INCREASING DENTAL ACCESS:A COLLABORATION BETWEEN A

COMMUNITY HEALTH CENTER AND A DENTAL RESIDENCY PROGRAM

Maryann Bailey, DDSDirector of Dental Services

Westside Health

Robert Arm, DMDDirector General Practice Residency Program

Christiana Care Health System

James Baker, DDS Delaware Institute of Dental Education

and Research, State of Delaware

Goals:Today: Provide some practical information on dental

residency programs and how to incorporate residents into a community clinic setting.

Demonstrate the value of a partnership with teaching hospital to increase access to care

If time: Provide a history of the Dental Program at

Westside Health Review difficulties recruiting dentists in the

State

Design – Based on needs of both programs

Accreditation ADA Access to Care

Education

Westside X 1 2

CCHS X X 2 1

Westside Health’s mission

Respond with compassion and respectto the health care needs of vulnerable individuals and families by providing equal access to quality health care, with an emphasis on disease prevention and health promotion, regardless of ability to pay.

Westside Health

Federally Qualified Community Health Center with three locations in and around Wilmington, Delaware

Large organizational growth over the last 10 years

17 FTE medical providers – MDs and NPs Multicultural patient population, majority

speak Spanish as their primary language

100% FPL and Below

53%

101-150% FPL21%

Over 200% FPL

16%

151-200% FPL9%

Unknow n1%

Note: Federal Poverty Level for a family of three in 2004 was $15,670. (See http://aspe.hhs.gov/poverty/04poverty.shtml)Source: 2004 UDS Report to HRSA, BPHC

Figure 1

Westside Health PatientsBy Income Level, 2004

Westside Health Patients By Income Level, 2004

Westside Health PatientsBy Income Level, 2004

Private Insurance

8%

Medicare4%

None/Uninsured

39%

Medicaid49%

Source: 2004 UDS Report to HRSA, BPHC

Figure 2

Westside Health Patients By Insurance Status, 2004

White10%

Hispanic or Latino65%

Black/African

American21%

Asian/Pacific Islander

3%

American Indian/Alaska Native

1%Source: 2004 UDS Report to HRSA, BPHC

Figure 3

Westside Health Patients By Race/Ethnicity, 2004

5,700

22,288

9,044

32,031

11,805

43,292

0

10,000

20,000

30,000

40,000

50,000

2002 2003 2004

We stside H e alth - Patie nts and Patie nt Visits

Patients

V is its

Identification of Need

Patient Satisfaction Survey performed in 1996 asked patients to write in their recommendations for increased services at Westside.

The resounding answer was:

“Dental”

Linkage with CCHS

Gave input into equipment and staffing needed to adequately run a dental program.

Offered assistance in recruitment of dentist to Westside and would help prepare that person for the Delaware Clinical Exam.

Interested in resident rotations at our CHC once a qualified dentist in place.

Dr. Arm’s expertise helped us apply for another New Access Point Oral Health Grant in 2001.

Westside Dental Program

Opened December 2002 2,500 square foot space with four

operatories. Initial dentist was a NHSC Ready

Responder placed at Westside for a short time to establish dental care.

Nationwide recruitment for a Director of Dental Services

Director of Dental Services Recruited

Westside covered my travel to Delaware to screen potential dental exam subjects.

This was an organization-wide effort, as staff and their families offered to be a test subject in exchange for free dental care and time off.

Dr. Arm coached me, a periodontist, on exam topics and refreshed my general dentistry skills before the exam in January 2003.

Westside provided transportation to Philadelphia for the exam subjects and dental supplies.

I chose to bring my own Dental Assistant for the exam.

Dental Program Expansion, 2004-Present

226256

335

286 302327 337

314353

293327

383

468

543 551

436

584565

150

200

250

300

350

400

450

500

550

600

650

Jan-04

Feb-04

Mar-04

Apr-04

May-04

Jun-04

Jul-04 Aug-04

Sep-04

Oct-04

Nov-04

Dec-04

Jan-05

Feb-05

Mar-05

Apr-05

May-05

Jun-05

Month

Num

ber o

f Vis

its

Number of Visits Goal

Westside’s Dental Program

March 2003-- 1 FTE dentist and 0.8 FTE hygienist

The need in the community far outweighed the capacity of our small dental clinic.

Met again with CCHS to discuss dental resident rotations.

2004 Oral Health Expansion Grant Proposal

Fit out and equip another four operatories, bringing total to eight.

Add another fulltime dentist Increase hygiene hours Extend hours to include two evenings

per week. Establish dental residency rotation at

Westside

Dental Resident Rotations At Westside

The final piece of the Oral Health Expansion Grant

Westside had experience working with Family Practice residents from CCHS.

Both partners committed to the realization of this plan with Senior Leader support..

Value of Dental Residency Affiliation

Increased access to care– residents can perform evaluations and treatment with

oversight from dental preceptor. Cost efficient Cost efficient

– use of facilityuse of facility– cost of providerscost of providers

Potential to help with future recruitment of dentists for Westside and the state

Contributes to the professional development of Westside dentists.

Referral source for difficult patients– oral surgery, patients requiring sedation, and medically compromised patients.

Residency Collaboration

Just started July 2005 Westside hosted the new residents for an

afternoon of orientation before start date. Resident rotations will increase dental

providers by 0.6 FTEs. Thus far, staff impressed with

professionalism of the residents and patients are pleased with care.

– Christiana HospitalChristiana Hospital, , in Newark, a 780-in Newark, a 780-bed hospital, providing the highest bed hospital, providing the highest capabilities in neonatal care, plus major capabilities in neonatal care, plus major regional, comprehensive, heart and regional, comprehensive, heart and cancer centers.cancer centers.

– Wilmington HospitalWilmington Hospital,, in Wilmington, a in Wilmington, a 291-bed, community hospital, providing 291-bed, community hospital, providing emergency and acute care services to emergency and acute care services to those who live and work in the city and those who live and work in the city and its suburbs.its suburbs.

Christiana Care operates two acute-care teaching hospitals in New Castle

County, DE

CCHS Mission

To improve the health of all individuals in the communities we serve.

CCHS Vision

To establish a strong, independent, coordinated healthcare system of unsurpassed excellence which is patient-focused and community-based.

CCHS’sAffiliation Requirements:

Facility must meet all accreditation standards–Space–Documentation–Quality assurance–Patient procedures, work-ups, etc–Support staff – 4 handed assisting

- dental hygiene

CCHS’sAffiliation Requirements:

Must have an approved attending– Evaluate residents – Evaluate patients treatment – Have a desire to teach/mentor– Fill out evaluations, required forms– Be part of resident review committee

CCHS’sAffiliation Requirements:

Qualified Residents– Qualified candidates – can we recruit?– Spots must be filled– All residents must be accepted to rotations -

can’t refuse anyone All must be part of any remediation plans

– Residents must be team players– Diverse backgrounds/schools

CCHS’sAffiliation Requirements:

Distant Sites – Housing must be provided– Distant learning available

Requirements for Dental Resident Rotations - Met

Qualified dentist on staff to precept the residents

Enough physical space and equipment to support operations – 4 new operatories added

Fully staffed practice to efficiently assist dental care by the residents.

Establish policies, documentation guidelines, and quality improvement activities compatible with the standards of the Commission of Dental Accreditation.

Goals of Christiana Care Health System Affiliation with Westside

Increased opportunities for resident education Educate residents on culturally effective care

through exposure to a multicultural patient population.

Improve educational curriculum – 4 handed dentistry

Maintain accreditation Increase access to dental care in the community

– mission statement of both Retain dentists in state after residency.

Currently, over 80% stay in Delaware.

CCHS General Practice Residency Program - Changes

Goal – Increase the residency from six to eight residents per year – two added in 2005 to support Westside rotation

Problems recruiting residents – broken contracts, withdrawals

Even with only six to start WE STAYED COMMITTED TO THE PROGRAM

Seventh added late June Eight to be added in September

Problems – Change Rotations: THIS YEAR

•24 blocks – ½ month but 8 residents 8+ months - General Dentistry

• 1 1/2 months - OMFS

• 1 1/2 Months - Consult Rotation

•Wednesday AM- Endodontics

•Wednesday PM – Implants

•Thursday PM – Periodontics

•Friday AM - Pediatrics

Implant Program –

A Key to Attracting Residents

Wednesday PM – Implant TeamDrs. Zucker, Baker, Isaacs

Drs. Rafetto, Granite - OMFS

Rotations

Consultations - Inpatient/ ambulatory Emergency Department Anesthesia Other sites

Problems with scheduling

PROGRAM ANNOUNCEMENT

Delaware State Loan Repayment Program

For Physicians and Dentists

June 2002

Appropriate access to health care services throughout the state requires an adequate number and appropriate geographic distribution of physicians and dentists. The documented shortage of physicians and dentists in certain parts of Delaware is a concern.

And Help From the State

Challenges – Westside

Scheduling Scheduling – Best for patients and scheduling Best for patients and scheduling same time each weeksame time each week

SeminarsSeminars– Problems with last minute changesProblems with last minute changes

Residents are slowerResidents are slower Orientation – takes chair side time away Orientation – takes chair side time away Time from dentists schedule to superviseTime from dentists schedule to supervise

Challenges - Christiana

Recruitment of residentsRecruitment of residents Making a rotation schedule for several Making a rotation schedule for several

sitessites Meeting educational demandsMeeting educational demands Scheduling seminarsScheduling seminars Continuity of CareContinuity of Care

Challenges - CCHS Residents

Missing special clinics –Missing special clinics –– Pediatric Dentistry Friday AM’sPediatric Dentistry Friday AM’s– Endodontics Wednesday AM’sEndodontics Wednesday AM’s

TravelingTraveling– Returning for seminarsReturning for seminars

Length of session –Length of session –– CCHS has different hoursCCHS has different hours

Benefits - Westside

Increased ProvidersIncreased Providers Evening CoverageEvening Coverage Referral source for difficult caseReferral source for difficult case

– Major Oral SurgeryMajor Oral Surgery– Difficult EndodonticsDifficult Endodontics– Those who need sedationThose who need sedation– Medically compromisedMedically compromised

Benefits - CCHS Resident

Excellent 4-Handed DentistryExcellent 4-Handed Dentistry– One assistant assigned to residentsOne assistant assigned to residents– Better chair side set-upBetter chair side set-up

Efficient patient careEfficient patient care More continuity of care – return casesMore continuity of care – return cases

ALL SEVEN RESIDENTS STATED:ALL SEVEN RESIDENTS STATED:– No problemsNo problems– Enjoy the rotationEnjoy the rotation

Plans for Program Evaluation

Did program improve access to dental care?

Were the educational standards met? Did residents remain in Delaware? Were any dental residents attracted to

community dentistry through exposure to Westside?

Did this affiliation assist in recruitment of future dentists to Westside?

Outcome Assessment

Only time will tell– need a minimum of two years experience to track changes.

Hopefully, this program will help change the face of dental care in Delaware.

Delaware State Loan Repayment Program established in 2002 for dentists to help with recruitment. This is just a start.

Working together to increase access to care with the State and changing the requirements.

Starting NeedsStarting NeedsChampionsChampions

Westside Health

Lolita Lopez, President and CEO

Drs. Donohue, Bailey

Christiana Care

Drs. Arm, Granite, Administration

Delaware

Public Health, DIDER

Starting NeedsTaking a Chance

Willing to try, reevaluate, change At least a two year commitment Starting Funds Building/expansion expense

Westside - Gaining Momentum

Evening hours added. Final four operatories completed Hygiene hours increased Practice Management changes to limit new

patient scheduling to one month at a time. Establishment of same day or next day

emergency appointments. Development of an internal referral system to

give priority to children, pregnant women, and adult patients with chronic disease.

Westside - Gaining Momentum (cont)

Integration of dental health into the Bureau of Integration of dental health into the Bureau of Primary Health Care sponsored Health Disparities Primary Health Care sponsored Health Disparities CollaborativesCollaboratives

Diabetes Dental Sessions established to provide Diabetes Dental Sessions established to provide unique changes in Delivery System Designunique changes in Delivery System Design– CDE present in dental waiting room to provide CDE present in dental waiting room to provide

education on dental health with diabeteseducation on dental health with diabetes– Private grant funding obtained to financially support Private grant funding obtained to financially support

initial diabetic dental appointment and hygieneinitial diabetic dental appointment and hygiene– Patient gift bags as incentive to follow through with Patient gift bags as incentive to follow through with

dental care.dental care.