2016 National Medicaid & CHIP Oral Health Symposium _______________ Session # 1

Understanding Poverty To Reduce Oral Health Disparity

Cindy Shirtcliff, LCSW Washington Marriott Wardman Park June 13th-14th, 2016

Presentation Objectives —  Define Poverty —  Explore Poverty Through the Individual, —  —  —  —  — 

Organizational and Community Lens Research Areas in Poverty Mental Model of Poverty Hidden Rules Language Register Practical Applications

Disclosure and Conflict of Interest Declaration I declare that neither I nor any member of my family have a financial arrangement or affilia6on with any corporate organiza6on offering financial support or grant monies for this con6nuing dental educa6on program, nor do I have a financial interest in any commercial product(s) or service(s) I will discuss in the presenta6on.

Bridges Out of Poverty —  Bridges Out of Poverty defines poverty as “…the extent to which an individual does without resources.”

—  “Resources” include: —  —  —  —  — 

Financial Mental Emotional Spiritual Physical

Research Areas —  There are four main areas of research related to poverty: —  Individual —  Social Capital —  Exploitation —  Political Policy

Mental Model of Poverty —  Child care

Debt

—  Food

Safety

—  Agency Time

Chemical Dependency

—  Transportation

Mental Health

—  Jobs

Criminal Justice

—  Clothing

Family & Friends

—  Housing

RELATIONSHIPS

System

Hidden Rules —  Each individual brings with him/her the hidden rules of the class in which he/she was raised

—  Hidden rules are unspoken cues and habits of an environment or of a population

Hidden Rules —  Hidden rule of time —  In poverty the immediate is most important.

Individuals are concerned with getting their immediate and daily needs met and have little time to focus on the future

—  In middle class future is most important and having their immediate needs met allows individuals to focus on the future

Tyranny of the Moment —  The “tyranny of the moment” keeps individuals in poverty focused on the crisis of the now

—  Agency time seeking resources makes life difficult and chaotic

—  Survival needs of food, housing, transportation take priority over dental appointments

Language Registers —  People in poverty often speak in a casual register —  Middle class speaks in a formal register —  Most agencies operate from the middle class lens

Oral Health Hidden Rules —  “I expect to lose my teeth someday” —  “I only go to the dentist if I have a toothache” —  “Going to the dentist costs too much” —  “Dentists are for rich people” —  “They are only baby teeth”

The Bridges Lens “Bridges Out of Poverty changed how we planned, how we viewed our pa:ents, and how we came to understand how we use our own economic class lens [in order] to communicate with pa:ents who have a very different experience and focus.” –Advantage Dental

© 2015 by aha! Process. Inc. All rights reserved. www.ahaprocess.com

Accessing Dental Care: The Bridges Lens/Resources Social Capital

Spiritual

Language Register

Hidden Rules

Patient

Physical

Financial

Emotional Role Models

Mental

© 2015 by aha! Process. Inc. All rights reserved. www.ahaprocess.com

What the Data Shows •  There is disparity in patient care between lower hierarchy groups and greater hierarchy groups

•  Disparity is not necessarily associated with insurance or access (estimated 10%)

•  Disparities are more likely associated with human interactions in healthcare settings

© 2015 by aha! Process. Inc. All rights reserved. www.ahaprocess.com

Systems Change —  Making our message more meaningful —  Giving our message a future focus —  Separating environmental barriers from personal strengths

Proprietary informa6on of Advantage Dental, Redmond, OR, www.AdvantageDental.com

Bridging Oral Health Care with Understanding Poverty —  Patient Centered Care —  Rapport Building —  Promote patient engagement —  Ask them vs. tell them

—  Awareness and

—  Bridges Health Concepts —  —  —  — 

Understand hidden rules Relate and engage Future focus message Planning backwards

understanding —  Preventive treatment plan

—  Better understanding to reduce barriers to care

Proprietary informa6on of Advantage Dental, Redmond, OR | www.AdvantageDental.com

Community Collaborations —  Public Health —  Women, Infants and Children (WIC) —  Pregnant women and children birth – 5 —  Home visiting programs

—  Early Head Start and Heat Start —  Preschool age

—  School-Bases On-Site Prevention Programs —  School age

—  Department of Health and Human Services —  Seniors and People with Disabilities —  Patients with special healthcare needs —  Residential facilities and brokerage companies

—  Medical-Dental Integration —  OB-GYN | Pediatricians | Family practice | Expanded care clinic Proprietary informa6on of Advantage Dental, Redmond, OR, www.AdvantageDental.com

Community Outreach Taking the Science to the People —  Dental Office (traditional) —  Wait in office for dentist —  Dental fear

—  Dental Outreach (non-

traditional) —  Risk assess —  Pregnant women, Women, Infant & Children (WIC), Head Start, schools, medical offices, residential facilities

—  Trusted community partners —  Collaborative efforts with community partners

Community Teams —  Regional Manager / Community Liaison (RMCL) RMCL’s attend meetings and monitor the initiatives and actions of CCOs and other stakeholders within their designated regions. They report findings back to Advantage Dental headquarter employees to allow for region specific tailored services to best meet the needs of the community. RMCL’s also provide training for Providers and staff on issues related to patient care such as poverty, cultural competency, and Trauma informed Care. These employees also support Advantage Dental’s Dental Director and Director of Community Dental Programs in the development, implementation and participation in community outreach programs.

—  Expanded Practice Dental Hygienists (EPDH) Advantage Dental employs several Expanded Practice Dental Hygienists (EPDHs) who provide community outreach services to organizations throughout the state, including schools, Head Start, WIC, etc. EPDHs typically provide on-site dental services that may include screenings, education, fluoride treatments, sealants, and referral to dental home. (EPDHs are hygienists with expanded licensure that allows them to perform dental hygiene services without the supervision of a dentist in public health settings.)

Urgent Chair —  Schedule for emergency patients —  Build Oral Health Social Capital

Questions ?

References —  Payne, Ruby, PhD, DeVol, Phil, Dreussi Smith, Terie, Bridges Out of Poverty, 2001

—  Payne, Ruby, Phd, Dreussi Smith, Terie, MAEd,

Shaw, Lucy, MBA, Young, Jan, DNSc, Bridges to Health and Healthcare, 2014

—  Shirtcliff, Cindy, LCSW, Dreussi Smith, Terie, MAEd, Northwest Dentistry, Outreach, Prevention and the “Urgent Chair”, Volume 94, Number 4, July-August, 2015

Bioskech Ms. Cindy Shirtcliff is a Licensed Clinical Social Worker. She received her B.S. in Psychology from the University of Oregon and a Masters in Social Work from University of Nevada, Reno. Ms. Shirtcliff has experience in crisis interven6on and evalua6on, child and family counseling, and has taught at Umpqua Community College. She joined Advantage Dental in 2011, as a Regional Manager Community Liaison. She is a cer6fied trainer in the Bridges Out of Poverty constructs and is the co-author of Outreach, Preven.on and the “Urgent Chair.” Ms. Shirtcliff specializes in developing outreach resources and programs aimed at decreasing barriers to accessing oral health care for those in poverty.

Contact Information Cindy Shirtcliff, LCSW Regional Manager Community Liaison Advantage Dental 442 SW Umatilla Avenue, Suite 200 Redmond, Oregon 97756 541-504-3986 [email protected]

2016 National Medicaid & CHIP Oral Health Symposium _______________ Session # 1

The Role of Dental Education in Medicaid Access and Utilization Rachel L. King, DDS, MPH Washington Marriott Wardman Park June 13th-14th, 2016

Learning Objective(s) Participants will gain knowledge of:

—  Fee for Service Medicaid Model in Rhode Island —  Dental Health Professional Shortage Areas —  Safety Nets —  Educational Models Addressing Access —  Benefits and Challenges of an Education-Based Treatment Setting

Disclosure and Conflict of Interest Declaration I declare that neither I nor any member of my family have a financial arrangement or affilia6on with any corporate organiza6on offering financial support or grant monies for this con6nuing dental educa6on program, nor do I have a financial interest in any commercial product(s) or service(s) I will discuss in the presenta6on.

Rhode Island —  Population: 1,056,298 —  Adult Medicaid Enrollment2: ~180,000

—  Dentists3: ~580 —  General Dentists: ~450 —  ~55 dentists per 100,000 —  ~1 dentist per 1,825

Rhode Island Adult Medicaid —  Eligibility o  Adults between the ages of 19 and 64, with income at or below 138% of federal poverty level

—  Dental Benefits o  Fee for service o  Provide for certain basic services to restore normal form and func6on

—  U6liza6on1 o  Less than 1/3 of eligible adults u6lize dental services §  A decline from 35% noted acer ACA benefit change o  2014: 44.1% of ED visits for non-trauma6c oral condi6ons were Medicaid covered pa6ents versus 32.1% in 2013

What’s the Problem? —  Dental Workforce1 o  As of 2011 survey, less than 30% of Rhode Island general den6sts had >10% of their prac6ces comprised of Medicaid pa6ents

§  Pediatric versus Adult —  Dental Health Profession Shortage

Areas o  Ra6o of at least 5000 people to 1 den6st

—  Popula6on Specific Barriers to Care

Dental Health Professional Shortage Areas

DHPSAs4

Population Density5

Access Barriers —  Dental Insurance Coverage*** —  Finances —  Public Transporta6on —  Childcare —  Work Conflicts —  Knowledge and Awareness —  Cultural —  Language

Access Barriers

LACK OF PROVIDERS

Safety Net6 —  Federally Qualified Health Centers —  Community Health Centers —  Dental Schools —  Residency Programs —  Mobile Dental Clinics —  Health Departments —  Volunteer Programs (Mission of Mercy) —  Hospital Emergency Departments

Challenges —  Excess demand o  Long wait time for initial visits o  Long intervals between visits

—  Provider Retention o  Financial o  Work Pace o  Autonomy

—  Population Barriers o  Maintaining up to date contact information o  Language o  Culture o  Systematic

RI Medicaid Adult Dental Learning Collaborative Goals —  To increase the

number of dental providers accep6ng Medicaid in Rhode Island

—  To increase access to dental care services for low-income adults eligible for Medicaid

St. Joseph Health Center ****Data graphs from mini-residency****

Education Based Strategies —  Dental School Curriculums —  Residency Training Programs —  Con6nuing Educa6on for Ac6ve Providers —  Licensure Requirements —  Loan Repayment Programs —  Alterna6ve Provider Educa6on

A New Training Philosophy… —  University of New England - College of Dental Medicine o  Community Based Training

o  Clinical rota6ons and externships at community based sites

o  Loca6ons of externships relevant to the student o  Encourage more den6sts to work in under-served communi6es

o  Spots reserved for New England residents to facilitate keeping new den6sts in the region

Continuing After Graduation —  NYU Lutheran Dental —  Six dental residency training programs o  Advanced Educa6on in General Den6stry o  General Prac6ce Residency o  Dental Public Health o  Pediatric Den6stry —  340 training sites in 26 states —  Community health centers and hospitals focused on caring for underserved popula6ons —  1.5 million vulnerable pa6ents treated annually

New Ideas for Established Practitioners —  Con6nuing educa6on7 focused on: o Evidence based care o Community based approaches o Inter-professional collabora6on o Cultural competence o Case management o Health home concept

Policy —  Requirements for State Licensure —  Community based prac6ce or advanced training in primary dental care

o  Community Health Center o  FQHC o  DHPSA regions o  Public service o  Advanced Educa6on in General Den6stry o  General Prac6ce Residency o  Pediatric Residency

Incentives —  Reward those who practice in underserved location o Loan repayment programs o Scholarships o Supplemental Stipends

Think Outside the Box —  Dental Therapists —  Public Health Hygienists —  Advanced Dental Hygienist Prac66oners —  Community Dental Health Coordinators —  Medical-Dental Integra6on —  USE THE DATA

Challenges and Obstacles —  Buy-in o  Practitioners o  Students o  Policy Makers o  Dental Associations o  Communities

—  Overhauling the traditional approach to dental care

o  Altering the “old-school” mentality o  Implementing the whole patient concept o  Developing a collaborative dental community

Value of Education —  Cost-Effec6ve Manpower —  Evolving Percep6ons of Underserved Popula6ons —  Cultural Competence —  Cul6va6on of a Desire to Serve —  Providing Workforce to Shortage Areas —  Sustainable Models for Comprehensive Pa6ent Care

ACCESS

Questions

References (1) 

Oh, Junhie (2015). Medicaid Expansion and Change in Hospital Emergency Department Visits for Oral Health Conditions among Rhode Island Adults. National Oral Health Conference, Kansas City, MO. April 2015. http://www.nationaloralhealthconference.com/docs/presentations/2015/04-29/Junhie%20Oh%20%20Medicaid%20Expansion%20and%20Change%20in%20Hospital%20Emergency%20Department%20Visits %20for%20Oral%20Health%20Conditions%20Among%20Rhode%20Island%20Adults.pdf

(2) 

Medicaid & CHIP January 2016 Application, Eligibility, and Enrollment Data. https://www.medicaid.gov/medicaid-chip-program-information/program-information/downloads/updatedjanuary-2016-enrollment-data.pdf

(3) 

Kaiser Family Foundation State Health Facts Professionally Active Dentists April 2016 http://kff.org/other/state-indicator/dentists-by-specialty-field/

(4) 

Rhode Island Department of Health www.health.ri.gov

(5) 

US Census Bureau www.census.gov

(6) 

Institute of Medicine and National Research Council. Improving access to oral health care for vulnerable and underserved populations. Washington DC: The National Academics Press, 2011 http://www.hrsa.gov/publichealth/clinical/oralhealth/improvingaccess.pdf

(7) 

National Academies of Sciences, Engineering, and Medicine. 2016. A framework for educating health professionals to address the social determinants of health. Washington, DC: The National Academies Press. doi:10.17226/21923. http://www.nap.edu/catalog/21923/a-framework-for-educating-health-professionals-to-address-thesocialdeterminants-of-health

Speaker Biosketch Dr. Rachel King is currently comple6ng a residency specialty program in Dental Public Health through NYU Lutheran at the St. Joseph Health Center training site and the Rhode Island Department of Health Oral Health Program in Providence, Rhode Island. Dr. King graduated from Amherst College in 2005 with a Bachelor’s degree in Neuroscience, received her DDS degree from Stony Brook University in 2009, and completed specialty training in Pediatric Den6stry in 2011 at the University of Medicine and Den6stry of New Jersey. She prac6ced pediatric den6stry in the Air Force while comple6ng her Master of Public Health degree at UMASS Amherst, which she received in 2015. Dr. King is passionate about improving access to care for vulnerable popula6ons and believes that a changing philosophy in den6stry and dental educa6on is on the horizon.

Contact Information Rachel L. King, DDS, MPH

Dental Public Health Resident NYU Lutheran (NYU Langone Health System) St. Joseph Pediatric and Family Dental Center 21 Peace Street Providence, RI 02907 [email protected] 850-687-2099

2016 National Medicaid & CHIP Oral Health Symposium _______________ Session # 1

Increasing Access and Utilization The Provider Perspective

Dr. Elias G. Koutros Washington Marriott Wardman Park June 13th-14th, 2016

Disclosure and Conflict of Interest Declaration I declare that neither I nor any member of my family have a financial arrangement or affiliation with any corporate organization offering financial support or grant monies for this continuing dental education program, nor do I have a financial interest in any commercial product(s) or service(s) I will discuss in the presentation.

Learning Objectives Par6cipants will gain knowledge and competency in: o  Determining whether to expand the payer-mix to include Medicaid.

o  Assessing the logis6cs involved with Medicaid par6cipa6on.

o  Determining if there is capacity within the prac6ce to expand Medicaid par6cipa6on.

o  Con6nuous prac6ce monitoring to determine the efficacy of con6nued expansion.

o  Barriers to widespread enrollment in a community. o  Professional and personal goals.

Why Expand Into Medicaid? —  The decision is unique to every provider and

may be driven by your State guidelines. o Adult vs. Child Coverage o Reimbursement scale could make it prohibi6ve.

Why Expand Into Medicaid? —  Charitable Goals o  Opportunity to directly support those in need

o  Opportunity to extend

help and provide care to the adults in families of children already in prac6ce



Why Expand Into Medicaid?

—  Need to support the schedule o Can be profitable o Excellent source of added income

Logistics —  Hardware and socware requirements.

HIPAA Compliance

Digital X-rays vs. Film

Claims Processing

Logistics —  Case Managers — Support enrollment, eligibility verifica6on, and explana6on of benefits — Provide communica.on — Assist with educa.on — Help with appointment compliance

Logistics —  Facility o Handicap Accessibility o Expanding workforce or equipment purchases o Parking/wai6ng room

Logistics —  Enrollment o NPI for individuals and facility o Understand the limita6ons of the coverage

Capacity —  How many new

Medicaid pa6ents can we accommodate in a day?

—  How many can we treat in a day?

Capacity —  How stressed is the prac6ce? — Are there empty 6me slots in a providers

schedule? — Do operatories remain idle for a significant period of the day? — Is there enough room in the schedule, or do you need to expand days or hours?

Monitoring —  Knowing the details of your prac6ce

socware and how to use it to run reports.

—  Being produc6ve with your 6me. —  Are we getng paid for everything being done?

Barriers —  Benefits and Fee Schedules o RI is in the bouom 1% o Many services are not

covered at all for adults

§  periodontal care §  posterior restora6ons.

o FQHC compe66on on a

different reimbursement scale



Barriers —  Individual Pa6ents o Hopelessness o Neglect o Working poor o Fraud

Barriers —  Convincing colleagues that it is a worthwhile endeavor o Oral Surgeons o Endodon6sts o Periodon6sts o Orthodon6sts

Personal Goals —  It becomes quickly evident that there are

many people who are in great need of care. o Saving lives o Renewing smiles o Job crea6on o A family that appreciates what we do

Personal Goals —  Profitable in a roundabout way. —  Emo6onally and spiritually fulfilling.

Questions

Speaker Biosketch Elias Koutros, DDS is a 1990 graduate of the NYU College of Dentistry. He completed a one-year residency for the New York Health and Hospital Corporation at Woodhull Hospital in Bedford Stuyvesant Brooklyn. He worked as a general dentist for 6 years in a group practice in Brooklyn, NY; followed by an additional 6 years working for a Large Corporate Dental Practice. In 2004 Dr. Koutros founded Spartan Dental Inc, and has been building and managing his own practice. Dr. Koutros is a member of the Rhode Island’s Oral Healthcare Commission and has served as a consultant for Delta Dental in the past.

Contact Information Elias G. Koutros, D.D.S. President and Owner Spartan Dental, Inc. 105 Sockanosset Cross Road Cranston, Rhode Island 02920 [email protected] 401-383-7569