Public Health Reports
Meet the Author! Live Webcast
Innovations in Oral Health Care for
People Living with HIV/AIDS
Speakers:
Sara S. Bachman, Ph.D., Jane Fox, MPH, David Reznik, DDS, Carol Tobias, MMHS
Guest Editors of the May/June 2012
PHR Special Supplement on Innovations in Oral Health Care for People Living with HIV/AIDS
Moderator:
CDR Mahyar Mofidi, Ph.D., DMD
Tuesday, May 22, 2012 | 1:00-2:15 PM (EST)
You will be given a phone number and access code when
you log into the webinar.
Public Health Reports Special Supplement
Innovations in Oral Health Care for
People Living with HIV/AIDS
Webinar Learning Objectives
• Present findings from the Special Projects of
National Significance (SPNS) Innovations in Oral
Health Care Initiative.
• Describe ways to improve access to oral health care
and associated outcomes for people living with HIV.
• Discuss ways innovative strategies can be applied to
other vulnerable populations.
• Fills research gaps related to oral health care for
people living with HIV/AIDS.
Innovations in Oral Health Care for People
Living with HIV/AIDS
• Special supplement to Public Health Reports presenting
findings from the Special Projects of National
Significance Innovations in Oral Health Care Initiative.
• The Oral Health Initiative encompassed 15 sites from
around the country, about half in urban and half in rural
communities.
• Results show innovative program models can engage
and retain people who are living with HIV/AIDS into oral
health-care.
• Articles in this special issue represent the most
comprehensive additions to the body of knowledge
about oral health care for people living with HIV/AIDS in
a decade.
The Initiative and Evaluation at a Glance
• The purpose of the Oral Health Care Initiative was to develop and
implement innovative models of oral health care.
• The multi-site evaluation was conducted by the Health and
Disability Working Group at the Boston University School of Public
Health.
• Goals of the Evaluation Center included:
– Help sites improve access and adherence to high quality oral
health care for underserved populations.
– Implement a mixed methods multi-site evaluation of the
demonstration projects.
– Assist grantees in implementing both the multi-site evaluation
and their local evaluations.
– Disseminate findings to a broad range of audiences including
oral health care providers, medical care providers, consumers
and policy makers.
Evaluation Questions
• Do the demonstration programs increase access to oral health care
for the target population?
• What are the main similarities and differences in strategies and
program models to increase access to oral health care across
programs?
• Are the oral health services performed in accordance with
professional practice guidelines?
• Do clients experience improvements in health outcomes over time?
• Are clients’ oral health care needs met?
• Do clients experience improvements in oral health related quality of
life after enrollment in oral health care?
• What strategies are most effective in furthering successful program
implementation: barriers, facilitators, key lessons learned?
• What strategies to address the structural, policy and financing issues
can be replicated in other settings?
In this Webinar we will….
• Provide a brief overview of key results of the
multi-site evaluation
• Highlight innovative practices
• Describe lessons learned about sustainability
and financing
• Identify applications to other vulnerable
populations
Study Sample Demographics (N=2469)
• 75% male
• 40.3% black, 21.4% Latino
• 32.8 % high school
education, 42.0% beyond
high school
• 30.7% working
• 54.4% monthly income
< $850
• Mean age: 43.6 (18 – 81),
• Years positive: 9.54
Last dental visit
3%
21%
29%
Never
12%
35%
< 12
months
1 - 2 yrs
2 - 5 yrs
>5 yrs
Sample Baseline Characteristics
Prior Dental Care
• Usual place for dental
care: 37.6% none; 30.4%
private dentist
• 48.5% reported needing
dental care since testing
HIV+ but were unable to
access it
• Of those who could not
access dental care,
64.4% stated
cost/affordability as the
reason
Prior HIV Care
• 97.3% reported a
regular place for HIV
care and 95.5% had
seen their HIV provider
in the past 6 months
• 84.6% had an HIV case
manager and 77.4%
were taking ARTs
• 57.35% had a CD4
count over 350 and
44.2% had an
undectable viral load
Increasing Access to Oral Health Care
By the end of the
study:
• Patients made over
15,000 clinic visits
• They received over
37,000 services
• 917 (42%)
completed a Phase
1 treatment plan
In the first 12
months of oral
health care
# provided
Clinic Visits
Phase 1
Treatment Plans
Completed*
Comprehensive
Exams
*Phase 1 Treatment Plan = Prevent and treat active disease
Patients who
received any
service
n
%
11,315 2178
717
100%
717
33%
2077 1944
89%
Program Models and Interventions
• Program models
– AIDS service organizations
– Hospital–based programs
– Community Health Centers
• Interventions
– Expansion of clinic space and/or services
– Dental case management
– Mobile dental units
Patient Perspectives on Innovation Impact
• Reasons for retention in oral health care
–
–
–
–
Staff and environment
HIV knowledgeable dentist
Dental case manager
Maintaining oral and overall health
• Impact of participation in oral health
– Improved awareness about HIV health and oral health
– Better oral health hygiene practices
– Improved self-esteem and appearance
Innovative Practices
The Rural Alliance
• Partnerships
– HIV Alliance
– Community Health Centers of Lane County
– Lane Community College
• Service Delivery
– Sites
– Transportation
– Staffing
• Dental hygiene students, dental assisting students, hygiene
faculty, dentists, denturist, and a dental case manager.
Lessons learned about sustainability/financing
Medicaid Adult Benefits
• Medicaid is a major source of health-care coverage,
including oral health care, for PLWHA.
• Comprehensive adult dental coverage under
Medicaid is only available in approximately 20% of
states.
• More than half of the states offer emergency or
highly restricted dental services only.
• Medicaid programs that offer some oral health
benefits may not provide adequate coverage to
eliminate oral disease.
Lessons learned about sustainability/financing
Medicaid Adult Benefits
• Medicaid coverage for adult dental services has
often been the victim of budgetary cuts during
periods of fiscal retrenchment.
• A fiscal year 2010 survey of Medicaid programs
reported a reduction in Medicaid adult dental
benefits in 20 states, more than in any year in the
past decade; 14 states planned to reduce benefits in
FY 2012.
Limits of dental coverage for people living with HIV
Medicaid Adult Benefits
• Most people with HIV who qualify for Medicaid do so by
meeting the program’s income and disability standards.
However, many PLWHA may not gain Medicaid coverage
until their illness progresses to the point that they are
determined to be eligible as a result of disability.
• Presently, 68% of PLWHA have incomes below 100% of the
federal poverty level, yet only 34% qualify for Medicaid.
• Implementation of the Medicaid expansion contained in the
Patient Protection and Affordable Care Act (ACA) would
cover adults within 133% of the Federal Poverty Limit and
would greatly benefit PLWHA.
• However, adult dental care is presently not included in the
Medicaid expansion.
Lessons learned about sustainability/financing
Ryan White HIV/AIDS Programs
• The Ryan White HIV/AIDS program, administered by the
Health Resources and Services Administration, is the
third largest public financing program for HIV/AIDS care
after Medicaid and Medicare.
Of note: Medicare does not offer a dental benefit but
does reimburse for oral pathology services including
biopsies and destruction/removal of lesions (e.g. oral
condylomas).
• Grants from the Ryan White program provide funds that
function as a “payer of last resort” for more than
500,000 uninsured or underinsured people each year.
The majority of these recipients live below the federal
poverty level and are ethnic and racial minorities.
Lessons learned about sustainability/financing
Ryan White HIV/AIDS Programs
• The Ryan White program funds HIV-related health
care and services through multiple grant
opportunities called Parts.
– Part A funds are awarded to eligible metropolitan areas
that are disproportionately affected by HIV/AIDS
– Part B funds are awarded to States
– Part C and Part D funds target primary care providers in
the community such as hospitals or community health
centers.
– Part F funds healthcare educational programs including
the Dental Reimbursement Program, the CommunityBased Dental Partnership Program, AIDS Education and
Training Center and the Special Projects of National
Significance program.
Lessons learned about sustainability/financing
Ryan White HIV/AIDS Programs
• 75% of funding in Parts A, B and C must be spent on
Core Services:
– Primary Care
– Medications
– Oral Health Care
– Mental Health Care
– Substance Abuse Services
– Medical case management/treatment adherence counseling
• Other services such as food, transportation, peer
counseling, translation, etc. are considered support
services
Program Sustainability
• Sustainability depends on several factors:
– Medicaid dental coverage in the state
– Leveraging multiple Ryan White Program funding
sources to sustain the delivery of care.
– Applying for foundation grants and other sources
of funding outside of the Ryan White Program.
– Leadership
• AIDS Service organization
• Dental providers
Sustainability: An Example
• HIV Alliance in Oregon
– The SPNS Oral Health Initiative helped the
program establish a dental clinic and hire a
project coordinator.
– The Ryan White Dental Reimbursement Program
(Part F) created an ongoing source of revenue for
oral health services.
– Part B funding will fund the dental case manager,
cover denture costs, and pay for transportation.
– Foundation grants to cover additional costs.
Sustainability: An Example
• Tenderloin Health Care
– The SPNS Oral Health Initiative was instrumental in
establishing dental operatories in the same facility where
clients received their HIV care.
– The Dental Director of the San Francisco Department of
Health, Dr. Avi Nath, successfully applied for Part A funds
to sustain the program once SPNS funding ended.
– Working with the University of California at San Francisco
(UCSF) Dental School’s General Practice Residency
Program (to manage some surgeries, endodontics and
dentures) allowed UCSF the ability to apply for Part F
Dental Reimbursement funds to help defray the costs.
Application to other vulnerable populations
• People with HIV, seniors, adults with disabilities are
living longer:
– More people, more teeth and more complex oral health care needs
• Self-perception of dental health is poor
1
• 50% of seniors say their teeth are poor or very poor
• Poor oral health is associated with weight loss, failure to thrive,
pneumonia
• Oral health remains a much greater need – more so
than general health care
2
1www.smilesforlifeoralhealth.org
2
The national survey of children with special health care needs chartbook 2005-2006. Rockville, Maryland: DHHS 2007.
Similar Barriers to Care
Overall
access
barriers
3
30-50% of adults
with disabilities have
significant barriers to
dental care3
Only 43% of seniors
visit the dentist in a
year1
Financial
barriers
70% of seniors lack
dental insurance1
Adults with
disabilities are twice
as likely to forgo
dental care for cost
reasons4
Other
barriers
Transportation
Finding a dentist
who will treat them
Drainoni M, Lee-Hood E, Tobias C, Bachman SS, Andrew J, Maisels L. Cross-disability experiences of barriers to health-care
access. Journal of Disability Policy Studies Fall 2006 Fall 2006;17(2):101-15.
4Rapalo DM, Davis JL, Burtner P, Bouldin ED. Cost as a barrier to dental care among people with disabilities: A report from the
florida behavioral risk factor surveillance system. Spec Care Dentist 2010 Jul-Aug;30(4):133-9.
Care Facilitators
Dental provider education
Patient education
Care coordination, systems navigation, appt.
follow up
Service integration with medical care and social
services
Outreach and transportation to services
Outcomes beneficial for other vulnerable
populations
Eliminate
pain and
infection
Interprofessional
team
building
Improve
overall oral
health
Improving
self-esteem
Engagement in
preventive
care
Encourage
better care
of overall
health
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