State of New Mexico Office of Oral Health. What is Public Health? Winslow’s definition of public health is “the science and art of preventing disease,

State of New Mexico Office of Oral Health

What is Public Health?

Winslow’s definition of public health is “the science and art of preventing disease, prolonging life, and promoting physical and efficiency through organized community efforts” [Burt and Eklund, 2005:36].

Concerned with the health of the population

Defined by the American Board of Dental Public Health, AAPHD, ADA, and APHA Oral Health Section-

“Dental public health is the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts. It is that form of dental practice which serves the community as a patient rather than an individual. It is concerned with the dental education of the public, with applied dental research, and with the administration of group dental care programs as well as the prevention and control of dental diseases on a community basis” [Burt and Eklund, 2005:40].

What is Dental Public Health?

1988 Institute of Medicine (IOM) Core Functions of Public Health Assessment: the regular collection and

dissemination of data on health status, community health needs and epidemiologic issues

Policy Development: promotion of the use of the base of scientific knowledge in decision making on policy matters affecting the public’s health

Assurance: the provision of services necessary to achieve mutually agreed-upon goals, either directly, by encouraging other entities to supply them or by regulation [Burt and Eklund, 2005:37]

Cultural Competency 1996 Archbold M. definition of Cultural

Competency: “ A set of academic and personal skills that

allow us to increase our understanding and appreciation of cultural differences between groups.”

[Bilingual Advantage, Inc.,

2006]

Socioeconomic position

Race and Ethnicity

Social Networks and Social Support

Work Conditions

[IOM, 2003]

Social Determinants of Health

GeneticBiologicalCultureEnvironmentSocioeconomic StatusCan have interaction among themselvesMay influence one another [Kwan and

Peterson, 2010]

Factors that Play a Role in Determining Oral Health

Prevention Primary Prevention- Prevention of disease School based or school linked programs.Secondary Prevention- Identify and control

disease process in early stagesTertiary Prevention- Prevent disability by

restoring to optimal level of functioning after the damage is done

[Turnock, 2009]

Department of HealthOral Health Programs•Office of Oral Health

•Office of Primary Care and Rural Health•Office of School and Adolescent Health

New Mexico 121, 356 square milesIn excess of 2 million persons (2011)Asian– 1.6% (2011) Black/African American—2.5% (2011)American Indian– 10.1% (2011)Hispanic Latino origin– 45% (2011)White– 41% (2011)Approximately 34% of the population live in rural

areasApproximate poverty rate in rural areas—24% (2011)

Dental Access to Care in NM 32.8% adults reported no dental visit within

the past year in 2010 DOH surveyNew Mexico ranks 49th in the number of

dentists per 100,00023% had no insurance coverage in 2010

[NM State of Health, 2012]

New Mexico Continued: 33 counties in New Mexico32 are considered Health Professional

Shortage Areas (HPSAs)26 are considered dental HPSAs 2 rural counties do not have dentists

NM Office of Primary Care and Rural Health

New Mexico

Barriers to Accessing Health CareLong travel distances [Bushy, 2009:26]Lack of public transportation [Bushy, 2009:26]Cannot take time off from work [Burt and Eklund,

2005]Unreasonable office hours [Burt and Eklund, 2005]Limited telephone and internet services [Bushy,

2009:26]Shortage of health care providers [Bushy, 2009:26]Inability to seek or obtain entitlements [Bushy,

2009:26]Limited economic resources– income and insurance

[Bushy, 2009:26]Challenging roles and unpredictable weather conditions

[Bushy, 2009:26]

New Mexico Dental Providers Licensed dental providers in 20111,326 dentists1,320 hygienists1,471 assistants [NM State of Health, 2011]

Licensed dental providers in 20091,326 dentists1,132 hygienists1,878 assistants [NM Dental Health Care Board 2011]743 dentists provided services to a Medicaid patient.

Licensed does not mean practicing!

Office of Oral Health

Office of Oral HealthBudget $3.1 million general fund

Staffing 8 FTE: 3 dental hygienists, 3 dental assistants, 2 dental case managers*, 1

dentist*, and 1 financial operations specialist. 1 DCM and 1 dentist under contract

Preventive material and operating supplies Supports operating dental vans, purchase of preventive material, educational

material, portable equipment, and screening supplies.

Contractor support School based dental sealant and restorative care contractors. Basic preventive and treatment services for indigent New Mexicans.

Contractors reimbursed for services based on current NM Medicaid rates.

* contract employee

Primary PreventionDental Sealant Program3 state teams services 50% F&RSLP elementary schools 3 private contractorsState Fluoride Varnish Program

•Santa Fe and Rio Arriba Counties•State wide: Head Start, Pre-K, Cleft Palate•Dental Case Manager (2 county)•State contractors

Preventive and Restorative Care Under Contract (Uninsured)

•Mira Consultants – screening, dental sealants and treatment (children) •El Centro Family Health – preventive and treatment•UNM Dental Sciences – preventive and treatment•Community Dental Services – preventive and treatment• Sandoval Health Commons (WIC preventive/referral)

Office of Oral Health State Fiscal Year 12Total Population Served # of unduplicated indigent persons 0-4 1797 # of unduplicated indigent persons 5-19 11068 # of unduplicated indigent persons 20-64 4825 # of unduplicated indigent persons 65+ 806 18496 Dental Sealants

Screening 7,724Child receiving 6,524

Fluoride VarnishScreening 1,243*Child receiving 2,722**

* Children receiving general screening vs. X-ray.** Total children receiving an application.

Office of Primary CareFY 2013

Program allocated over $12.6 million general fund for the operation of 97 Primary Care Clinics 37 clinics provide dental services

FY 2012 196,000 dental encounters were reported by the clinics

New Mexico Dental Support Center (NMDSC) In 2009, NMDOH received a three-year workforce grant to establish a New Mexico Dental Support

Center (NMDSC) to provide a wide range of support to dental professionals who work in rural areas and in community health centers, as well as a center of professional support and network of communication for dental educators throughout the state.

During the past three years, the NMDSC has provided communication networks for providers and educators, new provider orientations, face-to-face meeting with providers, continuing education opportunities, provider meetings, direct assistance, funding for community-based prevention projects, educator meetings and professional development for educators.

The NMDSC has established and maintained a database and electronic distribution list of NM dental providers who work in rural areas and community health centers, and a database and electronic distribution list of NM dental educators. The NMDSC has provided quarterly provider meetings and monthly newsletters in partnership with the New Mexico Primary Care Association, and coordination and facilitation of dental educator annual meetings and periodic conference calls. Over 80 dental providers have received technical assistance and over 37 have received scholarships.

Since funding ended in August 2012, the NMDSC is unable to sponsor continuing education events, provide scholarships and professional development, and fund prevention projects, however, it will continue with all other activities and remain a valuable resource for NM dental providers and educators.

Important dates in NM Dental Public Health1942- full-time dental consultant in PH Dept

[Special Feature Public Health, n.d.]1948- clinic for indigent children [Greenfield,

1962]1953- Public Health Dept. Div. of Dental Health

[Special Feature Public Health, n.d.]1962- 2nd mobile dental clinic [Greenfield, 1962]1963- mobile units reach 22 communities

[Special Feature Public Health, n.d.]1975- 3 mobile units & 3 fixed facilities [J.

Calderone, personal communication, 6/23/2010]1979- school based sealant program- 15 teams

[J.Calderone, personal communication, 6/23/2010]

Important Dates Continued:1983- RDH can apply sealants under general supervision

[J. Calderone, personal communication, 6/23/2010]1985- sealant program only [J. Calderone, personal

communication, 6/23/2010]1997- Special Needs Code [R. Lyons, personal

communication, 7/12/2010]2005- WICHE awardees must practice in NM [J.

Harrison, personal communication, 6/23/2010]2010- NM Board of Dental Health Care accepts all dental

exams for licensing [J. Harrison, personal communication, 6/23/2010]

2012 Legislature expands scope of practice for dental hygienists.

Characteristics of the Frontier and Rural Lifestyle and Culture

Extensive distances between people and servicesWork and recreational activities are often cyclic

and seasonal in natureProminence of high-risk land oriented

occupations and activitiesSocial interactions that facilitate, frequent,

informal, face-to-face contactsClose social or kinship relationships among

community membersPreference for informal support systems in time

of need

Characteristics of the Rural and FrontierLifestyle and Culture Continued

Individual and community self-relianceSmall towns as centers of tradeChurches and schools are centers of socialization

for residentsImportance of local health systems, especially

hospital and long-term care facilities, to the economy

Overlapping roles and relationships for clinicians as community members

[Bushy, 2009:21]

Features Encountered by the Rural Provider Limited health care services and resourcesGeographic barriers to health care servicesConflicts between community values and professional

guidelinesChallenges to privacy and confidentialityA clinician providing care to a neighbor, a friend, or

family memberA provider trying to deliver quality care, despite being

professionally isolated, with limited access to peers and specialists

Overlapping professional and personal boundariesCommunity expectations and professional stress [Bushy, 2009:16]

Difference between Rural and Non Rural Populations

Less dentists in rural areas

Less dental care in rural areas

Higher caries rate in rural areas

Higher tooth loss in rural areas [Rural Health Research

Center, 2009]

What are the sources of patient care revenue?Medicaid- dental insurance for low income patients- fee-for-

service or capitation; can be main source of reimbursement for “safety-net clinics”

State Children’s Health Insurance Program (SCHIP)- Medicaid expansion programFee-per-visit- FQHCFee-per-covered member- managed care Insurance- indemnity; possible deductible and co-paymentFull Pay- Not eligible for Medicaid/No insuranceSliding Fee Scale- “safety-net” clinic reduced fees in

accordance to ability to payMinimum- may be offered to people below the poverty level

[Safety Net Dental Clinic Manual, 2009]

Community Health Centers Economic Opportunity Act of 1964—add federal funds to

community resourcesProvide services to populations with limited health care

accessFederally Qualified Health Centers (FQHCs)—Receive

Section 330 grant fundingMust adhere to certain federal regulationsOutpatient health programs/facilities operated by tribal

organizationsBoard of Directors, Executive Director, and Key

Management Team734 FQHCs offered dental services as of 2007

[National Network for Oral Health Access, 2009]

All Levels of Services1. Emergency Dental Services2. Prevention & Diagnosis 43. Basic Dental Care 3

4. Rehabilitative Services- 2 includes crown, bridge, 1 dentures

[National Network for Oral Health Access 2009]

Quality Assurance and Improvement Quality—IOM 1990 definition— “the degree to

which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

Quality Assurance—reactive—examine after—focus on provider competence

Quality Improvement—proactive—quality built into work—preventive—focus on systems and processes

[Safety Net Clinic Manual, 2009:2]

NM Programs available for Dental ProfessionalsNew Mexico Health Service CorpsHealth Professional Loan Repayment Western Interstate Commission Higher

Education (WICHE) Loan- for- serviceGraduate Scholarship Rural Health Provider Tax Credit

[NM State of Health, 2009]

New MexicoWhat is the NM State Tax Credit? What are the

requirements to qualify? How do I apply?—Eligible dentists and hygienists who practice in a designated rural health care underserved area can apply for an income tax credit. Maximum tax credit for dentists is $ 5000/yr, for hygienists it is $ 3000/yr. There is a list of approved rural practice locations. For additional information and to apply visit-- http://www.health.state.nm.us/ Click on Rural Health. The Provider Tax Credit is at the bottom.

State and local community partners.5 Regional Planning meetings.

Develop strategies to turn the curve for the local community.

Water Fluoridation In New Mexico, community water fluoridation has come under attack by the local and

national anti-fluoridation movement. The Albuquerque Water Authority ceased water fluoridation to its customers

without public notice. The city of Santa Fe has proposed to stop fluoridating but the matter has been put

on the shelf. Santa Fe Oral Health Coalition formed to promote fluoridation and to

improve the oral health status of pre-school and school aged children within the city and county.

Coalition will partner with the city of Santa Fe to promote oral health with the various school systems.

The city of Farmington will be the next community to be targeted by the anti-fluoridation movement .

The city of Espanola will be considering fluoridating its water.

Office of Nutrition and Physical ActivityOOH partners with the ONPA to promote child nutrition, physical activity and general health.ONPA has integrated in its educational material oral health specifically the consumption of fluoridated water. ONPA is funded by CDC and the Commuity Transformation Grant

Strategic Plan & Partnerships + Tools + Support

= More Direct Path to Improved Oral Health for the people of New Mexico

References:Burt, B.A. & Eklund, S.A. (2005). Dentistry, Dental Practice,

and the Community (6th ed.). St. Louis: Elsevier Saunders. Bilingual Advantage, Inc. (2006). Cultural Competence/CLAS

Training for Healthcare Workers. NMDOH.Bushy, A. (2009). A Landscape View of Life and Health Care in

Rural Settings. In W.A. Nelson (Ed.), Handbook for Rural Healthcare Ethics: A Practical Guide for Professionals. Retrieved from

http://dms.dartmouth.edu/cfm/resources/ethicsCDC (Centers for Disease Control and Prevention). (2010).

Community Water Fluoridation. Retrieved from http://www.cdc.gov/fluoridation

Doescher, M.P., Keppel, G.A., Skillman, S.M., & Rosenblatt, R.R. (2009). The Crisis in Rural Dentistry. Rural Health Research Center. Retrieved from www.ruralhealthresearch.org

GADS Report. (2009). New Mexico Health Policy Commission.Greenfield, M. (1962). A History of Public Health in New

Mexico. Albuquerque: University of NM Press Institute of Medicine. (2003). The Future of the Public’s

Health in the 21st Century. Washington DC: The National Academies Press.

References Continued: Kwan, S. & Peterson, P.E. (2010). Oral Health: Equity and Social

Determinants. In E. Bias & A.S. Kurup (Eds.), Equity, Social Determinants and Public Health Programmes. Geneva: WHO Press. Retrieved from http://whqlibdoc.who.int/publications/2010/9789241563970_eng.pdf

New Mexico State of Health. Oral Health. (2009). Retrieved on February 19, 2010, from http://nmhealth.org/pdf/SoHiNM%202009%20(12-21-08)pdf.

National Network for Oral Health Access. (2009). Operational Manual for Health Center Oral Health Programs: Chapter One—Health Center Fundamentals.

New Mexico Office of Oral Health. (2009). Office of Disease Prevention & Health Promotion. (2009). Public

Comment – Healthy People 2020. Retrieved on June 24, 2010, from http://healthypeople.gov/hp2020/Objectives/TopicArea.aspx?id=38&TopicArea=Oral+Health

Rural Health and Rural Human Services Resources for New Mexico. Retrieved on June 10, 2010, from http://www.raconline.org/states/newmexico.php.

Safety Net Clinic Manual. Retrieved from http://www.dentalclinicmanual.com.

Special Feature: Public Health in New Mexico 1919-1979. (n.d.) Turnock, B.J. (2009). Public Health What It Is and How It Works

(4th ed.). Sudbury: Jones and Bartlett.

Acknowledgments

Carol Hanson RDH, MPH Bill Burns, DDS, MPH

Rick Champany, DDS Wendy Churchill, DDS Cindy Cullen, RDH