Community Dental Health
Coordinator (CDHC)
An integrated model to reduce
disparities in oral health
Agenda
 The access to dental care paradox?
 Frameworks for developing solutions for the
access problem
 Community Dental Health Coordinator
– Scope of services
– Education
– Next steps
Define the Problem?
The way we see the problem, is the
problem.
Steve Covey
Problem #1
 Not enough dentists
 Cannot find dentists to work in underserved
areas
 Dentists do not accept Medicaid
 Dentists are rich and they do not care
 Dentists….
 Dentists…
Solution #1
 Train more dentists
 or
 Provide incentives for dentists to work in
underserved areas
 or
 Train alternatives providers
 or
 Ask why dentists do not do it?
Solution #1
 These solutions will work if the problem is the
“dentist”
 However, if the problem is
– Organization of dental care
– Reimbursement
– Cultural, economic, social, behavioral barriers both
facing the dentists and underserved populations,
then
 These solutions will not work
Detroit and Suburbs: 2005
Projected Household
Income by Census Tract
Push pins are private
practice dentists.
Define the problem!
 0.2% out of the 18,000 children <1 year old
 0.8% out of 26,000 children <1 year old
Define the problem!
 15% out of the 168,000 children (2-21 years)
 42% out of 203,000 children (2-21 years)
Problem #2: If we see them they will be
fine
 Self-care + access
 What type of access?
– Preventive
– Restorative
 Disease management is the road to recovery
 We will fill our way out of the problem
 We will seal our way out of the problem
 We will scale our way out of the problem
The Dental and Medical Care Paradox
 Whitehall study of civil servants in the UK
– Social gradient of disease
– Allostatic load
– Social support, efficacy, fatalism, literacy
 Universal health care
– Equality of primary and basic access to healthcare but the
inequalities in health outcomes will persist
18.00
16.00
14.00
12.00
10.00
8.00
6.00
4.00
2.00
0.00
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5
9
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21
25
29
33
37
41 45
49
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97 101 105 109 113 117 121 125 129 133 137 141
Access to dental care is not a
dental problem
Access is necessary but not
sufficient factor in reducing the
inequalities in health outcomes
Competing Determinants Framework (CDF)
National and State Policy
Support for families with children
Welfare policy
Health insurance
Health promotion
Disease prevention
Training of workforce
Primary health care
Secondary and tertiary care
Individual
Oral health beliefs and behaviors
Dental fatalism
Oral health literacy
Oral health self-efficacy
Daily effective preventive practices
Regular preventive dental care
Early detection and prevention
Reduction of exposure to risk factors
Resilience
Religiosity
Community
Accessible and quality dental care
Transportation
Employment
Educational opportunities
Safety
Positive cultural and behavioral norms
Healthy foods
Social capital
Family
Family support
Oral health behaviors
Health values
Healthy norms and practices
Who is responsible for the
problems of dental access and
oral health disparities?
Multi-level Responsibility
 National and state policy
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Medicaid
Community health centers
Tax policy
Welfare policies
Educational standards and funding
Agriculture quota
Research funding
Globalization and free trade
Multi-level Responsibility
 Local policy
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Crime
Transportation
Education
Taxation
Economic development
Investment in health care
>Public health versus tertiary care
Multi-level Responsibility
 Individual level
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Dental anxiety
Locus of control (fatalism)
Oral heath self-efficacy
Social support
Role models
Education
Employment
General and social health
Multi-level Responsibility
 Family level
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Family structure
Child care
Employment
Safety net
Social support
Understand the Social Context
Framework or roadmaps or blueprints
 Frameworks are tools for
– Defining problems
– Designing solutions
– Evaluating outcomes
 Instructions versus Self-Determination Theory
– I will tell you what to do versus what would you
like to do?
– What is important to you?
Mission
Mission
Framework for Reducing Oral Health Disparities
Create a sustainable healthy community model which integrates community-based oral health
promotion and prevention, provided by culturally competent community health teams, with evidence
based clinical care provided by dental and medical clinicians working in Federally Qualified Health
Centers.
INPUTS and PRE-REQUISITES
ACTIVITIES
Social
Marketing
Underserved
Community
FQHC Dental
Clinics
Training of the
Clinical COHIP team
Community
Screening for
Need for
Urgent Care
Screening &
management
of dental
anxiety &
fatalism
Referral, social
supp. &
dental care at
the FQHC
clinic
Training of Dental and
Medical Staff at the FQHC
Clinics
Community
Organziations
(WIC, Head
Start, faith-based
organization and
others)
Evidencebased dental
and preventive
care
Decreased
Dental
Fatalism and
Anxiety
Increased
Oral Health
Literacy
Increased
Oral Health
Self Efficacy
Preventive
plans and
follow-up using
motivational
interviewing
Reduction in Untreated
Disease
Reduction of Early or
Incipient/early Lesions
Increase in
risk-based
preventive
visits
Risk-based
clinical
prevention
Databases and
management support
Long-term Outcomes
Improved Quality of Life
Increase in
preventive
behaviors at
home
Sustainable Model
Community
Health Teams
Training of Community
Health Workers
Intermediate
Outcomes
Community Health Workers
 Community health workers are trained to
promote health in their own communities.
They provide leadership, peer education, and
resources to support community
empowerment.
 CHWs integrate information about health and
the health care system into the community’s
culture, language, and value system, thus
reducing many of the barriers to health
services
Ro et al., 2007
Community Health Workers
 CHWs offer interpretation and translation services,
provide culturally appropriate health education and
information, assist people in receiving the care they
need, give informal counseling and guidance on
health behaviors, advocate for individual and
community health needs, and provide some direct
services such as first aid and blood pressure
screening
Effectiveness: CHWs
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Improved access for minority women in
prenatal care,
cancer screening,
child sick visits,
immunizations for children,
chronic illness care,
maternal health,
STD testing,
smoking cessation, and
mental health and outreach services.
Effectiveness: CHWs
– Influenced positive behavioral changes in the areas of
weight loss and breastfeeding among African Americans,
– Reduced drug use
– Increased condom use among homeless women,
– Increased physical activity among African-American women
with type II diabetes
Effectiveness
– Reduced missed appointments and increase follow-up care.
CDHC
 Dual skills
– CHWs
– Dental skills
>Extenders of the supervising dentist, the decision maker
>Could increase the efficiency and reach of PA 161
hygienists
>Dentists is RESPONSIBLE for dental care
 No cavitated teeth should be left behind unless it is appropriate
>Triage
>Care process and team approach
 Quantity is key for survival in the underserved zone
 Quality should be outcome driven
The CDHC’s Main Functions
Recruitment and registration
Screening for emergencies
Patient navigation
Oral health assessment
Navigation with dentists and hygienists
Prevention of dental & oral diseases
Palliative care
Navigation with dentists and hygienists
Develop tailored preventive plans
Recall based on risk status
Community Dental Health Coordinator
Integrated Dental
Care System
Oral Health
Promotion
Prevention of Dental/
Oral Diseases
Improve access to dental care
and reduce oral health disparities
Palliative
Care
Patient
Navigation
CDHC: Entry Tracks
 High school graduates
– 1 year didactic + practical training at a CODA
accredited program
– 6-month internship
 Dental assistants
– Modules (TBD): < 1 year
– 6-month internship
 Dental hygienists
– Modules (TBD): < 1 year
– 6-month internship
 Other healthcare and health service providers
– Social workers
– Nurses
VISION
CDHC
Detection and Continuity of
Care Record (CCR)
X-rays, Photo
Integrated
Dental Care
System
Online secured
database
Supervising dentist
Management plan
Authorization
CDHC
Dental care by
supervising dentist
or hygienist
CDHC
Preventive and
palliative care
Navigation of care
Preventive recall
Tracking
VISION
Improve access to dental care and
reduce oral health disparities
Oral Health
Promotion
Health promotion is the science & art of
helping people change their lifestyle to
move toward a state of optimal health
Promotora
VISION
Improve access to dental care and
reduce oral health disparities
Palliative
Care
Manual Restorative Treatment
Interim (temporary) restorations
Scaling
Perform gross debridement in community settings
which may include scaling using anterior and/or
posterior sickle hand scalers for patients with Perio
type I (gingivitis) and have calculus that impedes
maintaining good oral hygiene.
Once scheduled, the patient will be seen by the dental
hygienist or dentist at the community health
centers.
VISION
Improve access to dental care and
reduce oral health disparities
Patient
Navigation
Entry into and Movement through a
Complex Bureaucratic Healthcare System
Eligibility for Medicaid and other programs
Registration
CDHC Curriculum
 Community health worker & health
promotion modules
– Advocacy and outreach
– Communication & cultural competency
– General & motivational interviewing skills
– Coordination, documentation & reporting
– Teaching & learning skills
– Legal & ethical issues
CDHC Curriculum
 Dental Skills Modules
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Introduction to dentistry
Screening & classification
Prevention of dental caries
Prevention of periodontal diseases
– Prevention of oral cancer
– Palliative care
– Payment for dental care
– Clinical support system
– Community-based internship
Training
 The CDHC will be trained in accredited dental
schools or community colleges with dental
programs.
Pilot or Demonstration Projects
 Three sites for three years
 Rural
 Urban
 Indian tribal area
Budget for each site
Training of CDHCs
Stipends
Portable equipment and maintenance
Coordination
Evaluation
Estimated to be around $300,000 per year for 3
years
 ADA has invested over $330K to develop the “turnkey” curriculum
 ADA has allocated $2 Million for the pilots
 Local funding is required
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CDHC: Employment
 Community settings
– Community health clinics
– Schools
– WIC clinics
– Head and Early Head Start centers
– Institutions
– Medical and other health clinics
(e.g. Indian Health Service, FQHCs)
CDHC: Financing Strategy
 Breakeven point
– About 600 Medicaid recipients per salaried
CDHC ($27,000, total cost is $70,000)
– For DH working as a CDHC, the breakeven
point will be around 900 Medicaid recipients.
 Revenue neutral model that is not dependent
on operating grants
CHW Legislation
 In the State of Minnesota, CHW Legislation of 2007
was passed.
– Covers the care coordination and patient education
services provided by a community health worker if the
community health worker has:
> Received a certificate from the Minnesota State Colleges and
Universities System approved community health worker
curriculum; or
> At least five years of supervised experience with an enrolled
physician, registered nurse, or advanced practice registered
nurse.
Community health workers eligible for payment under clause
> Must complete the certification program by January 1, 2010, to
continue to be eligible for payment
– Community health workers must work under the
supervision of a … physician, registered nurse, or
advanced practice registered nurse.
Integrated Oral Health Promotion
and Dental Care Model
Ultimately education [health
promotion] and prevention will be
the linchpins in eliminating…
untreated dental disease.
ADA’s State and Community Models for Improving Access to
Dental Care for the Underserved—A White Paper