4

Settings of Oral Health Care

The oral health care system is bifurcated with its two parts functioning in almost complete separation; in general, they use different financing systems, serve different population groups, and provide care in different settings. In the private delivery system, care is typically provided in small, private dental offices and financed primarily through employer-based or privately purchased dental coverage and out-of-pocket payments. The safety net, in contrast, is made up of a diverse and fragmented group of providers in various settings. It is financed primarily through Medicaid and the Children’s Health Insurance Program (CHIP), other government programs, private grants, and out-of-pocket payments. (Financing will be discussed more specifically in Chapter 5.) The safety net has an important role providing care to the underserved, but it is limited in its capacity. As discussed in Chapter 3, the nondental health care workforce is becoming increasingly involved in the provision of oral health care. While primary care settings (including private medical offices) should also be seen as settings of care for oral health, this chapter will focus primarily on settings for care provided by dental professionals.

This chapter gives an overview to the delivery of care in both private practices and safety net settings, including descriptions of their patients, staffing, challenges, and successes. The capacity of the system to care for vulnerable and underserved populations will be addressed, as well as particular non-financial challenges. Finally, the chapter concludes with descriptions of innovations occurring across the country to change how and where oral health services are provided in order to meet the needs of vulnerable and underserved populations.



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4 Settings of Oral Health Care T he oral health care system is bifurcated with its two parts functioning in almost complete separation; in general, they use different financ- ing systems, serve different population groups, and provide care in different settings. In the private delivery system, care is typically provided in small, private dental offices and financed primarily through employer- based or privately purchased dental coverage and out-of-pocket payments. The safety net, in contrast, is made up of a diverse and fragmented group of providers in various settings. It is financed primarily through Medicaid and the Children’s Health Insurance Program (CHIP), other government programs, private grants, and out-of-pocket payments. (Financing will be discussed more specifically in Chapter 5.) The safety net has an important role providing care to the underserved, but it is limited in its capacity. As discussed in Chapter 3, the nondental health care workforce is becoming increasingly involved in the provision of oral health care. While primary care settings (including private medical offices) should also be seen as set- tings of care for oral health, this chapter will focus primarily on settings for care provided by dental professionals. This chapter gives an overview to the delivery of care in both private practices and safety net settings, including descriptions of their patients, staffing, challenges, and successes. The capacity of the system to care for vulnerable and underserved populations will be addressed, as well as par- ticular non-financial challenges. Finally, the chapter concludes with descrip- tions of innovations occurring across the country to change how and where oral health services are provided in order to meet the needs of vulnerable and underserved populations. 157

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158 IMPROVING ACCESS TO ORAL HEALTH CARE PRIVATE DELIVERY SYSTEMS Most dental services are provided in private dental practices owned and staffed by a single dentist. Approximately 92 percent of professionally active dentists work in this private practice model (ADA, 2009a). (See Box 3-1 in Chapter 3 for a description of types of dentists.) About 60 percent of private practice dentists are solo dentists (Wendling, 2010). Thirteen percent of private practice dentists are employees, and 3 percent function as independent contractors (ADA, 2009d). Private practices tend to be located in areas that have the population to support them; thus, there are more practices located in urban areas than rural areas, and more practices are located in high-income than low-income areas (ADA, 2009a; Solomon, 2007; Wall and Brown, 2007). Staffing Independent dentists usually employ one or more individuals in the private practice setting, with an average of 4.8 total staff members per dentist (ADA, 2009b). On average, the independent dentist employs 1.3 dental hygienists per dentist and 1.8 chairside assistants per dentist. Nearly 90 percent of independent dentists employ at least one full-time person, and 68 percent employ at least one person who only works part-time. The ma- jority of these dentists employ chairside assistants (94 percent of dentists), secretaries/receptionists (91 percent), and dental hygienists (68 percent). Some independent dentists employ office managers (31 percent), financial coordinators (16 percent), and other personnel such as sterilization assis- tants and laboratory technicians. However, dental assistants often perform many of these duties. Workload Independent dentists work about 47.5 weeks annually and 35.9 hours per week. These dentists spend about 90 percent of their work hours treating patients (ADA, 2009a). In a survey by the American Dental As- sociation (ADA) of the perceived workload of independent dentists, about 20 percent stated they were “not busy enough, could have treated more patients” (ADA, 2009a). Independent general practitioners have an aver- age of 1,871 active patients1 (for single dentist practices) (ADA, 2009a). Independent general practitioners spend about 51 minutes per patient, and their patients have about 3.3 visits per year. Independent specialists spend slightly less time per patient (42 minutes), and the typical patient visits 1 Active patients are commonly defined as those treated within the previous 2 years.

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159 SETTINGS OF ORAL HEALTH CARE 40 36.5 30 20 17.3 13 12.5 10 6.9 5.3 4 3.2 1.4 0 Operative Prosthodontics Diagnostic Preventive Endodontics Oral and Maxillofacial Surgery Periodontics General Services Orthodontics FIGURE 4-1 Percentage distribution of time spent by independent general practitioners in private practice, 2007. SOURCE: ADA, 2009a. more frequently (five times per year). Independent general practitioners only spend about one-quarter of their time on diagnosis or prevention (see Figure 4-1). Both new and existing patients wait about a week for a new appointment (a decrease of one full day from 2003). Independent dentists see a little over five walk-in or emergency patients each week. In 2007, in- dependent dentists had about 81 weekly scheduled visits (including dental hygiene appointments). In the private practices of independent dentists, dental hygienists work, on average, almost 47 weeks per year and 24 hours per week (ADA, 2009b). Dental hygienists see about 25 patients per week. Chairside assis- tants work almost 48 weeks per year and 32 hours per week. Patient Population The patients of independent general practitioners are spread relatively evenly across the age spectrum (see Figure 4-2). Specialists see a signifi- cantly greater proportion of patients aged 17 years or less, likely due to the practice profiles of orthodontists and pediatric dentists (ADA, 2009a). Slightly more than half (55 percent) of independent dentists’ patients are female, and nearly two-thirds (63 percent) have private insurance (ADA, 2009a). Only 7 percent of the patients of independent dentists re-

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160 IMPROVING ACCESS TO ORAL HEALTH CARE < 5 years 4% > 65 years 5 to 17 years 15% 13% 55 to 64 years 18 to 34 years 21% 19% 35 to 54 years 29% FIGURE 4-2 Age breakdown for patients of independent general practitioners in private practice, 2007. NOTE: Does not total 100 percent due to rounding. SOURCE: ADA, 2009a. ceive public assistance for their dental coverage; the remaining 30 percent of patients are not covered by any dental insurance. Nearly two-thirds of all independent dentists (63.3 percent) and slightly more than half of all new independent dentists (57.5 percent) do not have any patients covered by public sources. Expenses and Income In 2007, the average gross billings per owner from the primary private practice for all independent dentists was approximately $774,000 (or about $656,000 per dentist in the practice and $500 per active patient), of which approximately 94 percent was collected2 (ADA, 2009c). Independent den- tists in incorporated practices tend to have higher gross billings per owner than those in unincorporated practices. Independent dentists primarily receive payment from private insurance and direct patient payment (see Figure 4-3). Specialists tend to receive less payment from private insurance and more from direct patient payment. 2 Gross billings are the total amount of fees charged. Calculations are made on a per owner basis assuming equal contribution by all partners. Gross billings are only reported for independent dentists who own their private practice.

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161 SETTINGS OF ORAL HEALTH CARE Other, 1% Managed care, 10% Direct patient payment, 39% Private insurance, 44% Government programs, 6% FIGURE 4-3 Sources of gross billings, all independent dentists, 2007. SOURCE: ADA, 2009c. In 2007, practice expenses (excluding the salaries of owners, but in- cluding the salaries of other employees) accounted for 59 percent of gross billings from the primary private practice of all independent dentists (ADA, 2009c). As discussed in Chapter 3, the salaries of private practice dentists vary depending on employment situation and type of practice. For all inde- pendent practitioners, net income does not vary greatly by number of years since graduation. However, this does not take the number of hours worked into account. Between 2003 and 2007, the net income of independent den- tists increased about 1 percent annually (when adjusted for inflation) (ADA, 2009c). Between 1982 and 2000, dentists’ real income grew without change to their workload (essentially, the number of patients seen per day and the number of weeks worked per year remained relatively constant) (Guay, 2005). This increase in productivity is, in part, due to the increased use of dental hygienists and dental assistants (Brown, 2005; Guay, 2005). (The capacity and efficiency of the oral health care system is discussed further later in this chapter.) Demand for dental care may vary with the economic climate of the country (Guay, 2005; Wendling, 2010). For example, the recent recession was identified as a key factor contributing to 2009 having the slowest rate of growth in health spending (4 percent) in the last 50 years (Martin et al., 2011). Notably, expenditures on dental services had a negative rate of growth (–0.1 percent) in 2009, down from a positive rate of growth of 5.1 percent in 2008.

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162 IMPROVING ACCESS TO ORAL HEALTH CARE THE ORAL HEALTH SAFETY NET Underserved and vulnerable populations often cannot access the private dental system due to geographic, monetary, or other barriers, and so they rely on the safety net. While the term safety net may give the impression of an organized group of providers available to serve anyone who cannot access the private system, the dental safety net is composed of unrelated entities that both individually and collectively have very limited capacity. Generally, the safety net is composed of an array of providers, including (but not limited to) Federally Qualified Health Centers (FQHCs), FQHC look-alikes, non-FQHC community health centers, dental schools, school- based clinics, state and local health departments, and not-for-profit and public hospitals. Each type of provider offers some type of dental care, but the extent of the services provided and the number of patients served varies widely. Even with this variety of options, the safety net still does not meet the needs of all who are left out of the private system, often because of a lack of capacity of these providers or a perceived lack of affordable options by individuals (Bailit et al., 2006; Haley et al., 2008; Kenney et al., 2009; Mertz and O’Neil, 2002). The following sections give brief overviews of several types of providers and programs typically considered as part of the safety net. Federally Qualified Health Centers An FQHC is any health center that receives a grant established by sec- tion 330 of the Public Health Service Act.3 FQHCs must be located in or serve a medically underserved area or medically underserved population, provide both primary health care services as well as supportive services (e.g., education, transportation, translation services), and see patients re- gardless of their ability to pay for those services. FQHCs are governed by community boards that have a fiduciary responsibility for the center, and more than half of the board members must be patients of the health center and represent the population served. The statute that established FQHCs specifically identifies migratory and seasonal agricultural workers, the homeless, and residents of public housing as underserved populations. Thus, some FQHCs are referred to as Migrant Health Centers, Health Care for the Homeless Programs, and Public Housing Primary Health Care Centers. All of these programs fall under the umbrella term FQHC. FQHCs receive a number of additional benefits in addition to section 330 grants, including higher Medicare and Medicaid reimbursement rates, access to 3 42 U.S.C. §254b.

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163 SETTINGS OF ORAL HEALTH CARE providers funded by the National Health Service Corps, and drug pricing discounts (HRSA, 2010). FQHCs primarily provide care to underserved and vulnerable individu- als. In 2009, 71 percent of patients served by FQHCs had income at or below 100 percent of the federal poverty level, 93 percent had income at or below 200 percent of the federal poverty level, 38 percent were uninsured, and 37 percent were insured by Medicaid. Table 4-1 illustrates the propor- tion of FQHC patients who come from vulnerable and underserved popula- tions, as compared to their representation in the U.S. population as a whole. The FQHC program is growing steadily. In 2009, the Health Resources and Services Administration (HRSA) funded 1,131 FQHCs, which are lo- cated in all 50 states, the District of Columbia, and Puerto Rico (HRSA, 2011b). That number is up from 914 FQHCs in 2004. Funding for FQHCs is also increasing. The American Recovery and Rehabilitation Act includes $2 billion for FQHCs (HHS, 2010a), and the health care reform bills in- cludes $11 billion for a Community Health Centers Trust Fund that will allow FQHCs to expand access and make capital improvements, and $1.5 billion for a new National Health Service Corps Trust Fund.4 FQHCs are required to provide certain services—including preventive, but not comprehensive, dental services—either in the clinic or by referral. In 2008, 80 percent of the 1,080 FQHCs provided on-site dental services, and 88 percent provided dental services on site or by referral (Anderson, 2010; Cottam, 2010). This reflects significant progress towards the Healthy People 2020 goal of 83 percent of health centers including an oral health component (HHS, 2010b). In 2009, FQHCs provided dental care to 3.4 million patients, in 8.4 million dental visits, which is nearly a three-fold increase over the number of patients and visits in 2000 (HRSA, 2011c; Ruddy, 2007). This care is not exclusively preventive; although FQHCs are not required to provide comprehensive oral health services, over 75 percent do so, and millions of patients received restorative and rehabilitative care through FQHCs in 2009 (Anderson, 2010; HRSA, 2011b). The expansion of dental services in FQHCs reflects a concerted commitment from HRSA. Since 2001, HRSA has invested $55 million in oral health service expansion grants (Anderson, 2010). In addition, a statutory change in the Children’s Health Insurance Program Reauthorization Act allows FQHCs to expand their reach outside of their physical facilities.5 FQHCs may now contract with private practice dentists to provide oral health services to FQHC 4 Patient Protection and Affordable Care Act, Public Law 148, 111th Cong., 2nd sess. (March 23, 2010); Health Care and Education Reconciliation Act of 2010, Public Law 152, 111th Cong. 2nd sess. (March 30, 2010). 5 Children’s Health Insurance Program Reauthorization Act of 2009, Public Law 3, 111th Cong., 1st sess. (February 4, 2009), §501.

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164 IMPROVING ACCESS TO ORAL HEALTH CARE TABLE 4-1 Underserved and Vulnerable Populations Served in FQHCs as Compared to Their Representation in the U.S. Population, 2009 Percentage of Percentage of U.S. FQHC Population Population Poverty At or below 100% of poverty 71 14 Medical insurance status Uninsured 38 17 Medicaid (Title XIX) 36 16 Private insurance 15 64 Race Asian/Pacific Islander 5 5 American Indian/Alaska Native 2 1 African American 27 13 White 62 72 Ethnicity Hispanic/Latino 16 35 NOTES: Percentages are of the FQHC population reporting a certain characteristic. SOURCES: DeNavas-Walt et al., 2010; HRSA, 2011c; U.S. Census Bureau, 2010. patients in the dentist’s office. Previously, some states required the dentist to individually enroll in Medicaid before providing services for the FQHC (CMS, 2011b). FQHCs employ over 8,000 full-time equivalent dental staff, includ- ing over 2,500 dentists and over 1,000 dental hygienists (HRSA, 2011e). FQHC executive directors report that they most commonly recruit dentists through the National Health Service Corps, although only 10.2 percent of FQHC dentists report receiving a NHSC scholarship, and an additional 19.4 percent report receiving NHSC loan repayment (Bolin, 2010). Even fewer dental hygienists report receiving funding from the NHSC. A large number of FQHC dentists previously worked in the private sector; 31.9 percent reported previously working as a private practice owner, partner, or associate, and 18.5 percent reported previously working as an employee dentist in a private practice (Bolin, 2010). Dentists and dental hygienists working at FQHCs report being generally satisfied with their work: 80.2

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165 SETTINGS OF ORAL HEALTH CARE percent of dentists and 93.3 percent of dental hygienists intend to remain employed in a health center practice (Bolin, 2010). But more than 39 percent of health centers reported at least one dentist vacancy, and over 50 percent of those positions were vacant for more than 6 months (Bolin, 2010; Cottam, 2010). With the rapid expansion of dental programs in FQHCs, there appears to be a lack of training and guidance for FQHC dentists. FQHC dental pro- grams are unique within dentistry because they generally function within a general health clinic, may not be ultimately overseen by a dental profes- sional, and charge per encounter, rather than per procedure. Therefore, specialized guidance may be necessary for the dental programs to thrive (Geiermann, 2010). Previously, HRSA offered training and technical as- sistance to FQHC dentists through its regional dental consultant program. That program has essentially been eliminated, with the retirement of the last consultant in 2009 (Geiermann, 2010). The number of dental public health professionals employed by HRSA has dwindled from a high of over 100 to under 20, most of whom are not able to provide technical assistance to FQHCs. Anecdotal reports indicate that current FQHC dentists do not have a reliable source of assistance (Geiermann, 2010). Indeed, the last oral health guidance to FQHCs was issued in March 1987 (Geiermann, 2010). FQHC Look-Alikes FQHC look-alikes were established by Congress to extend the con- cept of FQHCs (HRSA, 2003). Look-alikes must meet all of the statutory requirements of FQHCs—for example, they provide services to the medi- cally underserved, operate as nonprofits, and be governed by a community board—but they do not receive grant funding under section 330 (HRSA, 2003). FQHCs look-alikes are eligible for many, but not all, of the benefits extended to FQHCs, such as increased Medicaid and Medicare payments and drug pricing discounts (HRSA, 2003). Very little data are available about the dental care provided at FQHC look-alikes because they are not required to submit detailed information to the Department of Health and Human Services about visits. Community Health Centers Many community health centers (CHCs) do not receive federal funding or subsidies and operate completely outside of the FQHC system. Some of those health centers are nonprofits, while some are supported or operated by state and local governments. There is no national database of CHCs, so very little information is available about the types of services they provide or the numbers of patients they serve. One study roughly estimated that

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166 IMPROVING ACCESS TO ORAL HEALTH CARE they serve about 2.2 million dental patients each year (Bailit et al., 2006). CHCs generally have very limited funding. In 2001, for example, Illinois CHCs had an average annual budget of $182,000 (Byck et al., 2005). Dental Schools and Residency Programs Dental students gain experience treating patients in dental school-based clinics. The patients served in those clinics are generally low-income, so dental school clinics are considered part of the dental safety net (Bailit et al., 2006). Dental students provided about 2.9 million patient visits in 2001–2002, with an average of 13 visits per patient, meaning that dental students treated about 224,000 patients during the year (Bailit et al., 2006). The number of patient visits has remained relatively constant; in 2009, dental students had 2.9 million patient visits in dental school clinics and in community-based rotations (ADA, 2010). The care provided in dental school clinics is affordable but time con- suming for patients because clinics are organized as student teaching labo- ratories rather than patient-centered delivery systems (Bailit et al., 2007). Dental Education at the Crossroads recognized that the mixed missions of educating students and caring for patients lead to trade-offs in both ef- ficiency and quality of care: Dental students must gain sufficient clinical experience in a variety of technical procedures to become competent entry-level practitioners, quali- fied to graduate and become licensed. A procedure-driven learning pro- cess does not necessarily translate into efficient, high-quality patient care, particularly when student care is further constrained by low budgets for clinical and administrative support. (IOM, 1995) Some progress has been made toward increasing the efficiency and pa- tient-centeredness of dental school clinics, but more can be done (Formicola et al., 2008). In addition to on-site clinics at dental schools, dental students also pro- vide care through community rotations in FQHCs and community health centers (ADA, 2010). Of the 2.9 million dental visits provided by dental students in 2009, approximately 450,000 were provided in the community (ADA, 2010), and a large proportion of those visits were in underserved communities (Atchison et al., 2009). Residencies in dentistry, as in medicine, are an important source of care for underserved populations, including economically and socially disadvan- taged populations and medically compromised patients (Mito et al., 2002). One recent study concluded that requiring 1 year of residency training would significantly expand the capacity of community hospitals (or dental schools) to care for the underserved (Bailit et al., 2006). By their estimates,

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167 SETTINGS OF ORAL HEALTH CARE approximately 1,800 additional dental school graduates would participate in a 1-year general dentistry residency program and an additional 887,000 patients would receive care each year. School-Based Dental Clinics School-based health centers (SBHCs) were developed to provide basic health care services, including dental care, in elementary and secondary schools. SBHCs are perhaps the most convenient care location for both children and parents because they eliminate the need for transportation, parent time off, and missed school. Children with access to a SBHC are more likely to have seen a dentist in the past year than similar students without access to a SBHC (Kaplan et al., 1999). In addition, children at high risk for dental caries who have access to a school-based dental seal- ant program are more than twice as likely to have sealants than children without access (Siegal and Detty, 2010). SBHCs are also associated with improved academic performance, increased use of primary care, reduced use of emergency rooms, and increased use of vaccines (Allison et al., 2007; Walker et al., 2010; Young et al., 2001). While SBHCs offer significant potential to increase access to oral health care, only a small number of schools have SBHCs, and only a small per- centage of those SBHCs offer dental services. Approximately 1,900 school- based health centers operate throughout the country (NASBHC, 2010). Table 4-2 summarizes the oral health services provided by SBHCs during the 2007–2008 school year. Many SBHCs offer simple preventive oral health care, such as oral health education and dental screenings, both on site and by referral, but fewer clinics offer more complex procedures. For example, 84 percent of SBHCs provide oral health education both on site and by referral, but that number drops to 57 percent for dental screenings, 20 percent for dental examinations by a dentist, and the ability of an SBHC to provide oral health services is limited by the number staff qualified to provide oral health services. Only 12.4 percent of SBHCs have a dental provider on staff (NASBHC, 2010). The dental capacity could potentially be expanded by using the new and emerging providers discussed in Chap- ter 3, as is now done with nurse practitioners and physician assistants in providing medical care in SBHCs. SBHCs have successfully worked in collaboration with public health departments (discussed below) to provide both screening and treatment services. Recognizing the potential for SBHCs to expand access to oral health care to underserved populations, HRSA re- cently announced a grant program to fund comprehensive oral health care services in SBHCs (HRSA, 2011d). Although some concern has been raised about whether SBHCs have an adequate funding source (Silberberg and Cantor, 2008), the Patient

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182 IMPROVING ACCESS TO ORAL HEALTH CARE make arrangements for the child to receive it.10 Appropriate care is deter- mined by the state’s Early and Periodic Screening, Diagnosis, and Treatment program and periodicity schedule. Head Start programs must also obtain or arrange for testing, examination, and treatment for children with known or suspected dental problems, and develop and implement a follow-up plan for any problems identified. To foster access to oral health for children enrolled in Head Start, in 2006, the Office of Head Start invested $2 million in grants to 52 Head Start, Early Head Start, and Migrant/Seasonal Head Start programs for the Head Start Oral Health Initiative; grantees received supplemental funding for 4 additional years. While grantees reported successfully developing partnerships with community organizations and providers who would serve Head Start children, educating staff about the importance of oral health, and incorporating oral health education into the curriculum, they reported that they likely could not sustain much of the oral health programming when the grant funding ended (Del Grosso et al., 2008). Requirements Tied to Public Education Several states have introduced programs requiring a dental examina- tion or oral health assessment prior to school entry, though the provisions of these programs differ across states. Even though the requirements have been legislated, many of the plans do not have enforcement or follow-up mechanisms in place. In addition, little data exist on the impact of these types of requirements. Examples include the following: • Illinois will withhold student report cards if the requirement is unfulfilled (Conis, 2009). • In 2008, Kentucky passed a law effective in the 2010–2011 school year requiring children to have a dental examination prior to en- rolling in public school (Conis, 2009). • New York requests parents to provide a dental certificate docu- menting an oral health exam at certain points during a child’s school career (Conis, 2009). Alternative Sites of Care Portable Equipment Patient-centered approaches to caring for vulnerable and underserved populations may require consideration for bringing oral health care to the 10 Ibid.

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183 SETTINGS OF ORAL HEALTH CARE sites that are more convenient for those populations. In particular, older adults and disabled individuals may be unable to travel to travel to dentists’ offices. In these cases, portable equipment is increasingly being used to provide on-site, community-based care in settings such as nursing homes, group homes, schools, and Head Start centers. For example, Apple Tree Dental (Apple Tree) is a private, nonprofit organization in Minnesota that has provided care to individuals with spe- cial health care needs across the life span in a variety of settings for over 25 years (Silow-Carroll and Alteras, 2004). The program has two dental clinic “hubs,” but it provides most of its care through community-based mobile programs. Apple Tree contends advantages to mobile care include reduced anxiety for patients (due to the familiar environment), interdisci- plinary care, and improved efficiency (e.g., reduction in transportation costs for each patient) (Silow-Carroll and Alteras, 2004). Apple Tree has been a source of community-based educational experiences for dental hygienists and dental assistants through partnerships with dental hygiene and dental assisting programs. Apple Tree also collects data on its patient population, which facilitates research on special care populations. In 2008, Apple Tree reported almost 60,000 patient encounters (Helgeson, 2009). In another example, Dr. Greg Folse made a presentation to this commit- tee regarding his work providing mobile oral health services for residents in 23 nursing facilities (Folse, 2010). Dr. Folse estimated that 61 percent of the dentate nursing home residents (or 45 percent of the total resident popu- lation) needed surgical interventions due to abscesses and/or severe gum disease. He further estimated that this meant that 1,062 existing patients were in need of surgical interventions and that an additional 371 new resi- dents would need such care each year. In 2009, working part-time in these nursing homes and using portable equipment, Dr. Folse reported being able to treat 392 surgical cases, manage 3 cases of oral cancer, direct between 1 and 5 dental emergencies weekly (many of which were life threatening), and treat 262 denture patients. He also noted one death occurring as a result of oral disease. Dr. Folse also noted using portable dental equipment to care for children in Louisiana schools. He reported using 15 dentists and 18 expanded duty dental assistants to provide care in 275 schools. He stated that the benefits of using portable equipment included decrease in “no-show” patients, no late appointments, and no loss of time from work for parents. Disadvantages include difficulty with scheduling time during the school hours and obtaining parental consent. Dr. Folse noted that since 2001, his Louisiana school-based model had treated over 20,000 children in the school setting and included over 30,000 patient visits.

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184 IMPROVING ACCESS TO ORAL HEALTH CARE Retail Health Clinics Retail health clinics have been rapidly developing as a new site of care for general health care (Hunter et al., 2009; Laws and Scott, 2008; Mullin, 2009; Pollack and Armstrong, 2009; Pollack et al., 2010; Rudavsky et al., 2009; Thygeson et al., 2008; Wang et al., 2010). Recently, retail dental clinics have been proposed as an alternative site of dental care (Scott, 2009, 2010). Much like retail health clinics, retail dental clinics would be located in pharmacies, grocery stores, and large retailers. The clinics would offer a limited menu of services at set prices, focus primarily on preventive and diagnostic care, and refer patients with more complex needs to dentists. Al- though no retail dental clinics currently exist, an economic model suggests that they could be viable if dental professionals could provide care without the presence of a dentist (Scott, 2009). Dental Homes While not a physical site of care, the dental home is an emerging strat- egy to increase access to consistent oral health care. A dental home is an ongoing relationship between a patient and a dentist (AAPD, 2010a). The dentist provides, among other things, regular comprehensive oral health assessment and care, individualized preventive care based on caries- and periodontal-risk assessments, education on proper nutrition and home care, and referrals to specialists when necessary (AAPD, 2010b). To date, dental homes have centered on providing care to children. However, the medical home model, on which dental homes are based, has been used with all populations to provide acute, chronic, and preventive medical services (Martin et al., 2004). Thus, there may be an opportunity to expand the dental home beyond the pediatric population. One example of a dental home program is the Access to Baby and Child Dentistry (ABCD) program, operated across Washington state through a variety of public–private partnerships (ABCD, 2011; Donahue et al., 2005). Partners include local health departments, the Washington State Dental Soci- ety, local dental societies, the Washington Department of Health (WDOH), the Washington Department of Social and Health Services (WDSHS), the University of Washington School of Dentistry, the Washington Dental Ser- vice Foundation, private dentists, and other community partners. Local health departments typically manage the daily functions of ABCD pro- grams. They work with the state and local dental professional organizations to encourage dentist participation. Dentists who participate in the program receive training and are paid an enhanced reimbursement rate. The health departments also actively recruit Medicaid-eligible children to the program through partnerships with community organizations such as WIC, Head

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185 SETTINGS OF ORAL HEALTH CARE Start, and Early Head Start. In addition, the health departments provide case management services to ABCD families. The WDSHS, WDOH, Uni- versity of Washington School of Dentistry, and Washington Dental Service Foundation oversee the program at the state level. The WDSHS oversees Medicaid financing in the state, and thus provides reimbursement to ABCD- certified dentists, and provides billing assistance, among other things. The WDSHS also contracts with the University of Washington Dental School to provide training and ongoing education to ABCD providers. The WDOH provides technical assistance and grants to local health departments. The Washington Dental Service Foundation provides start-up grants and ongo- ing technical assistance to local ABCD programs. ABCD programs have significantly increased the rate of dental visits among children enrolled in Medicaid (Grembowski and Milgrom, 2000; Lewis et al., 2009; Milgrom et al., 1999), particularly among the youngest children (Kaakko et al., 2002). However, the evidence indicates that the programs may be more successful at encouraging parents to make a single dental appointment than develop an ongoing relationship with a dentist, which is a key component of a dental home (Kaakko et al., 2002; Milgrom et al., 1999). More long-term evaluations of the program need to be done to assess the program’s ability to establish dental homes. FINDINGS AND CONCLUSIONS The committee noted the following findings and conclusions: • Most oral health care in the United States is provided in the pri- vate practice setting by dentists, who employ dental hygienists and dental assistants. • Most patients seen in the private practice setting either have dental insurance or pay out of pocket. • Only a small portion of private-sector oral health care is supported by publicly funded programs such as Medicaid. • An array of programs provides oral health care to underserved and vulnerable populations, including FQHCs, dental schools, and health departments. • An oral health safety net exists in concept, but the components of this safety net are not necessarily connected or coordinated. • No single setting of care will meet the various needs or over- come the multitude of barriers for vulnerable and underserved populations. • More research is needed on the impact of individual site of care models in improving access to care.

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186 IMPROVING ACCESS TO ORAL HEALTH CARE • More research is needed on best practices for individual sites of care. • There is room for building the capacity of the safety net to care for vulnerable and underserved populations, but it will not be enough to care for all patients in need. Strategies to improve access to care for these populations will require the participation of dentists in the private practice setting. REFERENCES AAPD (American Academy of Pediatric Dentistry). 2010a. Definition of dental home. http:// www.aapd.org/media/Policies_Guidelines/D_DentalHome.pdf (accessed May 23, 2011). AAPD. 2010b. Policy on the dental home. http://www.aapd.org/media/Policies_Guidelines/ P_DentalHome.pdf (accessed May 23, 2011). ABCD (Access to Baby and Child Dentistry). 2011. Partners & roles. http://www.abcd-dental. org/part.html (accessed May 24, 2011). ADA (American Dental Association). 2004. State and community models for improving access to dental care for the underserved—a white paper. Chicago, IL. ADA. 2009a. 2008 survey of dental practice: Characteristics of dentists in private practice and their patients. Chicago, IL: American Dental Association. ADA. 2009b. 2008 survey of dental practice: Employment of dental practice personnel. Chi- cago, IL: American Dental Association. ADA. 2009c. 2008 survey of dental practice: Income from the private practice of dentistry. Chicago, IL: American Dental Association. ADA. 2009d. Distribution of dentists in the United States by region and state, 2007. Chicago, IL: American Dental Association. ADA. 2010. 2008-09 survey of dental education: Academic programs, enrollment, and gradu- ates—volume 1. Chicago, IL: American Dental Association. Allison, M. A., L. A. Crane, B. L. Beaty, A. J. Davidson, P. Melinkovich, and A. Kempe. 2007. School-based health centers: Improving access and quality of care for low-income adolescents. Pediatrics 120(4):e887-e894. Anderson, J. R. 2010. HRSA oral health programs. Paper presented at 2010 Dental Manage- ment Coalition, June 27, Annapolis, MD. Anthonappa, R., and N. King. 2008. Six-month recall dental appointments, for all children, are (un)justifiable. Journal of Clinical Pediatric Dentistry 33(1):1-8. ASTDD (Association of State and Territorial Dental Directors). 2010. Synopses of state dental public health programs: Data for FY 2008-2009. Sparks, NV: Association of State and Territorial Dental Directors. ASTDD. 2011a. Membership roster. http://www.astdd.org/membership-roster/ (accessed Janu- ary 25, 2011). ASTDD. 2011b. Mobile and portable dental services in preschool and school settings: Com- plex issues. Sparks, NV: Association of State and Territorial Dental Directors. ASTDD. 2011c. Mobile portable dental manual. http://mobile-portabledentalmanual.com/ index.html (accessed March 10, 2011). ASTDD. 2011d. State & territorial dental public health activities: A collection of descriptive summaries. http://www.astdd.org/state-activities/ (accessed January 25, 2011). Atchison, K., A. Thind, T. Nakazono, D. Wong, J. Gutierrez, D. Carreon, and R. Andersen. 2009. Community-based clinical dental education: Effects of the pipeline program. Jour- nal of Dental Education 73(2):S269-S282.

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