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6 End-of-Day Discussion: Day 1 Moderator: David N. Sundwall, M.D. Utah Department of Health Sundwall remarked that he recently read a report from a 1934 commis- sion on public health that noted difficulties with access, geographic distri- bution, and provider mix as well as a call for more dentists, more primary care, and more nursing involvementâall the same issues facing the health care system today. He added that in spite of many challenges, including the current economic crisis, this is a time for optimism. He noted that the federal government is investing in health professions education. Sundwall invited members of the planning committee to summarize their perceptions of the themes discussed during the first day of the workshop. Discussantsâ panel Elizabeth Mertz, M.A. Center for the Health Professions, University of California, San Francisco Solutions to challenges in improving access to oral health services require paradigm shifts in the way we think about the workforce, differ- ent models of care delivery, and the different responsibilities of the actors within the care delivery system. Moving beyond thinking of dentists having the sole responsibility for oral health care is a complex and multifaceted issue. However, the change in the paradigm of care delivery seems to be 47
48 THE U.S. ORAL HEALTH WORKFORCE toward what most practitioners already know: it takes a team to address these issues and not just one individual practitioner. Other important fea- tures of paradigm shifts include considering the nomenclature used for the workforce, identifying all potential members of the oral health team, and how to think about a dental, medical, or health care home. Another challenge to improving access relates to the model of care delivery, including private practice models, institutionally based models, public health models, and models with dentistry at the center. Strong leaderÂ ship exists for each of these approaches, and those leaders need to work together regarding how the different models fit together in a broader system of health care delivery. Other considerations include focusing on specific populations, the role of the government, and how what happens within the microcosm of dental care and medical care is a reflection of society more broadly in terms of health disparities and other social pressures. Finally, more evidence and resources are needed such as the devel- opment, standardization, and dissemination of curricula in oral health for nondental professionals. Additionally, there is a lack of performance standards across the oral health system. A better scientific evidence base is needed so that new models of care and existing models of care can be held accountable to the same standards. Shelly Gehshan, M.P.P. Pew Center on the States Many people argue that a system of oral health care does not exist. Since the system has failed large portions of society, many people are will- ing to forego that system and move forward with other solutions outside of traditional dentistry. Dentists are a smart and entrepreneurial group but seem more averse to the use of new types of practitioners (who might be a source of increased revenue and referrals) than the increasing number of dental schools. Organized dentistry, like any other large organization, is not able to change quickly. While many leaders in organized dentistry have great energy and enthusiasm to address access problems, the formal policies remain antiquated. In addition, state practice laws need to be reexamined so that one professional group is not regulating another. More thinking is needed on how to ensure the public is safe with respect to all practitioners. Finally, Gehshan recognized the range of entrepreneurial activity occurring in the dental fields. Len Finocchio, Dr.P.H. California HealthCare Foundation There are many reasons for the irrationality behind how the oral health system evolved. Consideration is needed for how to integrate medical, den-
END-OF-DAY DISCUSSION: DAY 1 49 tal, and public health. Another necessary consideration is how to reorient the delivery of oral health services across different sectors and distribute the delivery of those services using the mix of the workforce in order to optimize oral health outcomes. That is, instead of basing solutions on cur- rent scopes of practice, more attention is needed on how to best use each member of the health care workforce to meet the best identifiable public health outcomes. In addition, more attention is needed regarding how to determine if those outcomes have been met. For example, public programs need to become smarter purchasers of oral health services. Daniel Derksen, M.D. University of New Mexico Proposed workforce solutions to improving access to oral health ser- vices show great efforts to improve collaboration and respect between oral health disciplines. The current economic crisis acts to exacerbate the loss of confidence in the health care system that is arising in the general public. The United States puts more money into its health care system than any other society, yet does not achieve better outcomes. More needs to be done to assure the quality and value of the health care services delivered. Consideration is needed for the balance of the health care system to ensure that focus is on those services that improve health for both individuals and society as a whole. The professions need to come together to work on these problems to make sure the individuals, communities, and populations are best served by existing resources. Proposed workforce models serve as good starting points and now consideration is needed for the policy recommenda- tions that will move the oral health care system forward as a whole instead of focusing on the interests of individual professionals. Marcia Brand, Ph.D. Health Resources and Services Administration There is an extraordinary amount of innovation in proposed solutions to oral health access challenges, and the federal government may be able to play a facilitative role in improving the oral health system. For example, current health workforce policy work requires a discipline-by-discipline examination in order to answer a single question, and consideration is needed regarding strategies to share information, such as for best prac- tices among disciplines. The Health Resources and Services Administration Â ecently introduced the Health Workforce Information Center to provide r a single location for information about the health care workforce, which â âSee www.healthworkforceinfo.org.
50 THE U.S. ORAL HEALTH WORKFORCE might be a good place to share best practices. Also, some provider groups have fairly good data about their workforces, and some good data exist regarding demand for oral health services. However, a research agenda is necessary to provide better understanding about the different models of oral health care delivery. reaction and discussion Moderator: David N. Sundwall, M.D. Utah Department of Health An open discussion followed the discussantsâ presentations. Audience members were able to give comments and ask questions of the discussants. The following sections summarize the discussion session. Vulnerable Populations A participant commented that the prison populations (including residents of federal prisons, state prisons, and detention centers) are vulnerable popula- tions in need of special consideration. He stated that there are over 2 million incarcerated persons in the United States and very little is known about their oral health care. The participant added that other institutional populations in need of attention include residents of mental health facilities and nursing homes. Another participant noted in light of the current mode of practice, little will be done to impact caring for the underserved unless the entire oral health workforce is reorganized. Another participant added that in order to meet the needs of underserved populations, practitioners need to get into the communities to reach people where they live and work to overcome barriers these people face in getting to traditional locations of care. Public Health Several participants commented that more attention is needed on the public health dental workforce instead of focusing just on clinical provid- ers of oral health care services. One participant added that public health dentists need to teach dental public health in schools of dentistry and pro- grams of dental hygiene. Public health dentists also need to be conducting public health research to address prevention issues. Another participant commented that as discussions about the economy and health reform go forward, a national plan is needed to promote prevention so that access is less of a problem.
END-OF-DAY DISCUSSION: DAY 1 51 Professional Liability A participant commented that professional liability needs to be consid- ered because it influences how any new type of model may be arranged. He noted that as the director of a community health center there is substantial responsibility on a daily basis for what happens under the reach of the health center and that level of legal responsibility may lend to the cau- tiousness of discussions about changing the way services are delivered. The participant said that as new models go forward, consideration is needed for who can be responsible legally, professionally, and ethically. Another participant added that liability does not fall just on one person in situations of collaborative practice. She noted that every licensed professional takes legal responsibility for the services he or she provides. Learning from the Past Several participants noted the wealth of history regarding studies on access to oral health services. One participant referenced the Institute of Medicine study Dental Education at the Crossroads (IOM, 1995), noting that most if not all of the recommendations have not been acted upon. A Â nother participant urged more consideration of other public health fac- tors, referencing a study done in the 1970s that looked at the oral health workforce in several countries. The study found that the oral health work- force did not show any direct relationship to oral health outcomes. Instead, she said, oral health outcomes were associated with issues of public accept- ability, public attitudes, lifestyle practices, socioenvironmental issues, and prevention policies. Another participant noted that in the 1990s, a coalition of organizations worked to ensure oral health was included in health care reform discussions, and that such an opportunity exists again today if all groups work together. Improving Progress A participant commented that the talents of all practitioners in the oral health care system need to be recognized and that instead of focusing on hierarchy, more attention needs to be placed on putting the patient at the center of care. Another participant said innovative models are crucial to making progress and that more opportunity for experimentation is needed. The participant stated that all the organized professions need to look o Â bjectively at the outcomes of new models of care to consider if there are better models of practice. Another participant stated the board of trustees of the American Dental Association is dedicated to finding solutions to the
52 THE U.S. ORAL HEALTH WORKFORCE access-to-care problem. He noted an upcoming summit on access to care and another one on diversity that seek input from all points of view. The participant agreed that more collaboration is needed and suggested the formation of oral health coalitions.