The Virtual Dental Homefiles.ctctcdn.com/e875664f001/5234616c-1cee-4e5c-a... · The Dental Home The dental home is the ongoing relationship between the dentist and the patient, inclusive

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Wel

com

e to

Lisa Greenshields, RDHAP, BS

Susan McLearan, RDHAP, MA

Sacramento Dental Hygienists’ Association

September 24, 2014

Course Objectives Be able to discuss the reasons behind the

movement to expand the dental workforce

Be able to define direct access and list four types

existing in the U.S.

Be able to discuss the most prominent workforce

models currently being tested

Be able to list the settings and scope of the

RDHAP

Be able to compare aspects of the VDH Project

with the current roles of the RDH and RDHAP

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The Surgeon General’s Report

• “Although there have been gains in oral health status for the population as a whole, they have not been evenly distributed across subpopulations.”

• Profound health disparities exist among populations including:

– Racial and ethnic minorities

– Individuals with disabilities

– Elderly individuals

– Individuals with complicated medical and social conditions and situations

Reports Dental Hygiene Workforce

Registered Dental Hygienists in California: Regional Labor Market Chart

Mertz and Bates

Center for the Health Professions

hppt://www.futurehealth.ucsf.edu

2008

Data from 2005

Reports Access, Quality Assurance, etc.

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Governor’s Report

• January 2014

• National Governor’s Association (NGA)

• Center for Best Practices Health Div.

• The Role of Dental Hygienist in Providing Access to Oral Health Care

– states can consider doing more to allow dental hygienists to fulfill these needs by freeing them to practice to the full extent

of their education and training.

UCLA Study

Friday, September 5, 2014

Preventive care outreach programs

in unorthodox settings are

successful in getting underserved

screened for health conditions…….

Total Population

281,000,000

Institutionalized

4,000,000 (1.4%)

Community Living

277,000,000 (98.6%)

Severe Medical

Co-morbidities

24,500,000 (8.7%)

Generally Healthy

252,500,000 (89.9%)

Economically

Disadvantaged

43,000,000 (15.3%)

Not Economically

Disadvantaged

209,500,000 (74.6%)

Remote

3,000,000 (1.1%)

Non-remote

40,000,000 (14.2%)

Remote

10,500,000 (3.7%)

Non-remote

199,000,000 (70.8%)

Note: The percentages are of the total population.

Source: ADA 2006 CDHC Report, 2000 Census

Population Categories

82,000,000 = 29.18% 192,000,000 = 70.8%

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70%

Well Served

30%

Underserved

Population Categories

192 million 82 million

Complex medical, physical,

and social conditions

Culturally diverse

Institutionalized

Economically disadvantaged

Rural

Children’s Use of Dental Care

in California

Among the findings:

– 24 percent of all children in California have

never visited the dentist.

– Significant racial/ethnic differences in dental visit rates exist, even among Latino and Asian subgroups.

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The Elderly

and Infirm

• Suffer disproportionately from

– Active and untreated mouth infections

– Loss of teeth

– Old and ill-fitting dentures

– Impairments in salivary and masticatory function

Source: Centers for Medicare and Medicaid Services

U.S. Dept. of Labor, Bureau of Labor Statistics: Occupational Outlook Handbook 2008-09

Projections data from the National Employment Matrix

General Dentists: http://www.bls.gov/oco/ocos072.htm#oes_links

Dental Hygienists: http://www.bls.gov/oco/ocos097.htm#projections_data

General Dentists = 9% increase, Dental Hygienists = 30% increase

136,000 149,000

167,000

217,000

0

50,000

100,000

150,000

200,000

250,000

2006 2016

Number and Projections of General Dentists and Dental Hygienists

General Dentists

Dental Hygienists

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WHAT IS

DIRECT ACCESS?

What are Workforce Models?

Direct Access –Definition ADHA

• Direct access means that the dental hygienist can initiate treatment based on his or her assessment of patient’s needs without the specific authorization of a dentist

• RDH may treat the patient without the presence of a dentist, and can maintain a provider-patient relationship

Direct Access

• One way to address the gaps in workforce vs. need

• Patient does not have see the dentist first, they can go straight to the RDH

• May mean that the RDH may bill directly for services they render

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All red states are not equal.

General Supervision

8 states

Public Health Hygienists

13 states

Collaborative Practice

12 states

Independent Practice

6 states

Direct Access

No Direct Access = 13 states

General Supervision Hygienists can initiate patient care with a dentists authorization,

in writing, such as seeing a patient of record in a nursing home

• Maryland

• New York (until 2015)

• Oklahoma

• Rhode Island

• South Carolina

• Tennessee

• Texas

• Vermont

Note that none can direct bill

for services rendered

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Public Health Hygienists Hygienists work under the supervision

of local state or federal programs

• Connecticut $

• District of Columbia

• Florida

• Iowa

• Kentucky

• Massachusetts $

• Missouri $

• Montana $

• Nebraska $

• Nevada $

• New Hampshire

• Pennsylvania

• Wisconsin $

$ = Direct billing allowed

Collaborative Practice Hygienists may provide services outside of a dental practice

according to the terms of a collaborative agreement.

Pre-diagnosis/treatment plan not required.

• Alaska

• Arkansas

• Idaho

• Kansas

• Michigan $

• Minnesota $

• New Mexico $ Rx

• New York (2015)

• Ohio

• South Dakota

• Virginia-Pilot Project

• West Virginia

Independent Practice Hygienist may practice without supervision in defined venues

and receive direct reimbursement

• Arizona $

• California $

• Colorado $ DH Diagnosis

• Maine (2014) $, no programs yet

• Oregon $ Rx

• Washington $

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Collaborative & Independent

Practice

• Some no special requirements

• Some require additional training

• Many have years of practice requirements

– Maine=Highest requirement is 6 years and 6,000 hrs

– California 3 yrs, 2,000 hours, Bachelor’s or equivalent

New(er)

Workforce Models

• Mid-level Therapist (ADHA Model 2004)

– DHAT-Alaska

– DT and ADT- Minnesota

• Collaborative Practice

• Independent Practice (RDHAPs in California)

• Public Health Hygienists

• Community Health Aids

– Promatoras

– ADA Models (create new providers) • Oral Preventive Assistant (OPA)- preventive and scaling dental assistant

• Community Dental Health Coordinator (CDHC) community based mid-

level

• Apple Tree and other Mobile Dental Models*

DHAT- Alaska

• Not ADHA’s model

• Started in 2004-began practicing in 2008

• 24 month program administered by ANTHC in partnership with the University of

Washington DENTEX program

• Remote general supervision by tele-dentistry

• DHAT providers are often Alaskan Natives

who reside or grew up in the remote villages

they serve

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DHAT- Duties

• Oral health and nutrition education

• Sealant placement

• Fluoride treatments

• Coronal polishing

• Prophylaxis

• Expose radiographs

• Restorations

• Placement of pre‐formed crowns

• Pulpotomies

• Non‐surgical

extractions

• Non‐surgical

periodontal therapy

Metropolitan State University

Advanced Dental Therapist

Apple Tree Model

• Modeled after Mayo Clinic

• 6 Free standing clinics

• Satellite site

– Equipment wheeled in

– Dental Director

– Utilize ADTs

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Apple Tree – San Mateo

Scheduled to begin satellite services in 2015

ADA’s Workforce Model

American Dental Association

“New Providers” Model

Oral Preventive Assist.

(OPA)

• Curriculum available thru ADA

• States decide duties

– Possibly sealants, fluoride and scaling Type I

• Is a certified dental assistant to work in an office or some community

Comm. Dental Health Coord.

(CDHC)

• Pilot Projects in 6 states

• New Mexico certificate program 2011

• 18 mo. program

• Can be an RDH or DA

‐ Oral health and nutrition education

Sealant placement ‐ Fluoride

treatments

Coronal polishing ‐ Scaling for Type I

Temporary fillings

Development and implementation of

community based programs

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Promotoras

CDHC

ADHP

RDHAP DHAT

Community

Oral Health Providers

RDHAP Movement in California

• 1972-73 AB 1503 creates Health Manpower Pilot Projects

• 1981 CDHA submits proposal

• 1981-86 raise money

• 1986 HMPP #139 begins was closed down in 1990

• 1990 HMPP #155 begins

• 1998 AB 560 passes after several failed attempts from initiation to legislation = 18 years (1980-1998)

• 2003 First training program WLAC

• 2004 UOP On-line training

• 2010 HWPP #172

• 2014 AB 1174

The RDHAP Model

• RDHAP – a California Workforce Model

• Not a mid-level

• Restricted practice sites/populations

• Many clients do need a DDS

• Most need prevention and case management

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RDHAP

Practice Sites

• Residences of the homebound

• Schools

• Residential facilities and other institutions

• Dental health professional shortage areas

RDHAP

Practice

This is what is seen every day

More than a perio problem

The Medical Home

• A.A. Pediatrics-1967

• Care management over time

• Patient-centered

• Comprehensive and team based

• In pediatric medical home models, there is also an emphasis on access and early intervention services

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The Dental Home The dental home is the ongoing relationship between the dentist and the

patient, inclusive of all aspects of oral health care delivered in a

comprehensive, continuously accessible, coordinated, and family-centered way

• Modeled after the medical home concept

• Articulated by the A.A. Pediatric Dentistry

“Virtual” Dental Home

• Modified from Dental Home

HWPP

# 172

California Health Workforce

Pilot Project

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HWPP #172

• Steps

– Infrastructure, training, agreements

– Expand the duties of existing providers

• x-ray decision

• “Interim Therapeutic Restorations”

– “Proof of concept” demonstration

– Measure health improvement, economic

modeling

– Advance legislation/ regulatory reform

– Stabilize and spread

The Virtual Dental Home Sites

Virtual Dental Home Sites

VDH Pilots In Training

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Quantifying and Collecting Data

Training the Virtual Workforce

Learning Laboratory

VIRTUAL DENTAL HOME

Equipment and Procedures

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Photographs-

Intra and Extra Oral Cameras

Photographs

CAMBRA Risk Assessment

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Basic Measures

Basic Measures

Performing Procedures

in the Community

• Care management over time

• Preventive education

• Prevention procedures

– Teeth cleaning

– Medical treatments

– Interim Therapeutic Restorations

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School Based

Planning

• Pre-existing • Treatment Plan

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Quick Facts

• Preliminary results indicate that the Virtual Dental Home Project can currently keep 60% of the student population healthy at the school site, providing continued hygiene care, sealants, fluoride varnish and interim therapeutic restorations (ITR).

Early Intervention

White Spot Lesions and

shallow cavitation

Prevention

• Calculus removal

• Pit/fissure sealant

• Fluoride varnish

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Radiographs

Radiographs

Intra- Oral Photographs

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Photographs

Sealants

Sealant

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Residence Based

VDH Set-Up in Activity Room

Virtual Dental Chart-X-Ray Set-Up

X-ray Set-up

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Resident with Mobile Oxygen

Interim Therapeutic Restoration

Set Up


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Interim Therapeutic

Restoration


Before

After

Glass Ionomer

I

T

R

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DDS Intervention

Results

From here To here

Prevention-More Than Restoration

Risk assessment and evaluation

Anti-bacterial regime

Maintenance

Re-Mineralization

Combating effects of xerostomia

Daily, effective oral hygiene

Case Management

Integration with medical and social services

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Caregivers, a major challenge

• Demonstrating • Pre and Post Brushing

Training the Caregivers

• Training Program • RNs, LVNs, CNAs,Others

Educator/School Staff In-service

Training Program School Nurses, Health Assistants, Teachers

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Institutionalizing

Prevention

Developing understanding and

appreciation for preventive products

Oral Chemistry

pH Testing

ATP Testing

Oral Chemistry

Fluorides Anti-microbials

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Oral Chemistry

Xylitol Ca+ Phosphates

Role of Nutrition

School Lunch SNF Snack Cart

Challenges

• Physical challenges in providing care

Operator challenges:

• Visibility

• Back support

Positioning with consideration to:

• Inability to swallow

• Head support

• Evacuation

• Fear

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Challenges

• Product delivery, use and oversight

• Patient/caregiver

• Follow-through and accountability

• General lack of experience with special populations

AB 1174

What is it?

• AB 1174 is a bill carried by Assemblymen Bocanegra and Logue intended to codify the duties proved safe by HWPP #172

• Clarifies and codifies RDAEF/RDH/AP ability to determine which x-rays to take

• Allows trained RDAEF/RDH/APs to place Interim Therapeutic Restorations (ITRs)

using glass ionomer filling material

AB 1174

Where it is now…

• AB 1174 has passed both the Assembly and the Senate (and subcommittees)

• Has been enrolled and sent to Governor Brown

• Governor Brown can sign it and it becomes

law, not sign it and it still becomes law, or veto it and it is “dead.”

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What happened…it all worked out Author’s View

• Clarified x-ray decision

• Clarified responsibility and limited number of auxiliaries supervised

• Provided additional duties for RDAEF, RDH and APs

• Set out training guidelines

• CDHAs concern of “potential misinterpretation” unjustified

CDHA View

• Did not acknowledge current RDH x-ray duty

• Added RDH supervision where there had been none

• Went over the top and did not acknowledge the role of the DHCC to develop regulations

• Various elements could be misinterpreted and

What might this mean

for dental hygiene?

• Continuing steps to increase scope of practice which can

• Lead to more opportunities and

• Utilization in alternative settings

References

Oral Health In American http://silk.nih.gov/public/[email protected], accessed September 20, 2014 Registered Dental Hygienists in California: Regional Labor Market Chart, http://futurehealth.ucsf.edu/Public/Publications-and-Resources.aspx, accessed September 20, 2014 Improving Access to Oral Health…..http://www.iom.edu/Reports/2011/Improving-Access-to-Oral-Health-Care-for-Vulnerable-and-Underserved-Populations.aspx, Accessed September 20, 2014 Oral Health In the Era of Accountability…, https://www.dentaquestinstitute.org/sites/default/files/reports/2011/12/Pacific_Center_for_Special_Care_Report.pdf The Role of the Dental Hygienist in Providing Access to Oral Health Care, http://www.nga.org/files/live/sites/NGA/files/pdf/2014/1401DentalHealthCare.pdf, accessed September 20, 2014 The Have and Have Nots…., http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/D/PDF%20DentalDisparitiesSnapshot07.pdf, Accessed September 20, 2014 Facts About California’s Elderly https://www.aging.ca.gov/Data_and_Statistics/Facts_About_Elderly/, accessed September 20, 2014

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References cont…

Direct Access Map and Chart http://www.adha.org/direct-access, accessed September 20, 2014 Alaska Dental Health Aid Therapists, http://itcaonline.com/wp-content/uploads/2013/06/Addressing-Early-Childhood-Caries-in-American-Indian-and-Alaska-Native-Communities.pdf, accessed September 20, 2014 Advanced Dental Therapy, Metropolitan State University http://www.metrostate.edu/msweb/explore/gradstudies/masters/msadt/. Accessed September 20, 2014 Apple Tree Dental http://www.appletreedental.org/, accessed September 20, 2014 Apple Tree Dental San Mateo http://www.peninsulahealthcaredistrict.org/apple-tree-center-for-dental-health/, accessed September 20, 2014 Review of Proposed Oral Health Workforce Models: Part 1, Access, August 2008, pg.21-31 Policy on the Dental Home, http://www.aapd.org/media/Policies_Guidelines/P_DentalHome.pdf, accessed September 20, 2014

References cont.

The Virtual Dental Home Policy Brief http://dental.pacific.edu/Documents/community/special_care/acrobat/VirtualDentalHome_OvierviewResults_PolicyBrief_May_2013.pdf, accessed September 20, 2014 HWPP #172 Application http://www.oshpd.ca.gov/hwdd/pdfs/HWPP/Abstract_HWPP172.pdf, accessed September 20, 2014 Basic Screening Survey Tools, http://www.astdd.org/basic-screening-survey-tool/, accessed September 20, 2014 Overcoming Obstacles To Oral Health, http://www.dental.pacific.edu/Community_Involvement/Pacific_Center_for_Special_Care_(PCSC)/Education_/Overcoming_Obstacles.html, accessed September 20, 2014