Forwarding Public Oral Health
with Theoretically Framed
Partnerships, Planning,
Programs, and Policies
Amy Brock Martin, DrPH
Presentation to Public Health Consortium
October 15. 2013
South Carolina
Rural Health Research Center
Who we are…
South Carolina Rural Health Research
Center
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1 of 7 Rural Health Research Centers
funded by the Health Resources and
Services Administration
Administratively located in the Arnold
School of Public Health at the University
of South Carolina
Mission: to increase knowledge of the
persistent inequities in health status
among populations of the rural US, with
an emphasis on factors related to
socioeconomic status, race and ethnicity,
and access to healthcare services.
South Carolina
Rural Health Research Center
Presentation Overview
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Introduce South Carolina’s demonstration of the Academic
Health Department Model through the Division of Oral Health
(DHEC) and SC Rural Health Research Center (SCRHRC)
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Guiding principles of partnership
Theoretically-driven State Oral Health Plan
Collaborative leadership model of SC Oral Health Advisory Council
and Coalition (SCOHACC)
Results of AHD Model
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Policy & practice achievements
ROI (extramural funding)
Scientific contributions
Epidemiological impact
Rural disparities & what we are doing about them
South Carolina
Rural Health Research Center
Why Public Oral Health Matters?
Oral health disparities hurt everyone!
Martin, AB et al. Dental Health Access to Care Among Rural Children, 2008, included in
CD, also available at http://rhr.sph.sc.edu/report/(72)%20Dental%20Health%20and%20Access%20to%20Care%20Among%20Rural%20Children.p
df
What are costly diagnoses to your states’ Medicaid programs?
Those who come early…Preemies
Huck O, Tenenbaum H, Davideau JL. Relationship between periodontal diseases and
preterm birth: recent epidemiological and biological data. Journal of Pregnancy, 2011,
Article ID 164654.
Those
who live long…Dementia/Alzheimer’s
Manczak M, Reddy, PH. Abnormal interaction of oliomeric amyloid-beta with
phosphorylated tau: Implications to synaptic disyfunction and neuronal damage. Journal
of Alzheimer's Disease 36(2), 2013, DOI:10.3233/JAD-130275.
Those
who with chronic disease…Diabetes & Cardiovascular Disease
Leite RS, Marlow NM, Fernandes JK. Oral health and type 2 diabetes. American Journal
of Medical Science. 2013 Apr;245(4):271-3.
South Carolina
Rural Health Research Center
Dental Health Professional Shortage Areas, 2012
South Carolina
Rural Health Research Center
Persistent Whole County Dental Health
Professional Shortage Areas, 2009 - 2012
South Carolina
Rural Health Research Center
Why Care About Safety Net
Populations?
South Carolina
Rural Health Research Center
IOM Academic Health Department
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IOM called for agency/academic partnerships to ensure the
effectiveness of public health in 1988 and 2003.
What is it?
 According to ASPH, it is a “partnership between a school
of public health (SPH) and a health department to create a
dynamic academic-practice collaboration, which effectively
pools assets of both
institutions.”http://www.asph.org/UserFiles/AcademicHealthDep
artments.pdf
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HRSA determined poor responses by SPH & agencies to IOM
call to action in 2005.
South Carolina
Rural Health Research Center
South Carolina’s SOHP Proof of Concept
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DHEC and SCRHRC began partnership
in 2006, facilitated by CDC Cooperative
Agreement, Strengthen State Oral
Disease Prevention Programs.
$15K contract codified relationship, which
has leveraged $5.2 million in oral health
grants and programs (excludes national
research grants)
State Oral Health Plan (SOHP) as
catalyst
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A collaborative leadership model with
SCOHACC used to develop 5-year SOHP
PRECEDE-PROCEED was used to
facilitate the SOHP.
South Carolina
Rural Health Research Center
SOHP GENERAL THEORETICAL FRAMEWORK (Green and Kreuter, 1999)
Phase 5
Administrative &
Policy
Assessment
Health
Promotion
Health
Education
Phase 4
Educational &
Ecological
Assessment
Phase 3
Behavioral &
Environmental
Assessment
Phase 2
Epidemiological
Assessment
Predisposing
Factors
Reinforcing
Factors
Behavior &
lifestyle
Health
Policy
Regulation
Organization
Phase 6
Program
Implementation
Phase 1
Social
Assessment
Enabling
Factors
Phase 7
Process Evaluation
South Carolina
Environment
Phase 8
Impact Evaluation
Rural Health Research Center
Phase 9
Outcome Evaluation
Quality of
Life
SOHP GENERAL THEORETICAL FRAMEWORK (Green and Kreuter, 1999)
Phase 5
Administrative &
Policy
Assessment
•Surveillance program
•Interventions for special
populations & chronic
diseases
•Social marketing
•Educational
materials
•Effective Advisory
Council & Coalition
•Committed public
leadership
Phase 6
Program
Implementation
Phase 4
Educational &
Ecological
Assessment
Phase 3
Behavioral &
Environmental
Assessment
Phase 2
Epidemiological
Assessment
Phase 1
Social
Assessment
Improved oral
health status of
South Carolina
citizenry
Improved
Quality of Life
For All of SC
•Workforce with
public health
competencies
•Infrastructure &
resources for
change
•Targeted
outreach
•Workforce
recruitment &
incentive programs
•Public demand for
oral health
improvements
•Changes in oral
health behavior,
knowledge &
values
•Availability of
workforce &
educators
•Ability to pay for
dental care
•Political will for
change
•Fluoridated Water
•Educated,
Strategic Dental
Workforce
•Public oral health
infrastructure
South Carolina
Phase 7
Process Evaluation
Phase 8
Impact Evaluation
Rural Health Research Center
Phase 9
Outcome Evaluation
Partnership Guiding Principles
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Funding opportunities should not drive the mission of DOH or
SCOHACC
Remain focused on SOHP goals and objectives to avoid mission
creep
Disseminate lessons learned through peer-reviewed venues
Focus on consensus building
Small funding opportunities should be used for credibilitybuilding efforts that can be leveraged into larger, innovative
grants
Respect partners’ expectations
 e.g. academic needs for scholarly output, DHEC needs for
epidemiological impact
South Carolina
Rural Health Research Center
Summary of Policy & Practice
Achievements since 2006
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South Carolina
Rural Health Research Center
Act 235
Pew Rankings
Congressional testimony
NCSL Presentation
OB guidelines
School nurse dental screenings
Community water fluoridation advocacy
training
Oral health integrated into Dept. of Ed.
Health and Safety Standards
Early childhood guidelines
Fluoride varnish reimbursement policy
(Medicaid)
AAPD/Head Start Dental Home
Leadership State
Extramural Funding ($5,220,000)
Grant
Funding Amount
Time Period
Grantee
CDC State
Infrastructure
$1.5 million
2013-18
DHEC
HRSA Oral Health
Workforce
$1.5 million
2012-15
USC
DentaQuest
Foundation
$300,000
2012-14
USC
DQF Planning
$100,000
2011-12
USC
CDC State
Infrastructure
$1.75 million
2008-2013
DHEC
Head Start Dental
Home
$10,000
2009-10
DHEC
ADA School Nurse
Study
$50,000
2009
USC
ASTDD – Head Start
Study
$2,500
2007
DHEC
ASTDD – CSHCN
Study
$7,500
2006 & 2008
DHEC
South Carolina
Rural Health Research Center
South Carolina
Rural Health Research Center
South Carolina
Rural Health Research Center
South Carolina
Rural Health Research Center
Results:
Scientific Contributions
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Presented 12 posters and conducted 5 invited oral presentations at
state and national conferences (APHA, Academy Health, Academy
for Health Equity, NOHC, AAP, SCRHA, James E. Clyburn Health
Disparities Lecture)
Published 2 manuscripts in peer-reviewed journals (Maternal &
Child Health Journal and Pediatric Dentistry) with 1 in development
and 1 in R&R (APHA & Public Health Dentistry).
Influenced 3 national studies funded through the core RHRC grant:
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National Rural Children’s Oral Health Disparities Chartbook (2008)
State Policy Levers for Addressing Preventive dental Care Disparities
for Rural Children (2012)
Dental Sealant Utilization Among Rural and Urban Children (2013)
South Carolina
Rural Health Research Center
OHNA Summary Results for 2012/2013
Percent of Children by Indicator*
Weighted analysis for public schools in K and 3rd grade. Sealants only include children in 3rd grade.
South Carolina
Rural Health Research Center
Results: Epidemiology Impact
South Carolina
Rural Health Research Center
Percent of Caries Experiences by
Race/Ethnicity
2007* (p<0.0001 for race; ethnicity not calculated due to low observations)
2012* (p<0.0001 for race; p=0.01 for ethnicity)
South Carolina
Rural Health Research Center
Percent of Caries Experiences by
Medicaid Member Status
2007
2012* (p<0.0001)
South Carolina
Rural Health Research Center
Percent of Caries Experiences by Free
& Reduced Lunch Participation
2007* & 2012* (p<0.0001)
South Carolina
Rural Health Research Center
Percent of Caries Experiences by
Rural vs. Urban School
2007* (p<0.0001)
2012* (p=0.048)
South Carolina
Rural Health Research Center
Percent of Sealants by Race/Ethnicity
2007 (no race differences; not calculated for ethnicity due to low observations)
2012* (no race differences; p=0.022 for ethnicity)
South Carolina
Rural Health Research Center
Percent of Sealants by Medicaid
Member Status
2007* (p<0.0001)
2012 No differences
South Carolina
Rural Health Research Center
Percent of Sealants by Free &
Reduced Lunch Participation
2007 & 2012 (No differences)
South Carolina
Rural Health Research Center
Percent of Sealants by Rural vs. Urban
School
2007 & 2012 (No differences)
South Carolina
Rural Health Research Center
Percent of Untreated Caries by
Race/Ethnicity
2007* (p<0.0001 for race; not calculated for ethnicity due to low observations)
2012* (No differences for race or ethnicity)
South Carolina
Rural Health Research Center
Percent of Untreated Caries by
Medicaid Member Status
2007 (No differences)
2012 (p=0.007)
South Carolina
Rural Health Research Center
Percent of Untreated Caries by Free &
Reduced Lunch Participation
2007* (p<0.0001)
2012 (No differences)
South Carolina
Rural Health Research Center
Percent of Untreated Caries by Rural
vs. Urban School
2007* (p<0.0001)
2012* (p=0.007)
South Carolina
Rural Health Research Center
Percent of Tx Urgency 1 by
Race/Ethnicity
2007* (p<0.0001 for race; not calculated for ethnicity due to low observations)
2012* (No differences for race or ethnicity)
South Carolina
Rural Health Research Center
Percent of Tx Urgency 2 by
Race/Ethnicity
2007* (p<0.0001 for race; not calculated for ethnicity due to low observations)
2012* (No differences for race or ethnicity)
South Carolina
Rural Health Research Center
Percent of Tx Urgency 1 and 2 by
Medicaid Member Status
2007 (No differences)
2012 (p=0.0111)
South Carolina
Rural Health Research Center
Percent of Tx Urgency 1 and 2 by Free
& Reduced Lunch Participation
2007 (p<0.0001)
2012 (No differences)
South Carolina
Rural Health Research Center
Percent of Tx Urgency 1 and 2 by
Rural vs. Urban
2007 (p<0.0001)
2012 (p=0.0083)
South Carolina
Rural Health Research Center
OHNA Takeaways…how do we see the
glass?
Half Full
Half Empty
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Caries experience has
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Sealants improve a little
declined but disparities
with lots left to do
continue to exist
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Rural disparities remain
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Untreated caries & Tx
throughout the indicators,
urgencies drop is sizeable
except sealants
 race, ethnicity, and F&RL
disparities disappear!
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Tx Urgency 2 is nearly
eliminated
South Carolina
Rural Health Research Center
Addressing the rural disparities….
South Carolina
Rural Health Research Center
South Carolina Act 235 (2010)
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Created the Community Oral Health Coordinator program (COHC) within DHEC.
work with school nurses in a targeted community program to improve dental health in the state’s
public schools.
operate in three to five counties identified as dental health professional shortage areas. The
program will provide dental health education, screening, and treatment referral for public school
students in kindergarten, third, seventh, and tenth grades; or upon entry into a South Carolina
school.
provide community oral health education and training
coordinate transportation and other non-clinical support to patients and their families
link dentists who provide Medicaid services or would provide free or reduced-cost care to children
identified by the screening that do not have a dental home
help ensure that parents understand the importance of not missing appointments and the need for
follow-up care
provide a connection people in local communities with the tools they need to improve oral health
NO FUNDING APPROPRIATED!
South Carolina
Rural Health Research Center
HRSA Oral Health Workforce Grant
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Teledentistry feasibility study
 N=387
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(21.5% response rate)
COHC Training Center
Community Water Fluoridation Advocacy
Rural Safety Net Expansion
South Carolina
Rural Health Research Center
“Perfect Storm” of Opportunity
1. Oral Health 2014 Planning Grant –
Sustainability Workgroup
2. MIECHV Grant
3. HRSA Oral Health
Workforce Grant
South Carolina
Rural Health Research Center
Oral Health 2014 – DentaQuest Foundation
System-Level Goals
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To increase the number of dentists who see children
aged 0 to 3 years
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To increase the number of physicians who apply
fluoride varnish
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To integrate community oral health coordination into
the SC Maternal, Infant, and Early Childhood Home
Visitation program
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Increase the knowledge of early childhood oral health
needs among the aforementioned providers using
Smiles for Life
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Increase the knowledge of COHC techniques among
existing care coordinators in community systems, e.g.
WIC, BabyNet, FQHCs etc.
South Carolina
Rural Health Research Center
Person-Level Goals
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Increase in the number of children aged 0
to 3 years with preventive dental services
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Increase in the number of children
receiving fluoride varnish from their
medical home
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Decrease in early childhood caries-related
treatment
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Increase parents’ perceived value of oral
health services of children aged 0 to 3
How does DQF ‘ask’ align with the
SOHP? PRECEDE-PROCEED
Predisposing
Factors
Health Promotion
Health
Education
Reinforcing
Factors
Parents engaged
in care &
behaviors;
med/dental
interconnected
Safety Net Ed
COHC Ctr
Flu advocacy
Policy
Regulation
Organization
Engaged
Stakeholder
Collaboratives;
COHC through
MIECHV
Organized in the ‘Early
Childhood’ Chapter
Parents, MDs, &
DMDs value oral
health services
for 0-3
Enabling
Factors
Local fluoridation
advocacy teams;
adequate care
capacity for 0-3
South Carolina
Behavior &
lifestyle
Improved
appropriate use
of preventive
oral health
services
Environment
Access to
fluoridated
water &
affordable, high
quality oral
health services
Rural Health Research Center
Health
DMD visit by 1;
risk-based
varnish received
Quality of
Life
Improved oral
health for kids 03
How does our DQF ‘ask’ align with
Medicaid priorities? Triple Aim Model
Source: Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, and Cost.
Health Aff. May 2008. 27(3):759-69.
Achievement of Triple Aim is contingent upon the
Improved population health:
following conditions:
•Reduction in early childhood caries
1. Focus on a specific population
2. Consistency in approach/care for the specified
population
3. Use of an organization (an “integrator”) that
accepts responsibility for all three aims for that
population. Berwick et al states the integrator’s role
includes at least five components:
• partnership with individuals and families,
• redesign of primary care, (in our case, oral)
• population health management,
• financial management, and
Improved care experience:
Decreased per capita
• macro system integration.
•DMD visit by age 1 with
annual visits thereafter
•Receipt of risk-based
fluoride varnish
South Carolina
costs:
•Increased overall
savings to Medicaid
due to increase in
preventive service
utilization
Rural Health Research Center
Unanticipated Benefit
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Public Health Leadership Development
 Martin
obtains public oral health practice
experience
 Former DOH Director (Veschusio) obtains technical
training by entering the HSPM DrPH program
 We have trained 7 graduate students with DOH
through public health practica and graduate
assistantships.
 Valeria
Carlson (HPEB) works for CDC
 Gerta Ayers (HSPM) works for DOH and is currently
interim director
outh arolina
S C
Rural Health Research Center
Summary – Facilitators of Success
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Deliberate (usually) delivers!
Theoretically-driven strategic plan
Mutually agreed upon guiding principles and
expectations
Data-driven solutions
Leadership development
South Carolina
Rural Health Research Center
Contact information
Amy Brock Martin, Dr.P.H.
brocka@mailbox.sc.edu
SC Rural Health Research Center
220 Stoneridge Drive, Suite 204
Columbia, SC 29201
803-251-6317 (telephone)
http://rhr.sph.sc.edu
South Carolina
Rural Health Research Center