Midlevel Dental Providers One Approach to Expanding Access to Care

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Poll  How informed are you on midlevel dental providers? 1. 2. 3. 4.

Very informed Somewhat informed Not very informed Not informed at all

Overview: Midlevel Dental Providers

Andrew Peters The Pew Charitable Trusts [email protected]

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Objectives 1. Access: Understand the factors driving the dental care access problem in the U.S. 2. Midlevel Dental Provider Models: Understand the four models being used in different parts of the country to expand access to care for the underserved. 3. State Activity: Learn about current state laws and legislative interest in authorizing midlevel dental providers.

The Problem: Access to Care

Mission of Mercy clinic in Cape Girardeau, Missouri on May 3, 2013. People camped out in line for two days to receive free dental care.

• • • •

Many Americans lack dental insurance Maldistribution of dentists Few dentists accept Medicaid Too few children on Medicaid get dental care 6

7

Few Dentists Accept Medicaid 2012 survey of 33 states

Less than

Filed

30%

50

of dentists

claims or more

8

9

10

One Solution to Improve Access: Midlevel Dental Providers

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What are mid-level providers? • They fill roles similar to nurse practitioners or physician’s assistants in medicine • Scope of practice: preventive and routine restorative care • Models vary by scope of practice, settings for practice and supervision requirements 12

Why employ midlevels? 1. Extend reach of dental practices to underserved people 2. Make it economically viable for dental practices to treat more Medicaid patients

3. Improve efficiency and economic bottom line 13

14

Evidence on safety of dental therapists

Review of 1,100 studies show that dental therapists deliver safe, effective care

15

Nurse Practitioner Workforce Growth

Source: Unpublished data from the National Organization of Nurse Practitioners Faculties; Analysis by the Center for Health Professions, UCSF, 2004.

16

State Legislative Activity: Mid-Level Dental Providers 4 states authorizing new providers

15 states considering new providers WA

OR

ME

ND

MT ID

WI

SD

UT

IL

NJ

OH

IN

KS

MD

WV

CO

CA

VA

MO

KY

NC TN

AZ

OK NM

SC

AR MS TX

AL

GA

LA

AK FL

HI

CT

PA

IA

NE

MA

NY

MI

WY NV

NH

VT

MN

DE

RI

Models Examined • Dental therapist (hygiene based) • Dental Therapist (non-hygiene based) • Community Dental Health Coordinator • Hygienists with additional training to provide atraumatic restorative treatment 18

Dental Therapy without a dental hygiene degree

2003: Began practicing on Alaska tribal lands 2009: authorized in Minnesota

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Dental Therapists (non-hygiene based) Model (Location) Dental Health Aide Therapist (Alaska tribal lands)

Supervision Can work without a dentist in the same location, performing procedures based on standing orders issued by supervising dentist.

Education Certificate program (20 months + 400 clinical practice hours under dentist direct supervision)

Allowable Procedures (not a complete list) • • • • • • • •

Dental Therapist (Minnesota)

Some procedures (preparing cavities and restoring and extracting teeth) require a dentist in the office; others (Xrays , fluoride varnish) do not.

Bachelor’s degree (28month post-highschool program; requires 10 prerequisite courses)

• • • • • •

Perform exams Take X-rays Conduct cleanings Apply fluoride varnish and sealants Prepare and restore decayed primary and permanent teeth Place pre-formed crowns Perform pulpotomies Extract (non-surgically) primary and permanent teeth Take X-rays Apply fluoride varnish and sealants Prepare and restore decayed primary and permanent teeth Place temporary and preformed crowns Perform primary tooth pulpotomies Extract primary teeth

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Dental Therapy with a dental hygiene degree 2009: Advanced dental therapists authorized in Minnesota. 2014: Dental hygiene therapists authorized in Maine

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Dental Therapists (hygiene based) Model

Supervision

Education

Allowable Procedures (not a complete list)

Advanced Dental Therapist (Minnesota)

Can work without a dentist in the same location, performing procedures according to standing orders issued by the supervising dentist.

Master’s degree (26 month degree; prerequisite bachelor’s degree in dental hygiene) + 2,000 clinical practice hours

All dental therapy procedures, plus: • Take X-rays • Apply fluoride varnish and sealants • Prepare and restore decayed primary and permanent teeth • Place temporary and preformed crowns • Perform primary tooth pulpotomies • Extract primary teeth, perform simple extractions of permanent teeth • Complete an oral evaluation and create a treatment plan

Dental Hygiene Therapists (Maine)

Must be supervised by a dentist in the same office.

4 years (or 2 years in addition to a hygiene degree)*

All dental hygiene procedures, plus: • Perform oral health assessments • Take X-rays • Apply fluoride varnish and sealants • Prepare and restore decayed primary and permanent teeth • Place pre-formed crowns • Perform primary tooth pulpotomies • Extract (non-surgically) primary and uncomplicated permanent teeth

*Legislation was passed in Maine in April 2014. Regulations and training programs are still being developed.

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Community Dental Health Coordinators • Offer oral health education to underserved communities and link residents to dentists in their communities. • 2011: New Mexico authorizes CDHCs

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Community Dental Health Coordinators Supervision Can work without a dentist in the same location, performing procedures authorized by a supervising dentist.

Education 18 months (12 months online and 6 month internship)

Allowable Procedures (not a complete list) • Take X-rays • Apply fluoride varnish and sealants • Perform coronal polishing • Prepare teeth for temporary restorations • Place temporary restorations, including Interim Therapeutic Restorations

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Dental Hygienists with Restorative Duties Current Status:

Numerous states allow hygienists to perform restorative duties using a hand piece but not a drill.

Examples:

Virtual Dental Home demonstration, California; ForsythKids Program, Massachusetts 25

Dental Hygienists with Restorative Duties

Supervision Typically direct or general, although some states allow for public health supervision or independent practice

Education Varies, typically through a certificate course

Training Varies

Allowable Procedures (not a complete list) Expanded functions vary state by state, but may include: • Apply cavity liner/base • Place (and also carve and finish) amalgam restoration • Place and finish composite restoration • Place and/or remove temporary fillings, which may include Interim Therapeutic Restorations • Place and/or remove temporary crown • Fabricate temporary crown

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Understanding Scope of Practice Registered Dental Hygienist with restorative duties

Community Dental Health Coordinator

Dental Health Aide Therapist (AK)

Dental Therapist (MN)

Advanced Dental Therapist (MN)

Dental Hygiene Therapist (ME)

Dentist

Preventive Services

Full

Routine

Routine

Routine

Full

Full

Full

Restorative Services

Very few

Very few

Routine

Routine

Routine

Routine

Full

Prescribing Rights

No

No

No

No

No

No

Yes

In some states

Yes

Yes

No

Yes

No

n/a

In some states (varies)

No (general)

No (general)

No (indirect or general)

No (general)

No (direct)

Yes

Practice w/out dentist on site Independent Practice (supervision requirements)

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Length of Training (Post High School): US and International Dental Providers 9 8

Assistants & CDHC

Hygienists

Therapists

HygieneTherapists

Dentist

7 6

5 4 3 2 1 0

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Midlevel Dental Providers in Practice: 5 Examples

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1

Main Street Dental Care, Solo Dental Practice (Minnesota)

2012 (DTs first year at practice) Patients DT saw:

241

DT’s procedure volume:

972

DT’s procedure mix:

Mostly composite restorations 30

2 A dental therapist at Battlefords Dental Group (Saskatchewan) 31

3

Dental Health Aide Therapists (Alaska)

Patients:

637

Patients:

715

Procedures:

2622

Procedures:

32 4,734

4

A dental therapist at the People’s Center Health Services (Minneapolis) 33

5 Dental Hygienists with expanded restorative skills at the Virtual Dental Home (California)

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New Findings: Economics of Midlevel Dental Providers

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Main Street Dental Care (Minnesota)

Total cost of employment Increase in Medicaid patients served Additional revenue to practice

$90,700 50% $23,000

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Battlefords Dental Group (Saskatchewan)

Total Therapy Collections in 2012: $529,000

Profit $217,000

Commissions paid: $192,032

Overhead: $120,000

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Dental therapists cost their employers less than 30 cents for every dollar of revenue they generate.

Total Revenue Generated by Advanced Dental Therapists and Dental Therapists in Minnesota (in green) and Dental Health Aide Therapists in Alaska (in blue)

http://www.communitycatalyst.org/doc_store/publications/economic-viability-dental-therapists.pdf; Report conducted by Dr. Frances M. Kim, May 2013

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Dental Health Aide Therapists (Alaska)

Annual billing per DHAT:

$150,000 - $250,000 above employment costs Annual savings in patient travel per DHAT:

Over $40,000 39

Cost to employ: $136,000 Medicaid revenue:$167,000 Medicaid revenue exceeds costs by over $30,000

A dental therapist at the People’s Center Health Services (Minneapolis) 40

Virtual Dental Home (California) California vs. National average per visit

Costs: $115 Revenue: $61

$99 $112

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For Additional Information Andrew Peters The Pew Charitable Trusts [email protected] http://www.pewtrusts.org/en/research-andanalysis/reports/2014/06/30/expanding-the-dentalteam

http://www.pewtrusts.org/en/projects/childrensdental-policy 42

AK DHAT Educational ProgramEducation and Practice Basics The American Academy of Dental Therapy, 2011

Mary E. Williard, DDS Midlevel Dental Providers: One Approach to Expanding Access to Care Webinar, June 30, 2015

History of Dental Caries in Alaska Native People Archeological records show caries rate of ~1% 1921

Improved air transportation and dietary changes

1928 – 1930’s

1984

1999

2003

1925

Studies show lowest caries rate in the world NZ Dental Nurse

Price, WA. 1939. Nutrition and Physical Degeneration. 8th ed. Lemon Grove, CA.

Prevalence of dental caries in children 2x same aged U.S. children

Vast majority of children have dental caries

AK students to NZ

Dental Therapists: A Definition • Primary oral health care professionals • Basic clinical dental treatment and preventive services • Multidisciplinary team members • Advocate for the needs of clients • Refer for services beyond the scope of the dental therapist’s practice.*

*SASKATCHEWAN DENTAL THERAPISTS ASSOCIATION

There Was Opposition

The Fight is Winnable and Worth It

Conan Murat, DHAT, standing his ground

“A Review of the Global Literature on Dental Therapists”* Dental Therapists: • Decrease cost of care • Improve access to care • Provide care safely • Public values the role of dental therapists • Traditionally 2 years education http://www.wkkf.org/news-and-media/article/2012/04/nash-report-is-evidence-that-dental-therapists-expand-access *Prepared by: David A. Nash, Jay W. Friedman, Kavita R. Mathu-Muju, Peter G. Robinson, Julie Satur, Susan Moffat, Rosemary Kardos, Edward C.M. Lo, Anthony H.H. Wong, Nasruddin Jaafar, Jos van den Heuvel, Prathip Phantumvanit, Eu Oy Chu, Rahul Naidu, Lesley Naidoo, Irving McKenzie and Eshani Fernando Supported by the W.K. Kellogg Foundation

Curriculum DHAT curriculum adapted by AAPHD panel American Association of Public Health Dentistry • 11-person academic panel • Model curriculum • Two-year, post-secondary • Open access online: • http://onlinelibrary.wiley.com/doi/10. 1111/jphd.2011.71.issue-s2/issuetoc

The Journal of Public Health Dentistry, Special Issue: Workforce Development in Dentistry: Addressing Access to Care Spring 2011 Volume 71, Issue Supplement S2

DHAT Education by Hours First year: 40 weeks Second year: 39 weeks Total: 79 weeks (3160 hours) Curriculum Break-down year 1 Biological Science: 30% Social Science: 10% Pre-clinic: 40% Clinic: 20%

Curriculum Break-down year 2 Biological Science: 15% Social Science: 7% Pre-clinic: 0% Clinic: 78% (1215 hours)

Curriculum Break-down both years combined: Biological Science: 22.5% Social Science: 8.5% Pre-clinic: 20% (632 hours) Clinic: 49% (1548 hours)

Different Providers Different Education

DHAT

DENTIST

NEED TO KNOW

NEED to know+ nice to know

Limited scope, 46 procedures

Large scope, 500+

Supervised

Team leader

Prevention oriented team approach

Surgically oriented

Accessible to students in target populations

Education is difficult to access, especially for minorities

Culturally competent

Struggling to address cultural competency

Patient centered

Practice centered

The Heart of DHAT Prevention and Promotion

DHAT students doing screenings and fluoride applications at a Head Start

From ANTHC Consultant Survey of AK Tribal Dental Directors

700 visits

500 visits

Each DHAT team on average, provides care to 830 patients during approximately 1200 patient encounters (or visits) each year. Scott and Co. Consulting

Improved Access and Quality • 25 certified DHAT • 81 communities in rural AK • Over 40,000 people have access • Continuity of care • Higher level of care possible • Dentist working up to their licensure DHAT Aurora Johnson, NZ Educated

Keys to DHAT Success

• Not Mini Dentists • Part of a dentist led team • 2 Year Education • Competency based • Accessible to non-traditional students • Cultural Competence • General Supervision • Appropriate Scope: • Diagnosis and Treatment Planning • Extractions • Certification/ Recertification • Community-based

Trisha Patton, DHAT student, taking x-rays

DHAT Educational Program Mary E. Williard, DDS 907-729-5600 4200 Lake Otis Parkway, Ste. 204 Anchorage, AK 99508

DHAT training is ANTHCsmile on Facebook website: http://anthcoralhealth.org

Division of Community Health Services

Utilization of a Dental Therapist in a FQHC

Eric Elmquist D.D.S.

Overview • • • • •

Background on Dental Therapist in MN My Process in hiring a Dental Therapist How was the Dental Therapist utilized in our clinic What worked, what didn’t Future

Legislation Enacted 2009 • MN Created both Dental Therapists and Advanced Dental Therapists • DTs/ADTs work under a written collaborative management agreement with a MN licensed dentist • The purpose of this provider is to extend dental care to underserved communities

Lake Superior Community Health Center- Clinic Background • • • • • •

FQHC Health Center established 1973 Superior Site – 8 Dental Chairs, Established 2005 Duluth Site – 11 Dental Chairs, Established 2007 Minnesota and Wisconsin offer MA Reimbursement for Adult Preventative, Restorative and Emergency Services Clinic increasing depended on Oral Health Program financially

Transitions at LSCHC • Started rebranding and extensive promotion

campaign for first time since opening of dental clinic • Dental Staffing Changes • Dental Program Expansion

Care Delivery Challenges 2013 greatest number of encounters seen in our dental clinic • Increased wait time for routine appointments • Hard to keep both sites open 5 days a week • Dentist seeing more ER patients Everyday • DDS Scheduling causing FD nightmare Were we meeting the needs of our Patient population?

Staffing Options • • • •

Dentist Dental Students Dental Therapist Restorative Functions Dental Assistant

Developing the Dental Therapist Program • Needed to educate the dental staff about the position. • Needed to education patient population. • What was the goal for the Dental Therapist?

Dental Therapist in Action Dental Therapist Started November 2013 • Production expectation 1.1 patients per hour • Quality Assurance the same as any new provider • Majority of Patients was adult restorative

Clinic Production 2014

Clinic Production Other things helping production: • • • •

Hired Temporary Dentist Hired Permanent Dentist Stricter failed appointment policy Increased use of Restorative Functions Dental Assistants • Staff was great

Production and Scheduling Considerations Patient Population: • • • • •

DT seeing an Adult population Longer appointments More complex procedures More procedures per appointment Decreased Production- Was this a problem?

Other Benefits of Dental Therapist • Improve the Morale, Communication and Collaboration. The Dental staff was working as a Team. • Increase Patient Satisfaction - we were being responsive to their needs • Made our Clinic more Visible • Provided Same Quality Care to More Patients

If I Knew Now… • Formal Utilization and Scheduling Plan for Position • More Education of Entire Clinic • One Dentist as Point Person • Used State and Community Resources • Set Realistic Expectations

Conclusions •

Did the DT increase access?

•

Was the DT position successful in our clinic?

•

Did the DT solve our access needs?

Future of Program

Contact Eric Elmquist, D.D.S. Access Community Health Center [email protected]

Q&A

Contact us! National Network for Oral Health Access Jodi Padilla, MBA NNOHA Policy Analyst 303-957-0635 x1 [email protected] www.nnoha.org