6

A Vision for the Delivery of Oral Health Care to Vulnerable and Underserved Populations

The committee’s ultimate goals in this report are to synthesize current issues related to accessing oral health care, to examine strengths and deficiencies in the delivery system that responds to these issues, and to provide a vision for improving the delivery of oral health care to underserved and vulnerable populations across the life cycle.

The committee faced several challenges in addressing these goals because (1) vulnerable and underserved populations in the United States are numerous and heterogeneous; (2) as such, these populations have a broad range of unmet needs and face diverse barriers to access; (3) oral health care for vulnerable and underserved populations is delivered in myriad settings and through varied institutional structures, with limited common goals and no coherent, organizing system; (4) there is no agreed-upon set of essential oral health services with which to evaluate the success of efforts designed to improve access; and (5) there is a lack of agreement on how to expand the capacity of the oral health workforce to meet the needs of underserved and vulnerable populations, and this issue is politically charged.

Recognizing the challenges described above, the committee drew upon the existing literature to formulate a number of key findings and conclusions that are highlighted in the preceding chapters. In this final chapter, the findings are consolidated into four overall conclusions. These conclusions in turn serve as the foundation for the committee’s vision for improving the delivery of oral health care to underserved and vulnerable populations across the life cycle. This chapter presents the committee’s vision and 10 specific recommendations—directed to both public and private entities—for improving access to oral health care.



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6 A Vision for the Delivery of Oral Health Care to Vulnerable and Underserved Populations T he committee’s ultimate goals in this report are to synthesize current issues related to accessing oral health care, to examine strengths and deficiencies in the delivery system that responds to these issues, and to provide a vision for improving the delivery of oral health care to under- served and vulnerable populations across the life cycle. The committee faced several challenges in addressing these goals be- cause (1) vulnerable and underserved populations in the United States are numerous and heterogeneous; (2) as such, these populations have a broad range of unmet needs and face diverse barriers to access; (3) oral health care for vulnerable and underserved populations is delivered in myriad settings and through varied institutional structures, with limited common goals and no coherent, organizing system; (4) there is no agreed-upon set of essential oral health services with which to evaluate the success of efforts designed to improve access; and (5) there is a lack of agreement on how to expand the capacity of the oral health workforce to meet the needs of underserved and vulnerable populations, and this issue is politically charged. Recognizing the challenges described above, the committee drew upon the existing literature to formulate a number of key findings and conclu- sions that are highlighted in the preceding chapters. In this final chapter, the findings are consolidated into four overall conclusions. These conclusions in turn serve as the foundation for the committee’s vision for improving the delivery of oral health care to underserved and vulnerable populations across the life cycle. This chapter presents the committee’s vision and 10 specific recommendations—directed to both public and private entities—for improving access to oral health care. 229

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230 IMPROVING ACCESS TO ORAL HEALTH CARE Numerous coordinated and sustained actions will be needed to imple- ment the committee’s recommendations and to achieve its vision. Therefore, the committee identifies important actions that various stakeholders can take and identifies the relevant policy levers that are most likely to produce both short-term and long-term change (see later in this chapter for a sum- mary of key implementation strategies by actor). OVERALL CONCLUSIONS After reviewing the evidence, the committee concluded the following: 1. Improving access to oral health care is a critical and necessary first step to improving oral health outcomes and reducing disparities. 2. The continued separation of oral health care from overall health care contributes to limited access to oral health care for many Americans. 3. Sources of financing for oral health care for vulnerable and under- served populations are limited and tenuous. 4. Improving access to oral health care will necessarily require mul- tiple solutions that use an array of providers in a variety of settings. The committee’s overall conclusions reflect the need for action to ad- dress issues of access to oral health care. If the current approaches to oral health education, financing, and regulation continue unchanged, equitable access to oral health care cannot be achieved. However, this report should not be perceived as simply a call for more spending. Investing additional money in a delivery system that is poorly designed to meet the oral health care needs of the nation’s underserved and vulnerable populations would produce limited results and would be fiscally irresponsible. Rather, the re- port calls for transformation through targeted investments in programs and policies that are most likely to yield the greatest impact. A VISION FOR IMPROVING ACCESS TO ORAL HEALTH CARE While the majority of the U.S. population is able to routinely obtain oral health care in traditional dental practice settings, millions of Ameri- cans have unmet oral health needs due, in part, to major barriers in access to care. This is especially true for the nation’s vulnerable and underserved populations. The committee’s review of the evidence, as presented in this report, makes a compelling case for action. Failure to address the challenges that millions of Americans face in accessing oral health care will exacerbate the disproportionate burden of oral diseases experienced by vulnerable and underserved populations. Therefore, the committee provides a vision of

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231 A VISION FOR THE DELIVERY OF ORAL HEALTH CARE B OX 6-1 Vision for Oral Health Care in the United States Everyone has access to quality oral health care across the life cycle. To be successful with underserved and vulnerable populations, an evidence-based oral health system will 1. liminate barriers that contribute to oral health disparities; E 2. Prioritize disease prevention and health promotion; 3. Provide oral health services in a variety of settings; 4. ely on a diverse and expanded array of providers competent, com- R pensated, and authorized to provide evidence-based care; 5. nclude collaborative and multidisciplinary teams working across the I health care system; and 6. Foster continuous improvement and innovation. how public and private providers should address the delivery of oral health care to underserved and vulnerable populations (see Box 6-1). The committee’s vision is both aspirational and achievable. That is, there are immediate steps that can be taken to improve access to oral health care, while other goals focus beyond what is attainable exclusively in the near term. These goals will only be realized by sustained and concerted efforts over time. The committee’s recommendations, therefore, spell out what is achievable at present as well as what our nation should aspire to. RECOMMENDATIONS The committee arrived at set of 10 recommendations. If acted upon in a coordinated and comprehensive manner, these recommendations will im- prove access to oral health care for underserved and vulnerable populations. Integrating Oral Health Care into Overall Health Care The committee’s vision calls for an array of providers to participate in the delivery of oral health care. This strategy will help groups that are unable to obtain oral health services in traditional dental practice settings to receive care from the range of health care professionals that they en- counter more routinely. For populations that rarely visit dentists, nondental health care professionals may be in the best position to provide oral health education, screening, and prevention. Young children, for example, visit

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232 IMPROVING ACCESS TO ORAL HEALTH CARE pediatricians and family physicians earlier and more frequently than they visit dentists (Dela Cruz et al., 2004). With proper training, these primary care providers are well situated to educate parents about how to prevent oral disease, assess risk for oral disease, screen for early childhood car- ies, and deliver preventive services (e.g., fluoride varnish). Similarly, older adults living in institutions receive much of their routine care from nurses and nursing assistants who can also screen for dental disease, provide rou- tine oral health care (e.g., toothbrushing and denture care), and promote preventive care. Ensuring that nondental health care professionals are properly trained to take a role in delivering quality oral health care will be crucial. Defining a multidisciplinary, core set of oral health competencies is the first step in training nondental health care professionals to provide oral health care. These competencies would describe essential skills that health care profes- sionals need in order to provide quality oral health care upon completing their training. The overall aim of a minimum core set is to establish base standards across the health professions and to reduce the burden on each profession to develop their own competencies for oral health. Individual professions, however, may choose to build upon the core set to reflect their specific expertise and interaction with individuals and within communities. The core set of oral health competencies for nondental health care pro- fessionals needs to be developed with input from a variety of stakeholders to ensure that they are appropriately broad and, therefore, applicable to many health professions. The competencies also need to reflect the col- lective expertise and experience of dental professionals and their nonden- tal health care professional counterparts to ensure that the competencies prepare professionals to provide care that meets appropriate standards of quality (i.e., care that is safe, timely, effective, efficient, equitable, and patient-centered). Therefore, the committee recommends RECOMMENDATION 1a: The Healthcare Resources and Services Administration (HRSA) should convene key stakeholders from both the public and private sectors to develop a core set of oral health competen- cies for health care professionals. At minimum, the core competencies need to prepare graduates to • Recognize risk for oral disease through competent oral examinations, • Provide basic oral health information, • Integrate oral health information with diet and lifestyle counseling, and • Make and track referrals to oral health care professionals.

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233 A VISION FOR THE DELIVERY OF ORAL HEALTH CARE Fortunately, there are models that can serve as a basis for developing a core set of oral health competencies for nondental health care profession- als. For example, as discussed in Chapter 3, the University of Washington developed and implemented curriculum to train medical students about oral health that has subsequently been endorsed by the American Association of Medical Colleges (Mouradian et al., 2005). The curriculum includes competencies in five general areas: oral public health, dental caries, peri- odontal disease, oral cancer, and oral-systemic interactions. Similar sets of competencies have been developed or proposed for other disciplines (e.g., geriatrics and physician assistants [PAs]) and health issues (e.g., family violence) (Danielsen et al., 2006; Knox and Spivak, 2005; Partnership for Health in Aging, 2008). Once a core set of competencies has been developed, it will need to be adopted by health professional schools and incorporated into the cur- riculum. The committee concludes the best way to incorporate the oral health competencies into health professional education is for accrediting and certification bodies to require them for accreditation and maintenance of certification. Therefore, the committee recommends RECOMMENDATION 1b: Following the development of a core set of oral health competencies for nondental health care professionals • Accrediting bodies for undergraduate and graduate-level nondental health care professional education programs should integrate these core competencies into their requirements for accreditation; and • All certification and maintenance of certification for health care professionals should include demonstration of competence in oral health care as a criterion. Finally, HRSA can play an important role in supporting the adoption of oral health core competencies into nondental health professional educa- tion programs. To that end, the committee suggests the following strategies: • HRSA can strengthen the integration of oral health core compe- tencies into nondental health professional education programs by requiring that Title VII–funded programs include interprofessional education on oral health. • HRSA can support curriculum development and dissemination ef- forts for nondental health professional education programs. Creating Optimal Laws and Regulations The committee’s vision underscores the need to eliminate barriers to accessing oral health care. Due to their powerful influence on oral health

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234 IMPROVING ACCESS TO ORAL HEALTH CARE practice, the committee identified the variety of regulations and policies that determine how care is provided—and more importantly by whom—as a key area of focus for efforts to eliminate barriers. Despite the existence of national accreditation standards on education and training of oral health professionals, regulations defining supervision levels and scopes of practice vary widely by state. For example, a recent re- view of dental hygiene practice acts revealed great variability among states regarding required levels of supervision by settings of care, type of service, and other special requirements (e.g., minimum hours/years of clinical ex- perience or possession of professional liability insurance) (ADHA, 2011). In some instances, dental hygienists are permitted to provide some services in public health settings under the general supervision of a dentist, but in the same state, are not permitted to provide the same services in private dental offices without direct supervision (ADHA, 2011; HRSA, 2004). Furthermore, seven states require that a dentist be present when a hygien- ist applies dental sealants (ADHA, 2011). As a result of overly restrictive regulation, states may miss critical opportunities to serve greater numbers of individuals in need of care. Some states seek to meet the growing public needs by altering their scope of practice and supervision regulations to allow a broader range of oral health care professionals to see patients without a dentist’s direct super- vision. For example, California’s Health Workforce Pilot Project includes a process to evaluate new workforce models prior to adoption of new profes- sions or expanded scope of practice for existing professions. The registered dental hygienist in alternative practice license in California, which allows dental hygienists to practice in certain community settings without a den- tist’s direct supervision, was a result of this process. California also has a current project evaluating the placement of Interim Therapeutic Restora- tions by Dental Hygienists and Dental Assistants under general supervision in community settings. The majority of state laws, however, lag behind in this regard. As a result, the services that oral health care professionals are able to provide vary significantly and decision making regarding such regulations are often unrelated to competence, education and training, or the safety of those services. Previous IOM reports have supported the idea of expanding scope of practice in alignment with professional competencies (IOM, 2001, 2008, 2010). For example, the report Crossing the Quality Chasm: A New Health System for the 21st Century noted that, “scope of practice acts and other workforce regulations need to allow for innovation in the use of all types of clinicians to meet patient needs in the most effective and efficient way possible” (IOM, 2001). More recently, the report The Future of Nursing: Leading Change, Advancing Health recommended that scope-of-practice barriers be removed to enable advanced nurse practitioners “to practice

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235 A VISION FOR THE DELIVERY OF ORAL HEALTH CARE to the full extent of their training and education” (IOM, 2010). Building from these reports and the evidence from other professions, the commit- tee determined that amending existing state laws, including practice acts, will set the stage to increase access to basic oral health care. Therefore, the committee recommends RECOMMENDATION 2: State legislatures should amend existing state laws, including practice acts, to optimize access to oral health care. At minimum, state dental practice acts should • Allow allied dental professionals to practice to the full extent of their education and training; • Allow allied dental professionals to work in a variety of settings under evidence-supported supervision levels; and • Allow technology-supported remote collaboration and supervision. This recommendation will enable an array of health care professionals to work in community settings, change supervision requirements to levels supported by evidence, and allow the use of telehealth technologies to reach underserved populations with care that is as effective as that delivered in person. By allowing an array of health care professionals to address basic oral health needs, dentists will be able to dedicate themselves to providing more complex care and treating more patients with complex needs. Because amendments to state practice acts provide an important oppor- tunity to expand access to oral health care, it is incumbent upon the states to adopt effective reforms. States can be supported in these efforts with strong evidence and clear guidance. This committee, therefore, proposes the following as strategies for implementation and dissemination: • In the short term, the Centers for Medicare and Medicaid Ser- vices (CMS) can support states by disseminating rules and policies that promote Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries’ access to appropriate care, and ensuring that its rules and polices reflect the practice abilities of current and new types of licensed providers. • In the long term, the Office of the Assistant Secretary for Plan- ning and Evaluation can help ensure that state practice acts are structured to optimize access to oral health care by examining and reporting on the impact of state practice acts on oral health care delivery to vulnerable and underserved populations. These reports would need to be conducted and published periodically to support sustained attention to increasing access.

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236 IMPROVING ACCESS TO ORAL HEALTH CARE Private foundations and organizations that focus on state policy can also play an important role in supporting efforts to eliminate unnecessary regula- tory and policy barriers to oral health care. Therefore, the committee sug- gests the following as specific examples of activities for such organizations: • Foundations, professional organizations, and public policy orga- nizations are ideally suited to conduct and disseminate an initial review of state practice acts with a focus on access to services. • Foundations, professional organizations, and public policy orga- nizations can support states by issuing “best practices” briefs to highlight what each state is doing and what impact it is having on access. Improving Dental Education and Training The committee’s vision supports changes to dental education and train- ing that will ensure that current and future generations of dental profession- als can deliver quality care to diverse populations, in a variety of settings, using a variety of service-delivery mechanisms, and across the life cycle. Greater emphasis will need to be placed on increasing the diversity of the workforce, including in the areas of race and ethnicity, as well as geographic distribution. The creation of such an improved and responsive education system can play a key role in eliminating barriers to oral health care. Training a Diverse and Experienced Workforce The 2004 Institute of Medicine (IOM) report In the Nation’s Com- pelling Interest emphasized the importance of ensuring greater diversity among health care professionals as it “is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, better patient–provider communication, and better educational experiences for all students while in training” (IOM, 2004). Similarly, the ADA’s Future of Dentistry report concluded that, “Dental schools have a responsibility to recruit and retain underrepresented minority students and faculty and for training students to be culturally competent in dealing with various populations” (ADA, 2001). Several innovative strategies have been used across the country to achieve these aims. For example, as discussed in Chapter 3, bridge and pipeline programs are two strategies used to address the imbalance between the numbers of minorities in the oral health profes- sions and those in the general population. While evidence indicates that strategies undertaken by dental pipeline programs show promise, they have made only modest gains in national enrollment among underrepresented minority students to date (Brunson et al., 2010).

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237 A VISION FOR THE DELIVERY OF ORAL HEALTH CARE In addition to efforts to increase the diversity of dental professional students, oral health curricula need to be updated to ensure that future dental professionals have substantial practical experiences in a variety of settings (e.g., Federally Qualified Health Centers [FQHCs], nursing homes, local health departments). Skills needed to work in these settings and with these populations include the ability to work in interprofessional teams with general health, education, and social service professionals; the ability to work in dental professional teams; and the ability to use new service- delivery mechanisms such as telehealth technologies for supervision, con- sultation, and collaboration. Providing students with clinical exposure in community-based settings increases the likelihood that students may return to such settings in their future careers and improves their comfort level with caring for vulnerable and underserved populations. The ADA recognized the importance of clinical experience in community settings in its Future of Dentistry report, that stated: “Dental schools should develop programs in which students, residents, and faculty provide care for members of the underserved populations in community clinics and practices” (ADA, 2001). And more recently, the ADA reaffirmed this position on community-based education programs in its new Accreditation Standards for Dental Educa- tion Programs. The new standards state that: “Dental education programs must make available opportunities and encourage students to engage in service learning experiences and/or community-based learning experiences” (ADA, 2010). Finally, schools will require more faculty members with experience and expertise in caring for vulnerable and underserved populations to adequately prepare students to work with these groups. Therefore, the committee recommends RECOMMENDATION 3: Dental professional education programs should • Increase recruitment and support for enrollment of students from underrepresented minority, lower-income, and rural populations; • Require all students to participate in community-based education rotations with opportunities to work with interdisciplinary teams; and • Recruit and retain faculty with experience and expertise in caring for underserved and vulnerable populations. To support Recommendation 3, the committee further recommends RECOMMENDATION 4: HRSA should dedicate Title VII funding to • Support the development, implementation, and maintenance of substantial community-based education rotations, and

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238 IMPROVING ACCESS TO ORAL HEALTH CARE Increase funding for recruitment and scholarships for underrepre- • sented minorities, lower-income, and rural populations to attend dental professional schools. Continuation and scaling up of proven strategies will help prepare and ultimately promote a greater desire among future oral health care profes- sionals to provide care to underserved and vulnerable populations. HRSA can play an important role in supporting this important shift in dental education and training. The committee, therefore, suggests that • HRSA can help dental professional schools meet the require- ment for all students to participate in substantial rotations in community-based settings by dedicating Title VII funding to sup- port the development and implementation of these programs. • Furthermore, HRSA could provide additional funding to dissemi- nate model practices. Private foundations have been at the forefront of efforts to increase enrollment of students from underrepresented minority, lower-income, and rural populations, and they can continue to play an important role. The committee, therefore, suggests that • Private foundations and professional organizations can strengthen the efforts of dental professional education by funding bridge pro- grams that recruit high school students from underrepresented minority, lower-income, and rural populations for predental college education. • Private foundations and professional organizations can also fund the development of innovative educational models to pre- pare students to work in diverse settings and with new delivery mechanisms. Promoting Advanced Practical Experience As discussed throughout this report, underserved and vulnerable popu- lations have both distinct and heterogeneous needs. Therefore, all oral health care professionals need to be sufficiently educated and trained to care for a broad range of individuals and populations. This is especially critical for dentists who will be called upon to provide specialized care and treat patients with the most complex needs. However, as discussed in Chapter 3, upon completion of dental school, students may have had few opportunities to integrate their skills and knowledge with practical hands-on experience

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239 A VISION FOR THE DELIVERY OF ORAL HEALTH CARE and may not feel adequately prepared for independent practice. To address this problem, the committee maintains that more dental students need to pursue postgraduate residency training so they are prepared to work with all populations. Moreover, the evidence reviewed in Chapter 3 demonstrates that ad- ditional training is needed to better prepare oral health care professionals to care for underserved and vulnerable populations. Postgraduate dental education is seen as an opportunity to address these needs. Dentists who have completed general dentistry residency programs report feeling more comfortable caring for underserved patients and patients with complex needs, and they deliver care for those patients more often, even after com- pleting residency. Residencies in dentistry are also an important source of care for the underserved. Therefore, the committee recommends RECOMMENDATION 5: HRSA should dedicate Title VII funding to support and expand opportunities for dental residencies in community- based settings. Subsequently, state legislatures should require a minimum of 1 year of dental residency before a dentist can be licensed to practice. This recommendation is not new; it was included in the 1995 IOM report, Dental Education at the Crossroads (Crossroads), where the com- mittee found that A year of postgraduate or advanced education in general dentistry would allow students to gain speed and confidence in procedures, broaden their patient management skills to cover more complex problems, and mature in the nontechnical aspects of patient care. (IOM, 1995) To be optimally effective in preparing dentists to care for underserved and vulnerable populations, it will be necessary for dental residencies to include clinical experiences with young children, individuals with special health care needs, and older adults. It should be noted that the authoring committee of Crossroads recom- mended creating more opportunities for residencies rather than require them (IOM, 1995). This current committee recommends the same as a short-term goal. To be maximally effective in addressing issues of access, the committee recommends that these residency opportunities should take place in settings where services are most needed. To that end, the commit- tee has identified “community-based settings” as logical partners for dental residencies. Further, as Crossroads noted, “financial pressures on hospitals have resulted in a modest decline in the number of hospital-based general dentistry programs, and uncertainties over future funding for graduate

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244 IMPROVING ACCESS TO ORAL HEALTH CARE • States can use Maternal and Child Health Services Block Grant (Title V) funds to evaluate and assess their case-management ser- vices to to determine the most effective strategies to improve access to oral health care. • Professional organizations and patient advocacy organizations can work with their constituencies to help identify populations in need of case management and the specific administrative barriers serving these populations. Promoting Research Over the course of this study, the committee encountered considerable gaps in the evidence base regarding important aspects of oral health and the delivery of oral health care to vulnerable and underserved populations. For example, little is known about the best ways to care for the distinct segments of the American public that are not well served by the traditional oral health care system. To this end, there are a number of programs cur- rently under way designed to deliver oral health care to underserved and vulnerable populations through innovations in use of the workforce and in alternative settings of care. Additional research on the effectiveness of these (and other) strategies toward improving access to oral health care will provide the evidence needed to make policy decisions. It will also foster the continuous improvement and innovation in the delivery of oral health care that the committee calls for in its vision. First, as discussed earlier, research is needed on how to best include nondental health care professionals in oral health care. In addition, within the dental professions, several new models seek to develop new types of dental professionals, or expand the role of existing dental professionals. For example, as discussed in Chapter 3, evaluations of the dental health aide therapist program in Alaska to date point to the quality and acceptability of dental therapists in providing care to remote populations. These findings are similar to evaluations of dental therapist programs in other countries where these professionals have a long history of serving as members of the dental team. However, evaluations to date have also been limited owing to the small number of dental therapists in Alaska, and it is not yet pos- sible to determine the broader implications of this and similar programs designed to improve access to oral health care in the United States. More research is needed to establish a sufficient evidence base to support broader dissemination of these programs. Research is also needed to evaluate newer methods and technologies for providing oral health care to underserved and vulnerable populations. For example, as discussed in Chapter 4, the use of telehealth technologies is emerging as a strategy to provide dental services in underserved communities where significant barriers to receiving care in a traditional dental office setting exist.

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245 A VISION FOR THE DELIVERY OF ORAL HEALTH CARE As described in Chapter 4, a range of strategies has been developed to deliver oral health care to vulnerable and underserved populations in a variety of settings outside the traditional dental practice setting. Some of these efforts build on the capacity of existing community services (e.g., dental professionals partnering with the Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]); others broaden the kinds of services provided at sites in the community (e.g., school-based health centers, mobile vans and other mobile equipment, and state and lo- cal health departments); still others are entirely new settings of care (e.g., retail dental clinics). While individual programs have been evaluated in terms of acceptability and effectiveness, less is known about which settings of care are most effective for reaching underserved and vulnerable popula- tions. Therefore, more research is needed to determine the best strategies for reaching these populations in general as well as strategies for addressing the needs of specific subpopulations (e.g., individuals with special health care needs or older adults). In addition, as discussed in Chapter 2, quality improvement efforts in oral health are hampered by a deficiency in the collection, analysis, and use of data related to important aspects of oral health. For example, a review of current National Quality Forum–endorsed measures finds no measures related to oral health (NQF, 2010). Further, the annual AHRQ National Healthcare Quality Report and the National Healthcare Dis- parities Report currently include only information about access to dental services, and not about the state of quality in oral health care (AHRQ, 2010). The lack of quality measures and the absence of a universally ac- cepted and used set of diagnosis codes among dentists make it difficult to assess the quality of specific services and procedures and limits the conclu - sions that can be drawn regarding their relationship to longer-term oral health outcomes. While concerns have been raised for the quality of care provided by dental professionals that are not dentists, there is little abil- ity to assess the technical competence, practice procedures, and quality of care and outcomes of care provided by any dental professionals, which makes comparison of care rendered by different types of professionals even more challenging. Finally, as alluded to earlier, little has been done to investigate better methods of financing and regulation that might lead to improvements in dental coverage, access to oral health care, and, again, improvements in oral health status. Therefore, the committee recommends RECOMMENDATION 8: Congress, the Department of Health and Human Services (HHS), federal agencies, and private foundations should increase funding for oral health research and evaluation related to underserved and vulnerable populations, including

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246 IMPROVING ACCESS TO ORAL HEALTH CARE New methods and technologies (e.g., nontraditional settings, non- • dental professionals, new provider types, and telehealth); Measures of access, quality, and outcomes; and • Payment and regulatory systems. • Given the need for further research, the committee concludes that a variety of stakeholders will need to take additional actions to support this recom- mendation, including • Federal agencies can increase funding for programs that success- fully provide education and preventive and treatment services to vulnerable and underserved populations such as Head Start, the WIC program, and school-based health centers. • HRSA can support the research agenda by providing funding for oral health demonstration projects that use a new delivery system—including new workforce models—that will successfully provide education, prevention, and treatment services to under- served populations through Head Start, WIC, and school-based health centers. Expanding Capacity Achieving the committee’s vision for oral health care will require that there are adequate resources available to meet the oral health needs of the public. As described throughout this report, these needs are great, and they are growing. For example, the ACA requires health plans offered on state health insurance exchanges to offer pediatric oral health benefits. The ACA, thus, will increase the number of children with oral health benefits. As more children receive coverage, there will be a need for increased capacity of the oral health delivery system. Supporting State Oral Health Programs State oral health programs are essential to effectively direct resources and monitor the impact of oral health efforts. One important function of state oral health programs is their ability to monitor and analyze the burden of oral health diseases, conditions, and personal behaviors over time. This information is critical to judicious planning, implementation, and evaluation of dental public health services. A recent examination of progress in children’s oral health since the surgeon general’s report on oral health concluded The importance of surveillance and the dental public health infrastructure, including the dental public health workforce, cannot be overemphasized.

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247 A VISION FOR THE DELIVERY OF ORAL HEALTH CARE Data are essential for establishing baselines and evaluating programs, poli- cies, and trends. (Mouradian et al., 2009) While there is little evidence regarding the specific impact and effec- tiveness of oral health surveillance (Beltrán-Aguilar et al., 2003; Tomar and Reeves, 2009), there is strong evidence from other fields (e.g., com- municable diseases and occupational health) to support the effectiveness and importance of surveillance activities (IOM, 2002). For example, HIV/ AIDS surveillance efforts were critical to understanding the number and characteristics of individuals affected by the epidemic (Gostin et al., 1997). Ultimately, these data helped guide targeted resource allocation for preven- tion and treatment programs (Fleming et al., 2000). The impact of other functions of state oral health programs (e.g., planning and supporting community water fluoridation, dental sealant programs, fluoride varnish programs, dental screening programs, and oral health programs specifically for pregnant women) as well as relevant state characteristics (e.g., provision of Medicaid adult dental benefits, counties without dentists and/or Medicaid dentists, and overall demographic infor- mation) are documented in the annual Association of State and Territorial Dental Directors (ASTDD) Synopses of State Dental Public Health Pro- grams (ASTDD, 2010). According to the ASTDD, With expanded infrastructure and capacity, state oral health programs are better able to monitor oral health status, address high-risk populations, increase population-based prevention activities, and extend resources to local health agencies and communities in order to implement oral health strategies. (ASTDD, 2000) Despite the positive impact of state oral health programs, funding for state and local dental public health services continues to be limited. In FY 2010, the Centers for Disease Control and Prevention (CDC) provided $6.8 million to just 19 state oral health programs to support evidence-based prevention programs (e.g., community water fluoridation and school-based sealant programs), surveillance of oral disease burden, and to develop plans to improve oral health and address disparities. Recognizing the critical role of state-based programs, the committee recommends RECOMMENDATION 9: The Centers for Disease Control and Pre- vention (CDC) and the Maternal and Child Health Bureau (MCHB) should collaborate with states to ensure that each state has the infra- structure and support necessary to perform core dental public health functions (e.g., assessment, policy development, and assurance).

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248 IMPROVING ACCESS TO ORAL HEALTH CARE The committee proposes the following strategies to support the imple- mentation of this recommendation: • The CDC can continue to increase the number of states that receive cooperative agreement funding for dental public health programs. • The MCHB can support an oral health component under Title V through block grants (formulary grants to states), discretionary funds, and/or “set asides” (a percentage of funds) for oral health. • Congress can fund the Oral Healthcare Prevention Education Campaign authorized by the Patient Protection and Affordable Care Act (ACA) [Public Law 111-148, Title IV, Sec. 4102] which calls for a national public education campaign focused on oral health and disease prevention targeted towards vulnerable and underserved populations. • Private foundations can partner with public agencies to develop, implement, and evaluate public education and oral health literacy campaigns. Capitalizing on Federally Qualified Health Centers FQHCs play an important role in increasing access to oral health care for vulnerable and underserved populations. For example, FQHCs are required to provide certain services—including preventive, but not com- prehensive, dental services—either in the clinic or by referral. The FQHC program is growing steadily. In 2009, HRSA funded 1,131 FQHCs, which are located in all 50 states, the District of Columbia, and Puerto Rico (HRSA, 2011). That is an increase from 914 FQHCs in 2004. Funding for FQHCs is also increasing. The American Recovery and Rehabilitation Act2 includes $2 billion for FQHCs (HHS, 2010), and the health care re- form bills include $11 billion for a Community Health Centers Trust Fund that will allow FQHCs to expand access and make capital improvements, and also appropriate $1.5 billion to a new National Health Service Corps Trust Fund.3,4 In 2009, over 3.4 million patients used dental services in the health center system (HRSA, 2011). Still, the number of patients whose oral health needs are served by the health center system has been only a small fraction of the underserved population (Bailit et al., 2006). Even with the expected health center expansion, the health center dental system will be inadequate to meet the demand for oral health services. Support and reform 2 American Recovery and Reinvestment Act of 2009, Public Law 5, 111th Cong., 1st sess. (February 17, 2009). 3 Health Care and Education Reconciliation Act of 2010, Public Law 152, 111th Cong., 2nd sess. (March 30, 2010). 4 Patient Protection and Affordable Care Act, Public Law 148, 111th Cong., 2nd sess. (March 23, 2010).

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249 A VISION FOR THE DELIVERY OF ORAL HEALTH CARE of the health center oral health delivery system will be needed to realize the potential of this vital national resource. Based on these findings, the committee concludes that with adequate support, FQHCs are well positioned to significantly expand the delivery of oral health care to vulnerable and underserved populations. Furthermore, because FQHCs employ both dental and nondental health professionals, clinics can engage additional members the health care team in providing basic oral health care to the populations they serve. The committee, there- fore, recommends RECOMMENDATION 10: To expand the capacity of FQHCs to de- liver essential oral health services, HRSA should • Support the use of a variety of oral health care professionals; • Enhance financial incentives to attract and retain more oral health care professionals; • Provide guidance to implement best practices in management, op- eration, and efficiency; and • Assist FQHCs in all states to operate programs outside their physi- cal facilities and take advantage of new systems to improve the oral health of the population they serve. The committee believes that the following strategies will be needed to support the implementation of this recommendation: • Public-private partnerships can supplement loan repayment pro- grams for oral health care professionals who are willing to serve a designated amount of time in medically underserved areas. • HRSA can support dissemination and implementation of this rec- ommendation by identifying FQHC “best practices” to highlight what states and/or individual clinics are doing and what impact these efforts are having on access. • HRSA can support the demonstration and dissemination of mod- els that extend the reach of FQHCs by operating programs out- side their physical facilities and that use new delivery models and techniques. • Other nonprofit community health centers can take the steps out- lined in this recommendation to increase the delivery of essential oral health services to greater numbers of vulnerable and under- served individuals. Box 6-2 provides a summary of the committee’s suggestions for a variety of ways in which the implementation of the preceding recommendations may be supported.

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250 IMPROVING ACCESS TO ORAL HEALTH CARE BOX 6-2 Summary of Key Implementation Strategies for the Committee’s Recommendations Health Resources and Services Administration (HRSA) • equire that Title VII–funded programs include interprofessional edu- R cation on oral health to promote the integration of oral health core competencies in nondental health professional education programs. • upport curriculum development and dissemination efforts for non- S dental health professional education programs. • edicate Title VII funding to support the development and imple- D mentation of required substantial rotations in community-based set- tings at dental professional schools. Additional funding could be provided to disseminate model practices. • upport care for underserved and vulnerable populations where they S live, work, and learn by designating the types of clinical experiences and settings that would qualify for dental residencies. • rovide funding for oral health demonstration projects that use a P new delivery system—including new workforce models—that will suc- cessfully provide education, prevention, and treatment services to underserved populations through Head Start, WIC, and school-based health centers. • dentify FQHC “best practices” to highlight what states and/or indi- I vidual clinics are doing and what impact it is having on access. • upport demonstration and dissemination of models that extend the S reach of FQHCs by operating programs outside their physical facili- ties and that use new delivery models and techniques. The Centers for Medicare and Medicaid Services (CMS) • isseminate rules and policies that promote Medicaid and CHIP ben- D eficiaries’ access to appropriate care, and ensure that rules and po- lices reflect the practice abilities of current and new types of licensed providers. • nsure that Medicaid beneficiaries receive the appropriate level of E care and equitable access to care by appointing and convening a committee of key stakeholders to establish an essential dental ben- efits package for Medicaid. • nsure that Medicaid beneficiaries receive the services for which E they are eligible by issuing guidance to states on how to reach popu- lations that are covered but do not receive the care. • equire states periodically to submit plans on how to increase Medic- R aid visit rates, and provide technical assistance on how to help them improve. • ssue guidance to state Medicaid officers on strategies to reduce I administrative burdens associated with provider participation in Medicaid.

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251 A VISION FOR THE DELIVERY OF ORAL HEALTH CARE The Office of the Assistant Secretary for Planning and Evaluation (ASPE) • xamine and report on the impact of state practice acts on oral E health care delivery to vulnerable and underserved populations. These reports will need to be conducted and published every 5 years to support sustained attention to optimizing access. Congress • rovide enhanced federal matching funds to the states to help offset P the additional expense of increasing Medicaid reimbursement rates to cover the cost of providing oral health care. To be most effective, Congress can require that an enhanced match be tied to efforts by states to streamline administrative procedures related to provider and patient participation in Medicaid. • und the Oral Healthcare Prevention Education Campaign authorized F by the Patient Protection and Affordable Care Act (ACA) [Public Law 111-148, Title IV, Sec. 4102] which calls for a national public education campaign focused on oral health and disease prevention targeted towards vulnerable and underserved populations. Dental Professional Schools and Teaching Hospitals • stablish formal relationships with community-based care settings E (such as FQHCs, nursing homes, state and local health departments and prisons) for dental residency programs. Foundations and Organizations Conduct and disseminate an initial review of state practice acts with a focus on access to services. • ssue “best practices” briefs to highlight what each state is doing and I what impact it is having on access. • ork with constituencies to help identify populations in need of case W management and the specific administrative barriers serving vulner- able and underserved populations. • und bridge programs that recruit high school students from un- F derrepresented minority, lower-income, and rural populations for predental college education. • und programs and public campaigns to raise awareness that oral F health care is a Medicaid benefit that people need to use. • artner with public agencies to develop, implement, and evaluate P public education and oral health literacy campaigns.

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252 IMPROVING ACCESS TO ORAL HEALTH CARE CLOSING THOUGHTS The release of this report coincides with a transformative moment in the nation’s health care system. Efforts are under way to ensure that all Americans have access to affordable health coverage. In the midst of these changes, the distinct deficits faced by vulnerable and underserved popula- tions deserve particular attention. As the nation struggles to address the larger systemic issues of access to health care, greater effort will be needed to ensure that oral health is included in this conversation. The enduring separation of oral health care from overall health care has marginalized issues related to oral health. As a result, oral health coverage has not been a primary focus of health reform. Further complicating matters is that these issues emerge at a time of significant economic challenges. For example, as states look for ways to address budgets shortfalls, many are eliminating their already limited coverage of oral health services. This strategy was even highlighted in a February 2011 letter to states providing guidance on potential cost-savings in Medicaid programs in which the secretary of HHS reminded governors that “while some benefits, such as hospital and physician services, are required to be provided by State Medicaid programs, many services, such as prescription drugs, dental services, and speech therapy, are optional” (HHS, 2011). Finally, there will be a sharp increase in the demands on the oral health delivery system by children and the growing numbers of retirees. For one, the ACA will increase coverage for oral health benefits for children. Even more significant, as increasing numbers of baby boomers (those born be- tween 1946 and 1964) become eligible for Medicare, considerable attention will need to be paid to how these aging adults will pay for and obtain oral health care. The relative size of this cohort—approximately 78 million— coupled with increases in longevity will create an unprecedented demand for oral health care for older adults. In light of the above issues, it is the committee’s strong intent that this report calls into sharp focus the challenges that millions of Americans face in accessing oral health care. The recommendations in this report provide a roadmap for creating an integrated delivery system that provides qual- ity oral health care to vulnerable and underserved people where they live, work, and learn through changes to education, financing, and regulation of oral health services. Failure to act now virtually guarantees that the na- tion’s inadequate and inequitable access to oral health care will persist with far-reaching individual and societal consequences.

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