The Marquette Story

1. The Marquette Story A History of Local, Regional and State Collaboration 1988 – 2008 Dr. James Hayward

2. Context—1988 • Widely dispersed population of low income families, 43% below 200% federal poverty level • Only 33% of the UP residents have fluoridated water • Poor diets, tobacco use, lack of awareness of the importance of dental health, socio-economic instability in family settings • Only a small percentage of Medicaid eligible patients were being seen by private sector dentists

3. Context--1988 (continued) • Frustrated by low Medicaid reimbursement levels and onerous paperwork, Superior Dental Society requested visit from the Director of the Medicaid program in 1988 • Meeting was unsuccessful with no hope of improvements; dentists told director they would stop seeing new Medicaid patients • Health Department had existing dental education and fluoride mouth rinse programs in elementary schools

4. Context--1988 (continued) • When she couldn’t find anyone who would see her three children, a mother contacted the media, including the Detroit Free Press. • That catalyzed an effort to find a solution

5. Who Were The Stakeholders • Angry Medicaid Mom With Three Kids • Health Department • Superior District Dental Society in Marquette • Medicaid Recipients and Low Income Families in Marquette Co. • Michigan Department of Community Health • State-Level Medicaid Taskforces in 1997 and 1999 • Michigan Oral Health Coalition born in 2003 • Schools and Head start Sites • Kellogg Foundation – Empowering Children Initiative

6. The “Current Reality” (1988) • 21,442 Medicaid beneficiaries in the UP did not receive any dental care. • Out of 194 practicing dentists in the UP, only 47 did more than $5,000 in Medicaid reimbursed services • Beginning of a collaborative effort between the Superior District Dental Society and the Marquette County Health Department to provide access to care for this underserved population

7. Desired future • Increase access to care from less than 25% of Medicaid eligible children and teens in Marquette Co. • Reduced incidence of dental decay • Reduction in untreated dental decay • Increase in the number of first and second molars protected with pit and fissure sealants • Improved oral hygiene at home • Data collection as proof that it is working (for funders, public, professional satisfaction, Mqt. Co. Board of Health and Dental Clinic Advisory Board)

8. Pathways—Financing, Clinic Services, Workforce • 3 dentists helped with clinic design (Kipka, Asano, Miller) • First 3-chair clinic opened--Defant building. Hired dentist. (1993) • Kellogg Foundation contributed for capacity-building and start-up support (1994 – 1998) • Health Department/County added $160,000 - $180,000 / year • Staff saw parents with same issues; moms with bad teeth or no teeth • Opened 5-chair dental clinic for adults at KI Sawyer. Hired 2 more dentists, a hygienist and 2 more dental assistants (1999)

9. Pathways – (Continued) • Prevention and treatment program started at the Marquette Co. Medical Care Facility (nursing home) with one dental operatory installed in house and administered by a contractual hygienist PA 161 and dentist • $400,000 State Grant expanded and relocated Marquette clinic for children to 6-chairs on West Washington Street. (2000) • Dental students and residents from University of Michigan School of Dentistry came up to work in clinics as an externship experience (2000 - 2004) Two returned post-graduation.

10. Pathways—Prevention and Education • Prevention programs in schools and head start sites in Marquette and Alger Counties continued to expand under BeccaMaino, RDH, PA 161. Patients needing care were referred to dental clinic or private dentist if they had one. • School-based services expanded to include oral screenings, cleanings and sealants with portable equipment • Dental health education offered to over 1700 students in elementary schools and head start sites in County • Early childhood caries prevention education in prenatal classes at both hospitals, Red Cross babysitting classes, and middle school family life classes

11. Pathways—Oral Health for Seniors • Rate of decay in nursing homes is very high—medications dry the mouth, diet that promotes caries, patients’ inability to care for themselves • Established one-chair treatment room with contractual dental hygienist, dentists and specialist at Marquette Co. Medical Care Facility (nursing home) • Every resident receives oral health screening at admission and at least yearly • Prevention education--training every 4 months for CNAs in prevention techniques for cooperative and uncooperative patients as well as family members in caring for aging family members’ teeth. • Use of fluoride and xylitol products

12. Outcomes / Results • Used Healthy People 2010 Objectives as a basis for documenting outcomes • 75% of Marquette County Medicaid beneficiaries received oral health care vs. 25% statewide • % of untreated dental caries was reduced to (all exceeding Healthy People 2020 objectives) • 58% in 2-5 year olds • 45% in 6-12 year olds • 36% in 13-20 year olds

13. Outcomes / Results (continued) • Permanent molars sealed increased to 51% in 6-12 year olds and to 35% in 13-20 year olds (exceeding Healthy People 2010 objectives) • % of hospital operating room visits decreased in the under 21 population for Marquette County residents • Capacity increased to see children and special needs patients from outside Marquette County • With Kellogg Foundation training, funding capacity increased through grant applications, local business and service clubs • Tribes contributed some 2% slot machine tax funding in support of treatment of Native American patients

14. The Situation in 2008 • State eliminated Medicaid benefits for adults (2003) • Sawyer clinic closed in 2004; purchased by UPARHS • Student resident externship program discontinued to preserve staff dentists in Marquette clinic for children • Nursing home program was discontinued in 2004; nursing home was able to sustain it on its own • State decreased revenue sharing with Counties (2007) • Reductions in County Health Department budget and reduced capacity to generate revenue made county dental clinic unsustainable. January 2008, MCDC took over the Marquette County Health Department Clinic

15. Insights…. • What excited you about this story? • What were the keys to success? • Any leverage points that caused transformative change? • What insights might apply to your own community?