ADEA SymposiumAlaska Dental Health Aide Therapist Program*

10:15 to 11:30 am: Description of the DHAT Program in Alaska11:30 to 12:15 pm: The Evaluation of the DHAT Program

*Supported by grants from: The W.K. Kellogg Foundation in collaboration with the Rasmuson, Bethel Community Services, Murdock, Paul G. Allen and Ford Foundations

ADEA SymposiumAlaska Dental Health Aide Therapist Program*

10:15 to 11:30 am: Description of the DHAT Program in Alaska11:30 to 12:15 pm: The Evaluation of the DHAT Program

*Supported by grants from: The W.K. Kellogg Foundation in collaboration with the Rasmuson, Bethel Community Services, Murdock, Paul G. Allen and Ford Foundations

Description of the Alaska DHAT Program

Overview of DHAT Program: Ron Nagel, DDSEducation programSystem of Care

Norton Sound Program: Mark Kelso,DDSUnalakleet Therapist: Aurora Johnson, DHAT

Questions & Answers: A. Formicola, moderator

The Alaska DHAT Program is operated by the Alaska Native Tribal Health Consortium (ANTHC)

Dental Health Aide Program

Ron Nagel DDS MPHAlaska Native Tribal Health

Consortiumwww.ANTHC.org

Newtok Clinic, Yukon-Kuskokwim

Community Health Aide History

Developed by physicians some 38 years agoCompetency based credentialing Today about 550 CHAs provide primary health care in rural Alaska (350,000 patient encounters annually)Their training starts with EMT or ETT trainingThey are an integrated part of the delivery system working with Doctors, Nurses, and PAs. They are not a second level of care

Federal Health Aide Program Certification Board

The Community Health Aide Program Certification standards are administrated by a Federal boardThis standing committee serves to credential providers and to respond to provider issues and patient complaintsThere are provisions in the standards for discipline, suspension or revocation of a certificate

Federal Health Aide Program Certification Board

The Community Health Aide Program Certification standards are administrated by a Federal boardThis standing committee serves to credential providers and to respond to provider issues and patient complaintsThere are provisions in the standards for discipline, suspension or revocation of a certificate

Dental Health Aide Therapists

At least 52 countries utilize Dental Therapists – IDJ (2008) 58, 01-70Function as part of the dental team under the supervision of a dentistNew Zealand has 88 yrs experience and Canada has over 38Exceptional safety record under general supervision for children and adults

Dental Health Aide Therapists: Scope

Clinic or village based Provide the spectrum of health education and preventive servicesRestore teeth to function utilizing amalgam and composite materialsProvide SSCs and pulp treatment for primary teethExtract teeth and manage dental emergenciesScreen for oral and peri-oral diseaseThey are equipped to help us provide the educational, preventive and safety net services that are most needed

Dental Health Aides

Dentists

Dental Patients Seeking Care

Traditional

Dental Health Aide Model

Clinical Guidance

AFHCAN CartAlaska Federal Health Care Access Network

Wireless NetworkingTouchscreenMobile –Customized

ConsultationPatient educationProvider education

WWW. AFHCAN.ORG

DHAT Oversight

DHATs are assigned to a primary supervising dentistSupervising dentists provide patient consultations and program planningMonitor the referral process and DHATs understanding of their scopeChart reviews, patient satisfaction surveysStandardization of treatment to improve outcomes

Quality Assurance

Begins with a 400+ hour directly supervised preceptorshipDHAs must demonstrate the practical professional competencies for their level of certification throughout their careerEvery two years each DHA must provide evidence that they completed the CE requirements (24 hrs) Dentists proactively monitor sentinel events and treatment outcomesThese administrative controls help to assure quality and that a single standard of care is met in tribal programs

Competency Based Credentialing

Frequent sampling of knowledge and skills over time – not a single event testWe look directly at the services that they provide day to day to achieve high predictive validity with this processEach DHAs’ scope of practice is individually assigned based on competency through standing orders

DENTEX training programUniversity of Washington MEDEX NorthwestTwo year program based on NZ, Canadian, and other modelsIntegration into community based prevention programs throughout trainingA new mix of skills that includes the behavioral and public health skills needed to affect changeThe use of simulation and extensive patient contact to develop a high level of skill

ADEA SymposiumAlaska Dental Health Aide Therapist Program

Mark Kelso, D.D.S.Dental Director

Norton Sound Health CorporationNome, Alaska

ADEA SymposiumAlaska Dental Health Aide Therapist Program

Aurora JohnsonDental Health Aide Therapist

Unalakleet, Alaska

The Evaluation Plan for the Alaska DHAT Program

National Advisory Committee for the DHAT Evaluation: Caswell Evans, DDS, MPH

Chairman of the NAC

The Evaluation Plan: Scott Weatherhall, MD, MPHSenior Program DirectorResearch Triangle International

Questions & Answers: Caswell Evans, moderator

Members of the National Advisory Committee for the DHAT Evaluation

Myron Alukian JrRobert BrandjordGeorge BrennemanL. Jackson BrownDominick DePaolaCaswell Evans (chair)Chris HallidayLawrence HillRaymond Lala

Shelia RiggsStephen SchroederMary SmithAndrew SnyderRichard ValachovicBrad WhistlerDoug WhiteBerda Willson

RTI International is a trade name of Research Triangle Institute

Evaluation of the Dental Health Aide Therapist Model

American Dental Education AssociationMarch 16, 2009

Scott F. Wetterhall, MD, MPH

Background on RTI International

RTI InternationalSecond largest non-profit research group in U.S.

Based in North Carolina, offices worldwide

Life and social science work in wide range of areas

Experience in program evaluation and health services research

Framework for evaluation

Overview of evaluation process

1. Engage stakeholders

Persons served by the DHAT programAlaska Native Tribal Health ConsortiumDHAT Evaluation Tribal Coordinating CommitteeNational Advisory CommitteeW.W. Kellogg FoundationRasmuson FoundationBethel Community Services FoundationIndian Health ServiceOthers

2. Describe the program

Reviewed background material and literature

Met with AK Tribal Coordinating Committee

Met with National Advisory Committee

Made 3 site visits in 2008

Consulted with knowledgable stakeholders

3. Focus the evaluation: specific objectives

Examine patient access to care and satisfaction

Assess quality of preventive and restorative treatment

Examine implementation of community-based prevention plans and programs

Assess practices procedures

3. Focus the evaluation—stages in program development

ProgramPlanning

ProgramImplementation

ProgramEffects

3. Focus the evaluation

Evaluate villages served by DHATs in all five tribal

health areas

Focus on program implementation

Provide baseline for future assessment of

program impact

4. Gather credible evidence

Implementation assessmentIntegrity of implementation compared to program model

Differences/similarities across DHATs

Barriers/facilitators of implementation

Health outcomes assessmentSafety (including adverse outcomes)

Quality

Patient-oriented outcomes (e.g., pt. satisfaction)

4. Gather credible evidence: methods

Key informant interviews

Patient surveys

Patient examinations

Direct observation of treatment

Patient record audit

Direct observation of practice procedures

Key informant interviews

DHAT

Supervisory dentist

Community Health Aide

Clinic manager

School personnel

Village elders

Patient surveys

AHRQ’s CAHPS (Consumer Assessment of Healthcare Providers and Systems) for pt. satisfaction

Oral quality of lifeOral Health Impact Profile-14 (Slade) in adultsEarly Child Oral Health Impact Scale (ECOHIS) (Pahel)

Patient examinations

Random sample of village residents

“Calibrated” dental inspectors

Summary of community oral healthWHO Oral Health Survey methods—DMFTCommunity Periodontal Index for >18 years old

Quality of prior restorative treatment using Ryge-Snyder criteria

Direct observation of treatment

Class II amalgam and composite preparation

Stainless steel crown preparation

Provision of oral health instruction

Patient record audit

Systematic sample of DHAT-treated patients

Quality of preventive treatment (6 measures)

Effectiveness of care (5 measures) (Bader et al., 1999)

Use of services (receipt of prophylaxis, preventive:restorative treatment ratio)

Adequacy of record keeping

Direct observation of practice procedures

Use of modified Met Life practice assessment tool

Facilities, equipment, administration, infection control

Timeline

Mar 2009: Obtain AK IRB approval

May 2009: “Calibrate” 2 dental inspectors

May 2009: Field data collection in one site

Sept 2009: Data collection in four other sites

May 2010: Repeat visits to 5 sites

5. State conclusions and recommendations

Gain insights

Change practices

Assess effects

Affect participants

Uses of evaluation dataUses of data from this evaluation

6. Disseminate results: data sharing

Update funders and coordinating committees on a

regular basis

Study findings will be presented to the foundations

and coordinating committees for review prior to any

further dissemination

Oral presentations and peer-reviewed journal articles

For more information

Scott F. Wetterhall, MD, MPH

RTI International

www.rti.org

770-234-5046

swetterhall@rti.org