WORKFORCE • counseling families, • employing theory-based education and communication approaches, • engaging peer counselors when needed, • developing and implementing individualized care plans, • seeking to control caries activity, and • connecting the patient to traditional treatment sources for defini- tive repair. Ultimately, the goal of the POHE is to arrest the active caries disease process so that definitive dental repair is successful in both the short and long terms. reaction and DISCUSSION Moderator: Len Finocchio, Dr.P.H. California HealthCare Foundation Moderator: Daniel Derksen, M.D. University of New Mexico Open discussions followed the panelists’ presentations. For these ses- sions, workshop participants were asked to submit cards with comments and questions for the panelists. The following sections summarize the dis- cussion sessions. (See Appendix E for a broader sampling of the submitted questions and comments.) Scopes of Practice One participant questioned the ability of the high school-educated CDHC to place temporary fillings when dental hygienists may not perform this service. Grover said the CDHC will be able to work to the level of the competencies that they can demonstrate while under the supervision of a dentist. She said that this function would be only one part of the respon- sibility of the CDHC, who would then refer the patient to a dentist for a permanent restoration filling. In response to a question about the difference in scope of practice b ­ etween the OHP and the dental therapist, Brickle stated the two scopes were fairly equivalent. Brickle stated they explicitly looked to other coun- tries’ scopes of practice in the development of the OHP and that focus should remain on the ability of a practitioner to meet service needs rather than the exact name. Finally, a participant asked about the potential for changing licensing requirements to take advantage of foreign-trained dentists who are already 

WORKFORCE STRATEGIES FOR IMPROVING ACCESS 95 in the United States but currently unable to practice. Grover said that licens- ing continues to be a challenge and notes that there is great potential for the use of foreign-trained dentists, especially through their involvement in Advanced Education in General Dentistry programs. Financing Several questions arose regarding the financing of new models. Funding sources included private contributions, grant funding, partnerships with other entities (e.g., social service agencies, school systems), and income from billings for qualified patients. Other questions focused on cost-benefit analyses of these new models. Edelstein noted that very few medical-­surgical intervention opportunities actually produce a true cost-benefit analysis since the intervention itself can be very costly; therefore, an intervention that prevents surgical treatment can cover the cost of medical management. Glassman noted that for some of the models based on the community-based approach, increased interaction between professionals allows for better communication and more effective treatment in the most appropriate set- ting, thus reducing costs. In addition, keeping people healthy in community settings using effective prevention and care management strategies reduces costs incurred from operating room and emergency room use. Several participants asked about the costs related to the training of new types of practitioners. Ballweg said that like the international models, it is difficult to tease out these costs for DHATs due to global project budgets. She said the information should be better after graduating more classes of students. For the OHP, Brickle stated the proposed curriculum includes 44 semester hours at $350 per credit. Other considerations, she said, include cost efficiencies due to use of the dental hygiene program infrastructure. Speakers also commented on the need to change payment models. Derksen asserted that the current fee-for-service payment system encour- ages increased volume of services, provides greater reimbursements for subspecialty practices and procedures than for primary care services, and lacks any consideration for the quality or outcomes of those services. Pay- ment for the coordination of services also needs to be considered, Derksen said, especially how that payment could be disbursed as care changes to a team-based approach. The Centers for Medicare and Medicaid Services medical home demonstration project may be able to provide some lessons for these challenges. Related to payment issues, one participant posed the question of where CDHCs will refer patients as they identify more and more needs in the community setting if dentists refuse to care for Medicaid patients. Grover said the CDHC can screen and triage patients, deciding who can wait for care, and that dentists who don’t formally accept Medicaid will respond to 

96 THE U.S. ORAL HEALTH WORKFORCE a child in need. Grover stated the CDHC model is about building relation- ships in the community and helps to coordinate and navigate care. Creating Dual Strategies Speakers addressed approaches to interweaving prenatal and infant oral health care. Edelstein remarked that a dual strategy may be a ­medical- dental or community-dental approach. As the main disease process is over- whelmingly preventable, strategies need to be addressed by focusing on social, behavioral, and environmental determinants using the known tools of social and behavioral science. Caplin commented on the need to combine treatment with education so that patients and their parents have different expectations about oral health. For example, in some communities, Caplin stated, there is no expectation for tooth retention. By changing perceptions, especially of young mothers, their behaviors may change for the benefit of their children as well as for their future pregnancies. Improving Outcomes The speakers discussed the evidence that indicates that newer work- force strategies to improve access lead to improved outcomes. Edelstein commented that this evidence is not robust and often preliminary, but in individual projects they seem to demonstrate a culture change toward dis- ease management as well as long-term improvements in caries incidence. Glassman stated that many models have not been fully implemented and therefore cannot yet be fully assessed, but they are often based on other successful models. For example, he noted the long-term experiences in i ­ntegrating oral health professionals into social service systems in commu- nity settings. Newer models, he said, often add components to these previ- ously successful models, such as expanded scopes of practice and expanded collaboration, and so expectations are for similar or even better results. Caplin commented on early assessments, such as the numbers of completed cases as well as utilization rates, which indicate early successes in some of these programs. For example, he stated that future planned analyses of OHIP include pre- and posttesting in educational interventions and post- treatment surveys of the members of the oral health team.