Oral Health, Mental Health, and Geriatrics: The … Publication of the National AHEC Organization VOLUME XXIII, NUMBER 1 Autumn/Winter 2006 Oral Health, Mental Health, and Geriatrics:

A Publication of the National AHEC OrganizationVOLUME XXIII, NUMBER 1Autumn/Winter 2006

Oral Health, Mental Health,and Geriatrics:

The Growing Challenges

In This Issue

Training for What’s Ahead ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 1Joel E. Davidson, MA, MPA, and Tina Fields, PhD, MPH

Oral Health

The Supply of Dental Services: What Are the Issues? ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

3Howard Bailit, DMD, PhD, and Tryfon Beazoglou, PhD

Improving Access to Oral Health Care in Missouri Through AHEC Rotations ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 7Bonnie Branson, RDH, PhD, and Stephanie Taylor, BS

Innovative Service Learning Models: The Use of AHEC Partnerships to Increase Oral HealthAccess in Rural Mississippi ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 10

Stephen L. Silberman, DMD, MPH, DrPH; Neal Demby, DMD, MPH; Susan L. Dietrich, DMD; andSandra Hayes, MCS, MPH

Northeast Indiana AHEC Dental Clinic Provides Service Learning Opportunities for Dental Hygiene Students ○ ○ ○ ○ 12Nancy K. Mann, RDH, MSEd

USF Interdisciplinary Community Health Scholars Focus on Dental Needs in Sarasota, Florida ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 14Emily Meade, BA, and Anne Maynard, MPH

The Molar Express: Improving Access to Dental Services in Northern New Hampshire ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 17Alice Muh, BS, RN, CCM; Nicole LaPointe, MSW; and Martha McLeod, MOE, RD, LD

Meeting the Oral Health Needs of a Rural Community Through Collaboration and Determination ○ ○ ○ ○ ○ ○ ○ ○ ○ 19Shelba Scheffner, MPH, CHES; Debra Youngfelt, BS, CHES; and Rebekah McFadden, RN, BSN, CSN

Training Oral Health Students in Culturally Competent Care at a Community-Based Volunteer Health Clinic ○ ○ ○ 21Susan M. DiGiorgio-Poll, BS, MSEd

Persistence and Partnerships Pay Off in Improving Oral Health Services on Maryland’s Eastern Shore ○ ○ ○ ○ ○ ○ ○ 23Jacob Frego

Integrating Oral Health Into Primary Medical Care ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 26Malone Steele

AHEC and ACTS: The Advanced Clinical Training and Service Program with the Colorado AHEC System atthe University of Colorado School of Dentistry ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 28

Robin Ann Harvan, EdD; Rob Berg, DDS, MPH, MS, MA; and Robert Trombly, DDS, JD

Training Outreach Workers to Deliver Preventive Dental Services in Yap State, Micronesia ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 33Cindy Lefagopal, DDS

Mental Health

The Epidemic of Suicide: A Personal Story of Loss, Legacy, and Hope ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 35Sen. Gordon Smith (R-Oregon)

Mental Health and Behavioral Health Workforce: Challenges and Opportunities Including Implicationsfor Rural America ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

37Dennis F. Mohatt, MA, and Mimi B. McFaul, PhD

Integrated Care: The Process of Providing Mental Health Care in Primary Care Practices ––The Time Is Now ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

41Sally W. Smith, LCSW, RN

AHEC Builds Opportunity for Young Social Workers ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 43Virna Little, PsyD, LCSW-R, SAP

Geriatrics

Caring for Our Nation’s Elderly: Challenges for the Twenty-First Century ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 45Elyse A. Perweiler, MPP, RN, and Thomas A. Cavaliieri, DO, FACOI, FACP, AGSF

Central Coast AHEC—Working to Support the Growing Needs of an Aging Population ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 49John Beleutz, MPH, and Steve Lustgarden, MS

Collaboration on Geriatric Training Reaches Many ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 51Terry Gefell, MSEd, CHES, and Pamela Mayberry

Clinical Training of Medical Students in Interdisciplinary Care Utilizing a Geriatrics Program at PACE(Program for All-inclusive Care of the Elderly) ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 53

David Pole, MPH, and Richard Schamp, MD

South Central Kentucky AHEC Partners with Barren River Long-Term Care Ombudsman Program ○ ○ ○ ○ ○ ○ ○ ○ 57Lucy Juett, MS, and Ruth Morgan, BSW

Oral Health, Mental Health, and Geriatrics: The Growing Challenges

Volume XXIII, Number 1

Autumn/Winter 2006

A Publication of the National AHEC Organization

The National Area Health Education Centers Bulletin

The National AHEC Organization supports and advances the Area Health Education Centers/Health Education and TrainingCenters (AHEC/HETC) network in improving the health of individuals and communities by transforming health care through

education. The National AHEC Bulletin is published semi-annually by NAO.

Training for What’s AheadJoel E. Davidson, MA, MPA, and Tina Fields, PhD, MPH

With luck, we’ll all be old one day. And for those of usfortunate to have health insurance for and access to oraland mental health services, many of us will reach old agewithout having to worry about how and where we’ll getthose services, when and if they’re needed. But for millionsof Americans, that just isn’t the case. Oral and mental healthservices already are in short supply in many areas of our nation,as witnessed by the 3,440 Dental HPSAs and the 2,374Mental Health HPSAs, and the demand is growing. Clearly,the oral health and mental health workforce has not kept upwith the increasing demand for services.

At the same time there is increasing demand for oral andmental health services, America is rapidly aging. In 2003,the number of Americans age 65 and above was estimatedat nearly 36 million people. And it is expected to grow to72 million, or almost 20% of the population by 2030. Thisis going to require a health care workforce that betterunderstands the dynamics of aging and receives trainingspecific to an increasingly elderly population.

This issue of the National AHEC Bulletin explores thesethree health care areas by examining the current andprojected needs each one has, and showing how AHECsand HETCs are reaching out and working in their commu-nities and with academic institutions to begin addressingthese rapidly growing areas.

Howard Bailit, DMD, PhD and Tryfon Beazoglou, PhD intheir lead article for the Oral Health section raise importantconcerns about access disparities to oral health care facedby low-income, rural, and minority populations, despitetheir contention that the oral health of Americans has neverbeen better. They recognize the important role that ourprograms can play in assisting dental schools in organizingcommunity clinic rotations for dental students and assistingclinics with staff training, recruitment, and implementingbest delivery practices. The articles that follow show howAHECs have developed innovative programs and partner-ships with communities and academic centers, often servingas the lead organization, in bringing much-needed oralhealth care services to the underserved while providingvaluable training and experience for students enrolled notonly in oral health programs, but in others, as well.

The Mental Health section gives us a moving first-personaccount of the devastation that untreated mental illness canhave on individuals and families. U.S. Senator GordonSmith (R-OR) relates his son Garrett’s battle with mentalillness and his ultimate suicide. His family’s experience hasled Senator Smith to champion mental health efforts at thefederal level and he notes several important pieces oflegislation promoting the development of statewide suicideearly-intervention and prevention programs, and providingequity in provider reimbursement for mental health servicesfor providers and health care facilities. He encourages us to

Joel E. Davidson, MA, MPA is theExecutive Director of the SouthwestWisconsin AHEC in Madison, WI, amember of the National AHECBulletin Editorial Board, and issue co-editor of the Autumn/Winter 2006NAO Bulletin.

Tina Fields, PhD, MPH, is theProgram Director for the South TexasAHEC, the South Central RegionalDirector of the HETCAT-SouthCentral Region in San Antonio, TX, amember of the National AHEC BulletinEditorial Board, and issue co-editor of theAutumn/Winter 2006 NAO Bulletin.

The National AHEC Bulletin � Volume XXIII, Number 1 � Autumn/Winter 20062

Editorial Overview

Training for What’s Ahead

partner with our respective state’s agenciesto help provide education and awarenessthrough our networks and to assist withtraining health professions students andfaculty. Following Senator Smith’s article,Dennis Mohatt and Mimi B. McFaul raisethe call for a fundamental transformation ofpublic behavioral health systems by ad-dressing the multiple aspects of workforcedevelopment. Focusing on rural and frontierareas, they paint a sobering picture of theworkforce challenges ahead. They discussseven goals that respond to the workforceneeds by broadening the definition ofworkforce, strengthening it, and developingworkforce support structures. Two articlescomplete this section. The first one showshow an AHEC took the lead in integratingmental health services into twelve nonprofitprimary care clinics in North Carolina. Thesecond one shows how an AHEC-spon-sored social work internship at communityhealth centers in New York City has becomea tool to retain social work graduates to workin underserved neighborhoods.

The Geriatric section leads off with anarticle by Elyse A. Perweiler, MPP, RN, andThomas A. Cavalieri, DO, that puts intoperspective the impacts that our rapidlygrowing 65-plus age population will have onour society and challenges us to be morecreative to meet the increasing healthcare

demands of the elderly as federal resourcesfor training and education shrink. Theyclearly see an important role for our pro-grams and call on our responsibility ashealthcare professionals and educators toensure that healthcare providers are trainedto address the complex special needs of theelderly. The articles that follow demonstratecreative approaches to training healthprofessions students and professionals incaring for the elderly and how the elderlythemselves help in the education process,and show the importance of collaboratingwith others to accomplish more than we cando alone.

Two last thoughts are in order here: First,we want to thank everyone who submittedan article to the NAO Editorial Board forconsideration. We called and you responded.It is gratifying to receive and exciting to readall those articles about programs addressingthe challenges that this issue focuses on.Second, the Editorial Board wants toremind everyone that we welcome yourcomments about any of the articles, editori-als, or other information in this or anyedition of the National AHEC Bulletin. Ifyou have a comment, you may send it by e-mail to [email protected], by mail toNAO, 109 VIP Drive, Suite 220, Wexford,PA 15090, or by fax to 724-935-1560.

“Many thanks” from the AHEC/HETC NetworkA long-time leader of the AHEC/HETC movement, Mike Byrne, retired during 2006,and this transition warrants a special “thank you” from the National AHEC Organiza-tion. Though involved with the AHEC program from its inception, Mike’s AHEC workbegan in earnest in 1984 at the University of Louisville and he has remained activelyinvolved ever since – particularly through his highly effective leadership in AHEC’snational legislative agenda and the authorization process. Thank you, Mike, for youruntiring efforts and effective leadership. Your accomplishments within your own highlysuccessful and respected AHEC and HETC Programs and with the national programcontinue to inspire your colleagues and give us a legacy on which to build.

The National AHEC Bulletin � Volume XXIII, Number 1 � Autumn/Winter 2006 3

Oral H

ealthThe Supply of Dental Services:What Are the Issues?Howard Bailit, DMD, PhD, and Tryfon Beazoglou, PhD

The oral health of the American people hasnever been better, and race- and income-basedoral health disparities have declined dramati-cally in the past 35 years. These health statusimprovements are the result of community-level prevention programs (e.g., water fluorida-tion, more effective dental treatments includingsealants, and better personal behaviors). Still,large access disparities continue, and mostuntreated dental disease is seen in low-income,rural, and minority populations. Thesedisparities received national attention in theSurgeon General’s report (2000), The OralHealth of the Nation.1

Supply of Dental ServicesThe supply of personal dental services for thegeneral population is influenced primarily bythe number and productivity of dentists. Thereare approximately 150,000 dentists nowdelivering care to the United States population2

and 4,650 dental graduates enter theworkforce each year.3 Relative to the growth ofthe population, the number of dentists willdecline about 6% between 2000 and 2015.4

This decline is the result of a 34% reduction inthe number of dental school graduates thatoccurred between 1982 and 1993, when sevendental schools closed and many reduced theirclass size.4

Longer term, there is going to be a largeincrease in the number of dental schools anddentists. Since 2000, three new dental schoolshave opened and at least four more are indevelopment. In about 10 to 15 years, thenumber of dental school graduates is likely toincrease to 5,500-6,000 per year. This may bea low estimate, since additional schools arelikely to open as nontraditional private univer-sities see financial opportunities in startingdental schools with large classes, charging hightuition, and having low per- student educa-

tional costs. By 2020, the number of dentistswill grow faster than the population, increasingthe dentist-to-population ratio.

Another possible source of new dentists isforeign dental graduates. Almost all statesrequire foreign graduates to enroll in a U.S.dental school for at least two years and obtainan American dental degree to be eligible totake state or regional licensing examinations.As a result, there are relatively few foreign-trained dentists with U.S. dental degrees in thedental workforce. This situation could easilychange if states allowed foreign dentalgraduates who complete residency programs inthe United States to take the licensingexamination as they do foreign medical schoolgraduates. This issue is of great concern toorganized dentistry, especially in states such asCalifornia, where Hispanics make up asignificant and growing percentage (i.e., 25-30%) of the state’s population. In response toaccess complaints from their Hispanic constitu-ents, legislators have proposed that Mexican-trained dentists (dentists trained in Mexicowho do not have a U.S. degree or U.S. license)be allowed to work in public clinics. Thislegislation was enacted but was never imple-mented. The issue of foreign-trained dentalgraduates is far from resolved, however. As thepolitical power of Hispanics and other ethnicgroups with many underserved constituentsincreases in state legislatures, it is likely thatsome arrangements will be made to allow moreforeign-trained dentists to practice in theUnited States.

Another supply-side issue is the changinggender of dentists. By 2020, about 30% ofdentists will be female.5 Although femaledentists are equally as productive as maledentists when treating patients, they spendabout 15% less time in the workforce over their

Tryfon Beazoglou, PhD, isan Assistant Professor atthe University ofConnecticut School ofDental Medicine,Farmington, CT.

Although substantially more oral health providers and services areanticipated by 2020, it may not address oral health disparities and

access to care issues.

Howard Bailit, DMD,PhD, is a ProfessorEmeritus at the Universityof Connecticut School ofMedicine, Farmington,CT.


professional lifetimes, because more work part-time (30% female vs. 15% male).6 Thus, tomaintain the supply of dental services, largernumbers of dentists are needed to offset theincreasing number of part-time dentists.

ProductivityThe productivity of dentists is increasing at therate of about 1.3% a year.7 Dentists are able toprovide more services per unit time becausethey are using more space (dental operatories),employing more administrative and allied dentalhealth personnel, and expanding the duties ofdental hygienists and dental assistants.

Dental hygienists are animportant source of practiceproductivity. About 70% ofsolo general dentists employone or more full- or part-timehygienists.8 In many states,hygienists can treat patientswithout practice ownersbeing present, as long as theyfollow dentist-prepared

treatment plans. This is called indirectsupervision, and hygienists can see patientseven when the dentist is not in the office,substantially increasing the total patientcapacity of practices.

In a few states, such as Connecticut, hygienistscan work independently (without indirectsupervision) in public facilities, providing careusually to low-income patients and billingpublic insurers and patients for their services.In one state, Colorado, hygienists can openindependent private practices and compete withprivate dentists. Although the data are limited,few hygienists are working independently inpublic facilities or in their own private practices.9

Practice productivity also increases with theemployment of more dental assistants and theexpansion of their clinical duties. Ninetypercent of solo general dentists now employone or more dental assistants, and in manystates, the clinical duties of these assistants arebeing expanded.

Recently, a new type of dental allied healthworker, the dental therapist, has begunproviding care to Alaskan natives. Therapists

The Supply of Dental Services: What Are the Issues?

are modeled after the New Zealand dentalnurse and are trained in a two-year program toprovide dental care to children, including fillingand extracting teeth. In Alaska, they are oftenlocated in small, remote villages, where they arein telephone contact with supervising dentists.The American Dental Association has opposedthe use of dental therapists politically andlegally, arguing that they are inadequatelytrained to provide irreversible procedures (e.g.,filling teeth) and that the state dental practiceact in Alaska does not permit anyone butdentists to provide these services. Alaskannatives argue that dental therapists nowprovide services in some 40-plus countries andhave proven records of effectiveness and safety.They also argue that state dental practice actsdo not apply to them because tribal lands aresovereign nations. At this time it appears thatthe Alaskan natives are going to prevail andthat dental therapists will become part of thedental workforce on tribal lands in Alaska andprobably other states which have tribal lands.

It is difficult to precisely estimate the effect of allthese changes taking place in the dental deliverysystem on the supply of dental services. As a bestguess, the supply of dental services will increaseslowly until 2015 and then increase dramaticallyfrom 2020 to 2030. The major drivers for thegreater supply will be more U.S. and possiblyforeign- trained dentists and large gains indentist productivity resulting from the moreeffective use of allied dental personnel.

Supply of Dentists and Access DisparitiesThere is a common belief that the production ofmore dentists will result in greater access todental care by underserved patients. Suppos-edly, a greater supply of dentists will reduce therate of increase in dental fees, making caremore affordable. While the rate of increase infees will diminish with more price competition,it will have a limited effect on access to care forthe underserved.

Even with somewhat lower fee increases, mostlow-income patients will not be able to afforddental services from private practitioners. Inthe average general practice, 60% or more ofmonies generated from patient care coveroverhead expenses. Dentists can lower theirfees only so much before they start losing

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Relative to the growth of

the population, the number

of dentists will decline

about six percent between

2000 and 2015.



money. Although a few high- volume and low-margin practices are successful financially byfocusing on Medicaid patients, most privatedentists have little interest in this practice model.

The basic problem limiting access to care formost low-income patients is their lack ofpurchasing power and not the supply ofdentists (except in some rural areas or wherethe overhead is low). For example, in Califor-nia there is little difference in Medi-Calpatient dental utilization rates in San Fran-cisco, where there are large number of dentists,and rural areas of the state, where there arerelatively few dentists. If the availability ofdentists were the key issue, utilization rates inSan Francisco would be much higher.10

Another example comes from an innovativeprogram in 37 Michigan counties, where thedental Medicaid program was turned over to aprivate dental insurer that paid dentistscompetitive fees and used the same adminis-trative systems as privately insured patients.Within a few years utilization rates forMedicaid-enrolled children in these countiesrose from about 35% to 60%.11 The importantpoint is that utilization increased dramatically forMedicaid-eligible children without any increasein the number of dentists when Medicaid planfees and administration became competitive.

There is a second reason that increasing thesupply of dentists will not have a significantimpact on the access problems of theunderserved, because there is a finite amountof money that the public is willing to allocate todental care for the poor. For both the dentalMedicaid program and publicly run dentalsafety-net clinics, the amount of moneyallocated to these programs is limited bycompetition for public funds from other healthproviders and nonhealth programs. Thus, ifmore dentists accept Medicaid patients andtotal dental Medicaid expenditures increasesubstantially, states will control these costs bydecreasing Medicaid enrollment, changing thebenefit structure, or limiting fee increases. WithMedicaid medical care expenditures increasing7-12% a year in many states, there is littlechance that states will have additional resourcesto invest in Medicaid dental programs.

An increase in the supply of dentists will makedental care more affordable for large numbersof middle-income families that have resourcesto purchase services from private practitioners.Thus, a greater supply of services does benefitsome population groups.

AHEC ProgramsAHEC programs have the opportunity tosignificantly increase access to dental care in atleast two ways. First, more dental schools aresending senior students and general andpediatric dentistry residents to communityclinics caring for the underserved.12 Studentsare much more productive in these settingsthan in traditional dental school clinics becausecommunity clinics are real delivery systems. Ifall 56 dental schools had students andresidents spend four or five months in commu-nity clinics and practices, over one millionpatients would receive care.

AHEC programs have the background andexperience to assist schools in this effort,especially in rural areas. Most dental schoolsare reluctant to send students, because of thetransportation, housing, and other problemsassociated with rural externships. In NorthCarolina, the AHEC program has worked withthe health professions schools at the Universityof North Carolina Chapel Hill to organize andmanage community rotations. In addition toproviding care to theunderserved, students andresidents learn about careeropportunities in communityclinics, and a small butsignificant percentage spendtime in these settings aftercompleting their clinicaltraining. Likewise, evidencesuggests that clinic providersappreciate having the opportunity to interactwith students and residents, and this mayreduce staff turnover.

Another opportunity is for AHEC programs topartner with dental schools to support commu-nity clinics. This includes assisting clinics withstaff training and recruitment and specialtyand management consulting services. Arecent study reported that community clinicsare only half as productive as private dentists.13

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ealth

…there are relatively few

foreign trained dentists

with U.S. dental degrees in

the dental workforce.



The primary reason is that community clinicdentists use fewer operatories and allied healthpersonnel per dentist. Many clinics couldsubstantially increase the number of servicesprovided if they followed the best deliverypractices. AHEC programs need to bringdental schools, community clinics, organizeddentistry, and possibly other partners togetherto address the productivity problems of mostcommunity clinics.

In conclusion, for the next several years thesupply of dental services will increase slowly,and some middle income families, especiallythose living in rural areas, may have moredental access problems. Longer term, thesupply of dental services will increase substan-tially, as more dentists enter the workforce anduse allied dental personnel more effectively.The greater supply of dental services will have

References

1U.S. Department of Health and Human Services (2000). Oral Health in America: A Report of the SurgeonGeneral. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental andCraniofacial Research, National Institutes of Health.

2Bureau of Labor Statistics, U.S. Department of Labor (2005). “Dentists.” Accessed August 2006 at http://www.bls.gov/oco/ocos072.htm.

3American Dental Association (2006). 2004-05 Survey of Dental Education. Academic Programs, Enrollment,and Graduates, vol. 1 April 2006. American Dental Association, Survey Center.

4American Dental Association (2001). Future of Dentistry. Chicago: American Dental Association, HealthPolicy Resources Center:

5American Dental Association. The Survey of Dental Practice: Characteristics of Dentists in Private Practice andTheir Patients, 1980 to 2003. American Dental Association, Survey Center.

6American Dental Association (2001). The American Dental Association Workforce Model: 1996-2020. AmericanDental Association, Survey Center.

7Beazoglou, T., Heffley, D., Brown, L.J., and Bailit, H. (2002). “The Importance of Productivity inEstimating Need for Dentists,” Journal of the American Dental Association, 133, 1399-1404.

8American Dental Association (2002). The 2000 Survey of Dental Practice: Dentists in Solo and Non-solo PrivatePractice. American Dental Association, Survey Center.

9Brown, L.J., House, D.R., Nash, K.D. (2006). The Economic Aspects of Unsupervised Private Hygiene Practiceand Its Impact on Access to Care. American Dental Association, Health Policy Resources Center. Dental HealthPolicy Analysts Series.

10Dr. Robert Isman, Dental Program Consultant, Office of Medi-Cal Dental Services, Department of HealthServices, State of California (2006). Personal communication, August.

11Healthy Kids Dental (2002). Dental Public Health Activities & Practices. Michigan Department of CommunityHealth.

12Bailit, H., Formicola, A., Herbert, K., Stavisky, J., Zamora, G. (2005). “The Origins and Design of theDental Pipeline Program,” Journal of Dental Education, 69(2), 232-38.

13Beazoglou, T., Heffley, D., Lepowsky, S., Douglass, J., Lopez, M., Bailit, H. (2005). Dental Safety Net inConnecticut, Journal of the American Dental Association, 136, 1457-62.

limited impact on increasing access to care forunderserved and disadvantaged populations.The basic problem for most underservedpatients, including those enrolled in Medicaid,is the lack of purchasing power to pay fordental services. With medical-care costincreases running at two or three times thegeneral inflation rate, few states or the federalgovernment have the resources to significantlyincrease public support for dental Medicaidprograms or safety- net clinics. AHECprograms have an important role to play inassisting dental schools to organize commu-nity clinic rotations for senior students andresidents and developing partnerships withcommunity clinics to help the clinics operatemore efficiently. These interventions willnot solve the access disparity problem, butthey will make an important and positivecontribution.

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Oral H

ealthImproving Access to OralHealth Care in MissouriThrough AHEC RotationsBonnie Branson, RDH, PhD, and Stephanie Taylor, BS

In her 2001 study, Branson found that only 10AHEC programs indicated a partnership witheducational institutions to provide an oralhealth component in the AHEC experience,and the majority of these experiences utilizeddental hygiene students to provide the oralhealth services. Based on this insight, facultyat the University of Missouri-Kansas City(UMKC) School of Dentistry began exploringand developing options for academic service-learning experiences. Working with Missouri’sregional AHEC offices, UMKC dentalhygiene students have been placed at Feder-ally Qualified Health Centers (FQHCs). TheAHEC rotations are part of a unique service-learning experience, now in its third year ofoperation, and have proven to be a positiveexperience for all involved.

For two weeks in the summer, dental hygienestudents participate in rotations to rural andunderserved areas in the state of Missouri.These rotations give students an opportunity toexperience dentistry away from the confines of

Bonnie Branson, RDH,PhD, is an AssociateProfessor at the Universityof Missouri School ofDentistry, Kansas City,MO.

Stephanie Taylor, BS, is theExecutive Director of theWest Central AHEC,Kansas City, MO.

a dental school setting. Students rotate toFQHC dental clinics throughout Missouri.Seven regions are visited by dental hygienestudents, allowing for oral health services in allgeographic areas of the state. Dentists anddental hygienists at the FQHC clinics providesupervision while the dental hygiene studentsrender routine dental hygiene treatmentincluding head-neck and oral exams, exposingdental radiographs, treatment planning, oralhygiene education, scaling and root planning,and community education programs. Inaddition to treatment at the FQHCs, thedental hygiene students provide communitydental education programs for groups from daycare centers, summer camps, and seniorcenters; they also develop and present adulteducation. These experiences create anopportunity for students to interact with apopulation that may never be seen in thetraditional dental office setting. Studentsbecome more aware of the diversity of ourpopulation and the role of public health asdemonstrated by comments such as, “I neverreally knew how many poverty-stricken peoplethere are out there,” and “I finally understoodwhat public health is.”

Student FeedbackComments made by dental hygiene studentsafter completing summer AHEC rotations in2004 and 2005 include “I really had anawesome experience,” and “It made me feel asif I chose the correct profession.” One studentcommented, “I learned what it is like to workalongside a dentist in a real clinic setting,” and“It was great to know I could have a professionalopinion.” Comments such as these confirm thatthe mission of AHEC is being met.Jill Griggs works with patients during her two-week

dental hygiene rotation in southeast Missouri.

Dental hygiene students from the University of Missouri-Kansas CitySchool of Dentistry, in two-week summer rotations, work with dental staffat seven Federally Qualified Community Health Centers to provide much-

needed oral health care while learning about health disparities in their state.


Improving Access to Oral Health Care in MissouriThrough AHEC Rotations

The program’sobjectives focus onstudents’ familiaritywith 1) the similaritiesand differencesbetween privatepractice and publichealth clinics; 2)assessing, planning,implementing, andevaluating an oralhealth educationprogram; 3) workingwith a diverse popula-tion; and 4) under-standing the ethics ofdelivering health care toa whole community versus individual patients.Additionally, the rotations seek to continue todevelop the students’ clinical skills undersupervised instruction.

The rotation objectives are evaluated usingvarious measurements, including studentjournals, task records and post-program

surveys. Results fromthe 2004 and 2005student surveysindicate that objec-tives for the programhave been met. Thisfeedback can be seenin the results from an11-question surveydisplayed in Table 1.

Most notable werethe responses tostatement numbertwo, which addressedpopulation diversity(objective number

three). The response averages for thisstatement, which asked the students to ratetheir feelings regarding “I became moreaware of the needs of underserved popula-tions through this experience,” for 2004 and2005 were 1.19 and 1.17 (out of a possible1 for Strongly Agree).

Table 1. Student feedback for summer AHEC rotations.

Kelly Berger (left) educates community membersalongside Bertie Cronbough, RDH, at a communityhealth fair during her two-week dental hygienerotation in northwest Missouri.

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Also notable was the fact that the students inthe 2004 rotations responded with a neutralopinion (3.6-no opinion) to the statement“The AHEC rotation made me see employ-ment in a rural setting as an option for me inthe future.” This response raises the questionwhether the opportunities for dental hygieneemployment were thoroughly emphasized tothe students. The rotation group from 2005shows improvement in this area.

Other outcomes include the amount of careprovided to the residents of Missouri andthe placement of graduates in rural andpublic health settings. It is estimated that$45,000 worth of dental hygiene time and$90,000 worth of dental hygiene serviceswere provided each summer the programhas been in operation. Additionally, fourgraduates have been employed at FQHCsand two have joined the public healthservice as a result of the program.

RecommendationsAs with any new program, suggestions forimprovement have been made that includereorganization of paperwork and requestsfor earlier and more frequent communica-tion with all persons involved. Thesesuggestions have been addressed with eachnew set of student rotations.

Changes include strategies aimed atopening lines of communication and makingthe individuals involved in the experiencefeel more connected to one another. Thisincluded the development of a computer-based site to house all forms and informa-tion related to the rotation (Blackboardplatform). This site was made accessible toall students, faculty, and AHEC coordina-tors. Also, an on-line (Centra-One Plat-form) symposium was held in the spring of2005 with the AHEC coordinators todiscuss issues for the next rotation. In thespring of 2006 phone conferences were heldfor students and AHEC coordinators toconverse before the actual rotation. Revi-sions in the distribution of paperworkincluded sending student profiles to the

Improving Access to Oral Health Care in MissouriThrough AHEC Rotations

AHEC coordinators via hard copy andelectronically. These profiles now include astudent photo and biographical informationto create a more personal connection.

Ongoing SupportTo support learning and a communityconnection, students complete a communityprofile and research report to create astronger correlation to public health and theoral health objectives in Healthy People2010. These papers are part of the gradeddidactic instruction the students receive inthe Principles of Public Health course.

In addition, division-wide support of thefaculty is an important component of therotations. In order to foster faculty involve-ment, faculty members visit the studentswhile on rotation to provide oversight. Thesevisits enhance faculty support for theprogram. Moreover, the success of thesummer rotation is dependent on thefaculty’s ability to understand and supportthese activities. For this reason, the dentalhygiene faculty travel to the rotation sites toprovide oversight and also to serve in aconsultation capacity to the FQHC staff. Bygoing to the remote sites, faculty are able toaddress student questions in the settingwhere the issue arises and to incorporatethese scenarios into subsequent lectures inthe public health course.

In summary, this program represents a win-win situation for UMKC dental hygienestudents and individuals requiring oral heathcare in underserved areas of Missouri. Therewards are enormous for both the dentalhygiene students and the FQHC patients.AHECs that currently are not working withdental hygiene students should be encour-aged to develop meaningful partnerships toprovide a foundation for future collaboration.

Reference

1Roe, S., Branson, B. & Lackey, N. (2001).Interdisciplinary delivery of oral health care studenttraining components. J Allied Health, 30:195-198.

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lth Innovative Service LearningModels: The Use of AHECPartnerships to Increase OralHealth Access in Rural MississippiStephen L. Silberman, DMD, MPH, DrPH; Neal Demby, DMD, MPH; Susan L. Dietrich, DMD;and Sandra Hayes, MCS, MPH

Maintaining an adequate oral health workforcein Mississippi has been a challenge for manyyears despite the state legislature’s establishing adental school that accepted its first class in 1975.Even with the increased number of dentistseducated within the state, the workforce has notbeen able to keep up with growth of thepopulation; hence, the need for oral healthcareproviders has increased, most notably in ruralareas. Mississippi is a rural state with only 20%of its citizens living in cities with a populationgreater than 20,000 and 53% living in areasclassified as rural. This sparseness of the populationis one of the major factors in the geographicmaldistribution of healthcare providers.

Efforts to increase access and promotion ofquality oral health care have created a partner-ship that includes the Lutheran Medical Centerof Brooklyn, New York, the University ofMississippi Medical Center (UMMC) School ofDentistry, and the MS AHEC. The programthat developed is an attempt to address thecritical oral health workforce shortage in Missis-sippi. This program could be used by AHECs asa model for similar programs. This article describesthe development of the program; a future article willreport on results of the implementation.

The Lutheran Medical Center (LMC) is theeducational sponsor of four dental residencytraining programs which are accredited by theAmerican Dental Association Commission onDental Accreditation. For almost three decades,LMC has forged partnerships with CHCsthroughout the country as a strategy to increaseaccess to care by placement of full-time residentsin extramural practice settings for one or twoyears of advanced clinical training. This is

consistent with the mission of LMC in its role asan institution without walls - to increase accessand assure equity in oral health care for communityresidents. The LMC Department of DentalMedicine has been training dental residents since1974. Currently, the geographic areas of clinicaltraining sites include Alaska, Arizona, MetropolitanNew York City, Upstate New York, Hawaii,Maryland, Massachusetts, Michigan, Mississippi,New Mexico, Rhode Island, and Tennessee.

In order to assure access and equity in thiseducational model, the LMC Department ofDental Medicine established an innovativedistance learning curriculum. Approximately 130hours of synchronous didactic education isprovided via live video teleconferencing on aweekly basis, and asynchronous methodologiessuch as online literature reviews occur via onlinediscussion forums/threads. Over one year oftraining a general dentistry resident will provideapproximately 1,500 patient visits, and theLMC Dental Residency Network of residentsprovided over 100,000 patient visits in 2004.These data demonstrate that dental residents arean alternative resource to address workforceshortages in CHCs that result in increased access tooral health care to the most vulnerable populations.

The perspective of the CHC dental directors onimplementing a service-learning environmentwith the LMC has been positive as demon-strated by the results of a comprehensive 2005survey of CHC dental directors who superviseand mentor LMC dental residents. Further-more, when surveyed about the impact of theresidency training program on increasing access tooral health care and the impact of the residencyon recruitment and retention, 80% of the dental

Susan L. Dietrich, DMD,is the Director of GraduateDental Education at theLutheran Medical Center,Brooklyn, NY.

Neal Demby, DMD, MPH,is the Director of DentalMedicine at the LutheranMedical Center, Brooklyn,NY.

Stephen L. Silberman,DMD, MPH, DrPH, is aFamily Medicine Professor atthe University of MississippiSchool of Medicine, andProgram Director of theMississippi AHEC, Jackson,MS.

A plan is in place to address the dental shortage in Mississippi by developinga partnership between the MS AHEC, University of Mississippi School of

Dentistry, and the Lutheran Medical Center of Brooklyn, New York.Although the program is just being initiated, the authors believe that future

data will demonstrate the effectiveness of the program.


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directors indicated that the involvement in theresidency program assisted in improving accessto oral health care at the health center, and 71%of the dental directors indicated the residencyassisted in improving the recruitment andretention issues for the health center.

Similarly, a 2005 alumni study examined alongitudinal cohort of all general dentistrygraduates of LMC’s General Practice Residencyand Advanced Education in General Dentistry(AEGD) residency programs. Data suggest thatresidents who train in underserved areas developfuture practice patterns and a commitment tocaring for and integrating underserved popula-tions within these areas. In addition, the graduatestreat more complex cases, tend to use specialtyreferrals less frequently, and provide an access portalfor oral health services to the underserved.

Program PlanFor this program to work it was necessary to finda CHC that would provide a good model for thefuture development of other AEGD residencyprograms in Mississippi. In order to enlist thepilot CHC, the Mississippi AHEC presentedthe LMC program to CHC directors at theMississippi Primary Health Care Associationannual meeting. As a result, the GreaterMeridian Health Clinic (GMHC) was a strongadvocate and requested that it be considered asthe pilot. It was the first to step forward amongsix interested sites and among the most eager toparticipate. However, it was the combination ofthe rural sites served by this urban program andits existing affiliation with the School ofDentistry’s public health rotation for predoctoralstudents that made this the ideal model site.

The Greater Meridian Health Clinic operatesthree dental facilities and one mobile unit. Twoof the sites are in rural locations while one islocated in a small town. Two of the GMHCdentists have completed advanced training ingeneral dentistry at the University of Mississippiand a third is a graduate of the dental program.Based on data obtained in July 2006, GMHCserves approximately 15,252 people per month.Of that number, about 15%, or 2,304, receivedental services. The patient population consistsmainly of minority patients and personsconsidered disadvantaged. Approximately 27%,or 4,143, are covered by some form of insurance.

Prior to contact with the Mississippi PrimaryHealth Care Association, there were a numberof meetings between the AHEC Director andthe School of Dentistry (SOD) to describe the

Innovative Service Learning Models

program, address concerns, and prepareaffiliation agreements. From beginning to end,this process took about one year. It is important tonote that we employed the rules and regulations ofthe State Dental Board and were able to moveforward without any input from local dental societiesbecause the SOD is affiliated with the program andthe CHC staff holds faculty appointments.

The initial recruitment of graduating dentistswas not as successful as hoped, primarily due tothe late startup. However, since the LMCmodel has a rotating start date, it is still possibleto enroll recent graduates at a later time. Weexpect to recruit two graduates for next year’sprogram due to a more concrete marketing plan.The future looks bright for bringing AEGDprograms to rural areas, and plans areunder way to develop another dentalresidency program as soon as the firstresidents are accepted into theprogram. Since many of the CHCshave only a single dentist on staff,they would not be able to host anAEGD dental site. However, bycombining multiple small clinics andhaving the dental residents rotateamong the sites, we will be able tobring more AEGD programs to therural areas of Mississippi.

Expected outcomes of this programinclude an increase in workforcerecruitment and retention into ruralareas and an increase in access todental care. We project that whenthis program and future programs atother CHCs are functioning, therewill be at least five residents at anyone time providing dental service in the ruralclinic sites. This would translate to about 7,500visits annually. In addition, these programs willprovide educational opportunities for practitio-ners, residents, and staff through the distancelearning portion of the LMC AEGD program.Patients will also benefit through this processwhen special dental health education topics areoffered.

In summary, this article presents a plan that willbe implemented in the near future. Theprogram is designed to reflect the mission of theUniversity of Mississippi Medical Center,respond to contemporary health policy, andestablish a model that will break traditional andgeographic boundaries. The Mississippi AHECwill continue to expand this program to includenew AEGD programs at other CHCs.


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lth Northeast Indiana AHECDental Clinic Provides ServiceLearning Opportunities forDental Hygiene StudentsNancy K. Mann, RDH, MSEd

The Indiana University-Purdue UniversityFort Wayne School of Health Sciences(IPFW) in collaboration with the IndianaUniversity School of Medicine established theNortheast Indiana Area Health EducationCenter (NEI-AHEC) in October 2005.Located in Fort Wayne, NEI-AHEC workswith community partners in health care andpublic health, K-12, and postsecondaryeducation to increase exposure to healthcareers among disadvantaged andunderrepresented minority youth and toprovide community-based clinical educationopportunities for students enrolled in healthcare education programs.

One example of NEI-AHEC’s communitycollaboration is the monthly Allen CountyHealth Disparity Coalition’s Prevention Clinicthat began in January of 2006. Screeningservices at the clinic include weight, bloodpressure, blood glucose, cancer, cholesterol,HIV, oral, and others. Oral health exams areconducted by IPFW dental hygiene studentsand faculty in a room equipped by contribu-tions from the local dental society. Dentalscreenings are vitally important due to themouth-body connection since oral diseases canaffect health and well-being throughout life.

The IPFW dental hygiene students assist theNEI-AHEC in reaching three strategic goals:

1) Enhancing the curriculums of health careprovider students by offering ‘hands-on’learning experiences;

2) Promoting access by all citizens in the areato quality health and dental care; and

3) Working with underrepresented popula-tions to provide dental screening, casemanagement, health education, andreferral via service learning and collabora-tions with area health care providers.

Results of the screenings reveal a great needfor increased access to dental care in urbanFort Wayne despite two free or reduced-costclinics in the city. The population livingimmediately around NEI-AHEC has nottraditionally sought dental care at the othertwo sites for reasons including long waitinglines in the walk-in clinic and a six-monthwaiting list at the other clinic. The dentalscreenings conducted by the IPFW studentsand faculty demonstrated that the popula-tion residing near the clinic was willing tocome for dental care and that the populationhad a critical need for services.

To meet the identified need and providelearning opportunities for dental hygieneand dental assistant students, IPFW soughtadditional resources to equip two dentalrooms in the NEI-AHEC site. Withequipment valued at $30,000 generouslydonated by dentists throughout the north-east region who were either remodeling theiroffices or retiring from practice, IPFW wasable to equip two dental exam rooms and aprocessing lab. The equipment includeddental chairs with pole-mounted lights, fourstools, tray stands, two X-ray machines, anautomatic film processor, an air compressorfor air and suction, and an autoclave.Further donations of ultrasonic scalers

Nancy K. Mann, RDH,MSEd, is a ClinicalAssociate Professor ofDental Hygiene at theIndiana University –Purdue UniversityDepartment of DentalHygiene, Fort Wayne, IN.

Indiana University-Purdue University Fort Wayne School of HealthSciences offers a service-learning clinic for dental hygiene students which is

operated by the Dental Education Department staff and offers theopportunity to experience “the real world.”


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provide students withthe opportunity to treatpatients and performassessments, therapeu-tic and preventiveservices, education, andreferral. The dental clinicopened on October 2,2006, and is run byIPFW Dental EducationDepartment staff andfaculty.

One student noted, “The dental screeningswere an eye-opening experience. This wasthe first time that I actually saw an abnor-mal mouth, besides pictures. These peoplewere so thankful for what we were doing. Itwas just a great feeling helping out ourcommunity. I think the site is a greatlocation. It gives us the opportunity to go tothe community instead of them coming tous. I think this is going to be a greatlearning facility.”

At the same time students are gainingvaluable experience in the clinic, they arealso educating patientsof all ages through thedental public healthclass at IPFW. In theCommunity DentalHygiene course, thestudents observespecific target popula-tions and design acustom program for that group based onneeds. Within a class, the dental hygienestudents serve 10 varying target groupsbased on a needs assessment. For instance,since dental jewelry for the mouth (“grills”)is popular among urban Hispanic andAfrican-American middle and high school-aged students, the dental hygiene studentsinvestigated and presented information thattaught proper care for teeth and cautionedagainst ill-fitting mouth jewelry. Thestudents had to demonstrate cultural

Northeast Indiana AHEC Dental Clinic Provides ServiceLearning Opportunities for Dental Hygiene Students

sensitivity for hip hop,the genre of origin formouth grills, andremain nonjudgmental,while at the same timeproviding an importanthealth message for themiddle schoolers.

In other communityrotations, students

visited third-grade classrooms, Head Starts,and local Amish parochial schools withappropriate messages on oral health. At theend of spring semester 2006, the class hadpresented oral health information to 5,000individuals and distributed toothbrushesand toothpaste to all audiences. The largestgroups to receive the message were thirdgraders and sixth graders. Tobacco preven-tion information was included in everypresentation as everyone can benefit fromthat message.

The current class of IPFW dental hygienestudents is assessing oral health needs ofpregnant women in a prenatal class, youth

in a detention center,children at an orphan-age, and residents atnursing homes. Thisproject has openedstudents’ eyes to thechronic problem ofdental disease in low-income populations.

As Indiana attempts to address health careprofessional shortages, from the inner citiesto the rural areas, and to educate citizensabout health problems, the NEI-AHEC isproving to be a valuable partner by initiatingcollaborations between the university andcommunity health care agencies. Startingwith oral health issues seems a logicalapproach. After all, a healthy Indiananeeds healthy communities, and the mouthis the right place to begin.

There is a great need for

increased access to dental

care in urban Fort Wayne

despite two free- or reduced-

cost clinics in the city.

“This was the first time

that I actually saw an

‘abnormal’ mouth, besides

pictures.”


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lth USF InterdisciplinaryCommunity Health ScholarsFocus on Dental Needs inSarasota, FloridaEmily Meade, BA, and Anne Maynard, MPH

Pregnant women with periodontal disease(PD), a chronic bacterial infection of themouth characterized by inflammation of thegums, bone loss, and eventual tooth loss,have a 4.3-7.9% higher risk of preterm, low-birth-weight (PLBW) deliveries than womenwith no evidence of PD.1,2,3 While this findinghas significant research support, there hastraditionally been little attention paid to dentalcare during the gestational period, especially inunderserved communities.2

During the summer of 2006, a team of fourstudents from the University of SouthFlorida Area Health Education Center andGulfcoast South Area Health EducationCenter’s Interdisciplinary CommunityHealth Scholars (ICHS) program partneredwith the Healthy Start Coalition of SarasotaCounty, Inc. to assess needs, developresources, and launch a program to increaseawareness of the importance of good oralcare for pregnant women and reduceperiodontal disease in pregnant women.

The ICHS program is an annual 8-weeksummer training program for 16 healthprofessions students from the USF Collegesof Medicine, Nursing, Public Health, theSchool of Social Work, and undergraduatepre-health professions programs. Since1999, four interdisciplinary teams haveworked with medically underserved commu-nities/populations and community partnersto 1) develop a better understanding ofissues of health care in underserved commu-nities; 2) participate as members of interdis-

ciplinary health care teams; and 3) helplocal communities develop ideas for improv-ing health. In 2006, Gulfcoast South AreaHealth Education Center’s Sarasota ICHSteam of two social work students, one publichealth student, and one medical studentworked under the guidance of the HealthyStart Coalition’s Contract/Quality Manager,Jennifer Highland, MPH, RN, to 1) assess theavailability of oral health care for pregnantwomen in Sarasota County; 2) determine thelevel of unmet need for oral healthcareeducation of expectant mothers and women ofchildbearing age; and 3) develop instructionalmaterials to educate the community onpregnancy and oral health.

The ICHS team undertook an evaluation ofthe quality and quantity of oral health careresources for low-income, pregnant womenin Sarasota County by incorporating the AssetBased Community Development (ABCD)Model. ABCD is a community-drivendevelopment tool, as opposed to one devel-oped through external agencies. It evaluatesexisting community structures and queriesproviders to determine the assets of thecommunity and then utilizes these assets fordevelopment within that community. TheICHS team identified the Sarasota CountyHealth Department (SCHD) as the primarydental care provider in Sarasota County thataccepts Medicaid patients. The team theninterviewed both healthcare professionalsand expectant mothers visiting the SarasotaCounty Health Department about oralhealth and pregnancy.

Anne Maynard, MPH, isthe Associate Director ofthe University of SouthFlorida AHEC Program,Tampa, FL.

Emily Meade, BA, is aClinical TrainingCoordinator atGulfcoast SouthAHEC, Sarasota, FL.

Gulfcoast South AHEC’s Interdisciplinary Community Health Scholarspartnership with Healthy Start Coalition of Sarasota County to assessoral health issues of pregnant women provides students valuable service

learning experiences and new skills.


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The survey for expectant mothers and womenof childbearing age was administered in bothEnglish and Spanish by two of the ICHSstudents at the Sarasota County HealthDepartment’s obstetrics/gynecology waitingroom and in the Healthy Start waiting room.

A total of 34 women were interviewedbetween the ages of 20 and 36 with a medianage of 23 years: 14.7% of the women wereAfrican American, 29.4% were Hispanic, and55.9% were Caucasian. The women wereasked a range of questions concerning theirbeliefs about the importance of oral health carewhile pregnant, their personal oral healthcarehabits, the availability of dental care providers,and their means and methods of paying fordental care.

Of the women interviewed, only 26.5% ofthem believed there was a relationshipbetween oral health and the health of theirbabies. None of the women interviewedwere aware of a possible correlation betweenperiodontal disease and preterm, low-birth-weight infants. However, 59% of thewomen responded that they considered theiroverall oral health important but did not visitthe dentist regularly because of one of thefollowing factors: cost, lack of dental insur-ance, and/or a lack of time and opportunity.Thirty-four percent of the women had nodental insurance and 37% of the women hadMedicaid, which covers only emergencydental care and dentures for adults but nopreventive care. Thus, 73% of the popula-tion interviewed were either uninsured orunderinsured for preventive dental care.

Of all the women interviewed, an overwhelm-ing 42.4% responded that they visited thedentist only during emergency situations orthat they never went to the dentist. Approxi-mately 85% of the women claimed to brush atleast twice a day, but of these women, fewerthan half reported that they flossed.

Of the eight healthcare providers inter-viewed, five were providers of obstetric careand three were dental care providers. All ofthe dental care providers were aware of theimportance of good dental hygiene for

USF Interdisciplinary Community Health ScholarsFocus on Dental Needs in Sarasota, Florida

pregnant women and considered theevidence supporting the relationshipbetween PD and PLBW deliveries to besignificant. However, several of the obstet-ric care providers questioned a correlationbetween PLBW deliveries and PD. Overhalf of the obstetric care providers agreedthat their patients rarely broached thesubject of oral health with them and, whilethe providers recognized that oral health isimportant, they did not counsel theirpatients on its importance to the health ofthe baby. Both the dental care and theobstetric care providers interviewed alsoagreed that it was extremely difficult to getappointments at SCHD or find privateobstetric or dental careproviders in SarasotaCounty willing to takeMedicaid patients. Only 3-4% percent of the SCHDpatients are able to schedulean appointment with aperiodontal specialist at theHealth Departmentbecause the waiting list canbe over 4 months and anestimated 60-70% of thewomen seen at SCHD havesome degree of PD. Theproviders at SCHD werealso able to identify only oneprivate dental care providerin Sarasota County thataccepted Medicaid patients.

The survey results revealed that expectantmothers in Sarasota County were largelyunaware of the relationship between oralhealth and the health of their babies andhad not been informed of a possible correla-tion between periodontal disease and riskfor preterm, low-birth-weight infants, andthat some medical care providers wereunsure of the relationship as well. Usingthe data gathered from the interviewprocess, the ICHS team created twoeducational presentations on the importanceof good dental hygiene during pregnancyand the possible correlation between PDand PLBW. One presentation was createdfor healthcare providers and one for women

… annual 8-week

summer training program

for 16 health professions

students from the USF

College of Medicine,

Nursing, Public Health,

the School of Social Work,

and undergraduate pre-

health professions

programs.


References

1 Jeffcoat, M. (2006). Pre-term Births and Periodontitis: Does Periodontal Therapy Work? Conservative Treatment ofPeriodontal Disease Reduces the Incidence of Pre-Term Birth. Presented at Florida State University, Tallahassee, FL.

2 Griffith, S. (2006). First Link of oral bacteria and preterm birth found in human. Pregnancy News.

3 Hujoel, P.P., Lydon-Rochelle, M., Robertson, P.B. & Del Aguila, M.A. (2006) Cessation of periodontal careduring pregnancy: effect on infant birthweight. European Journal of Oral Sciences, 114, 2-7.

4 Dörtbudak, O., Eberhardt, R., Ulm, M., & Persson, G.R. (2005) Periodontitis, a marker of risk in pregnancyfor preterm birth. Journal of Clincial Periodontology, 32, 45-52.

of childbearing age. The team used thesepresentations to educate both the healthcareprofessionals and expectant mothers inSarasota County on three importantsubjects: 1) the importance of proper oralhealth care in women; 2) the need for

healthcare providers toeducate pregnant womenon the importance of properdental hygiene; and 3) theneed to increase thenumber of dentists inSarasota County that acceptMedicaid. The first 2community presentationswere given to a total of 48expectant mothers in the

Sarasota County Health Departmentwaiting rooms. The final presentation was

given to over 15 healthprofessionals at SCHD.The ICHS team alsodeveloped brochures for thecoalition to disseminate inwaiting rooms and toexpectant mothers and anewsletter for the coalitionto provide to health profes-sionals. The brochuresprovide information on good

USF Interdisciplinary Community Health ScholarsFocus on Dental Needs in Sarasota, Florida

oral health care and its importance topregnant women and new mothers. Thenewsletter provides health professionals withstatistics on periodontal disease and pretermlow-birth-weight infants, barriers SarasotaCounty women face in accessing dental care,the impact premature births have onSarasota’s local health care systems, andsuggestions for how healthcare professionalscan address the issues Sarasota Countywomen face in accessing care and receivinginformation about the importance of goodoral health care.

The Healthy Start Coalition of Sarasotacontinues to utilize the presentations andthe materials the ICHS team developed toeducate medical and dental students,healthcare providers, and women of child-bearing age on the possible correlationsbetween periodontal disease and preterm,low-birth-weight infants. Thus, the USFAHEC ICHS service learning program forhealth professions students providespractical experience in working with interdis-ciplinary teams, establishes a skill setneeded for future work with underservedcommunities, and benefits communities byproviding assets and resources not previouslyavailable to underserved populations.

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Only 26.5% of the

women believed in a

relationship between oral

health and the health of

their babies.

Several of the obstetric care

providers questioned a

correlation between

PLBW (preterm low-birth

weight) deliveries and PD

(periodontal disease).


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ealthThe Molar Express: ImprovingAccess to Dental Services inNorthern New HampshireAlice Muh, BS, RN, CCM; Nicole LaPointe, MSW; and Martha McLeod, MOE, RD, LD

The Molar Express is amobile, public health dentalclinic owned and operated bythe North Country HealthConsortium (NCHC) ofLittleton, New Hampshire.The clinic began providingservices to northern NewHampshire’s target populationof Medicaid-eligible children in the summer of2005. The Molar Express is based on a modeldeveloped in North Carolina. A customizedtruck transports two complete dental operatories,consisting of high-quality equipment adapted tobe easily portable, to North Country (NorthernGrafton and Coos counties) locations such asgovernment offices, schools, and health centers.The equipment is then unloaded at the designatedsite and the clinic is set up. A full range of preven-tive, diagnostic, and restorative dental services isprovided. Although the services are primarily forchildren, adults eligible for the Molar Expresssliding-fee scale are also seen as time allows.

Access to Dental Health CareChallenges to access to care [in rural areas]include lack of dentists, inadequate supply ofdentists who accept Medicaid or other dis-counted fee schedules . . . and socioeconomicnature of rural populations (poverty, loweducational attainment, cultural differences, lackof transportation) . . .1 Low income childrenhave two times greater prevalence of dentalcaries when compared to other children.2 Thisdescribes the current situation in NewHampshire’s North Country. Fewer than 20dentists serve the area and many of them do notaccept Medicaid. This scarcity of oral healthproviders translates into substantial barriers tooral health care, even for those families that haveprivate dental insurance. Many of the over 4,000North Country children who are Medicaideligible have never seen a dentist and aresuffering the consequences by displaying poor

oral health and poor overallphysical health. Moreover,socioeconomic data for theregion reflect an adultpopulation suffering fromtooth loss at a rate ap-proaching 50% higher thanthe state average.

The consortium’s 2,500 square mile northernNew Hampshire service area is designated as aMedically Underserved Area (MUA), a HealthProfessional Shortage Area (HPSA), and aDental Health PSA (DHPSA) by the HealthResources and Service Administration (HRSA).The population density of the North Country is75% lower per square mile than the stateaverage. According to recent census data, almost31% of North Country residents live below200% of the federal poverty level compared with19% statewide; nearly 29% of children in theNorth Country are Medicaid eligible comparedto 18% statewide.

Role of the Northern NH AHECThe Northern New Hampshire AHEC (NNHAHEC) is a program of the North CountryHealth Consortium (NCHC) and serves healthand human service organizations and educa-tional institutions in New Hampshire’s ruralnorthern tier. It provides continuing educationfor health professionals, health literacy aware-ness and training, support for health professionsstudents and preceptors, and health awarenessprograms. In addition, the NNH AHEC serves asthe convener of rural health working groups thatseek collaborative solutions for addressing healthcaredisparities in New Hampshire’s North Country.Northern NH AHEC provided funds andexpertise to bring the health providers togetherfor strategic planning around regional healthneeds and solutions. The group developed a listof key health issues that had potential for regionalsolutions, including access to oral health services.

Alice Muh, BS, RN,CCM, is the Workforce andEducation ProgramManager at the NorthernNH AHEC/NorthCountry HealthConsortium, Littleton,NH.

Martha McLeod, MOE,RD, LD, is the ExecutiveDirector of the NorthCounty HealthConsortium, Littleton,NH.

Nicole LaPointe, MSW, isthe Community andPublic Health Director ofthe North Country HealthConsortium, Littleton,NH.

The Molar Express mobile dental clinic van is successfully providingpreventive, diagnostic and restorative care dental services to children in

northern New Hampshire, and serves as a training site for dental hygieneand dental assistant students.

The Molar Express Truck: ready to roll.


References

1 Rural Healthy People 2010 (2003). Texas A&M University Health Science Center, Southwest Rural HealthResearch Center. Volume 1, p. 200.

2 Ibid.

Conception to ImplementationIn 2001 a North Country Oral Health WorkingGroup, made up of task forces from threecommunity coalitions, was convened by NNHAHEC. Its purpose was to look at how the oralhealth needs of the population might be metusing a regional approach. NNH AHEC staffsubmitted an Endowment for Health ThemeGrant, on behalf of the group that would fundcurrent planning and explore what was neededto set up a mobile service using the NorthCarolina Access Dental Model. A mobilemodel was chosen due to the lack of publictransportation. The endowment was unable tofund the group but encouraged it to apply forstrategic planning and needs assessmentfunding. NCHC submitted a StrategicPlanning Grant to the endowment in 2002 toconduct a needs assessment for the targetpopulation and to plan the mobile model. Afterconducting community forums to assesspriorities, the endowment set about developing astatewide oral health plan that was eventuallypublished in October 2004. In March 2004,NCHC submitted a theme grant that wasawarded three years of funding for the MolarExpress. In addition to the Endowment forHealth grant, funding was also received fromNew Hampshire’s Medicaid program, the CogswellTrust, Delta Dental, and North Country HospitalsFLEX funds. The result of several years ofresearch, planning, and grant seeking is the MolarExpress, a regional mobile oral health clinic modelproviding dental care to the underserved populationof northern New Hampshire.

When plans for the Molar Express were beingdeveloped, patient education was considered acritical component of the services to be provided.Critical to the success of the Molar Express isthe strengthening of public understanding of themeaning of oral health and the relationship of ahealthy mouth to a healthy body. Therefore,education and training in oral health care forboth consumers and providers is a part of theMolar Express’s overall work plan. There arenow programs to provide basic information topatients and families.

Northern NH AHEC is providing training forthe staff of the Molar Express to presentprograms for schools and primary care providers

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to increase awareness and screenings at anearlier age. In a key workforce developmentarea, an internship program with the MolarExpress for dental hygienists and dentalassistants has been developed with the long-term goal of developing an internship programfor dentists as well.

OutcomesSince the summer of 2005 the Molar Expresshas seen 550 unduplicated patients—over 90%of whom are children. These patients havereceived 3,537 dental procedures including oralevaluations, X-rays, prophylactic treatmentsincluding fluorides and sealants, fillings, andextractions. Services have been provided in over15 locations. To date, the Molar Express isaveraging eight clinic days per month. Theaverage cost of a clinic is $1,600 per day.Reimbursement for Medicaid patients is 70% ofnet billed charges. Sliding-fee patients pay 40-60% of the amount billed. Money receivedthrough grants has helped offset the costs forthis year. Services are provided by contractdentists and dental hygienists, staff dentalassistants, and a practice manager. Staffing foreach clinic is one dentist, one hygienist, and twodental assistants, who also serve as registrars.The first intern started this fall.

The Molar Express is a work in progress, andthe scope of services continues to evolve. In arecent local needs assessment, affordable oralhealth care remained at the top of the list ofunmet healthcare needs. Although the MolarExpress has had a positive impact in the region,it is clear that there is a need to increase theaverage number of clinic days each month andincrease services to adults. Medicaid-eligiblechildren have been the primary target becauseservices provided are covered by the state.There is no such coverage for adults. To offsetthe costs of improving access to care for adults,grant support and creating partnerships havebeen pursued. Challenges that continue arerecruitment and retention of dental providers,securing access to additional clinic sites, andimplementing an electronic medical record. Yetdespite these challenges, the Molar Express hasdemonstrated that a regional mobile model is anefficient way to provide services in a rural areaand it is a model that can be replicated.


Meeting the Oral Health Needsof a Rural Community ThroughCollaboration and DeterminationShelba Scheffner, MPH, CHES; Debra Youngfelt, BS, CHES; and Rebekah McFadden, RN,BSN, CSN

Through a partnership between EastcentralPennsylvania AHEC (ECPA AHEC), a localhospital network, and a visionary collaborativecalled Carbon County Partners for Progress,restorative and preventive dental services willbecome a reality for Medicaid-eligible childrenin Carbon County, Pennsylvania. ECPAAHEC was established in 2000, with CarbonCounty being one of the five counties in itsregion. This county, which covers approxi-mately 500 square miles, is largely rural, with apopulation of approximately 59,000 people.The Carbon County Health Profile providedby the Pennsylvania Department of Health(2005) indicates that 12.9 % of the populationof the county is eligible for medical assistance.1

How It All StartedInitially a group of local business leaders,politicians, employers, and school officialsconvened to discuss how to stimulate economicgrowth in Carbon County. They determined thatthere were many issues that warranted attentionif quality of life in the county were to improve.

The process began with the incorporation of anew organization, named Carbon CountyPartners for Progress. Shelba Scheffner,executive director of ECPA AHEC, becameone of the early members of Carbon CountyPartners for Progress. Local State Representa-tive Keith McCall secured funding for acommunity needs assessment that involvedapproximately 300 participants. Thecountywide planning workshop formed fourseparate task forces: Education, EconomicDevelopment and Heritage, Leadership, andHealth and Human Services. The Health andHuman Services Task Force identified

numerous local health challenges, including asignificant lack of dental services, bothpreventive and restorative, for the Medicaid-eligible population of Carbon County. Theneeds assessment found that none of the 27dentists who practice in Carbon Countyaccepted Medicaid as insurance payment fordental services. This health care disparitybecame a priority for Partners for Progress. Itfurther brought about additional partnershipswhich focused on improving oral health careservices to the low-income population.

The Health and Human Services Task Forceformulated a Dental Initiative Committee withthe sole purpose of addressing its vision tofacilitate restorative and preventative dentalservices to children with Medicaid in CarbonCounty. ECPA AHEC took the first step byapplying for Health Professional ShortageArea (HPSA) status through the PennsylvaniaDepartment of Health.

Dental Initiative Committee membersestablished an affiliation agreement wherebyECPA AHEC would be the lead agencyresponsible for the administrative oversight forthe Dental Access Project. Debra Youngfelt,health educator for ECPA AHEC, wasengaged through State Health ImprovementPlan (SHIP) grant money to lead the commit-tee and perform many of the tasks. Theprovision of oral health services in CarbonCounty promotes the AHEC mission, “toenhance access to quality health care, particu-larly primary and prevention care, by improv-ing the supply and distribution of health careprofessionals through community/academiceducational partnerships.”2

Debra Youngfelt, BS,CHES, is a HealthEducator/Planner for theEastcentral PennsylvaniaAHEC, Lehighton, PA.

Shelba Scheffner, MPH,CHES, is the ExecutiveDirector of the EastcentralPennsylvania AHEC,Lehighton, PA.

Eastcentral Pennsylvania AHEC, leading a multi-partner dental accessproject, gained federal funding to provide oral health care for Medicaid-

eligible children and shows how AHECs can serve as leaders to encourageother agencies to address health care disparities.

Oral H

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Based on all of the data collection and research,the Dental Initiative Committee members feltthat a school-based mobile dental van wouldbe most effective in providing dental services.A review of literature also supported thisdecision. In a research study by Siegel, Marx,and Cole (2005), consumers and providerswere surveyed to determine perspectives onaccess to dental care for Ohio Head Startchildren with the goal to assess the need andappropriate strategies for action. The research-ers found that Head Start staff and dentistsfelt that poor appointment attendance nega-tively affected children receiving care, butparents/caregivers said finding accessibledentists was the major problem.3 A school-based mobile dental van removes the barrier ofaccess/transportation to services in the ruralcounty and removes the barrier of poorappointment attendance.

Dental Initiative Committee members havepartnered with the Blue Mountain HealthSystem (BMHS) to serve as the administrativeorganization. Whereas Carbon CountyPartners for Progress, as a nonprofit corpora-tion, has raised funds to purchase a mobiledental van, equipment, and supplies and hirepersonnel to staff the van, the organizationdoes not have the ability to purchase andmanage the operation of the van. BMHSagreed to act as employer for the dental vanstaff and provide liability insurance, vehicleinsurance, office space, and general officesupplies and other services, as needed, to thevan and its staff. Liability insurance andvehicle insurance will be funded by dentalinitiative money but coordinated throughBMHS.

Show Me the MoneyThe next monumental task was to develop abudget for the program. Approximately

Meeting the Oral Health Needs of a Rural CommunityThrough Collaboration and Determination

$350,000 was needed to purchase the dentalvan, purchase all of the dental equipment, andpay salaries for a dentist, dental hygienist, andvan driver/office manager for the first sixmonths. The task of researching availablefunding opportunities became the priority ofthe Dental Initiative Committee. ThePennsylvania Department of Health PrimaryChallenge Grant worth $150,000 was writtenand submitted. One of the criteria for submis-sion of the Challenge Grant was obtainingmatching funding through the community.Through massive fundraising efforts on thepart of the Dental Initiative Committeemembers and unprecedented communitysupport, the matching funds were obtained.The community engaged in all types of creativefundraising activities, from a countywide dress-down day to a comedy night. The ChallengeGrant monies were approved as well.

Committee members have projected that afterthe dental van functions for two years, it will befinancially self-sufficient through independentbilling to Medicaid if it provides services to atleast 1,000 children twice during the schoolyear. The project will be sustained throughMedicaid billing of services and throughcontinued fundraising efforts with establishedcommunity partnerships.

Undoubtedly, many unforeseen challengesface the Dental Initiative Committee andAHEC in the years to come as the mobiledental van begins providing services. Yet thisgroup of concerned community partnersremains confident in the strength of itspartnership and spirit of collaboration andindeed is looking forward to these challenges.The AHEC mission to increase access toquality health care has been exemplified bythis partnership. ECPA AHEC is proud of itsrole in this exciting initiative and looks forward tosharing the progress and successes of the project.

References

1Carbon County Pennsylvania Official Internet Site. Retrieved June 30, 2006 from www.carboncounty.com.

2Eastcentral Pennsylvania Area Health Education Center. Retrieved July 17, 2006 from www.ecpaahec.org.

3Seigal, M., Marx, M., & Cole, S. (2005). “Parent or Caregiver, Staff, and Dentist Perspectives on Access toDental Care Issues for Head Start Children in Ohio,” American Journal of Public Health, 95, 1352-1359.

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Training Oral Health Studentsin Culturally Competent Careat a Community-BasedVolunteer Health ClinicSusan M. DiGiorgio-Poll, BS, MSEd

For over 10 years, the Southeast Pennsylvania AHEC (SE PA AHEC)has provided health professions students with community-based training.

In 2005-2006, SE PA AHEC supported 219 medical students, 36 physicaltherapy students, 37 nurse practitioners, 34 physician assistants, and 16

allied health students in primary care community-based training.

The Southeast Pennsylvania AHEC (SEPA AHEC) serves five counties in which alarge number of minority and underservedpopulations resides. Although the southeastregion has higher incomes than any othercounty in the state, it has higher rates ofpoverty and higher numbers of personsreceiving medical assistance payments thanthe remainder of the state. One approach tomeeting the healthcare needs of this regioninvolves the recruitment and retention ofprimary care providers and health profes-sions students to community-basedhealthcare facilities. With primary carepractitioners continuing to be in shortsupply in Pennsylvania, the SE PA AHECprovides health professions studentstraining experiences in family practice,internal medicine, pediatrics, dentistry, andother primary care fields.

One example of how SE PA AHECsuccessfully prepares students in thecommunity-based healthcare environment isthe training relationship with CommunityVolunteers in Medicine (CVIM), a non-profit community-based corporation inChester County. CVIM serves the primarycare medical and dental needs of theuninsured and underinsured working poor,many of them Latinos, and has a volume ofover 800 patients per month. What isunique about this clinic is that it is staffedby doctors, nurses, podiatrists, dentists,

dental hygienists, social workers, andpharmacists who donate 100% of their timeand services at CVIM.

SE PA AHEC has partnered with CVIMfor over six years and has supported bothdental hygienists and dental students intheir oral health training both at the CVIMclinic and off site at satellite locations. Over40 dental students from Temple UniversitySchool of Dentistry and dental hygieniststudents from Harcum College havecompleted their clinical training at CVIM.With over 110 patients seen weekly, theclinic benefits by having the studentsactively participate in the dental procedures.The dental students are encouraged, underthe supervision of a dentist, to perform awide variety of dental procedures on bothchildren and adults, including periodontaltherapy, biopsies, root canals, fillings, andextractions. The dental hygienist students,under supervision, perform teeth cleanings,fluoride varnishes, and dental sealants,while providing health education to eachpatient. The students also learn the impor-tance of volunteerism while being exposedto ‘hands-on’ learning experiences.

The fluoride varnish program is especiallyunique to CVIM, as it is the only clinic inthe county that performs this procedure freeof charge, and SE PA AHEC’s support ofthe program is essential to its existence.

Susan M. DiGiorgio-Poll,BS, MSEd, is the HealthPrograms Developer andSpecialist at the SoutheastPennsylvania AHEC, WestChester, PA.

Oral H

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Cultural C

omp

etencyTraining Oral Health Students in Culturally CompetentCare at a Community-Based Volunteer Health Clinic

Fluoride varnisheshave been applied toover 1,500 childrenfrom two schooldistricts both at CVIMand at various HeadStart locations through-out Chester County.Although there are nostatistics indicating thesuccess of this program, primarily because ofthe transient population, Alberta Landis,Director of Dental Services at CVIM, notesa decrease in hospital visits and referrals fordental-related issues as a result of theeducation, exams, and varnishes performedby CVIM staff and student volunteers.

In addition to a decrease in hospital visits,Landis and staff have attributed a signifi-cant improvement inoral hygiene care ofeach patient to theeducation and carereceived at CVIM.This is evident at threeto six months after theinitial dental appoint-ment. Childrenespecially benefit from the oral health andnutrition education. While waiting for theirvisits, each child who comes to the clinicreceives oral health messages and nutritioneducation while playing with arts and crafts.

Though most children are bilingual, manyparents cannot speak or understand English;interpreters are available if needed by the

staff or students. TheCVIM staff receivescontinuing education,including diversitytraining, which is animportant component ofthis program. Inaddition, Landisrecently visited theGuanajuato area of

Mexico with a select group of professionalsand toured hospitals and clinics in the area.These experiences are communicated to thestudents who train at the clinic, remindingthem of the Latino culture and how itapplies to the dental care and treatment ofthese individuals. For example, it is notuncommon for the entire family to attend adental appointment and to be present duringthe examination and procedures being done.

Therefore, whenscheduling appoint-ments, it is important toconsider the needs of thepatient to include familymembers at the time oftreatment. A DVD isavailable to patients thatexplains every aspect of

dentistry in both Spanish and English.

As a result of the collaboration between theAHEC and this community-based volun-teer clinic, students enrolled in oral health,dental, and allied health programs receivevaluable training and gain experience withunderserved communities where they areneeded most.

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AHEC…contracted with

a dental hygienist to train

bilingual Catholic nuns as

instructors of oral

health…

…a decrease in hospital

visits and referrals for

dental-related issues as a

result of the education…

AHECs and HETCs...Connecting students to careers,

professionals to communities, and

communities to better health.


Persistence and PartnershipsPay Off in Improving OralHealth Services on Maryland’sEastern ShoreJacob Frego

The Eastern Shore AHEC, located inCambridge on Maryland’s rural EasternShore, has been involved in three distinctoral health initiatives which are nowcoalescing to improve oral health services.

The first initiative began in 2002 when theTri-County Council for the Lower EasternShore of Maryland (a regional governmenteconomic development and planningagency) assembled a coalition including theEastern Shore AHEC, a community college,county government, a federally qualifiedcommunity health center, county healthdepartments, and an acute communityhospital to address the region’s estimatedshortage of 38 dental hygienists. No dentaltraining programs were located within theregion, and statewide there were only three,with the closest program 150 miles away.

After a series of meetings the coalitionconcluded that despite the desirability andimportance of establishing a dental hygienisttraining program, local resources wereinsufficient to do so. However, a uniquesolution was devised—if the region couldnot develop a dental hygienist program,then existing state resources would beutilized to export dental hygienist candi-dates out of region for training and thenhave the graduates return for service withinthe region. Details of this arrangement areas follows:

• Two qualified students per year fromthe local community college would beguaranteed admission to Allegany

College’s dental hygiene program, atwo-year program in western Mary-land.

• Student costs for housing, tuition,books, labs, and other fees, averaging$12,000-$13,000 per student, wouldbe paid for by a Workforce InvestmentBoard and the Three Lower CountiesCommunity Health Center (TLCHC),a federally qualified health center(FQHC).

• In return, the students agreed to returnto the region and practice for at leasttwo years at TLCHC or another agreedupon site.

This unique approach has now beenoperational for two years with two studentsgraduated and employed and three in thepipeline. It will soon be augmented with afour-year dental hygienist training programas this initiative has spurred the Universityof Maryland Dental School (UMDS) toestablish a dental hygienist program in theregion. Wor-Wic and Chesapeake Com-munity Colleges will serve as the didacticeducational sites and TLCHC as theclinical training site. The AHEC willincorporate the students in its clinicaleducation program. The Universityprogram became operational in the fall of2006 and is unique in that students willreceive their first two years of training at thecommunity colleges and their second twoyears from the University of Maryland viadistance learning. Students will be required totravel occasionally to the University inBaltimore to consult with their advisors, a

Jacob Frego is theExecutive Director of theEastern Shore AHEC inCambridge, MD.

Oral H

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Eastern Shore AHEC was the nucleus in aligning partners for threeinitiatives to address oral health needs, resulting in the submittal of the

outreach grant.


round trip of over 300 miles. Presently thetwo-year training program at Allegany Collegewill remain an educational option, butstudent expenses will not be reimbursed.

A second oral health initiative occurred in2004 while the dental hygienists programwas still under development. WicomicoCounty received a one-year HRSA planninggrant to address oral health needs within amulticounty area. This initiative, calledEastern Shore Oral Health Action Network(ESOHAN), had the primary objective todevelop an organized network addressingdisparities in access to and utilization of oralhealthcare services primarily affectingchildren and low-income families. Oralhealth care for Medicaid patients wasextremely limited with some of the involvedcounties having no providers acceptingthem. ESOHAN assembled a largecommittee to undertake this work, includingmembers who were working on the dentalhygienist shortage. Ultimately a model ofcare will be developed engaging private-sector dentists to provide service to Medicaidchildren. Again, the Eastern Shore AHEC wasa strong partner in this effort by bringing to thetable regional issues and contacts.

In spring of 2005, about midway throughthe ESOHAN planning grant, the Eastern

Persistence and Partnerships Pay Off in ImprovingOral Health Services on Maryland’s Eastern Shore

Shore AHEC assembled a review team todiscuss the opportunity of submitting toHRSA an oral health outreach grant. In thecenter’s view, the dental hygienists programand the ESOHAN planning program haddemonstrated the region’s commitments tooral health issues. In addition, substantialdata had been developed by the ESOHANproject documenting a need for expandedoral health services particularly for theMedicaid child. Lastly, a consortium ofagencies was in place and could be drawnupon to assist in an outreach grant project.Based upon these criteria, the decision wasmade to submit a grant. The Eastern ShoreAHEC was the nucleus around which thisdecision was made, and it brokered thearrangement resulting in the submittal ofthe outreach grant. This is the third oralhealth initiative, called Eastern ShoreChildren’s Regional Oral Health Consor-tium, or CROC.

Under the CROC proposal a consortiumwas established including partners who hadcollaborated on the earlier dental hygienistprogram and the ESOHAN planningproject. Consortium members include:

• The University of Maryland BaltimoreCollege of Dental Surgery (UMBCDS).

• Shore Health System’s DorchesterGeneral Hospital—an acute community

Scott Wolpin, DMD, chairing a recent Eastern Shore Children’s Regional Oral Health Consortium meeting heldat the Eastern Shore AHEC.

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hospital.• Three Lower Counties Community

Health Center, Inc.—an FQHC servingthe region.

• Choptank Community Health System,Inc. (CCHS)—another FQHC within theregion.

• Eastern Shore AHEC—the lead agencyand responsible for the administration andmanagement of the program.

The CROC proposal contained fourprimary components:

1) Developing a comprehensive dentalcenter for children in Dorchester County,which has no dental center or dentists inthe county accepting Medicaid patients.CCHS is responsible for development ofthe dental center;

2) Developing a regional hospital-basedpediatric dental program for a six-county service area. CCHS is respon-sible for establishing the program withUMBCDS providing the service of adental fellow working in the clinic’soperating room. TLCHC will refer tothe clinic for evaluation any child inneed of complex restoration andrehabilitative care, many of whompresently are transferred to Baltimorefor care;

3) Promoting an educational and outreachprogram directed at Medicaid childrenand their families will involve contactwith schools, dental providers, publichealth programs, and others throughoutthe mid- and lower-shore region. TheEastern Shore AHEC is principallyresponsible for this outreach program. Allsix counties in CROC’s primary servicearea have been designated as DentalHealth Professional Shortage Areas; and

4) Augmenting the training of dentalhygienists on the Eastern Shore byfacilitating placement in pediatric

Persistence and Partnerships Pay Off in ImprovingOral Health Services on Maryland’s Eastern Shore

settings. The Baltimore College ofDental Surgery, University of MarylandDental School, and the University ofMaryland’s Dental Hygiene Division inconjunction with Wor-Wic and Chesa-peake community colleges, will workwith the Eastern Shore AHEC tocoordinate the placement of dentalhygiene students in these settings.

The CROC proposal was approved byHRSA in April 2006. The program is nowoperational and in the development stage.And while the program is principallytargeted at a six-county service area, it isanticipated that program success willprovide an opportunity for children from theentire nine-county Eastern Shore area to bewelcomed at the clinic. CROC’s successwill be measured by the number of childrenreceiving oral healthservices, the number ofdental hygiene studentsseen by the center’s clinicaleducation program, and thenumber of educationaloutreach programs pre-sented and health careproviders trained.

What began as a workforceissue on the shortage ofdental hygienists andevolved into oral healthplanning has culminated in the CROCproposal promising to bring substantialimprovement in children’s oral health serviceto the region. The network of the EasternShore Oral Health Action Network will assistin the educational outreach, and the dentalhygienist students will be working with theEastern Shore AHEC in rotations through thenew dental center. These activities are alltraced to continued persistence in reaching theobjective of improving oral health services andadaptability and flexibility when working withmany partners to achieve the objective.

Oral H

ealth

…if the region could not

develop a dental hygiene

program then utilize

existing state resources

and export dental

hygienist candidates out of

(the) region.


Integrating Oral Health IntoPrimary Medical CareMalone Steele

New Hampshire is frequently ranked as one ofthe healthiest states in the nation. Yet, as oraldisease is now considered an epidemic in thecountry, it also is a growing problem in the state.1

New Hampshire’s low-income residents sufferdisproportionately from this preventable oralhealth disease. Adding to the challenges of oralhealth services in New Hampshire is the rapidlygrowing minority population, which has bothcultural and language differences that presentobstacles to care.

Recent data from 16 New Hampshire school-based dental programs indicate that among7,069 second and third grade students screenedfor dental disease, 24% had untreated decay,51% had a history of decay, and 39% had dentalsealants. Data from the statewide 2004 OralHealth Survey of Third-Grade Students foundsimilar results. During development of NewHampshire’s “Oral Health Plan: A Frameworkfor Action in 2002,” statewide town meetingsrevealed that many general dentists felt unpre-pared to treat young children, especially thosewith extensive dental disease.

The dental workforce presents dauntingchallenges for the state. New Hampshire hasapproximately 450 practicing dentists and only18 pediatric dentists. In 2003, only 60 dentistsaccepted Medicaid clients and each of thesedentists treated 100 or more Medicaid patients.Sixty-five towns and several census tracks inManchester (comprising 20% of the state’spopulation) were federally designated DentalHealth Professional Shortage Areas (DHPSA).Currently, insured patients experience a six-to-eight-month waiting period for nonurgent dentalappointments. Half the dental practices in NewHampshire report a shortage of hygienists.Approximately half of the state’s practicingdentists are over 50, and 20% are over 60.Dental workforce issues will worsen becauseeach year only two dentists graduate to replacethree retiring ones.

To address these needs, New Hampshire hasundertaken oral health initiatives in integrating

oral health education and preventive interven-tions into well-child visits. Clinical training in oralhealth education, preventive interventions, riskassessment, and oral health screening is beingprovided in the Dartmouth family practiceresidency and separately with primary careproviders in private practice and health centers.The goal of these initiatives is to enable primarycare providers to educate parents about theimportance of oral health or intervene earlyduring the scheduled prenatal and well-childvisits. However, the role of primary careproviders in oral health care is still unclear, andthere is a lack of information at the provider levelabout proper oral health screening and standardsof oral health care.

The state’s Health and Human ServicesDepartment has collaborated with SouthernNew Hampshire Area Health Education Center(SNHAHEC) to create “Integrating OralHealth Into Primary Medical Care: EarlyChildhood 0-5 Years Old.” During the first yearSNHAHEC completed a literature search ofnational and statewide oral health and primarycare literature for consumers and health profes-sionals and contracted with the New HampshireMinority Health Coalition to conduct focusgroups of health professionals and parents ofyoung children along with a web-based survey.Through this activity, SNHAHEC determinedthere were limited oral health materials forpregnant women and children under the age ofthree in the state.

SNHAHEC organized a planning committeeconsisting of physicians, nurses, dentists, andhygienists to design curriculum for the Lunchand Learn program, “Integrating Oral HealthInto Primary Medical Care: Early Childhood 0-5 Years Old,” and to develop low-literacy patienteducation materials. The learning objectives ofthe curriculum were to describe the importanceof risk assessments and strategies for implement-ing the assessment in a busy practice, to identifyoptions for providing fluoride, to demonstrateproper oral health screening techniques, and todiscuss the anticipatory guidance in relation to

Malone Steele is theProgram Coordinator forthe Southern NewHampshire AHEC inRaymond, NH.

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New Hampshire AHEC has been involved in an oral health

initiative that integrates oral health education and prevention

intervention into well-child visits.


the periodicity chart. Focus groups expressed theneed for patient education handouts with aconsistent message. SNHAHEC designed apatient education handout that has also beentranslated into Portuguese and Spanish. Theprograms were marketed across southern NewHampshire to Community Health Centers(CHCs), pediatric practices, and family practicesvia a brochure mailing. In addition,SNHAHEC marketed the oral health Lunchand Learn series via a monthly bulk email to allits members.

In the first year, 14 Lunch and Learn programsoccurred—6 for CHCs and 8 for private medicalpractices. Four of the medical practices werefamily practices and four were pediatric practices.SNHAHEC made oral health presentations tothe WIC representatives from across the state.In total, 36 providers, 63 nonprovider clinicalstaff, and 49 nonclinical staff were trained.

SNHAHEC collected 117 evaluations from theparticipants to discern what additional informa-tion was needed. Health providers indicatedthey would like information on fluoride varnish,xylitol and chlorhexidine, knee-to-knee exam,oral health and pregnancy, and oral healththroughout the life span. Physicians alsoidentified the need to learn about sealants anddry mouth associated with special medicationsand conditions. Health professionals alsoidentified specific ways they would change theirbehaviors in the workplace, including providingmore oral health education and performing oralscreenings. From this information SNHAHECcollaborated with the Community Health AccessNetwork to design an “Integrating Oral Healthinto Primary Medical Care: Middle ChildhoodThrough Adolescents” program. The newprogram is currently being offered to sites thatreceived the “Integrating Oral Health intoPrimary Medical Care: Early Childhood 0-5Years Old.”

SNHAHEC received a positive response to theoral health educational offerings. However, thechallenge to refer patients to dental professionalsin the community remains. Due to the workforceshortage of dentists, there are not enoughresources for patients needing dental care otherthan the emergency room. Access remains anissue. Many healthcare providers are frustratedthat dental professionals either will not acceptMedicaid patients or will not see very youngchildren. In recent years, Medicaid dentalreimbursement rates have been increased tominimize the financial barrier for participation in

Integrating Oral Health Into Primary Medical Care

the Medicaid program. In addition, the state’sdental director is negotiating with dentists whodo not currently accept Medicaid patients toaccept even a limited number and thus spreadthe patient load among more providers.

SNHAHEC feels that expanding this trainingto dental practices will minimize dentists’ fear ofworking with young children by offeringtechniques and resources to enhance practitio-ners’ ability to provide dental care to youngchildren. They may offer an evening programfeaturing a pediatric dentist to reinforce keystrategies for managing children’s behavior. Theattitude of medical professionals can also be achallenge. Often when a dental hygienist hasmentored a physician in performing oral healthscreenings, the physician will delegate the oralscreening to the hygienist. This defeats thepurpose of actively engaging the physicians toundertake oral screenings as a way of integratingoral health with primary care. SNHAHEC willcontinue to monitor this phenomenon andidentify strategies to shift attitudes about who isresponsible for oral health.

Barriers to progress also include financialconstraints on Medicaid reimbursement fordental procedures such as fluoride varnishapplied by nondental providers. Physicians areinterested in providing care for their patients,and SNHAHEC provides them with informa-tion about techniques and treatment optionsthat are available. However, given the limitedfinancial resources in New Hampshire, there islimited interest in expanding the benefits forMedicaid beneficiaries. As more physiciansseek to provide oral health screening andpreventive treatment to their patients, they maycreate a demand for such reimbursement. Webelieve that through oral health education andrecognition of the value of early dental diseaseprevention, a grassroots campaign will emergesupporting a change in reimbursement strategy.Medical professionals will join together andmake a case for expanded coverage.SNHAHEC is researching Medicaid reim-bursement of oral screening and prevention bynondental providers, and it has presentedpreliminary findings to the state.

SNHAHEC is currently having the Lunch andLearn project evaluated by the New HampshireMinority Health Coalition to assess whatbehavior changes have come about from theprogram. Results should be available by the endof the year.

Reference

1 U.S. Department ofHealth and HumanServices, Public HealthService, and Oral Health inAmerica: A Report of theSurgeon General, July2000.

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AHEC and ACTS: The AdvancedClinical Training and ServiceProgram with the Colorado AHECSystem at the University ofColorado School of DentistryRobin Ann Harvan, EdD; Rob Berg, DDS, MPH, MS, MA; and Robert Trombly, DDS, JD

The clinical training of dental students, like thatof other health care professionals, has tradition-ally been intimately connected to the oral healthneeds of underserved populations. Campus-based dental school clinics provide high qualitytreatment at fees considerably below theprevailing rates in their communities. TheUniversity of Colorado at Denver and HealthSciences Center, School of Dentistry has beenno exception in this regard. Like most otherschools, however, it is located on an academicmedical center campus in a metropolitan area.Since its founding in 1975, the Colorado schoolhas consistently worked with the Colorado AHECSystem to broaden its impact by conducting part ofits clinical training in rural and underserved urbancommunities across the state.

Ten years later, in 1985, the school formallyimplemented the Advanced Clinical Trainingand Service (ACTS) Program. Through ACTS,all of Colorado’s predoctoral dental students arerequired to complete clinical training rotations incommunity-based clinics. The program requiresthat at least one of each student’s four clinicalrotations be completed outside of metropolitanDenver. This ambitious goal has been met fortwenty years, but only with the collaboration ofthe state’s AHEC system.

The Colorado AHEC System has a centralprogram office located on the campus of theUniversity’s academic medical center. The statealso has five regional AHECs, each of which is

independent and guided by a local board ofdirectors. The central system office has a longhistory of collaboration with the University’sschools of dentistry, medicine, nursing, andpharmacy and graduate school programs.Designated leaders from each of these schoolshave served as AHEC liasons. Together, theseAHEC faculty members have collaborated onnumerous funded initiatives over the years,directed at a goal of fostering health care practicein underserved areas. Projects have ranged fromtargeted interdisciplinary continuing education inrural communities to creation of student andpractitioner interdisciplinary teams in rural areasto conduct focused health promotion projects.

Program descriptionThe ACTS program has traditionally begun inJanuary of the fourth and final year of the dentalpredoctoral curriculum. The entire springsemester has been devoted to four clinicalaffiliations, each lasting about five weeks, foreach student. In Colorado, the ACTS programrequires each senior dental student to spend aminimum of 100 days providing dental care tounderserved populations.

An ACTS dental student assigned to a commu-nity-based clinic becomes an unpaid, full-timestaff dentist at that clinic. Students providetreatment under direct supervision of the clinic’sstaff dentists, each of whom holds both aColorado dental license and a volunteer facultyappointment in the school’s Department of

Robin Ann Harvan, EdD, isthe Director of the ColoradoAHEC System at theUniversity of Colorado atDenver and Health SciencesCenter, Denver, CO.

Robert Trombly, DDS, JD,is Associate Dean forCommunity Programs andProfessor in theDepartments of RestorativeDentistry and AppliedDentistry at the Universityof Colorado at Denver andHealth Sciences Center,Denver, CO.

Rob Berg, DDS, MPH,MS, MA, is Director of theAdvanced Clinical Trainingand Service Program andAssociate Professor andChair of the Department ofApplied Dentistry at theUniversity of Colorado atDenver and Health SciencesCenter, Denver, CO.

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For over 20 years, Colorado AHEC has ensured that dental studentsparticipate in rural rotations. Through the ACTS program, all 4th year

dental students have required rotations at their choice of 50 remotecommunity-based clinics.


Applied Dentistry (the academic base of theACTS program). A written agreementextends the university’s campus to that dentalclinic, allowing for this supervision relationshipand for professional liability coverage of thestudent clinician.

ACTS dental students work with campus-basedfaculty members to determine the locations ofAHEC clinical rotations. Factors in clinical siteselection include clinical interests and foci, aswell as personal and family needs. As alreadynoted, the program requires that one affiliationbe scheduled outside the Denver area. Moststudents elect to practice at rural sites located asfar as four hours from the Denver campus. Forthese students, the Colorado AHEC programprovides valuable support.

The support’s most obvious feature is technicalassistance and funding to locate and arrangestudent housing. Regional AHEC staff workwith dental school faculty and staff to ensurethat students are placed in comfortable housingfor their AHEC clinical rotations. In addition,local AHECs typically are the first face of thelocal community to be seen by a student fromthe Denver campus. Regional AHEC staffwelcome students to their home-away-from-home. It is not unusual for AHEC centerdirectors to invite new students into their homesfor dinner. Finally, regional AHECs provide avaluable link between the University and thepracticing community in their areas.

Since the inception of the ACTS program, thefirst major revision of the program model wasimplemented in the summer of 2006. Theschool has restructured the fourth-year curricu-lum to allow a full year of AHEC clinical rotationopportunities, rather than the last six months oftheir senior year in dental school. Each studentwill continue to be required to provide 100 daysof treatment, but the experience has beenextended from one semester to two semesters.The rationale and benefits of this curricularchange included:

• Earlier exposure to community-based

clinical learning in underserved settings.

• More consistent patient care scheduling

and office staffing at the community-baseddental clinics.

• More consistent patient care scheduling

and staffing at the dental school clinic.

• More effective service to the State’s safety-net oral health care delivery system.

Program outcomesAs technology has changed since 1985, themethods used to track outcomes in the ACTSprogram have also changed. Since 1995,student productivity has been maintained in anongoing database. Dental student class sizeshave also changed; from as few as 28 to as manyas 50 4th year students are currently enrolled inthe dental program. All senior dental studentsparticipate in the ACTS clinical rotation programwith the Colorado AHEC System. Approxi-mately 50 clinical sites and over 80 clinicalpreceptors participate in the program.

In 2005-2006, ACTS students provided clinicalcare at over 27,000 patient encounters that hadan estimated market value of $3.4 million. Since1995, the total estimated value of care providedby ACTS students has exceeded $30 million.

Subjective assessments are also instructive.Each student completes an exit interview withan ACTS faculty member before completing theprogram. Anecdotally, ACTS students reportextremely high levels of satisfaction with theprogram. They praise the program for providingthem with a far broader base of clinical experi-ence than that offered at a traditional dentalschool. Also receiving high praise from studentsare the affiliations located outside the Denvermetropolitan area. Students report feelingwelcome in these communities and manyexpress their gratitude and how enjoyable it wasto live in a smaller community.

Tracking graduates of the program demonstratesuccessful community recruitment and reten-tion of alumni. Figure 1 illustrates where ourdental students currently practice. TheColorado AHEC System map (Figure 2)illustrates the counties and areas served byeach regional AHEC.

AHEC and ACTS: The Advanced Clinical Training andService Program with the Colorado AHEC System at theUniversity of Colorado School of Dentistry

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(Continued on page 32)

Conference Photos

Conference Photos


Future directionsThe CU School ofDentistry recentlyreorganized the organiza-tional structure, andamong revisions was thecreation of a newadministrative positionfor an Associate Dean ofCommunity Affairs andCurriculum. Among respective duties, theAssociate Dean for Community Affairs andCurriculum is responsible for the overall adminis-trative oversight of the ACTS program, allcommunity and legislative affairs, and worksdirectly with the Colorado AHEC Systemdirector as appropriate. Plans are underway tobroaden and expand the partnerships andcollaborations of the Colorado AHEC Systemand the CU School of Dentistry in the follow-ing directions:

• Delta Dental Foundation’s FrontierCenter- recently established anddedicated to enhancing patient carethrough collaborative interprofessionalinitiatives that identify the interfaces

AHEC and ACTS: The Advanced Clinical Training andService Program with the Colorado AHEC System at theUniversity of Colorado School of Dentistry

Figure 1. Distribution of practice sites for current dental students.

between the dental andmedical professions anduse the expertise ofdentists and physiciansto improve patient care.The Colorado AHECSystem director serveson the AdvisoryCommittee.• Rural Dentistry Tractfor Dental Students-developing a separate

track for dental students interested inrural practice.

• Colorado SmileMakers Program: MobileDental Clinic- program will support oralhealth care serves to underserved childrenin Colorado. Stating in 2007, this mobileclinic will serve as an additional AHECclinical rotation experience opportunity forthe ACTS Program.

• International Dental Student Program(ISP)-new two-year accelerated programoffers qualified graduates of foreign dentalprograms the opportunity to earn theDoctor of Dental Surgery degree. In 2007,the ISP students will also participate in theACTS Program, supported by the ColoradoAHEC System. In 2007, a total of 70dental students (20 ISP dental studentsand the cohort of 50 in the traditionalprogram) will annually participate inAHEC clinical rotation experiences.

• Primary Care Team Education-The Schoolof Dentistry plans to enhance the dentalschool curricula with learning opportunitiesand experiences as members ofmultidisciplinary and interdisciplinaryprimary care teams. Students from diversehealth professions disciplines participate inAHEC sponsored clinical education andwill learn, work and live together for aportion of their clinical training inunderserved areas of Colorado.

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(Continued from page 29)

All of Colorado’s

predoctoral dental

students are required to

complete clinical training

rotations in community-

based clinics.


Training Outreach Workers toDeliver Preventive Dental Servicesin Yap State, MicronesiaCindy Lefagopal, DDS

Yap is in the Western Caroline Islands, locatedbetween Guam and Palau. It is one of thestates of the Federated States of Micronesia.Yap is comprised of the main island and 134outer islands stretching eastward for about 720miles. The population of the state of Yap isapproximately 13,000 people.

There is one main hospital in Yap and are fivecommunity health centers in each municipality;there is limited funding for the medical and/ordental care of residents. In the scatter outerislands, there are 18 dispensaries on differentislands. Ninety-eight percent of households haveincomes below U.S. federal poverty designations.

Oral disease is one of the leading healthproblems in Yap. In the whole state of Yap,there are seven dental nurses, one dentaltechnician, and one dentist. Surveys ofelementary school children show an average of3.7 teeth per child affected with caries. Withonly one dentist for a population of 13,000people, it is essential to focus our efforts ondental disease prevention, and to reach allthose who need preventive services we mustdo outreach into schools and villages. In 2005,Yap Dental Clinic started an outreachpreventive program targeting the followingthree groups:

• Children in first grade to sixth grade (ages

6-12 years) for dental education, distribu-tion of brushes and fluoride toothpaste,and application of dental sealants, and todetermine the DMFT (decayed, missing,filled teeth) scores for each school

• Pre-school-age children for dental educa-tion of the parents, distribution of brushes

and fluoride toothpaste, and application(every two months) of fluoride varnish.

• Pregnant women for dental cleaning,fluoride varnish, oral health education,and any other treatmentthey need.

Pregnant women are reachedin the prenatal clinics andschool-age children at theschools by dental nurses. Themost difficult group to reach isthe pre-school-age children,especially since they need avisit every two months.

With the help of the YapAHEC, a branch of theHawaii/Pacific Basin AHEC,we developed a new course foroutreach workers to teach the skills needed todeliver, at home, the prevention package forpre-school-age children and to identifyproblems that need referral to a dentist ordental nurse. This three-credit course wasadopted by the College of Micronesia as partof the health assistant vocational curriculum.In May and June 2006, this course was taughtto two separate classes at Yap State Hospital(including 10 outreach workers who have beenhired by the new Wa’ab Community HealthCenter in the Yap main islands and 20 outer-island dispensary health assistants and birthattendants). After the training, thesenondental personnel were certified to applyfluoride as well as to perform oral examinationson the children.

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Yap AHEC has developed a three-credit course for outreach workers

that will enhance their ability to teach oral health education for pre-

school children who live in the 134 outer islands of the Federated

States of Micronesia.

Yap is one of four states that

compose the independent

nation of the Federated

States of Micronesia. This

country has a compact of

free association with the

United States that provides

support for education,

health and military needs.

Cindy Lefagopal, DDS


Our program objective was to providepreventive care and education to 99%of the preschool children, elementarychildren, and pregnant mothers and toreduce DMFT among these targetpopulations. As of this writing, 50% ofchildren from grades 1-6 have receivedfissure sealant, compared with 0% fromprevious years. Every pregnant motherwho attends the prenatal clinic for thefirst time receives fluoride application,oral health education, and any neces-sary dental treatment. These traineesfrom our Yap AHEC-College ofMicronesia course are now deliveringthe oral health program to the preschoolchildren.

In conclusion, AHEC has workedwith a community health center and alocal college to create a unique coursethat trains outreach workers to addressoral health needs of a truly disparategroup of individuals whose homes arescattered over a 720-mile stretch ofocean and who have little access totraditional dental services. Clearly,this collaboration demonstrates aneffective model to provide preventivedental care services to a unique yetunderserved community.

Training Outreach Workers to Deliver PreventiveDental Services in Yap State, Micronesia

Wa’ab CHC Outreach Worker Class.

Map of Yap State (showing Wa’ab Community Health Center districts).

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Sen. Gordon H. Smith (R-OR)

The Epidemic of Suicide: APersonal Story of Loss, Legacy,and HopeSen. Gordon Smith (R-Oregon)

Throughout the United States, every 41seconds, someone attempts suicide. Every 16.7minutes, someone completes suicide. Every day,hundreds suffer in silence. Simply put, suicide isan epidemic. Mental illness is a very real disease that if leftuntreated, too often can take a human life. Yet,in spite of the alarmingly high rates of suicide inour country, mental health continues to fall undera subordinate category of medicine, leaving toomany individuals without proper care. To curbthis growing epidemic, a great deal of work needsto be done to improve the accessibility, parity andstigma of mental health in America. My wife and I are among thousands of Ameri-cans who make up a fraternity of sorrow, unitedby the loss of a loved one to suicide. My son,Garrett Lee Smith, courageously battled amental illness for many years, a battle thatultimately ended when he took his own life onSeptember 7, 2003. His death brought morepain and sorrow upon our family than wethought we could bear. But the goodness andsupport of countless people has given us the grace toendure our grief, and the strength to face tomorrow. As I have grown to understand my own son’sstruggle with mental illness, I have learned howdevastating it can be for individuals and theirfamilies. To find further meaning in Garrett’slife, my wife Sharon and I have committedourselves to helping others who cope with theproblems he struggled with daily. We arededicated to breaking down the stigma of mentalillness and educating Americans about thewarning signs that are present when someone isconsidering suicide. No family should experi-ence the pain of losing a child, and no one shouldface the challenges of mental illness alone. When Garrett died, I felt the ultimate failure ofnot having fully understood the depths of hisdepression or how to help him with his illness.There was a time shortly after his death when Ieven questioned whether I should continue inpublic service. Fortunately, I realized that Icould use my position in the federal government

to help educate my colleagues and the public onthe importance of mental health treatment. Icouldn’t save Garrett, but I hope my efforts canhelp save others.

I am grateful to have friends and colleagues inCongress who recognize that this issue doesn’tdiscriminate along party lines or geographicalboundaries. A year after Garrett’s death,Congress overwhelmingly passed the GarrettLee Smith Memorial Act. This legislationprovides federal grants to promote the develop-ment of statewide suicide early intervention andprevention strategies intended to identify andreach out to young people who need mentalhealth services. In addition, this bill makesavailable competitive grants to colleges anduniversities to create or enhance the schools’mental and behavioral health programs. Funding for the Act is directed to three primaryelements. The first component is the SuicidePrevention Technical Assistance Center, whichis authorized at $5 million for Fiscal Year 2007to support its mission of providing technicalassistance and support to grantees. Additionally,$30 million is authorized in Fiscal Year 2007 tohelp states and tribes develop and implementstatewide youth suicide early intervention andprevention strategies. The funds will help raiseawareness and educate people about mentalillness and the risk of suicide, help identifyyoung people with mental illnesses and allowstates to expand access to treatment options.Finally, $5 million is authorized to fund amatching-grant program to colleges anduniversities to help raise awareness about youthsuicide, as well as enable those institutions to trainstudents and faculty to identify and intervene whenyouth are in crisis. It also allows for schools todevelop a system to refer students for care. Grants through Garrett’s bill are administeredthrough the Substance Abuse and MentalHealth Services Administration (SAMHSA).Currently, thirty states, six tribes, and fifty fivecolleges and universities have received funds todevelop suicide prevention and interventionprograms to help alleviate the suicide epidemic.

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I am proud that the state of Oregon, as well asthree local programs, including the NativeAmerican Rehab Association of NW, Inc.-Portland, University of Oregon - Eugene andBlue Mountain Community College -Pendleton, were among the recipients. Although we have made great strides withfunding for program participants, we still have a lotof work ahead of us to ensure that all states receive agrant. We must continue to advocate for fullfunding of Garrett’s bill so no one has to suffer alone. An important aspect of the Garrett Lee SmithMemorial Act is ensuring that a network of careand services is available throughout every state,including rural areas. An absence of adequatemental health facilities and professionals has ledsuicide to become the second leading cause ofdeath in rural areas. As mental illness does notdiscriminate between geographic lines, neithershould quality of or access to care. AHECs can be pivotal in these efforts. I wouldencourage all AHECs to partner with their stateagencies as youth suicide prevention strategiesare developed. Education for safety-net andother providers in underserved areas andawareness programs provided through AHECnetworks would be crucial to reaching rural andinner city communities. AHECs are in a uniqueposition to assist in suicide prevention as they helptrain thousands of health professions students andfaculty across the country who can help identify andassist persons with a mental illness. Also to ensure that rural counties have the toolsthey need to meet the mental health needs of itscitizens, I also am proud to be a sponsor of theRural Hospital and Provider Equity (R-HoPE)Act of 2006. This legislation is designed toensure rural hospitals, rural health clinics, ruralambulance providers, rural home healthagencies, rural mental health providers, ruralphysicians and other critical allied healthclinicians are accessible and paid accurately andfairly. The legislation also contains a mentalhealth provider reimbursement provision thatwould allow marriage and family therapists andlicensed professional counselors to bill Medicarefor their services. In addition to providing greater access to mentalhealth services, our country must work towardsachieving mental health parity. Through parity,we can alleviate some of the burden on thepublic mental health system that results when

The Epidemic of Suicidefamilies do not have access to treatment throughtheir private health insurance plans. I am pleased that once again Oregon is leadingthe nation by enacting mental health paritylegislation that will go into effect next year. Butthe federal government must act as well to senda strong message that excluding people sufferingfrom mental illness from heath insurancecoverage is unacceptable. I am working to pass a bill that would createparity within Medicare. Presently, Medicarebeneficiaries must pay a 50 percent copay formental health related outpatient services asopposed to 20 percent for all other outpatientcare. The Medicare Mental Health CopaymentEquity Act of 2005 will take an important firststep to achieving mental health parity forMedicare beneficiaries. Fortunately, congressional awareness of mentalhealth issues has increased over the years. In2006, Senators Pete Domenici, EdwardKennedy, Tom Harkin and I formed a bipartisanMental Health Caucus in the Senate. Togetherwe are working to find ways to effect real change,to improve the parity, quality and accessibility ofmental health care which will restore dignity tothose suffering from mental illness. As Chairman of the Senate Special Committeeon Aging in the 109th Congress, I was fortunateto lead the Senate in studying issues of impor-tance to America’s seniors. The committee hasafforded me the opportunity to raise awarenessabout the prevalence of suicide among seniorsand study prevention strategies. Many peopleare unaware that seniors have a higher rate ofsuicide than any other age group. Recently, Iconducted a hearing in the committee that shedlight on successful models of early interventionand prevention, especially in the primary caresetting. I look forward to continuing to study thisissue when Congress returns for the 110th

session next year. I am pleased to be a champion of this cause, notbecause I volunteered for it but because I havesuffered over it. I believe that we have madegreat process, but there is still a lot of work aheadof us. It is my hope that Congress continues towork together in a bi-partisan fashion toprioritize mental health and human life. Withthe united effort of friends, family, and public andprivate enterprise, I feel that we can bring hope tothose who suffer from mental illness and ultimatelyend the epidemic of suicide in America.

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Mental Health and BehavioralHealth Workforce: Challengesand Opportunities IncludingImplications for Rural AmericaDennis F. Mohatt, MA, and Mimi B. McFaul, PhD

The President’s New Freedom Commission’sreport Achieving the Promise: TransformingMental Health Care in America (2001) indicatedthat the mental health system is fragmented andcalled for a fundamental transformation of publicbehavioral health (mental health and substanceabuse) systems. System transformation requiresthat policy makers, administrators, providers, andother stakeholders address multiple aspects ofworkforce development. These include recruit-ment, retention, and training, as well as under-standing workforce trends and projections,shifting treatment philosophies, and servicedelivery models. While these issues areapplicable to behavioral health systems acrossthe country, they are brought into sharpest focuswhen considering rural and frontier areas. Thisarticle will address each of these issues generallybut will illustrate them concretely as they exist inrural areas.

Defining WorkforceThe behavioral health workforce includesprofessionals in both mental health andsubstance abuse fields from a variety of disci-plines including psychiatry, psychology, socialwork, psychiatric nursing, counseling, marriageand family therapy, psychosocial rehabilitation,school psychology, and pastoral counseling.These professionals are generally involved in theprovision of health promotion, prevention, andtreatment services. The workforce includesprofessionals with graduate training, those withassociate or bachelor’s degrees, and persons inrecovery and their family members at varyingeducational levels. In some communities, such asrural areas, where there is a shortage of profes-

sionals, other community members become partof the workforce as they are often the first-lineresponders (e.g., paramedics, primary carephysicians, indigenous healers, and lawenforcement).

Population and Workforce TrendsMajor changes in America’s general workforceare anticipated to continue between now andthe year 2025. This change is brought into sharpfocus when the percentage of the populationentering the workforce is compared with thepercentage leaving it. For instance, the WesternInterstate Commission for Higher Education(WICHE) Mental Health Program analyzeddata regarding population projections from 2000to 2025 for its 15 member states (Alaska,Arizona, California, Colorado, Hawaii, Idaho,Montana, Nevada, North Dakota, New Mexico,Oregon, South Dakota, Utah, Washington, andWyoming). On average, WICHE states will seea projected 21.7% increase in the number ofpeople between the ages of 18 and 64 enteringthe workforce by 2025. However, the projectedaverage percentage of persons 65 and older (i.e.,retirement age) leaving the workforce inWICHE states is a staggering 118%. Theimplications of this data are clarified when oneconsiders projected behavioral health workforceneeds.

Table 1 was created with data from the Bureauof Labor Statistics website and indicates thepercentage change (in descending order) in totalemployment between 2004 and 2014 for 12behavioral health occupations nationally.Although not all encompassing, this chart

Mimi B. McFaul, PhD, isa Research Associate in theMental Health Program atthe Western InterstateCommission for HigherEducation, Boulder, CO.

Dennis F. Mohatt, MA, isthe Director of the MentalHealth Program at theWestern InterstateCommission for HigherEducation, Boulder, CO.

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The article explores factors that impact the mental and behavioral health workforceand advocates seven goals to achieve a system transformation. The authors’

recommendations to strengthen the mental and behavioral health workforce provideopportunities for AHECs/HETCs to play a vital role in bringing this about.


emphasizes the workforce needs we will befacing in less than 10 years.

At the highest level, we will be facing a 29%increase in workers, with an average need overallof 13% more workers in all fields listed above. Itis also interesting to note that this increase willaffect the entire training spectrum from on-the-job training up to the doctoral degree level.

Population and workforce trends point todifficulties meeting the behavioral health needsof the population in the coming years. However,when one considers the vast number of placesthat already have shortages of behavioral healthworkers, the situation may be even worse. Forinstance, the Health Resources and ServicesAdministration (HRSA) Bureau of HealthProfessions tracks workforce shortages for severalprofessions, including mental health. Mentalhealth professional shortage areas (MHPSAs)can be designated using any of the followingcriteria: 1) An urban or rural area (which neednot conform to the geographic boundaries of apolitical subdivision and which is a rational areafor the delivery of health services); 2) a popula-

Mental Health and Behavioral Health Workforce

Table 1. Projected employment for 12 behavioral health occupations.

tion group; or 3) a public or nonprofit privatemedical facility. A single county can have allthree. The map below shows that the majority ofthe country is a designated MHPSA andillustrates the magnitude of the crisis in access toand availability of mental health care forAmericans, particularly in rural areas.

One-fifth of America’s population, about 49million people, lives in rural areas; these ruralregions include over 2,000 counties and contain75% of the nation’s land. Furthermore, researchindicates that prevalence rates of mental illnessare similar for rural and urban populations, butrural communities lack availability, accessibility,and applicability of service options. Additionally,rural communities are diverse, which makes itdifficult for researchers to accept one definition of“rural.” For example, a remote community inAlaska may be culturally and ethnicallydifferent from a geographically isolated town inMontana and encounter different behavioralhealth issues.1

The following statistics from the President’sNew Freedom Commission on Mental Health,

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Subcommittee on Rural Issues2 reportidentified several workforce issues specific torural communities:

• More than 85% of 1,669 federally desig-nated MHPSAs are rural.3

• Few psychiatrists, psychologists, or clinicalsocial workers practice in rural counties, andthe ratio of these providers to the populationworsens as rurality increases.4

• For the past 40 years, approximately 60%of rural America has been underserved bymental health professions.

• The National Advisory Committee onRural Health5 reported that the supply ofpsychiatrists is about 14.6 per 100,000people in urban areas compared with 3.9per 100,000 in rural areas.

• These workforce shortages are even worsefor specialty areas, such as children’s mentalhealth, older adult mental health, andminority mental health.

• Social service agencies in rural areas aregenerally staffed by a range of undergradu-ate and/or graduate level providers andtypically do not provide any consistentstandards or core competencies.

This is not a new or cyclical phenomenon butrather a chronic situation that has seen littleimprovement in the past 40 years.

In addition to population and demographicchanges, there has been a significant shift inbehavioral health services delivery from

Mental Health and Behavioral Health Workforceinstitutionally centered care to a more commu-nity-based care model. This is particularlyexemplified in the emerging emphasis oninclusion of the consumer and family membersin directing their own behavioral healthdecisions. Additionally, the use of peersupports and increased access to informationthrough the Internet are altering the relation-ships among practitioners and family members,who are increasingly serving as the primarycare manager for consumers.6

The financing of services due to the increase inMedicaid as a funding source has also impactedbehavioral health service design and delivery.Money is a fundamental issue affecting thedevelopment of an adequate workforce.Education is expensive, health plans favorlower-paid providers, and mental healthprofessionals in the public system often are paidlower salaries. Staffing has been primarilyinfluenced by state practice regulations andinsurance reimbursement regulations more thanby science or competency.2

Frequently, different mental health disciplineshave different levels of training.7 Due topopulation and workforce changes, both mentalhealth and substance abuse professionalsrequire specialty training to work with popula-tions having unique needs; these includechildren, older adults, specialty substance abusedisorders, people living in rural areas, and peoplefrom different cultures.

Table 2. National strategic plan for behavioral workforce development.

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Strategies and RecommendationsA multi-year effort that included a diverse groupof participants to develop a national strategicplan for behavioral health workforce develop-ment produced seven primary goals that relate tothe following three categories: 1) broadening theconcept of workforce; 2) strengthening theworkforce; and 3) developing structures tosupport the workforce. The goals that relate toeach category are presented in Table 2.

Broadening the concept of workforce reflectschanges in treatment philosophy that emphasizeindividually tailored treatments based onsignificant consumer input. Other changesinclude redefining roles (i.e., who is the mainprovider of treatment) with increasing emphasison family members, peers, or other nontraditionalhelpers. This is critical in rural areas, where “growyour own” initiatives will be a particularlyimportant strategy to recruit “place-committed”people to become the workforce in their town orvillage. AHEC programs, which are known fortheir continuing education efforts and “grow yourown” programs, could play a vital role in takingthis from vision to reality.

Strengthening the workforce implies a focus onactivities related to best practices in recruitmentand retention, training and education, andleadership development for the workforce. It willbe useful to utilize best practices in recruitmentand retention, training and education, andleadership development for the workforce. It isimportant to implement and provide incentivesfor providers to do not only what is affordable but

Mental Health and Behavioral Health Workforcewhat is most effective for the treatment popula-tion. A healthy work environment with benefits,supervision, and opportunities for advancementwill also be important in growing the workforce.

Structural supports for the workforce include, forexample, a system for providing technicalassistance on workforce practices, improvedinformation technology to assist the workforceespecially in rural areas, and a national researchand evaluation agenda producing improvedinformation on effective workforce practices.Currently, workforce data are not collected in aconsistent manner, which makes reporting acrossdisciplines difficult. A related issue is the currentdelay of approximately 17 years from whenresearch is released to when it is accepted intothe practice environment.

The national, regional, and state efforts currentlyunder way indicate significant momentumbehind behavioral health workforce develop-ment, particularly in rural areas. Population andworkforce trends indicate that the need forbehavioral health workers will only increase overthe next 10 years. In order to meet theseprojections, specific strategies need to beemployed to broaden the concept of workforce,strengthen the workforce, and build structures tosupport the workforce. This is particularly true inrural areas, which face a unique combination offactors that create disparities in health care notfound in urban areas. Common sense indicatesthat significant time and effort be put towarddeveloping an effective behavioral healthworkforce for rural and frontier America.

References

1Mohatt, D.F., Adams, S. & Bradley, M. (2006). Rural Mental Health: An Overview and Annotated Bibliography1994-2005. Washington, DC: U.S. Government Printing Office.

2New Freedom Commission on Mental Health. (2004). Subcommittee of Rural Issues: Background Paper (DHHSPub. No. SMA-04-3890). Rockville, MD: U.S. Government Printing Office.

3Bird, D.C., Dempsey, P., & Hartley, D. (2001). Addressing mental health workforce needs in underserved ruralareas: Accomplishments and challenges. Portland, ME: Maine Rural Health Research Center, Muskie Institute,University of Southern Maine.

4Holzer, C.E. III, Goldsmith, H.F., & Ciarlo, J.A. (2000). The availability of health and mental healthproviders by population density. Journal of the Washington Academy of Sciences, 86 (3), 25-33.

5U.S. Department of Health and Human Services. (2004). Sixth annual report on rural health. Rockville, MD:National Advisory Committee on Rural Health, Office of Rural Health Policy, Health Resources and ServicesAdministration.

6Hoge, M.A., Morris, J.A., Daniels, A.S., Adams, N., Huey, L.Y., & Stuart, G.W. A Thousand Voices: TheNational Action Plan on Behavioral Health Workforce Development. Unpublished draft report.

7Koppelman, J. (2004). The provider system for children’s mental health: Workforce capacity and effective treatment.(NHPF Issue Brief No. 801). Washington, DC: National Health Policy Forum, George WashingtonUniversity.

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Sally W. Smith, LCSW,RN, is the ProgramManager for IntegratedCare at the MountainAHEC, Asheville, NC.

Integrated Care: The Process ofProviding Mental Health Carein Primary Care Practices ––The Time Is NowSally W. Smith, LCSW, RN

In 2003, a coalition of community organizationsin and around Asheville, North Carolina, cametogether to address a growing concern about thelack of comprehensive mental health care forchildren and families. The group included themedical director of the health department,representatives from community mental healthagencies, local management entities that receivestate mental health dollars and distribute dollarsto the region’s providers, Community Care ofNorth Carolina (Medicaid Managed Care),Buncombe County Medical Society, the regionalhospital, Mountain Area Health EducationCenter (MAHEC), and area pediatric practitio-ners. They were concerned about the recentclosings of a child psychiatric inpatient settingand a local sliding-fee-scale child and familycounseling center. This was occurring at the sametime that the statewide mental health reformwas making it harder for families to obtainmental health services. These issues led thiscollaborative to apply for funds to provide serviceto a large group of children and families in adifferent format.

As a result of this group’s efforts, MAHECreceived a two-year grant from the Kate B.Reynolds Foundation to integrate mental healthservices into twelve nonprofit primary carepractices in eight counties in western NorthCarolina beginning in 2004. The grant wasawarded to MAHEC to fund a full-timeIntegrated Care Project Coordinator withassociated supports. It was determined that thecenter was best positioned to manage this grantfor several reasons. First, MAHEC’s familypractice residencies through the University ofNorth Carolina have had a strong behavioralhealth presence for over 25 years. The center has

a strong commitment to train their residentsabout mental health issues and to work side byside with therapists in two family practiceresidencies and an OB/GYN residency.Second, AHEC has a long history of serving inleadership positions on many statewide groupsand committees that work on mental health andMedicaid Managed Care issues, lendingcredibility, recognition, and trust to the organi-zation at a statewide level. And finally,MAHEC was seen as an impartial andobjective organization that could effectivelyassist the community in its efforts to identifyand connect the providers, the services, and thepatients in integrating mental health servicesinto medical practices.

Although integrated mental health care was notdesigned to meet the needs of the patients withsevere and persistent mental health disorders(SPMI), it can be a very good choice for manypatients where their health and lifestyle arebeing impacted by depression, stress, anxiety,substance abuse, AD/HD, and other suchdiagnoses. The Surgeon General has estimatedthat approximately 20% of the population willneed some form of mental health servicesduring the course of their lifetime. Nearly 70%of all health care visits have primarily a psycho-social basis.1 Recent study suggests that onaverage, primary care patients with even mildlevels of depression use two times more healthcare services annually than their non depressedcounterparts.2

It is commonly accepted that integratingbehavioral health services into the patient’smedical home has many benefits, including 1)increased likelihood that a patient will follow up

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ealth

A collaborative effort to address mental/behavioral health for

children in western North Carolina has integrated mental health

services in 12 nonprofit primary care practices.


and get treatment by the behavioral healthperson at the practice; 2) increased patientsatisfaction; 3) improved patient outcomes; 4)decreased stigma for the patient who is receivingmental health services; and 5) lowered cost ofservice especially for the highest utilizing patients.Studies clearly show that these considerations canreduce inpatient admissions and inpatient lengthsof stay when admissions are necessary.

The Reynolds grant provided dollars to build aclinical, operational, and financial framework thatwould support integrated care in these 12practices. Conceptually, the model can bedescribed as the “three-legged stool.” The firstleg of the stool provides subsidy dollars tosupport the hiring of a licensed therapist. Thesubsidy dollars allow a practice some breathingroom until the therapist is fully trained, receivingpractice referrals, billing, and beginning to receivereimbursement. The second leg of the stool givesdollars to each of the practices to consult byphone or on-site with a psychiatrist. Thepsychiatrist does not see the patients directly butbuilds the capacity of the practice to treatpatients with mental health disorders byteaching, consulting and discussing individualcases. The third leg of the stool supports ongoingtraining opportunities locally, regionally, or on-sitefor the practitioners to increase their confidenceand competence when working with theirpatients’ mental health needs.

The project, along with several other integratedcare efforts within the region, has been verysuccessful. There is growing enthusiasm andinterest from across the state in providing morecare with this model. Six new behavioral healththerapists are now working in area practices, andsix different psychiatrists are providing consulta-tion services.

A comprehensive final report will not besubmitted to the Kate B. Reynolds Foundation

Integrated Care: The Process of Providing MentalHealth Care in Primary Care Practices

until the end of 2006, yet preliminary informa-tion shows that over 400 children and familieshave already been screened and/or treated as aresult of this program. It is expected that thisnumber will grow now that the infrastructure hasbeen fully developed and deployed.

As part of the grant evaluation, there areextensive pre-and post-surveys distributed tothe practice staff. Although the post-surveyshave not been completed and the final datacollected and compiled, anecdotal reports fromstaff are very positive and optimistic. Accordingto an area primary care physician, “having atherapist on-site has definitely improved theproductivity of our physicians.” A local nursewith an extremely active primary care practiceadds “I can’t do my job without the therapists.”

Although the Kate B. Reynolds grant ends soon,MAHEC believes in the concept enough tofund the project coordinator permanently. Thisposition will be subsidized through a combina-tion of new grant initiatives and revenue fromtrainings and workshops presented aboutintegrated care.

The future of integrated mental health care isbright, with some of the best minds and leadersin the state working on ways to further thecapacity for patients to be treated holistically inone setting where the entire person is cared forby the same system. Discussions are occurringwith universities to consider including integratedcare as part of their curricula for psychiatry, socialwork, and family medicine internships andresidencies. In November 2007, Asheville willhost the Collaborative Family HealthcareAssociation national conference, which has aprimary focus on furthering the efforts tooperationalize the clinical and financial aspects ofintegrated care. North Carolina is beginning tounderstand that integrated care can be part ofthe solution for mental health reform, and all areexcited to see what is next on the horizon.

References

1 Fries, J.F., Koop, C.E., Beadle, C.E., Cooper, P.P., England, M.J., Greaves, R.F., Sokolov, J.J., &Wright, D. (1993). Reducing health care costs by reducing the need and demand for medical services.The Health Project Consortium. New England Journal of Medicine, 329(5):321-25.

2 Simon, G.E. (1992). Psychiatric disorder and functional somatic symptoms as predictors of health careuse. Psychiatric Medicine, 10(3), 49-60.

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Virna Little, PsyD,LCSW-R, SAP, is VicePresident for PsychosocialServices and CommunityAffairs at the Institute forUrban Family Health,New York, NY.

AHEC Builds Opportunity forYoung Social WorkersVirna Little, PsyD, LCSW-R, SAP

Every year, 30-40 students find placementsat the Institute for Urban Family Health inNew York City to train as social workers.The opportunity to intern at the instituteand its community health centers hasbecome one of the most requested place-ments at many of the local universities.Fordham University, Columbia University,New York University, Yeshiva University,Lehman College, and Adelphi Universitysend undergraduate and graduate studentsto the institute for on-site, hands-onlearning. What makes this AHEC-spon-sored program so popular?

“Most students think of doing their intern-ships at social service agencies or hospitals.They have never considered an internshipat a community health center,” says MaxineGolub, MPH, regional director of the NewYork Metropolitan Regional AHEC(NYMRAHEC). “They are often surprisedto learn about the varied opportunities theAHEC social work internships offer. Studentswork at health centers, free clinics, school-based health centers, and sites that providehealth care for people who are homeless. It’s agreat opportunity for all the students.”

Many people do not realize the amount oftraining, especially field training, that isrequired to be a professional social worker.Requirements for an MSW include threeinternships, with an average of two to threefull days in the field for two semesters. Theinstitute offers opportunities for social workstudents in the areas of general practice,research, clinical work, and administration.

The institute’s social work internships,coordinated by the New York MetropolitanAHEC, place undergraduate and graduatestudents at community health centers, manyof which are located in traditionally

underserved neighborhoods in the Bronxand Manhattan. The students are given avariety of assignments, including direct carewith patients, outreach to community agencies,or conducting research projects. Interns are avital and valued part of the psychosocialservices department and the centers.

Community Health Centers (CHCs) offer arich learning opportunity that expandsbeyond general social services into publichealth and mental health.The client base is diverse—in age, race, ethnicity,socioeconomic status, andneed. Clients come withmultiple presenting issues.They may need crisisintervention because theyhave no food or shelter or because they areliving with family violence. They may needconcrete services such as food stamps orinsurance. They may need clinical servicessuch as therapy for relationship problems,depression, or anxiety. The CHC’s diverseclient base provides an excellent forum forfirst-year students to build a foundation andlearn about different services and popula-tions. The kind of diversity seen at commu-nity health centers is rare in most internplacements for social work students. Manysecond-year social work students have theopportunity to provide therapy to adults andchildren or run anger management or depres-sion groups. In addition to direct patient care,students participate in special learningactivities such as in-service training programsfor Community Health Center employees andlectures by institute staff members.

At participating CHCs, the social workersand social work students play a critical roleon interdisciplinary teams. Social workerscollaborate with primary care providers in

Mental H

ealthSocial work internships at an inner-city Community Health

Center provide sought-after and valuable training for students.

Interns are a vital and

valued part of the

psychosocial services…


treating patients andmake a tremendouscontribution to patientcare. Patients formrelationships with socialworkers that help toincrease their under-standing of medicalconditions and improvetheir adherence torecommended medicaltreatment.

Our program has beensuccessful in its goal ofretaining young socialwork graduates to workin underserved neigh-borhoods. We haveoffered several of ourinterns positions aftergraduation, and somehave been promoted. “Iam grateful for myexperience as an internwith the Institute.Many of my peers inschool did not get therange of experiencesnor have such dedi-

AHEC Builds Opportunity for Young Social Workers

cated supervisors as Iwas fortunate to have,”says Linda Tillmon,LMSW, now theinstitute’s regionaldirector of psychosocialservices in the Bronx.

We take pride in ourinternship program andwork hard to make sureit is a valuable experi-ence for all our stu-dents. Additionally, weare helping to makesure that all socialworkers who enter theprofession are quali-fied, competent, well-trained professionals.Not only do studentsreceive an excellentinternship, but theclients benefit from theservices as well. Thisinternship certainly isan example of a strongand lasting relationshipbetween AHEC and acommunity healthcenter.

Community Health

Centers offer a rich

learning opportunity that

expands beyond general

social services into public

health and mental

health.

The kind of diversity seen

at Community Health

Centers is rare in most

intern placements for

social work students.

“Many of my peers in

school did not get the

range of experiences nor

have such dedicated

supervisors as I was

fortunate to have.”

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NAO – celebrating anotherdecade of leadership

NAO Spring Policy/Leadership ConferenceApril 24-26, 2007

Hilton Washington1919 Connecticut Avenue, NW

Washington, DC

• Policy and leadership speakers• Educational programming for constituency groups• Policy education• Capitol Hill visits

Registration brochure will be available soon.


Caring for Our Nation’s Elderly:Challenges for the Twenty-FirstCenturyElyse A. Perweiler, MPP, RN, and Thomas A. Cavaliieri, DO, FACOI, FACP, AGSF

Thomas A. Cavalieri, DO,FACOI, FACP, AGSF, isInterim Dean and Professorat the University ofMedicine and Dentistry ofNew Jersey-School ofOsteopathic Medicine,Osteopathic HeritageFoundation EndowedChair for Primary CareResearch in Aging, Chair,DHHS-HRSA AdvisoryCommittee forInterdisciplinaryCommunity-BasedLinkages, and Director, NJInstitute for SuccessfulAging, Newark, NJ.

Elyse A. Perweiler, MPP,RN, is the Director of theNew Jersey AHECProgram, AssistantProfessor of Medicine at theUniversity of Medicine andDentistry of New Jersey-School of OsteopathicMedicine, and AssociateDirector for Planning,Development and PublicPolicy at the New JerseyInstitute for SuccessfulAging, Newark, NJ.

An Unprecedented Age WaveAt no time in the history of our nation has thechallenge of caring for older individuals beenmore cogent or more urgent than it is today. By2030, the size of the 65-plus population willdouble, reaching over 72 million, or almost 20%of the U.S. population.1 The long-heraldedimpact of the retirement of the baby boomers,those born between 1946 and 1964, is almostupon us. This year the first wave of the 78million baby boomers turned 60. By 2011,Medicare will feel the impact as the oldestmembers of the baby boom generation reachage 65. Given today’s life expectancy, many ofthem will live well into their eighties, present-ing new challenges for our healthcare deliverysystem. There will be an unprecedentedincrease in the 85-plus age group, which isprojected to grow from 4.2 million in 2000 to7.3 million by 2020.2,3

Not only is our population becoming older, but itis also becoming more diverse. Projectionsindicate that by 2030 minorities will comprise26% of the 65-plus population, up from 18% in2004. By 2030 the older Hispanic populationwill quadruple to eight million and the olderAsian population will quadruple to fourmillion.1,2,3 This unprecedented rate of agingmeans that not only will our healthcare providersneed to be culturally competent and prepared toaddress issues of healthcare literacy for minoritypopulations, but they will have to be prepared toaddress aging issues for this population as well.The healthcare delivery system will be challenged toprovide new modes of communication and deliverydirected at improving access to care for all elders.

Living Longer With Chronic ConditionsChronic illnesses become more prevalent withaging. Although prevalence of chronic diseases

varies by race and ethnicity, 75-80% of those 65and older have at least one chronic condition andapproximately 50% have two or more.4,5 Thefunctional limitations resulting from chronicillnesses such as hypertension, diabetes, arthritis,and heart disease impact quality of life and addto health care costs.6 Today, those over 65represent 13% of the population, yet they arethe highest users of health services, accountingfor half of all physicians’ visits and half of allhospital stays.7 Assistance with activities of dailyliving such as bathing, dressing, preparing meals,or shopping is needed by 14.3% of those 65and older and adds to the costs associated withtreating the elderly.8

Maintaining Independence, Function, andQuality of LifeHistorically, our healthcare system hasaddressed acute, episodic needs. As we lookat improving quality of life and empoweringthe elderly to take more responsibility for theirown health care, new systems of home andcommunity-based care are emerging. Inorder to improve lives, enhance function, andhelp the elderly maintain their independence,providers must now learn how to encourageolder individuals to adopt healthy habits. Thiswill be best accomplished by targetingevidence-based health behaviors such asphysical activity, dietary control, weight reduc-tion, and smoking cessation. Research hasshown that patients can maintain functionalability through education provided in ChronicDisease Self-Management Programs(CDSMP) and can learn to manage theirsymptoms, adhere to medication regimens, andadopt healthy lifestyle changes, thus preventingor delaying disability and minimizing theadverse consequences of chronic disease.8

Geriatriccs

This article provides a framework for addressing the challenges of caringfor a rapidly-growing aging population and reinforces the pivotal role

that AHECs will play in meeting the challenges.


Rebalancing Long-Term CareChoice and empowerment are the hallmarks oftoday’s newly emerging home- and community-based services system. The elderly want toremain in their own homes rather than ininstitutions, but the current long-term caresystem offers limited options. Under thePresident’s New Freedom Initiative, the elderlyand those with disabilities will now have thefreedom to choose where they want to live. As aresult, states have begun to rebalance their long-term care systems and reorient Medicaid fundsto support home- and community-based servicesand encourage consumer direction.9,10,11,12 Wemust prepare for the long-term implications ofthese changes for our healthcare system and forthe healthcare workforce.

Healthcare Workforce CrisisThe unique challenges of caring for the average75-year-old, who has three chronic conditionsand uses five prescription medications andassorted over-the-counter drugs, are oftencomplicated by both nonclassical presentations ofdisease and biopsychosocial issues. It requires aspecial body of knowledge to be aware of thesefactors, yet today’s healthcare practitioners havehad little or no specific formalized training incaring for the elderly. 4,7,12 This pervasive gap intraining exists across all the health professions.Not only is there a shortage of providers whohave been trained to care for the elderly, butthere are too few faculty with a background inaging who can train new providers.

A 2005 update of academic geriatric programs inallopathic and osteopathic medical schoolsconducted by the Association of Directors ofGeriatric Academic Programs (ADGAP)indicates that more than half of the academicleaders in geriatrics are not fellowship-trained ordo not have a Certificate of Added Qualification(CAQ) in geriatrics.14,15 There are currently only6,600 geriatricians in the nation, but projectionsindicate that 36,000 will be needed by 2030 tocare for the nation’s elders.13 The fact that thegeriatric workforce is in crisis has been docu-mented in nursing, social work, geriatric psychia-try and mental health, physical therapy, andpharmacy. 16 Fewer than 15,000 of the 2.56million nurses are certified in gerontology, andonly 3,500 of the 111,000 advanced practicenurses are gerontological nurse practitioners or

Caring for Our Nation’s Elderly:Challenges for the Twenty-First Century

clinical specialists. In social work, only 10% ofall social work students have had a singlecourse on aging and only 3% of master’s levelsocial work students were enrolled in gerontol-ogy programs.17

A Call to ActionAs the growth of the older population continuesto outpace the growth of the nation’s populationas a whole, the healthcare workforce will becaring for greater numbers of older individualsthan ever before. The implications are clear, as isthe mandate for training and education ingeriatrics for all healthcare providers. The 2005White House Conference on Aging affirmedthe need for health professions training ingeriatrics and addressed the need for a preparedhealthcare workforce in two of its top 10recommendations. Specifically, it supportedgeriatric education and training for all healthcareprofessionals, paraprofessionals, health-profession students, and direct-care workers andthe attainment of adequate numbers ofhealthcare personnel in all professions who areskilled, culturally competent, and have special-ized training in geriatrics.3

Ironically, despite the demographic imperativeand the recommendations made by delegates atthe White House Conference on Aging, federalfunding for education and training in geriatricswas eliminated from the President’s budget inFY 2006. As we advocate for reinstatement offederal funding for geriatric education in thecoming fiscal year, as well as other healthcareprograms vital to our elderly population, we mustcontinue to train our providers to address theneeds of elders and underserved populations.

A Challenge for the Twenty-First CenturyAs the population becomes more culturallydiverse and federal resources for training andeducation shrink, we must become increasinglycreative in order to meet the increasinghealthcare demands of the elderly. Ourhealthcare workforce, including primary careproviders and the paraprofessionals whocomprise the infrastructure of our healthcaresystem, must all be trained to address the specialneeds of the elderly. The challenges of contain-ing healthcare costs, managing multiple medica-tions, navigating fragmented health andcommunity-based service delivery networks,

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caregiving, and providing long- term care aresignificant. Rethinking our approach to caring forthe elderly, reexamining the resources within thehealthcare system, and developing a new systemfor home- and community-based care are critical.We must create new interdisciplinary teams thatwill be able to meet and overcome thesechallenges. Our efforts at training a newhealthcare workforce must be redirected to assistculturally diverse and underserved populationsin accessing appropriate geriatric care.

A Role for Area Health Education CentersThe focus on self-management of chronicdisease and other health promotion strategies is anew approach to independence, choice, andempowerment for our elderly citizens and fortheir caregivers. As we embark on thePresident’s New Freedom Initiative, elderlyindividuals will need assistance in learning howto modify their health behaviors and in accessingavailable services and resources. The AreaHealth Education Centers, as a portal tounderserved communities, will play a pivotal rolein preparing the healthcare workforce to meetthe challenges posed by the graying of America.

A number of AHECs have worked to meetthese challenges by incorporating CommunityHealth Workers (CHWs) as part of theinterdisciplinary team. Known by many names,including Community Health Advisors,Outreach Workers, Promotores, Lay HealthPromoters, Lay Health Advocates, and PeerEducators, CHWs are frequently volunteers orpart-time workers supported by funding forspecial projects. Often bridging the gapbetween health services and communities,CHWs play a significant role in delivery ofculturally competent home- and clinically-basedhealth care and are able to address issues relatedto healthcare literacy, health promotion, andchronic disease self-management programs(CDSMP). The ability of the CHW to forgethe way for new partnerships, assist in overcom-ing language and cultural barriers, and linkindividuals to nonmedical services often buildstrust, leading to improved access to care andbetter compliance with instructions for medicaltreatment.18

The three New Jersey (NJ) AHEC centers,Camden, Garden, and Shore AHECs,


exemplify the partnerships that are needed tomeet the complex needs of the increasinglydiverse elderly population through variededucational endeavors. Garden AHEC hasbeen providing a series of seminars for seniors onmajor health concerns, including falls, cancer,and advance directives, and will be adding othertopics, such as nutrition and depression. Allthree NJ AHECs also serve as communityservice rotation sites for third- year medicalstudents and have recently incorporatedcommunity health workers as new members ofthe interdisciplinary team. The addition ofcommunity health workers has put the NJAHECs in a better position to addressconcerns about healthcare literacy, to enhancecommunication and outreach, and to linkelderly people to services.

A New Project Empowers SeniorsThe Community Health Worker Institute(CHWI), in partnership with the University ofMedicine & Dentistry of New Jersey-School ofOsteopathic Medicine and its New JerseyInstitute for Successful Aging (NJISA), illustratethe role that AHECs can play in healthpromotion initiatives for the elderly. TheCWHI is a Model AHEC grant projectawarded to the NJ AHEC with CamdenAHEC as the lead agency. Under a new projectfunded by a grant from the state of New Jersey,the Health Enhancement and Learning Project(HELP) will address common chronic diseasesin elderly persons residing in senior housing.CHWs and bilingual peer educators will betrained in the Stanford Chronic Disease Self-Management Program and then will work incollaboration with other health professionals inconducting health assessments for underservedand minority senior housing residents, identify-ing healthcare needs, and assisting residents indeveloping a personal healthcare plan. Partici-pants will be enrolled in the Enhance WellnessProgram, which provides a web-based registryand reminders for staff to monitor how seniorsare doing with their personal health action plans.CHWs will play a key role in helping seniors tocomplete assessment forms and in providingeducation about various health promotionstrategies, serving as coaches and encouragingseniors to take responsibility for managing theirown chronic illnesses.

Geriatriccs


Social Responsibility and Community HealthAs we prepare for the impact of the age wave, itis incumbent on us to embrace the principles ofcommunity health and social responsibility. Wemust address the needs of the population as awhole, yet not neglect the needs of individuals.The underserved elderly merit our attention. Aseducators and healthcare professionals, it is ourresponsibility to ensure that all healthcareproviders are trained to address the complexspecial needs of the elderly. New directions forinterdisciplinary practice, creative restructuring ofhealthcare teams, and incorporation of commu-nity health workers into home- and community-based practices can facilitate access and break


down the barriers experienced by minority andunderserved populations. The promotion ofsuccessful aging must be done collaboratively,with the physician, the healthcare team, thepatient, and the family all working together.Maintaining functional independence andquality of life and the right to choose where onewants to reside and receive health care are thegifts we can give to our nation’s elderly. Togetherwe can educate providers and consumers andwork as partners. We can and must make acommitment to manage chronic diseaseseffectively and encourage healthy behaviors, notonly for elderly individuals but for the entirepopulation. This is our social responsibility, aswell as our medical mandate.

References

1He, W., Sengupta, M., Velkoff, V.A. & DeBarros, K.A. U.S. Census Bureau, Current Population Reports, P23-209,65+ in the United States: 2005, Washington, DC: U.S. Government Printing Office. Retrieved at http://www.census.gov/prod/2006pubs/p23-209.pdf.

2Administration on Aging, U.S. Department of Health and Senior Services, A Profile of Older Americans: 2005.Washington, DC: U.S. Government Printing Office.

32005 White House Conference on Aging, The Booming Dynamics of Aging: December 11-14, 2005, Report to thePresident and the Congress, released September 2006. Retrieved at http://www.whcoa.gov/press/05_Report_1.pdf.

4Merck Institute of Aging & Health, The State of Aging and Health in America, 2004. Whitehouse Station, NJ.Retrieved at http://www.cdc.gov/aging/pdf/State_of_Aging_and_Health_in_America_2004.pdf.

5Wolff, J., Starfield, B., and Anderson, G. November 11, 2002. Prevalence, Expenditures and Complications ofMultiple Chronic Conditions in the Elderly, Archives of Internal Medicine, (162), 2269-2276. Retrieved at http://www.partnershipforsolutions.org/DMS/files/Prevalence.pdf.

6Collins S.R., Davis, K, Schoen C., Doty, M.M. & Kriss, J.L. January 2006. Health Coverage for Aging Baby Boomers:Findings from the Commonwealth Fund Survey of Older Adults, Commonwealth Fund, Pub. No. 884. Retrieved atwww.cmwf.org.

7Merck Institute of Aging & Health, 2002. The State of Aging and Health in America. Whitehouse Station, NJ.

8Preventing Disability in the Elderly With Chronic Disease, Research in Action, Issue 3, AHRQ Publication No. 02-0O18, April, 2002. Retrieved at http://www.ahcpr.gov/research/elderdis.htm

9AARP, Reimagining America, AARP’s Blueprint for the Future, 2005. Washington, DC.

10HHS Provides Funding to States for Alternatives to Nursing Home Care in Medicaid, July 26, 2006, retrieved athttp://www.hhs.gov/news/press/2006pres/20060726.html.

11Money Follows the Person, retrieved at http://www.adapt.org/mfp1.htm, September 24, 2006.

12Alliance for Aging Research. (February 2002). Medical Never-Never Land: Ten Reasons Why America is Not Ready forthe Coming Age Boom. Washington, DC.

13Association of Directors of Geriatric Academic Programs (ADGAP), Geriatricians and Geriatric Psychiatrists, May2005. Training and Practice Update, (3)1.

14Association of Directors of Geriatric Academic Programs (ADGAP). (May 2006). The Status of the WorkforceStudy, Academic Geriatric Programs in U.S. Allopathic Medical Schools. Training and Practice Update, (4)1.

15Association of Directors of Geriatric Academic Programs (ADGAP). (September 2006). The Status of theWorkforce Study, Academic Geriatric Programs in U.S. Osteopathic Medical Schools. Training and Practice Update,(4)2.

16National Academy of an Aging Society, The Gerontological Society of America, Spring 2003. Public Policy & AgingReport, (13)2.

17The John A. Hartford Foundation, Ideas for Geriatrics Training and Services, 2004 Annual Report. New York.

18The Annie E. Casey Foundation. ( June 1998). A Summary of the National Community Health Advisor Study. ReprintedNovember 2000.

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Steve Lustgarden, MS, isProgram Manager of theHealth Projects Center atCentral Coast AHEC,Salinas, CA.

John Beleutz, MPH, isExecutive Director of theHealth Projects Center atCentral Coast AHEC,Salinas, CA.

Central Coast AHEC—Working to Support the GrowingNeeds of an Aging PopulationJohn Beleutz, MPH, and Steve Lustgarden, MS

Healthcare providers and healthcare systemsin the Central Coast region of California arenot adequately equipped to address thegrowing demand for geriatric services. Toaddress this problem, the Central Coast AreaHealth Education Center (CCAHEC) isworking to improve access to health care forolder adults in Monterey, San Benito, andSanta Cruz counties.

These three Central Coast counties served byCCAHEC are experiencing an increase in thenumber of elderly residents. Currently127,000 seniors reside in the tri-county area.Of that population, approximately 35,000 arehigh-risk seniors whose demand for healthcareservices is rapidly increasing. Over the next 30years, the senior population will more thandouble to 292,000 while high-risk seniors willincrease threefold to 84,000.

At present, there are about 9,000 certifiedgeriatricians and 1,800 MSN geriatric nursepractitioners in the nation for 36 millionseniors. Within the tri-county region there arefewer than six geriatricians and only one MSNgeriatric nurse practitioner for 127,000 seniors.

As the need for geriatric care has outpaced thesupply of health professionals trained in caringfor an aging population, CCAHEC has soughtto address these access to care challenges byacting as a catalyst for collaboration andprograms around geriatric health. CCAHEC’sstrategy has focused on the creation of theMonterey Bay Geriatric Resource Center(MBayGRC), an independent nonprofitregional consortium of educational andhealthcare organizations. CCAHEC has alsocreated key partnerships with the University of

California’s (UCSF) Natividad MedicalCenter (NMC) Family Practice MedicineResidency Program and Cabrillo College’sNursing Program.

In 2001, California AHEC providedCCAHEC with funding for the strategicplanning and development of MBayGRC.MBayGRC is a unique regional collaborationbetween 10 organizations that have madecommitments to work together to improveaccess and care for the senior population inMonterey, Santa Cruz, and San Benitocounties.

The MBayGRC strategy involves a two-foldapproach:

1) To develop interdisciplinary geriatric/chronic care management educationalprograms for family practice residents,nurses, allied health providers, seniors,and family and informal caregivers; and

2) To develop geriatric/chronic care man-agement centers to provide comprehen-sive assessments and chronic caremanagement services to seniors and theirfamilies and providers that enhance oraugment a community-based continuumof care.

MBayGRC’s members include: HealthProjects Center/Central Coast Area HealthEducation Center, Community Hospital of theMonterey Peninsula, Watsonville CommunityHospital, Natividad Medical Center, Clinicade Salud del Valle de Salinas, Palo Alto VAHealth Care System, UCSF School ofMedicine, California State UniversityMonterey Bay, and Cabrillo and HartnellCommunity Colleges.

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Regional collaboration leads to educational initiatives designed to

improve geriatric care in California’s Central Coast region.


The initial three years of funding fromCCAHEC has resulted in a sustainableorganization. MBayGRC has generated over$500,000 in additional grants and contracts tosupport programs.

MBayGRC’s current programs/initiativesinclude:

• Developing and piloting a geriatric corecurriculum for the UCSF family practiceresidency program at Natividad MedicalCenter.

• Developing and piloting a geriatric corecurriculum for the associate degree innursing program at Cabrillo College.

• Developing a Geriatric Assessment andCare Management Center at CommunityHospital of the Monterey Peninsula’sBehavioral Outpatient facility for olderadults with mood disorders and multipleco-morbidities.

• Developing a feasibility study andbusiness plan for a Geriatric Evaluationand Chronic-Care Management InpatientUnit at Natividad Medical Center.

• Sponsoring annual conferences on Agingand Chronic-Care Management forphysicians, nurses, and behavioral andallied health professionals. MBayGRC’ssecond annual “Aging and Chronic Care”will take place in January 2007.

• Sponsoring workshops/seminars ingeriatrics and chronic-care managementfor healthcare staff and community serviceagencies that provide support services tofamily caregivers and the frail elderly.

• Developing a Geriatric Assessment/Chronic-Care Management Center at theVeterans Administration Clinic inMonterey to provide patient services andto serve as a training site for family practiceresidents and nursing students.

• Sponsoring geriatric fellowships forgraduates of UCSF’s family practiceresidency program at Natividad MedicalCenter to become MBGRC faculty.

CCAHEC’s collaboration with and funding forMBayGRC have contributed to each of theabove initiatives. For example, together

Central Coast AHEC—Working to Support theGrowing Needs of an Aging Population

MBayGRC and CCAHEC have been able tosecure major funding to support the develop-ment of a geriatric/chronic care managementcore curriculum for students enrolled in theCabrillo College nursing education programand for residents in the UCSF/NMC familypractice medicine residency program.

CCAHEC funding has also provided theopportunity for students enrolled in theCabrillo nursing program to participate inenhanced gerontology didactic and clinicalpractice experiences. The gerontology-specifictheory classes total 16 hours. Clinical practiceconsists of gerontology-specific rotations inlong-term-care facilities, Fort Ord’s VeteransAdministration Clinic, Cabrillo College’sStroke Center, and at community-basedagencies.

CCAHEC supports the provision of UCSF/NMC family practice medicine residents withcommunity-based experience at a range ofcommunity agencies providing services to theelderly population. Residents spend timeworking with and learning from agenciesproviding services such as hospice care, respitecare, food for seniors, and adult day care.

Cabrillo College, with CCAHEC support, iscurrently developing joint simulation trainingfor Cabrillo College nursing students andNMC family practice residents utilizingpatient simulators. The simulations willpresent clinical geriatric case scenarios and willpromote collaborative practice andmultidisciplinary partnerships in the delivery ofpatient care. The simulation technologyenables the faculty operator to direct a varietyof patient events in which variable physiologi-cal symptoms unfold and to utilize video replaycapability after exercise debriefing withparticipants.

CCAHEC will continue to engage in innova-tive programs such as the work at CabrilloCollege. Its ability to do so is dependent oncontinuing creative collaborations through itsaffiliation in MBayGRC and through partner-ships with local academic institutions.

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Terry Gefell, MSEd,CHES, is Director ofDevelopment andCommunications at theCentral New York AHEC,Cortland, NY.

Pamela Mayberry isAssociate Director of theIthaca College GerontologyInstitute, Ithaca, NY.

Collaboration on GeriatricTraining Reaches ManyTerry Gefell, MSEd, CHES, and Pamela Mayberry

Since 2003, the Finger Lakes GeriatricEducation Center (FLGEC) at the IthacaCollege Gerontology Institute (ICGI) andthe Central New York Area Health Educa-tion Center (CNYAHEC) have joinedforces to expand and enhance the availabil-ity of geriatric training in a 16-county region.As a result of this collaboration, nearly1,500 health professionals and paraprofes-sionals have received much-needed trainingin their local communities.

The collaboration began with the implemen-tation of 11 geriatrictrainings held fromMarch through Decem-ber 2003 across eightcounties. In eachcounty, communitypartner teams workedin collaboration withICGI staff memberMarilyn Kinner to planthe trainings. Eachteam consisted of 6-10professionals represent-ing county offices forthe aging, skillednursing facilities, homehealth agencies, county health and socialservices departments, and rural healthnetworks.

Program topics addressed a variety of issuesfaced by caregivers of geriatric patients, suchas mental health issues, stress management,understanding and coping with challengingdementia-related problems, geriatricdepression, geriatric drug therapy, andbalance and gait disorders. In subsequentyears, other topics were added, including

sexual issues in long-term care, caring forcombative residents, and the dying process.

Since the initial program, more than 500health professionals have been reached,representing the fields of psychology,nutrition, family medicine, nursing, occupa-tional and physical therapy, social work, andmore. Nursing staff—namely, certifiednursing assistants, home health aides,LPNs, and RNs—constituted the largestsegment of the audience.

On-site programevaluation was con-ducted after eachworkshop. Evaluationsindicated that work-shops were very wellreceived; 61% ofattendees “stronglyagreed” and 39%“agreed” that theinformation wasvaluable professionally.Responses to usefulnesssurveys, sent to attend-ees three months afterthe workshops, indi-

cated that most participants applied theknowledge and skills obtained at the trainingto their daily work. One participant shared, “Ilearned more about caring for residents andunderstanding how our residents may bethinking. Most of all, I learned about myself.I learned that I play an important part in thesepeople’s lives. I am sharing their lives as theyare sharing mine.”

Marilyn Kinner, Outreach Program Coordina-tor for ICGI, comments, “Administrative staff

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The Central New York AHEC joined with two partners to train 1,500health professionals and paraprofessionals in geriatrics. The

interdisciplinary training allowed front-line personnel to understand theirroles in providing meaningful care to patients.

“With the aging of the

population…it is clear

that health workforce

development must reach

those professionals and

paraprofessionals working

with the elderly

population on a daily

basis.”


of local home health agencies and long-term-care facilities made every effort to allow asmany frontline workers as possible to partici-pate. The trainings were seen as an opportu-nity to help staff improve their skills and foradministrators to acknowledge the importanceof their work.”

Responding to needs identified by communityteams, a grant from CNYAHEC in fall 2004made possible the development of a one-daytraining, Building a Great Caregiving Team:Leadership Skills for Nurses. The training teamconsisted of two faculty members from IthacaCollege School of Business and a nursemanager from St. John’s Nursing Home. The

Collaboration on Geriatric Training Reaches Many

team developed an interdisciplinary curriculumto address topics such as coaching andmentoring, conflict resolution, and communica-tion skills. Standard leadership skills weremade pertinent to the long-term care setting.

In May 2005, the training was piloted with 22nurses from seven facilities in five countiesattending the training. Over 75% of theparticipants rated the teaching tools and overallworkshop as excellent or very good. “Iespecially appreciated the different perspec-tives of the lecturers; all information wasbeneficial for application in nursing,” com-mented one participant. Due to the success ofthis offering, additional trainings were offeredin 2005 and 2006, reaching an additional 36nurses.

“With the aging of the population, especiallyin rural areas, it is clear that health workforcedevelopment must reach those professionalsand paraprofessionals working with the elderlypopulation on a daily basis. The partnershipbetween CNYAHEC and ICGI has allowedus to offer on-site continuing education in ourmost rural communities,” explains Joanne RaceBorfitz, Executive Director of CNYAHEC.

To make training more accessible, in 2006three on-line modules were produced ongeriatric depression, home safety, and reducingfalls. Each training module comes with aprintable workbook containing interventions,resources, and references.

In addition to the community-based programsand the on-line modules, CNYAHEC has alsosupported ICGI’s annual conferences andspring/fall workshop series, reaching anestimated 500 additional health professionals.

Pamela Mayberry, Associate Director of ICGI,describes the synergy between ICGI andCNYAHEC: “The linkage with CNYAHECenhanced the institute’s rural training initiative.The collaboration increased our geographicreach and allowed us to serve professionals andparaprofessionals in counties where training oncritical topics had not been previously avail-able—a perfect example of how organizationswith similar goals can combine forces to accom-plish more than would be otherwise possible.”

Carol DuMond, Nurse Manager at St. John’s Nursing Home, leads a small groupdiscussion at the nurse leadership training held in Cayuga County in 2005.

William Rusen and Al Alfaro (left and right) from Cayuga Addiction RecoveryServices and Lisa Kendal from Family and Children’s Service address depression andchemical dependency in older adults at a September 2004 conference on MentalHealth and Mental Illness in Later Life.

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Richard Schamp, MD, isthe Medical Director ofAlexian BrothersCommunity ServicesPACE Program, St. Louis,MO.

David Pole, MPH, isDeputy Director of the St.Louis University AHECProgram Office, St. Louis,MO.

Clinical Training of MedicalStudents in Interdisciplinary CareUtilizing a Geriatrics Program atPACE (Program for All-inclusiveCare of the Elderly)David Pole, MPH, and Richard Schamp, MD

The AHEC Program Office at Saint LouisUniversity (SLU) School of Medicine is locatedwithin the Department of Community andFamily Medicine (CFM). In addition toworking with the East Central Missouri(ECMO) AHEC regional center, the programoffice has established an interprofessionalprogram committee that has, for the past fiveyears, discussed issues of providing care to themedically underserved, identified issues andbarriers to accessing quality care, and workedto place these discussions into curriculummodules of the schools of medicine, nursing,physical therapy, occupational therapy, socialwork, and public health. Additionally theAHEC program office has worked with CFMfaculty to design and implement electives thatprovide medical students clinical training in thecommunity where they can get firsthandexperience caring for the medicallyunderserved and/or participate on interdiscipli-nary team cares.

Mark Mengel, MD, MPH, Chair of Commu-nity and Family Medicine at SLU and theProgram Director for AHEC, recalls that“although there continues to be great discus-sion around the interprofessional model, as aclinician, I have found it challenging, at least,to implement and systematize. My experiencewith the Alexian Brothers Community Service(ABCS) PACE (Program for All-inclusiveCare of the Elderly) in Saint Louis is that theyexemplify the interprofessional team approachto patient care.”

In 2002, the SLU Department of Communityand Family Medicine developed an affiliationagreement with the PACE program to providea medical director and hired Richard Schamp,MD, a family practice physician, to function asa faculty member within the department andthe medical director for the program. With thedemonstrated success of the interprofessionalmodel at PACE, Dr. Mengel worked with Dr.Schamp to create an elective that would enablemedical students to experience firsthand theexemplary model of team care demonstrated inthis program. Dr. Schamp played a key role inthe development of this course and has workeddirectly with medical students participating inthis elective since 2003. Dr. Schamp enjoysworking with students in this setting, statingthat “this rotation is rich in pathology andopportunities for hands-on care of complicatedchronic disease as well as acute illness. Inaddition to the immersion experience into aunique interdisciplinary care model, studentsgain proficiency in skills of evidence-basedmedicine and information mastery in day-to-day practice.” Laura Frankenstein, MD, afamily practice physician, who is the currentmedical director for the SLU AHEC programoffice and was previously a medical provider atthe ABCS PACE program in Saint Louis,states that “students participate in the care ofmedically and socially complex elders in thiscomprehensive setting. It may be the first timea medical student has evaluated a patientalong with a physical therapist, gone on ahome visit with a social worker and a nurse, or

For four years, Saint Louis University’s AHEC has implemented aninterprofessional approach to patient care which allows medical students to

experience evidenced-based medicine for older patients who havemaintained their independence.

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been in a team meeting where the van driverhas a suggestion that will keep a patient frombeing hospitalized. Students are impressed bythe types of solutions possible when thepatients, families, and the array of providerswork together.”

Interprofessional Team Approach toProviding Clinical CareA patient’s healthcare needs often require theinput of a variety of professionals in addition toprimary medical care providers. Models ofprofessional interaction can be identified basedon the spectrum of interprofessional collabora-tion and coordination and range from indepen-dent medical management to interdisciplinarycollaborative care.1

Interdisciplinary collaborative care is notwithout its challenges. It often requires addi-tional time, and staff need to set common goals,define their roles, and establish open lines ofcommunication. The environment needs to beone in which members are open to learning andappreciate the scope of work of various disci-plines. Unfortunately, these interdisciplinaryteams often lack institutional support and thesupport to shift from disease-centered care topatient-centered care.2 The ABCS PACEprogram in St. Louis has met these challenges byhaving a well-developed system with definedroles and effective communications. Medicalstudents are able to step in, observe, andparticipate in true interdisciplinary care during atwo-week rotation. Students experience thebeneficial aspects of collaborative care that

Clinical Training of Medical Students in InterdisciplinaryCare Utilizing a Geriatrics Program at PACE

address chronic disease management in anelderly population.

What Is PACE?The PACE model is centered on the beliefthat it is better for the well-being of seniorswith chronic-care needs and their families tobe served in the community wheneverpossible. PACE serves individuals who areaged 55 or older, certified by their state toneed nursing home care, and who are ableto live safely in the community at the time oftheir enrollment. Nationally, only about 7%of PACE participants reside in a nursinghome; the majority are served on an outpa-tient basis.

PACE strives to provide the entire con-tinuum of care to seniors with chronic-careneeds while allowing them to maintain theirindependence in their homes for as long aspossible. Care and services include adultday care, nursing, physical, occupational,and recreational therapies, meals, nutritionalcounseling, social work, personal care, andhome health care. Other services that areavailable as needed include audiology,dentistry, optometry, podiatry, and speechtherapy. Medical care is provided by aPACE physician and includes all necessaryprescription medications.

Interdisciplinary Team (IDT) meetings playan important role at ABCS PACE indeveloping participant care plans, coordinat-ing the delivery of care, and communication.

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Table 1. Models of Professional Interaction.


Daily IDT meetings occur where staffmembers touch base about participants’status, provide updates, make adjustmentsto care plans, and problem-solve acrossdisciplines to determine priority actions.

Medical Student ExperiencesThis elective was designed with two primaryobjectives. The first was to provide medicalstudents with experience managing commonproblems/diseases including diabetes, heartfailure, coronary artery disease, cerebrovas-cular disease, peripheral vascular disease,osteoarthritis, COPD, depression, thyroiddisorders, and commoncancers. Also includedare issues common incare of the elderly suchas dementia, mobilityand gait disturbances,urinary incontinence,failure to thrive,pressure ulcers,delirium, polypharmacy,and acute care. Thesecond objective was toprovide students anopportunity to experi-ence and participate ininterprofessional teamcare to understand theroles of varioushealthcare providersand how the physician can, and must,interact with the team to create the mosteffective care plan for the patient. Thepatient mix at the ABCS PACE program is3% inpatient, 90% outpatient, and 7%nursing home/home care. During this two-week rotation, students evaluate approxi-mately 40 patients, participate in daily teammeetings, and follow the care of variouspatients through the team process.

Student Learning Experiences with theInterdisciplinary Team (IDT) MeetingStudents participate in the daily teammeetings and evaluations of current andpotential enrollees. The medical directorassigns students to specific patients and thestudents then work with members of the


team to develop care plans for new enroll-ees. Students participate in reporting to theIDT on updates of current patients’ statusand identification of patients’ needs and/orchanges in status (medical, mental, psycho-social, and functional). Students work withthe medical staff and learn how to coordi-nate tracking and evaluation of services andcare. Students participate in problemsolving and experience the challenges ofcoordinating and clarifying team care whenthe duties of various healthcare providersintersect.

During the course ofthe two-weekrotation, studentsassist to develop,modify, and approvepatient-care plansincluding changes inlevel of care, atten-dance, and additionor reduction ofservices. Dr. Schampmeets with studentsdaily and assignsfocused readingsbased upon the casepresentation and/orinterprofessional-careneeds of the patientsassigned to the

students. Students are able to discusscases, readings, and learning objectives withthe physician and/or team membersthroughout the afternoons each day. Themedical student is assigned times with mostof the other disciplines during the electivein order to observe the interdisciplinaryprocess from their perspective.

Within each patient’s care plan, studentsexperience the problems and challengesidentified with:

• Addressing participant goals for eachproblem vs. just the providers’ goals.

• Developing IDT interventions for eachproblem and how the healthcare providerswork together based upon their clinicalscope of work and experience.

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It may be the first time a

medical student has

evaluated a patient along

with a physical therapist,

gone on a home visit with a

social worker and a nurse,

or been in a team meeting

where the van driver has a

suggestion that will keep a

patient from being

hospitalized.


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• Clear presentation of the patients’status and measurable goals for theirgiven conditions.

• How the interventions are best man-aged and implemented.

• How to assess problems and how goalswere either met, not met, or will con-tinue to be pursued.

By the end of this elective,medical students areexpected to:• Describe interdisciplinaryroles in the comprehensivecare of frail elderly.• Participate in performingComprehensive GeriatricAssessments.• Perform fall assessmentand gait evaluations.• Evaluate and treatcommon geriatric syndromes.• Perform behavioral,

cognitive, and psychological screeningtests.

• Explain key geriatric pharmacologyprinciples.


• Discuss selected ethical issues, includ-ing end-of-life care and advancedirectives.

Students must have successfully completedboth the Family Medicine and InternalMedicine Clerkships prior to taking thiselective and are evaluated based upon awritten paper, preceptor evaluation, and anoral presentation on a mutually selectedtopic to the PACE clinical staff.

AHEC Role and Student FeedbackThe AHEC program office at SLU, as withthis example, is involved in the identifica-tion of clinical training opportunities in thecommunity, the development of the curricu-lum and/or clinical experience, and thepromotion and recruitment of medicalstudents to participate in the course.Although we have had only a handful ofstudents take this elective in the past threeyears, the feedback has been very positiveregarding the clinical training and theunderstanding and appreciation for thecontributions of different disciplines toimproved patient care. AHEC is working toenhance promotion of this elective formedical students at SLU.

References

1Ruebling, I. (2005). Beyond Sequential Care of Inter-disciplinary Team Care. St. Louis: Saint Louis UniversityAHEC Inter-professional Curriculum Committee.

2Ruddy, G. & Rhee, K. (2005). Trans-disciplinary Teams in Primary Care for the Underserved: A LiteratureReview. Journal of Health Care for the Poor and Underserved, 16:248-256.

The environment needs

to be one in which

members are open to

learning, and comprised

of members who

appreciate the scope of

work of various

disciplines.

Educational Opportunity AlertA New Look at the Old:

Research and Best Practices in the Care of Older AdultsA collaboration between the American Journal of Nursing and the Gerontological Societyof America has resulted in a project entitled “A New Look at the Old.” Educationalmaterials produced from this project include a print series on cutting-edge research andbest practices in the care of older adults. A video series of the same name is alsoavailable which includes 30-minute webcasts based on the topic in the journal articles andcase studies to assist in implementation of best practices, as well as outcomes fromthose facilities, agencies, and organizations employing them. The videos are specificallyproduced for an interdisciplinary audience and feature a range of professions in eachshow. Both the print series and the web casts are free and accessible atwww.NursingCenter.com/AJNolderadults.


South Central Kentucky AHECPartners with Barren RiverLong-Term Care OmbudsmanProgramLucy Juett, MS, and Ruth Morgan, BSW

Lucy Juett, MS, isDirector of the SouthCentral Kentucky AHEC,Bowling Green, KY.

Ruth Morgan, BSW, isDirector of the BarrenRiver Long-Term-CareOmbudsman Program,Bowling Green, KY.

A 20-year partnership between the BarrenRiver Long-Term Care Ombudsman Programand the South Central Kentucky Area HealthEducation Center at Western KentuckyUniversity has been working to improve thequality of services to long-term care facilityresidents and the level of training and knowl-edge to family practice residents. Thepartnership began in October 1986 whenthey came together around three areas ofmutual interest: physician training, empow-ering long-term care residents, and educat-ing families and facility residents who areconsumers of long-term care services.

The mission of the Barren River Long-Term-Care Ombudsman Program is to improve thequality of life and care of residents of long-termcare facilities, while the mission of the AHECis to promote healthy communities throughinnovative partnerships.

Physician TrainingThe South Central AHEC conducts a month-long community medicine rotation for familypractice residents through the University ofLouisville. While these physicians may care fora few nursing home patients, most of them areunfamiliar with the complicated long-term careenvironment. Their only exposure to the long-term care setting is when they make theirmonthly visit to the facility. Through theOmbudsman Program, the family practiceresidents are provided a full day of training.The day includes a lecture and a trip to a

nursing home for a review of the facility’sinspection reports and nonclinical bedsidechats with residents of the facility. Physiciansare provided with a list of long-term careresources to take with them.

At the end of the day of training physicians areexpected to:

• Understand the services of the Long-Term Care Ombudsman Program.

• Discuss the nursing home care planningprocess and the role of the physician inthat process.

• Understand the regulatory guidelines forlong-term care facilities.

• Understand statements of regulatorydeficiencies.

• Discuss the link between the regulationsand the facility staff ’s ability to implementphysician’s orders.

• Understand how to access nursing homeinspection reports.

• Receive a copy of the rights of residentsunder Kentucky law.

• Discuss the differences in servicesprovided by a nursing facility and apersonal care facility.

• Discuss some of the major care issues fornursing homes to include nutrition,hydration, use of restraints, and staffing.

Prior to the training, family practice residentsreported no knowledge of the OmbudsmanProgram and little knowledge of the long-termcare environment. Following the training, they

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South Central Kentucky AHEC and the Ombudsman Program provideunique insights in nursing homes for family practice residents to learnabout nursing homes and to understand nursing home residents on a

non-medical level.


recognize theprogram as avaluableresource forthemselves, theirpatients, andtheir patients’families; thesephysicians reporta better under-standing of theneeds of theirnursing homepatients. Theresidents ratethis experienceas one of the highest of the communitymedicine rotation.

Empowering Long-Term Care ResidentsThe two agencies also partner to empowernursing home residents to take a more activerole in directing their own quality of life andcare. Every long-term care facility shouldhave a resident council whose role is toprovide a forum where residents of the facilitycan meet to discuss their common concerns.Through the council, residents can communi-cate as a group with the facility administrationand make recommenda-tions and suggestions orfile grievances. TheOmbudsman Programstaff, aware that manyof these councils werenot effective, joinedwith the AHEC toempower these councils.

Since 1998, theagencies have jointlysponsored a day-long conference for del-egates of these councils. The conferenceincludes facilitated group discussions withresidents about life and care at their long-term care facility. These discussion groupsserve as training for council members whoreturn to their facilities and lead similarconversations with members of their respec-tive councils. The AHEC provided seedmoney for the first two conferences and

South Central Kentucky AHEC Partners with BarrenRiver Long-Term Care Ombudsman Program

continues tohelp plan,coordinateregistration, andprovide staff forthe day of theevent. Oneexample of howthe conferencehas empoweredresidents iswhen onecouncil submit-ted a list ofgrievances tothe facility’s

operating corporation, resulting in 13significant improvements in policies andprocedures affecting laundry, dietary,nursing, and other services. The councilmembers reported that their actions hadresulted in major improvements in theirquality of life and that their direct caregiverswere proud of them.

At the 2006 conference, council delegatesprovided a list of barriers encountered whenthey tried to make meaningful choices aboutthe things that affect them. The dynamics

and causes of some ofthese barriers will beexplored further throughthe partnership.

Joe Garst, EdmonsonCounty Health Careadministrator, indicatesthat the residents whohave attended from hisfacility have a muchbetter understanding of

the resident council’s role and how tocommunicate their concerns to staff.

Ann McKee, President of the Resident Councilat Rosewood Manor, notes that participation inthe conference has increased resident atten-dance at meetings and that residents are moreeducated about their rights, feel freer to speakup, and have a better understanding of how toprocess their concerns.

Ann McKee, President, Rosewood Health Care Center ResidentCouncil, enjoying her lunch at the 2006 Resident Conference.

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Prior to the training,

family practice residents

reported no knowledge of

the Ombudsman

Program…


Educating Long-Term Care ConsumersThe decision to move to a long-term-carefacility in the Barren River Area is noweasier thanks to a comprehensive consumerguide written by the Ombudsman Programstaff and called “Finding Long-Term Carein the B.R.A.D.D.” The AHEC providesfunding so that this helpful guide can bedistributed free to consumers throughoutthe 10-county Barren River Area. The guideincludes information on the various levels of

South Central Kentucky AHEC Partners with BarrenRiver Long-Term Care Ombudsman Program

Lucy Juett, Director, South Central KY AHEC, leads one of the group discussions onthe theme, Care Matters, with residents at the 2006 Resident Conference.

Residents of long term care facilities enjoy dining at a table decorated by one of the 20community organizations for the 2006 Resident Conference.

care offered by long-term care facilities,alternatives to nursing home placement, thelimits of Medicare skilled-care coverage,information about applying for Medicaidlong-term care benefits, and many helpfulconsumer tips. It also includes a comprehen-sive listing of every licensed long-term carefacility in the area.

Since this partnership began, more than 160family practice residents have been educated,

over 350 nursinghome residentshave been trained,and consumerguides have beendistributed to 5,500people. The SouthCentral KentuckyAHEC and theBarren River Long-Term Care Om-budsman Programhave forged a long-standing relation-ship which willcontinue to grow asthey seek new waysto merge themissions of theiragencies.

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The National AHEC Bulletin

is a publication ofThe National AHEC Organization (NAO)

EDITORIAL BOARD:Robert J. Alpino, MIAHeather Anderson, MPH, Co-ChairThomas J. Bacon, DrPH, Co-ChairJoel Davidson, MA, MPA*Tina Fields, PhD, MPH*Gretchen Forsell, MPH, RDSally A. Henry, MA, RN, FHCE, Co-ChairShannon KirklandKenneth Oakley, PhD, FACHERosemary Orgren, PhDCatherine Russell, EdDStephen Silberman, DMD, MPH, DrPhKathleen Vasquez, MSEdKelley Withy, MD

The National AHEC Program Office

AHEC Branch

Division of State, Community & Public Health

Bureau of Health Professions, Health Resources and Services Administration

Parklawn Building, Room 9 - 105

5600 Fishers Lane

Rockville, MD 20857Phone: (301) 443-6950Fax: (301) 443-0157

• Louis D. Coccodrilli, MPH E-mail: [email protected]

• David D. Hanny, PhD, MPH E-mail: [email protected]

• Norma Hatot E-mail: [email protected]

EX-OFFICIO MEMBERS:Louis D. Coccodrilli, MPHSusan MorelandTeresa M. Hines, MPHNancy SudgenAndy Fosmire

Staff Editor:Gay S. Plungas, MPH

*Co-editors

Requests for copies of the Bulletin should bedirected to NAO Headquarters.

• Vanessa F. Saldanha, MPH E-mail: [email protected]

• Jennifer A. Tsai, MPH E-mail: [email protected]

• Leo Wermers E-mail: [email protected]

National AHEC BulletinSpring/Summer 2007

Call For Articles“Re-Emerging Health Workforce Concerns”

Is the United States facing a health workforce crisis in the near future, such as a shortage of

nurses and primary care physicians? Many prominent researchers think so. Recent articles point to achronic maldistribution of healthcare workers, decreasing job satisfaction, lower reimbursements, a precipi-tous decline in the choice of primary care disciplines for medical school graduates, and the need for ahealth workforce that reflects the growing diversity of the country. These factors can have far-reachingimplications regarding access to health care, particularly for medically undeserved rural communities andother vulnerable populations groups, such as the elderly, poor and recently arrived immigrant groups.Additionally, with HRSA’s Bureau of Primary Care already in the process of expanding community healthcenters nationwide, there is an acute need for health professionals committed to caring for theunderserved.

Because the AHEC Program’s core mission is to address these very issues, the Spring 2007 edition

of the NAO Bulletin will highlight AHEC/HETC program successes in assessing and helping to build the healthprofessions workforce. Articles are solicited that describe effective AHEC/HETC programs, or AHEC/HETCsupported efforts, for example:

• Programs that increase the numbers of healthcare providers in rural and underserved areas.• Programs that improve retention of health care workers in rural and underserved areas.• Programs that have had an impact on the recruitment of health professionals to Community Health

Centers and other safety net sites through strong working relationships with AHEC/HETC.• Documented AHEC/HETC success stories related to broadening/impacting the diversity of the health

care workforce.• Successful strategies for assessing present and future health workforce needs.• Programs that have been successful in increasing the number of medical/osteopathic school gradu-

ates choosing primary care residencies (special tracks in the medical school curriculum, mentoringprograms, state supported incentive programs, etc.) in which AHEC/HETC plays a role.

Deadline for First Draft of Articles: Monday, February 26, 2007

Editorial Guidelines (Bulletin submission guidelines) can be found at the NationalAHEC webpage: www.nationalahec.org under NAO Bulletin or at:

http://www.nationalahec.org/Publications/documents/BULLETIN%20submission%20guidelines.pdf

Please submit drafts, photos, and accompanying materials to:

[email protected]

If you have any questions, please contact one of the following:

Kelley Withy, M.D. Heather Anderson, MPH Kenneth Oakley, Ph.D.

University of Hawaii California AHEC System Western New York Rural AHECHawaii/Pacific Basin AHEC 550 East Shaw, Suite 210 20 Duncan St., PO Box 152651 Ilalo St Fresno, CA 93710 Warsaw, NY 14569Honolulu, HI 96813 (phone) 559-241-7650 (phone) 585-344-1022(phone) 808-692-1060 (fax) 559-241-7656 (fax) 585-345-7452(fax) 808-692-1258 [email protected] [email protected]@hawaii.rr.com

Contact NAO

NAO Headquarters address:109 VIP Drive, Suite 220Wexford, PA 15090Phone: (888) 412-7424Fax: (724) [email protected]

NAO Headquarters Contacts

Judy [email protected]

Annie [email protected]

Barbara [email protected]

The National AHEC Organization MissionNAO is the national organization that supports and advances the AHEC/HETCnetwork in improving the health of individuals and communities by transforminghealth care through education.

The AHEC MissionTo enhance access to quality health care, particularly primary and preventivecare, by improving the supply and distribution of health care professionals throughcommunity/academic educational partnerships.

The HETC MissionHETCs provide community health education and health professions training programs in areas ofthe U.S. with severely underserved populations such as communities with diverse cultures andlanguages. Border HETCs target healthcare workforce needs to address thepopulation in close proximity to the U.S.-Mexico border and Florida using a bi-nationalapproach to border health issues. Non-border HETCs are located in other seriouslyunderserved areas of the country.

www.nationalahec.org

Oral Health, Mental Health, and Geriatrics: The … Publication of the National AHEC Organization VOLUME XXIII, NUMBER 1 Autumn/Winter 2006 Oral Health, Mental Health, and Geriatrics:

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