Midlevel Provider Models*
Ben Youel, UIC ASDA President
Friday, January 13th, 2012
*Adapted from presentation given in October
2011 at ASDA Central Regional Meeting
What are we going to cover?
• Four Models
• A Spectrum:
• Community Dental Health Coordinator
• Dental Therapist (MN)
• Advanced Dental Therapist (MN)
• Dental Health Aid Therapist (AL)
• Advanced Dental Hygiene Practitioner
Dental Health Aid Therapist
Dusty Pfundheller
District 5 Trustee
What is a DHAT?
• “Dental Health Aid Therapist”
• dependent practitioner working in a satellite clinic under the
general supervision by an off-site licensed dentist located at a
distant regional clinic
How Were DHAT’s Created?
• Alaska
• May 2000 – Oral Health in America: A Report of the Surgeon General
• Alaska Native Tribal Health Consortium (ANTHC)
• 85,000 Alaska Native people live in rural Alaska with no road access.
• 5 times caries risk in children
• Alaska allowed high school graduates go to New Zealand for a two
year program (2003 – 2005)
• 2004 – First DHATs began practicing
• In 2007 ANTHC partnered up w/ Kellogg Foundation to study at
University of Washington’s Medical School - 1 year is pre-clinical, 1
year clinical.
Training for DHAT
• 2 yr program
• Must have high school diploma or equivalent & 6wk
online anatomy & physiology course
• 1st year = pre-clinical work & classroom setting
• 2nd year = clinical experience, village practice rotations
• 400 clinic hours (six-month) residency program
• Every two years DHATs must be recertified.
• 24 CE credits
• Demonstration of ongoing clinical competency
Scope of practice
• Determined by the supervising dentist during the
residency based on DHAT’s demonstrated clinical skills
and tribal location needs
• Determines of clinical procedures and scope of practice
• Dynamic – may change periodically depending upon
the maturing skills-set of the therapist.
• Typical DHAT may provide oral exams, preventive
dental services, simple restorations, stainless steel
crowns, extractions and take x-rays.
Supervision
• General supervision by an off-site licensed dentist
located at a distant regional clinic.
Community Dental Health
Coordinators
Trent Lally
District 6 Trustee
What is a CDHC?
• “Community Dental Health Coordinator” or “CDHC”
• Part of an ADA comprehensive effort to improve access to oral
health care for underserved Americans.
• Promises to help Americans become better stewards of their oral
health.
Is the CDHC a “mid-level provider?”
• No. Mid-level providers are being promoted to drill,
fill, and extract.
• CDHC focuses on the root causes of disease – the lack
of adequate prevention and oral health literacy
among populations.
Background
• To help expand access to the same high quality dental
care available to all Americans, the ADA is helping to
develop a new member of the oral health team.
• National Coordinating and Developing Committee
(NCDC) was established to create a CDHC training
program.
• March 2009 – Pilots launched
How will the CDHC improve Access?
• Assist the dentist in the triage of patients
• Address social, environment and health literacy
• Educate community members
• Part of a comprehensive approach that also includes:
• Improving Medicaid reimbursement rates
• Placing new focus on oral health education and prevention
• Increasing government investments in the public health
infrastructure
• Students in the CDHC pilot program are recruited from
the communities in which they serve.
How are CDHC’s trained?
• Pilot Programs
• 18-month training program (12 months didactic + 6
months internship)
• University of Oklahoma
• Temple University
• A.T. Still University Arizona School of Dentistry
What is the CDHC scope?
• Collect information (photographs, radiographs)
• Screenings
• Fluoride treatments
• Sealants
• Temporary filings
• Simple teeth cleanings (gingivitis) until a patient can
have a comprehensive cleaning
Where do CDHC’s work?
• Clinics
• Schools
• Churches
• Senior Citizen Centers
• Other public settings
Update
• New Mexico first state to authorize CDHC model
Advanced Dental Hygiene
Practitioner (ADHP)
Burton Coleman
ASDA District 4 Trustee
What is it?
• Advanced Dental Hygiene Practitioner
• American Dental Hygiene Association (ADHA) proposed
position in 2004
A dental hygienist who has graduated from an accredited
dental hygiene program and has completed an advanced
educational curriculum approved by the ADHA, which
prepares the dental hygienist to provide diagnostic,
preventive, restorative and therapeutic services directly to
the public.
• Response to 2000 US Surgeon General’s Report
Where is it?
• Currently a proposed model
public health settings
schools
federally qualified health centers (FQHCs)
long-term care facilities
hospitals
nursing homes
• State by state, currently none in full form
Training & Curriculum
• Training requirements & curriculum not fully established
• Bachelor’s degree + 2 years = Registered Dental Hygienist
• RDH + 2 year Master’s level program
Scope of Practice
• Hygiene
• Dx + Perio eval, SRP, Prophy, Fluoride Tx, OHI
• Restorative
• Dx + Direct Restorations (composites, amalgams, sealants)
• Palliative Care
• Temp restorations, pre-formed crowns, pulp caps, place & remove
sutures
• Prosthodontics
• Adjust & repair removable, re-cement fixed
•
•
•
•
Surgery – dx, uncomplicated extractions
Path – dx & refer
Ortho – dx & refer
Anesthesia – local & N2O
*dentist supervision not required
The Dental Therapy Model
Ben Youel
District 7 Trustee
A Little History
• December 2006 – ADHP program approved by Board
of Directors of MN State Colleges & Universities
System
• Spring 2007 – Safety Net Coalition (SNC) convinces
MN Legislative Committee on Health Care Access to
recommend the creation of a dental MLP
• February 2008 – SNC introduces bill to create ADHP in
MN Dental Practice Act
A Little More History
• April 2008 – Bill passes to begin creation of an “Oral
Health Practitioner”
• April 2008 – U of MN unveiled proposed Dental
Therapy program
• May, July & September 2008 – U of MN delegation
visits Saskatchewan, New Zealand & England
• Early 2009 – “Dueling Bills” from U of MN/MDA &
from the SNC
And Finally…
• May 2009 – A compromise reached: Dental Therapy
(DT) & Advanced Dental Therapy (ADT) created
• Fall 2009 – DT program begins at U of MN & Oral
Health Care Practitioner (OHCP) program at
Metropolitan State University
• June 2011 – Seven students graduated with MS: OHCP
from Metropolitan State
• December 2011 – Nine students graduated with
either Bachelors or Masters Degrees in Dental Therapy
from U of MN
Licensure
• Dental Therapist
• Advanced Dental Therapist
• Graduate w/Baccalaureate or
• All requirements of Dental
Master’s in accredited dental
Therapist
therapy education program
• 2,000 hours of practice as DT
• Pass independent clinical
• Graduate w/Master’s in ADT
competency exam
• Pass board-approved
• Jurisprudence Exam
competency exam
• Apply for certification
Scope of Practice & Supervision
• Dental Therapist
•
•
•
•
•
•
•
•
•
•
•
•
•
Radiographs
Preventative Procedures & OHI
Sealants
Temporary Restorations
Space Maintainers*
Direct Restorations*
Pre-fab Crowns*
Pulpotomies (Primary teeth)*
Extractions (Erupted primary teeth)*
Tooth Reimplantation/Stabilization*
Local Anesthesia & Nitrous Oxide
Mouthguards
Provide, Dispense & Administer
Analgesics, Anti-Inflammatories &
Antibiotics
*Require Indirect Supervision
All duties subject to Collaborative
Management Agreement (CMA)
• Advanced Dental Therapist**
• All duties of Dental Therapist
• Oral Evaluations & Assessments
• Extraction (Periodontally involved
permanent teeth)
**All Require Only General Supervision
A Brief Summary of the MLPs
Locations
• DHAT = Alaska (trained in University of Washington)
• CDHC = University of Oklahoma, Temple University, &
A.T. Still University Arizona School of Dentistry; New
Mexico
• ADHP = Nowhere
• Dental Therapist / Advanced Dental Therapist =
Minnesota
What can each program do?
All can do:
• Collect information (photographs, radiographs)
• Screenings
• Fluoride treatments
• Sealants
• Temporary fillings (IRM)
What can each program do?
CDHC
DT
DHAT
ADHP
Triage
Develop and
implement community
education programs
Direct Restorations
Pre-formed crowns
Primary teeth
extraction
Perio-involved perm
teeth extraction (ADT)
Pulp capping
Pulpotomies
Local/Nitrous
Provide & administer
analgesics, antiinflammatories and
antibiotics (ADT)
Dx & Tx Planning
(ADT)
Repair removable
pros
Re-cement fixed pros
Space maintainers
Splinting
Full hygiene scope
Direct Restorations
Pre-formed crowns
Primary tooth
extraction
Non-surgical perm
teeth extraction
Pulpotomies
Local
Full hygiene scope
Direct Restorations
Pre-formed crowns
“Uncomplicated
extractions”
Repair removable
pros
Re-cement fixed pros
What is the opinion of American Dental
Students?
ASDA C-1 Policy:
• Only the dentist should perform the following functions. These
functions include but are not limited to:
• Examination, diagnosis and treatment planning
• Prescribing work authorizations
• Performing irreversible dental procedures
• Prescribing drugs and/or other medications
ASDA C-2 Policy:
ASDA is strongly opposed to independent dental hygiene
practice, and favors the team approach for providing
comprehensive dental care.
Resources
• www.asdanet.org - ASDA
• www.ada.org - ADA
• www.adha.org - ADHA
• www.dentistry.umn.edu – U of MN
• www.metrostate.edu – Metropolitan State U
• www.ykhc.org – Yukon-Kuskokwim Health Corporation
• www.wkkf.org – W.K. Kellogg Foundation
Questions?
uicasda@gmail.com