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Oral Health Care for the Underserved: What Resources Are Available? Mitsuko Ikeda Project Director National Network for Oral Health Access 2012 NATIONAL PRIMARY CARE CONFERENCE ON AGING 2012 HEALTH CARE FOR RESIDENTS OF PUBLIC HOUSING

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Oral Health Care for the Underserved: What Resources Are Available?

Mitsuko Ikeda

Project Director National Network for Oral Health Access

2012 NATIONAL PRIMARY CARE CONFERENCE ON AGING 2012 HEALTH CARE FOR RESIDENTS OF PUBLIC HOUSING TRAINING CONFERENCE

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What is NNOHA?

  • A nationwide network of safety-net oral health

providers and their supporters

  • Established in 1991 by a group of Dental Directors

from Federally Qualified Community Health Centers (FQHCs) who recognized the need for peer-to-peer networking, services, and collaboration to most effectively

  • perate Health Center

dental programs.

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What is NNOHA?

  • Mission: “To improve the oral health of

underserved populations and contribute to

  • verall health through leadership, advocacy,

and support to oral health providers in safety- net systems.”

  • Currently about 2,000 individual members
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About Health Center Oral Health Programs

  • Health Centers are non-profit clinics that provide high-quality

health care services to underserved, low-income individuals with little, or no insurance.

  • 828 Health Centers across the country offer dental services.
  • In 2010, Health Centers provided dental care to 3.75

million patients. At the same time, Health Centers provided medical care to about 16.8 million patients.

  • Age 65+: Approximately 7% or 1.76 million
  • Medical capacity exceeds dental capacity in Health Centers

2010 UDS: http://bphc.hrsa.gov/uds/view.aspx?year=2010

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2010 National Public Housing Data

  • 172,731 total patients
  • 66,545 patients under 19 (38.5%)
  • 97,605 patients ages 19-64 (56.5%)
  • 8,581 patients ages 65 and over (5%)
  • 38,988 dental patients
  • 36.1% of Patients best served in a language other

than English

2010 National Public Housing Data: http://bphc.hrsa.gov/uds/view.aspx?prog=PH&year=2010

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Seniors’ Oral Health

  • More older people are keeping their natural teeth than ever
  • before. However, among those aged 65 years and over there

are sharp differences by income, with those in poverty twice as likely as those with higher incomes to have lost all their teeth.

  • Many older Americans take medications for chronic

conditions that have side effects detrimental to their oral

  • health. These include antihistamines, diuretics, and

antidepressants.

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Seniors’ Oral Health

  • One-third of adults aged 65 years and over have untreated

dental caries; slightly over 40 percent have periodontal disease.

  • Only 22 percent of older persons are covered by dental

insurance; most elderly dental expenses are paid out-of- pocket.

http://www.cdc.gov/nchs/pressroom/01facts/olderame.htm#ORAL HEALTH

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Access Challenges for Adults & Elders

  • Transportation
  • Mobility
  • Language
  • System navigation
  • Lack of dental insurance
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Insurance Challenges

  • Lack of Insurance Options
  • Medicare = Routine dental care for adults not covered
  • Medicaid = Most states do not cover routine dental care

for adults

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Insurance Challenges

  • Among older adults, approximately 46% age 65-74 and 39% age 75

and over had at least one dental visit.

  • While 60% of older adults from a high-income family had at least
  • ne dental visit during the year, less than 31% of older adults from

a poor or low-income family had at least one dental visit during the year.

  • Approximately 70% of older adults did not have any dental

coverage in 2004.

2007 MEPS data

  • Public housing residents were more than twice as likely as other

city residents not to have had a preventive dental visit in the past 2 years.

Use of a Population-Based Survey to Describe the Health of Boston Public Housing Residents (2008)

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Challenges to Maintaining Oral Health

  • Medication Use
  • Affects oral health (e.g. Dry mouth)
  • Motor control issues
  • Diet
  • Current oral health status
  • Resources/food sufficiency
  • Access to variety
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Access Solutions

  • Starting a dental program
  • Medical-Dental Integration
  • Expanding non-dental providers role in oral health

access

  • Utilizing local / state resources
  • Workforce Innovation
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Starting a Dental Program

  • How to Start a Dental Clinic:
  • http://www.nnoha.org/practicemanagement/star

tclinic.html

  • Safety Net Dental Clinic Manual
  • http://www.dentalclinicmanual.com/
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Other NNOHA Resources

  • Factsheet - "Characteristics of a Quality Oral

Health/Dental Program"

  • Action Guide - "Oral Health and the Patient-

Centered Health Home"

  • Operations Manual for Health

Center Oral Health Programs

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State & Local Resources

  • Health Centers
  • Other FQHC’s and look-alikes
  • Dental & Dental Hygiene Schools
  • State Programs
  • http://www.bphc.org/programs/cib/chronicdiseas

e/oralhealth/sohp/Pages/Home.aspx

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One-Time Events

  • Mission of Mercy
  • Launched by Virginia Dental Association

Foundation in 2000

  • Currently in over 20 states
  • http://www.adcfmom.org/
  • Remote Area Medical (RAM):
  • http://www.ramusa.org/services/dental.

htm

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ADA Resources

  • OralLongevity DVD/Brochure
  • Educational DVD/Brochure (English/

Spanish) available upon request

  • www.orallongevity.ada.org
  • National Coalition Conference: Oral Health of

Vulnerable Older Adults and Persons with Disabilities (November 18, 2010)

  • http://www.ada.org/nccc
  • Overcoming Obstacles to Oral Health training

material

  • www.adacatalog.org (item P030)
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Other Resources

  • ASTDD Basic Screening Survey for Older Adults

Planning and Implementation Packet

  • http://www.astdd.org/basic-screening-survey-tool/#adults
  • Smiles for Life
  • Chapters on geriatric oral health,

screening etc

  • http://www.smilesforlifeoralhealth.org/
  • Oral Health America “Wisdom Tooth Project”
  • http://oralhealthamerica.org/programs/wisdom-tooth-

project/ (Work in progress)

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Workforce Innovation

  • RDH Direct-Access States
  • http://www.adha.org/governmental_affairs/dow

nloads/direct_access.pdf

  • RDH-AP in SNIF
  • Teledentistry
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Contact Us!

Mitsuko Ikeda | Project Director mitsuko@nnoha.org National Network for Oral Health Access PMB: 329 3700 Quebec Street, Unit 100 Denver , CO 80207-1639 Phone: (303) 957-0635 Fax: (866) 316-4995

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Dan Watt, DDS Dental Director Terry Reilly Health Services, Nampa, Idaho dwatt@trhs.org

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Dan Watt, DDS Dental Director, Terry Reilly Health Services, Nampa, ID dwatt@trhs.org

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 Oral pathogens found in defective cardiac

lesions, aortic aneurisms, carotid artery plaque

 Raises C reactive protein and TNC  At this point research not sure if it is a cause or

an added effect

 Some theories consider anatomic anomalies as

cause for oral pathogens to stick to endothelium

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 Bacteremia from oral disease cause increases

in blood proteins which adversely affects insulin

 The rise in blood sugar adversely affects the

gingival tissues so periodontal diseases are more rampant (AGE/RAGE)

 This symbiotic relationship can lead to a

downward spiral in overall health.

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 The biofilm associated with periodontal disease

is a reservoir for Diplococcus pneumonii, Helicobactor pylori, Cytomegalo virus, Human papilloma virus and other putative pathogens.

 Given the exposure to other possible infective

  • rganisms, it is a possible portal of entry for
  • ther disease-related microorganisms

 Studies show 1 in 10 pneumonia deaths in

nursing homes could have been prevented with improve oral hygiene.

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 ADA Oral Longevity Initiative (2004-2008) – a

collaborative between ADA, ADAF, GlaxoSmith Kline (GSK) to enhance and preserve oral health of older Americans

 2005 GSK pledges $1M over three years to

ADAF to address the needs of older adults.

 2007 Distributed ORAL LONGEVITY

BROCHURES, and DVD’s to 155,000 dentists

 2008 Focused consumer attention in AARP  Initiated SENIOR SMILES program

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20,000 40,000 60,000 80,000 100,000 120,000

Cancer Heart conditions Dental Diabetes mellitus Normal birth

(Millions of Dollars)

Source: Medical Expenditure Panel Survey 2007, AHRQ, US Dept of Health and Human Services

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CRISIS IN ORAL HEALTH

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 47 m have difficulty accessing dental care  17 children received no dental care in 2009  Over ¼ adults age 65+ have no teeth  830,000 visits to E.R for dental conditions in

2009, up 16% since 2006

 60% of kids have caries  Dentists per capita are declining especially

those treating low income

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3% needed urgent care 17% retained root tips 28% untreated caries 28% soft tissue problems 63% had dentures – 59% unsatisfactory

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 Change perceptions – Oral Health Matters  Overcome barriers..and replicate effective programs  Build science base- accelerate science transfer  Increase workforce diversity, capacity, & flexibility  Increase collaborations with extant aging networks  Up to professions, policymakers, and the public to

determine next steps

 So what has happened??

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  • 50 % of elderly (65+) perceive their dental health

as poor

  • 33% of the elderly have untreated cavities, but

this is a low estimate as 43% visit the dentist

  • Low income elderly suffer more severe tooth loss

than their wealthier counterparts

  • Gum disease in 41% of the elderly
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 Allow an array of different providers with overlapping

scopes of practice – doing so can increase access “without compromising quality, safety or patient satisfaction.

 Broaden the dental workforce by “expanding the roles

  • f existing dental professionals and developing new

types of dental professionals

 Amend existing laws …to remove current restrictions

that may cause them to “miss critical opportunities to serve greater number of individuals in need of care.

 Permit the kinds of technology-supported supervision

that facilitate care and expand access.

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Organized dentistry does not support mid- level providers or physician directed oral screening and preventive care. 90% of physicians think oral health should be addressed at well primary care visits, although less than 50% have had oral health training.

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PRIMARY DENTAL CARE - PROVIDED BY A GENERAL OR PEDIATRIC DENTIST OR DELEGATED TO ANCILLARY PERSONNEL UNDER THE DENTIST’S SUPERVISION PRIMARY DENTAL CARE PROVIDER - IS A LICENSED GENERAL OR PEDIATRIC DENTIST WHO ACCEPTS THE PROFESSIONAL RESPONSIBILITY FOR DELIVERING PRIMARY DENTAL CARE DENTAL HOME – IS THE ONGOING RELATIONSHIP BETWEEN THE DENTIST AND THE PATIENT, WHICH INLCUDES COMPREHENSIVE ORAL HEALTH BEGINNING NO LATER THAN AGE ONE AND CONTINUING THROUGHOUT THE PATIENT’S LIFETIME

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 National and Local Politics  Scope of Care  Coding  Financing

 Numbers or Health

 Insurance/Health (Medical/Dental) Silos  Lack of Expertise  Lack of a Health System  Administrative, Dental, Medical Champions

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Policy makers are placing greater focus on health homes in an effort to improve health outcomes. More than 30 states have initiated efforts to advance such homes. Health homes coordinate medical, behavioral, and dental services by full integration, co-location, shared financing, virtual linkages, and facilitated referral and follow-up

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 Dental Disease is Preventable  Good evidence that primary care interventions

can make a difference

 Shrinking Supply of Dentists – Growing

Population

 “Cannot Drill and Fill our way out of this Crisis”

 Individuals currently with poor access have

better medical access

 >100 million without Dental, 50 million lack medical

insurance

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 Improve Quality of care through better

management of chronic diseases (oral disease is

  • ne)

 Improve the Patient Experience – Make them

part of the Management Team

 Reduce health Care costs by better

management of disease risks.

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 Empower individuals to take ownership of their

health –Educate, information and dissemination

 Enhance communication between providers and

patients

 Create a health system that will focus on the

patient and is supportive of full care integration.

 Combine medical and dental Home Initiatives  Provide recognition and adequate reimbursement

to professionals who coordinate referrals and navigation through the whole health system

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 Economic downturn has worsened elderly oral

health

 Retirees have less discretionary income  Percent of those covered by third parties has

significantly dropped (Medicaid, etc.)

 Health centers note an increase in low-income self-

insured elderly patients who can only afford urgent

  • ral care. Can become too great of burden for health

centers to manage.

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 Increase funding support to Health Centers to

target elderly populations

 Increase prevention and case management services

through outreach education.

 Increase training of medical and non-dental

professionals in screening and prevention techniques.

 Increase Medicaid benefits to adults!

 DEVELOP BETTER BACTERIAL RISK FACTOR METRICS!

 Develop the political will

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  • Oral Diseases are multifactorial involving:

1.

Bacterial - Communicable

2.

Nutritional

3.

Pharmacological

4.

Sociological

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  • My family has bad genes
  • Going to lose them anyway
  • Soft teeth
  • Cost
  • Cultural habits
  • Lack of understanding
  • Cheaper foods (sugar added) taste better
  • Depression – lack of hope
  • Candy is a reward
  • I don’t want to brush someone else’s teeth
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Cariogenic diets are popular Obesity Sugar is addictive Processed foods are easier to prepare Poor dentition and pain upon chewing Children must rely on others Elderly also dependent on others Poor fitting dentures

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March 23, 2012

The Oral Health 2014 Initiative DentaQuest Foundation

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 What: Access to Dental Care Summit, March 2009  How: Convened by American Dental Association;

joined by 125 other organizations.

 Objective: Bring together representatives from a

variety of organizations to create a shared vision to improve the oral health of underserved populations in the United States.

 Who: Health care policymakers, dental education and

research institutions, dental association leaders, financing organizations including third-party-payers and philanthropy, non-dental health care providers, dental volunteer leaders, consumer advocacy groups, special interest groups, state dental societies.

 DentaQuest Foundation – NOHA founding member

Optimal Oral Health for All Idahoans.

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Works in collaboration with local, state, and national partners, to

reduce health inequities

highlight prevention

foster civic engagement

influence systems that promote oral health beyond the clinical setting

Makes grants and supports programs that

improve oral health policy

access to care

public and private funding for oral health

community-based prevention

Applies the guidance of the U.S. Surgeon General's Call to Action on Oral Health 2000 to change

perceptions of oral health

increase partnerships and collaborations

replicate programs demonstrating effective change

Surgeon General’s Call to Action: “The public health infrastructure for oral health is insufficient to address the needs of disadvantaged groups and integration of oral health and general health is lacking.”

Optimal Oral Health for All Idahoans.

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Optimal Oral Health for All Idahoans.

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 Medical and dental collaboration  Prevention and public health infrastructure  Oral health literacy  Metrics for improving oral health  Financing models  Delivery system improvements

Optimal Oral Health for All Idahoans.

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 A few committed souls  Seized an opportunity  Recognized the need to change the system  Followed the belief that it could be done  Recognized the power of a network for shared

leadership and ownership by many

 Shared the vision that there could be better oral

health care for all Idahoans

 The DQF agreed.  Idaho: one of 20 DQF grantees.

Optimal Oral Health for All Idahoans.

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 2012: Planning $100,000

 Competitive application YR2 – YR3

 2013: Implementation $150,000

 30% match = $45,000

 2014: Implementation $150,000

 40% match = $60,000

 Match: In-kind and hard

FUNDING AND SUSTAINABILITY

Optimal Oral Health for All Idahoans.

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 Access

 Lifespan  Medical-Dental Integration  Hospital Emergency Dental Care

 Prevention

 Population-Based Preventive Dental Measures  Education  Practiced Guidelines

 Policy

 Funding  Data  Leadership

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 Focus on individual overall health  Strengthen inter-professional and patient

education

 Integrate delivery and financing systems  Examine the role for medical and dental

records in patient-centered care

 Expand the dialogue on oral health

Optimal Oral Health for All Idahoans.

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 Idaho Primary Care Association

 Dirne Community Health Center  Adams County Health Center  Terry Reilly Health Services  Family Health Services

 Co-located medical and dental clinics

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We are continually faced with

  • pportunities disguised as

unsolvable problems.

Optimal Oral Health for All Idahoans.

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Optimal Oral Health for All Idahoans.

Thursday, June 14th

  • Release of Implementation Grant Request for

Proposals

Wednesday, August 15th

  • Deadline for Receipt of Implementation

Grant Proposals

Friday, September 28th

  • Implementation Grant Awards Announced!