PowerPoint Presentation

Bob Russell, DDS, MPHIowa Department of Public Health

Iowa Plan: Dental Public Health in Iowa1

Title V MCH Service Areas2Within each county are multiple agencies (local public and private/non-private agencies) that serve families:County health departmentsPublic health nursing servicesHome health care agenciesVisiting nurse servicesCommunity action programsPartners

33Open Mouth SurveysMedicaid ServicesTitle V Databases & ReportsPublic Health Supervision Reports

http://www.idph.state.ia.us/hpcdp/oral_health_reports.asp Assessment Examples4

4Back to the three core functions of public healthIn order to assess programmatic and policy needs - We monitor oral health status and prevalence of disease several ways. One thing that we do is to work with our contractors to conduct open mouth surveys. Our funding dictates that we primarily focus on children and specifically a National Performance Measure for the Title V block grant requires determining prevalence of sealants on 3rd graders. These surveys are conducted as often as needed based on statistical significance of results. Survey reports are posted on the IDPH Web site.We are also beginning to conduct more surveillance on children younger than school age between 0 and 5. Two years ago we did an open mouth survey of Head Start children. Last year we collected information on children in WIC. This year we plan to go into day care centers. We also review Medicaid data usually utilization and billing data. By looking at the ability of Medicaid-enrolled children to access services, we can assess the ability of at-risk children and families in general. It also provides us a means to determine if our programs are making an impact.We are also able to request specific reporting from Medicaid which helps us to look at specific issues for example, physicians who bill for fluoride varnish applications where they are located, how many they did. These things help us to determine program needs and potential policy changes needed.Another means of assessment includes reviewing information from databases for our MCH Contractors which track demographics, services provided (as well as barriers and needs) of CH and MH clients. We also receive annual reports from dental hygienists practicing under public health supervision which provides a glimpse at the number of services and population who receive care via public health settings. There are other things we can use such as the Behavioral Risk Factor Surveillance BRFSS and Iowas House hold Health survey. Our assessment function does not include RESEARCH which is something more applicable to the University.

National Trends in Caries-Free Schoolchildren Permanent Teeth

Ages 5-17 yearsAges 6-19 years

Fluoridation and Public Health2011 Training Program5Similarly, the percentage of caries free children has been increasing.Iowa: Untreated decay is decreasing

Iowa: Adults

79 elementary schoolsTotal: 990 elementary schools21 Junior High SchoolsTotal: 299 Junior High Schools9,941 Sealant placed on 1st molars in 2009-102,381 sealants placed on second molar teeth

Penetration of Public Health Sealant Programs in Iowa Decay Positive and Decay NegativeWe subset the dataset into two datasets: decay positive and decay negative. The graph demonstrates how the treatment rate differed between decay and no decay treatment groups. This shows that there is a possibility that the screenings do play some role in children seeking treatment.937.8% from East Central Iowa22.2% Rural (Not adjacent to urban)70.5% white, 16% unknown race/ethnicity85.2% spoke English95.5% had a Medical Home61.2% had a Dental Home49.9% Males73.5% were younger than 5

Decay Negative29.9% from East Central Iowa29.1% Rural (Not adjacent to urban)66.7% white, 16% unknown race/ethnicity80.5% spoke English92.2% had a Medical Home69.3% had a Dental Home52.7% Males56.8% were younger than 5

Decay PositiveResultsWe used logistic regression analysis to find associations between variables and outcome of not receiving treatment.

In CAReS, Medical and Dental Home are both determined for a child, based on responses to specific information from the parent or guardian. So, as you see on this slide, for the purposes of determining medical and dental home in CAReS:

Medical home: child has a usual source of medical care, the care is available 24/7, and the source of the care maintains the childs record

Dental home: the child has a usual source of dental care, that source of care maintains the childs record, and the child has seen a dentist within the past 12 months

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Iowa: a State in TransitionDemographic TrendsRapid Ethnic Diversification

Aging white populationLow fertility rates among whitesExodus of graduates to other statesHigher birth rates among native minorities Large influx of immigrants, primarily Latinos, to work in labor shortage

Need for increased outreach services

Need for new service hours

Child Care barriers

Geographic and transportation barriers

Different health care utilization patternsIowaImplications of Changing Demographics

Iowa Elderly in Assisted Living Centers2007 Survey Results15We have stated that 92% of Iowans are receiving optimally fluoridated water.What does this % really mean?92% of Iowans who receive their water from a Community Water Supply are receiving optimally fluoridated water.Overall, approximately 83% of Iowas total population is receiving optimally fluoridated water. This percentage may actually be higher depending on if the population who receives their water by a private well has naturally fluoridated water or is adding fluoride to their water.We have no system for tracking private wells or monitoring leaving over 248,205 estimated Iowans potentially lacking fluoridated water!

The Iowa PictureTrends are TroublesomeNo longer provides fluorideWater SystemCountyAshtonOsceola CountyColumbus JunctionLouisa CountyCoon RapidsCarroll CountyElkader Clayton CountyEverlyClay CountyFloydFloyd CountyFort MadisonLee CountyGrangerDallas CountyMaxwellStory CountySac CitySac CountySanbornOBrien CountySutherland OBrien CountyVictor Iowa County 17IowaConsidering discontinuation or reduction Water SystemCountyAplingtonButler CountyCedar RapidsLinn CountyDallas CenterDallas CountyDeSotoDallas CountyGilmore CityHumboldt CountyGrangerDallas CountyKeokukLee CountyMechanicsvilleCedar CountyNew SharonMahaska County OssianWinneshiek CountyTamaTama CountyI-Smile An Overview of Iowas Dental Home Initiative for Children

Bob Russell, DDS, MPHState Public Health Dental DirectorIowa Department of Public Health

192005 Legislative MandateBy July 1, 2008, every recipient of medical assistance who is a child 12 years of age or younger shall have a designated dental home and shall be provided with the dental screenings and preventive care identified in the oral health standards under the EPSDT program.20In response, the Iowa DHS partnered with the IDPH, the IDA, the IDHA, the University of Iowa, and others to develop a proposal that would fulfill the dental home mandate.

The result is the I-Smile dental home project.Iowa Legislative Mandate ModifiedBy December 31, 2010, every recipient of medical assistance who is a child 12 years of age or younger shall have a designated dental home and shall be provided with the dental screenings and preventive services, diagnostic services, treatment services, and emergency services as defined under the EPSDT program.* Language modified in 2008, HF2539212010 has come and gone, but the mandate is still in effect. The dental home is a system that allows all children, even those often excluded from receiving dental care, to have early and regular care to ensure optimal oral health.Conceptual Dental HomeThe I-Smile Dental Home

PHYSICIANDENTALHYGIENISTDENTISTNURSE2323What makes I-Smile unique is the way that we envision the dental home.The I-Smile dental home is not a dental office.

It is envisioned as a conceptual dental home. Uses a team approach to manage oral diseasePrimary prevention and care coordination are a large focusDentists provide treatment and definitive diagnosisOther health care professionals are part of a larger network providing oral screenings, education, anticipatory guidance, and preventive services as needed

I-Smile ObjectivesImprove the dental support system for families.Improve the dental Medicaid program.Implement recruitment and retention strategies for underserved areas.Integrate dental services into rural and critical access hospitals.24The original plan for implementing I-Smile identified 4 objectives.

The first objective, improving the support system for families, is the one with the most impact on our existing public health system specifically the states Maternal and Child Health system and is the one that I will focus on.

Partnerships and planningLink with local board of healthProvide training for child health agency staffDevelop agency oral health protocols Provide education and training for health care professionalsEnsure completion of screenings and risk assessmentEnsure care coordination servicesEnsure provision of gap-filling preventive services

I-Smile Strategies 25Each contractor must submit an action plan and budget, developing activities based on these strategies as well as based on their local needs and assets.

Strengthen Iowas Title V MCH System

Establish a dental hygienist within each Title V Child Health agency as the local I-Smile Oral Health CoordinatorCurrently, Iowa has 24 dental hygienists working as regional I-Smile CoordinatorsThey create a system to assure optimal oral health for children.

Improve Dental Support System for Families26Work on this objective occurs through our states Title V Maternal and Child Health system.

The Dept of Public Health has 22contractors private/non-profit or public agencies to implement the Title V child health program at the local level. Contractors are responsible for assuring health services for pregnant women and children.

For several years, the Department of Public Health and the Department of Human Services have had an interagency agreement. The agreement allows IDPH to assist in achieving EPSDT standards through these contractors and also allows the contractors to bill Medicaid for limited services provided to Medicaid-enrolled clients.

This has also been the means for funding Iowas ABCD program. Using lessons learned from our ABCD program, we were able to develop I-Smile strategies to be implemented through our local MCH contractors now also funded through the interagency agreement.

I-Smile Referral SystemI-Smile Referral System27I-Smile Dental Home Care Plan Diagram

I-SmileOral Health Coordinator Oral Screening and Risk Assessment Preventive CareEducationMedicaid, uninsured, and underinsured children from birth-12 years

Low RiskNo observable diseaseModerate RiskNo observable diseaseHigh RiskObservable diseaseHigh RiskSevere disease Level 1 Level 2 Level 3

PLANCare coordination

Referral for dental exam within 1 year

Oral screening, risk assessment, and preventive care in 6 months Care coordination

Referral for dental exam within 6 months

Oral screening, risk assessment, and preventive care in 3-6 months Care coordination

Referral for dental exam within 3 months

Oral screening, risk assessment, and preventive care in 3-6 months Care coordination

Immediate referral to dentist/specialist

Oral screening, risk assessment, and preventive care in 3 months

In 2012:More than 1 times as many children ages 0-12 saw a dentist for care than in 20053 times as many children ages 0-12 received care from a hygienist or nurse working for a Title V agency than in 200561 % of children ages 3-12 saw a dentistBased on SFY2012 Medicaid paid claims, Iowa Department of Human Services Still too many children under the age of 3 who do not receive dental services. Lack in dentists willing to see the very young child. Low participation by dentists willing to see Medicaid children. Low Medicaid reimbursement. Decreasing and aging dental workforceMal-distribution of available dental providers

I-Smile--Challenges

Iowa Facts: Decreasing and aging dental workforceIncreasing number of health professional shortage sitesMal-distribution of available dental providers

Along with low reimbursement rates, the other barriers to treatment for our children include a shortage of dentists. Dentists in Iowa are aging, the average age is 55, with retirements and fewer dentists staying in Iowa after graduation from dental school the numbers are project to decline. Of the dental workforce only 2% are pediatric dentists and they are located in the major metropolitan areas. General dentists are reluctant to see children, especially those under age 3.All of this background just goes to show you how important your role is when it comes to educating parents and reducing the risk of dental problems among our low income population. Poor kids are more likely to have dental problems therefore education and preventive services are their best defense against future problems!!

33Promote childrens oral health to parents and caregivers.Support gap-filling preventive services within public health and Title V agencies.Maintain partnerships with early childhood programs. Share information with stakeholders in anticipation of a changing health care system within Iowa. Continue to support health homes by collaborating with medical providers to include oral health as part of well-child care. Explore funding and collaborative opportunities with private organizations so that oral health becomes a priority statewide.

I-Smile--SustainabilityBecause children see their physician more during the years before age 3 and dentists are still reluctant to see young children physicians are being trained to do a more thorough oral evaluation during the well child exams. Medicaid is also paying for fluoride varnish application in the physicians office.I-Smile Screening Guide Basic Oral Health Screening InstructionsI-Smile Coordinator Office Lunch and Learn sessionsWeb-based training with CMEsPeer-to-Peer study groups

34Good oral health for all children beginning at birthLong-term savings in dental care costsImproved overall health of Iowa children and adults

I-Smile Future(became effective July 1, 2008)

A critical step in closing the gap in access to care for underserved children

Dental Screening RequirementSince 2008, Iowa children newly enrolling in elementary and high school must provide evidence of having a dental screening or exam. 36Elementary schoolPrior to age 6, but no earlier than age 3Licensed physician, physician assistant, nurse, dental hygienist, dentistHigh School:Within one year of enrollmentLicensed dental hygienist or dentistDental Screening Requirements37What if a child has a problem getting a screening?

What if a problem is detected and a child doesnt have a dentist?

Contact local I-Smile CoordinatorIntegration with I-Smile Dental hygienist providing direct care services in Iowa must work under the supervision of a dentist. In public health settings, this would be either public health or general supervision.

http://www.idph.state.ia.us/hpcdp/oral_health_resources.asp http://www.state.ia.us/dentalboard SupervisionRecommended by IDPH, this allows hygienists working in a public health setting to provide services without the patient first being examined by a dentist.

*Dentists providing public health supervision are not required to provide future dental treatment to patients served by the hygienist. Public Health Supervision40Requirements for Practice as a Public Health Supervision Hygienist (PHSH)SettingsRequirementsServicesSome services required to maintain Public Health Status:41Practice as Public Health Supervision Hygienist What Else Do I Need to Know?Statutes & RulesApplicable Forms State Dental Practice Act Iowa Code 153 Iowa Code 147 Iowa Code 272Chttp://www.state.ia.us/dentalboard/ Dental Board Ruleshttp://www.state.ia.us/dentalboard/ Public Health Supervision (PHS Application)http://www.idph.state.ia.us/hpcdp/ohds.asp

PHS Reporting Formhttp://www.idph.state.ia.us/hpcdp/ohds.asp

Iowa Dental Board http://www.state.ia.us/dentalboard/ 42A dentist is required to see a patient prior to a dental hygienist providing certain services under general supervisionSealantsProphylaxis RadiographsGeneral Supervision43

Currently, a hygienist must have an Iowa license and a minimum of three years of clinical experience to work under public health supervision.

Public Health Supervision*Language removed April 2009- For certain services (ie: prophys, sealants, and radiographs), there is no longer a period of time, no more than 12 months, in which an exam by a dentist must occur prior to providing this service to a patient again.

44Two options:National Health Service Corps federal programState Loan Repayment Program (called PRIMECARRE)

Site criteria:For PRIMECARRE, must be public or non-profit; NHSC also allows for-profitFederal Health Professional Shortage Area (found at http://hpsafind.hrsa.gov/) Sliding fee scale, accept Medicaid and Medicare

Loan Repayment 45Full-time or half-time (meet definition)U.S. citizenEducation-related debtsNo unfulfilled practice obligation to federal, state, local government or other entity (such as employer)Certification or license to practice in IowaServe all patients regardless of ability to pay

Applicant EligibilityFull time = 40 hoursHalf time = 20 hours

Cannot do both loan repayment programs at the same time (but can do them back to back)

Cannot have any other contractual obligation at the same time (employer contract)46Primary care physicianDentistDental HygienistPhysician AssistantNurse PractitionerCertified nurse MidwifeClinical PsychologistClinical Social Worker (LISW only)Psychiatric nurse specialistMental Health CounselorMarriage and Family Therapist

Eligible ProfessionsFor health care providers providing DIRECT CARE!!!

Private practice dentists would not qualify (they are not public/non-profit).

For RDHs they would have to work for an FQHC or other type of public health dental clinic.

47Both Programs: Clinician must be: working in a federally designated HPSA, US citizen, qualified student loan debt, cannot be fulfilling another obligation at the same timeNHSCPRIMECARREOnline application, http://nhsc.hrsa.gov/loanrepayment/ Application cycle once per year available on IDPH website, www.idph.state.ia.us. Current due date: October 24, 2012Federally AdministeredState AdministeredAll Federal Funds1:1 State/Federal FundsRequires Site Application Does not require site applicationFull time 2-year contract $60,000Half time 2-year contract $30,000Half time 4-year contract $60,000Full time 2-year contract up to $100,000 or Half time 2 year contract up to $50,000 (depending on availability of funding and number of applicants)Competitive Process based on HPSA scoresCompetitive Process with review committeeCan be For-Profit, Non-Profit, or Public SitesOnly Public or Non-Profit SiteEntire amount of funding provided to clinician at beginning of 2-year contract with NHSCHalf of funding provided at the beginning of each year of the 2-year contract; funds go directly to lenderOne-year continuationsCan re-apply in two-year increments48Comparison of the two programs:

Applicants must be licensed by January 1 (date the contract starts)

14 typically apply5-8 typically awarded48Iowa Department of Public HealthOral Health CenterLucas State Office Building321 East 12th StreetDes Moines, Iowa 503191-866-528-4020

Dr. Bob Russell, DDS, MPHPublic Health Dental Director(515) 281-4916Bob.Russell@idph.iowa.gov

Thank you!49Institute of Medicine, National Academy of Sciences. The Future of Public Health. Washington DC; National Academy Press; 1988. Public Health Functions Steering Committee. Public Health in America. Washington, DC: PHS; 1995.CDC. Ten Great Public Health Achievements - United States, 1900-1999. MMWR. 1999;48(12); 241- 243.http://www.idph.state.ia.us/hpcdp/oral_health.asphttp://www.ismiledentalhome.iowa.gov/

References5050Chart125.22621.418.216.815.2

% with Untreated DecayIDPH School-based Sealant ProgramPercent with Untreated Decay

Sheet1Column1% with Untreated Decay2005-0625.22006-07262007-0821.42008-0918.22009-1016.82010-1115.2To resize chart data range, drag lower right corner of range.

Chart123.319.818.541.94240.775.173.773.4

200420062008

Sheet1Age 65+ all teeth extractedAdults with any teeth extracted due to decay or gum diseaseAdults who visited dentist or clinic within past year200423.341.975.1200619.84273.7200818.540.773.4