Service Delivery Model

1. Service Delivery Model Upgrading access and delivery of dental services to a special needs group

2. Identifying the Need • One dentist and dental nurse currently providing dental care for a homeless population of 2,366 • HSE funded initiative • Traditionally emergency service and comprehensive treatment provided – Bottle Neck • Average of 750 appointments per year since 2003 • Eligiblityfor treatment depends on Medical Card entitlement • Opportunity to upgrade service delivery to reach more patients and remove the barriers to accessing care

3. Barriers to accessing care • Lack of available information • Location and timing of services • Fear and intimidation from dental staff • Financial difficulties or no medical card • The administrative systems and the attitudes of service providers. • THESE NEED TO BE ADDRESSED

4. Exceptional/High Risk • Clause activated - November 2011 • Medical Card holders eligible for full range of dental treatment by virtue of their dental vulnerablility (see Appendix 1) • PRSI scheme (social insurance) abolished 2009 and Medical Card limited to 2 emergency fillings per year in 2010 • Private GDPs are willing to accept referrals from Homeless services where they weren’t previously

5. Determining Priorities • The priority is to increase access for homeless people to dental services • Provide them with information on services available • Establish rapport with patients to alleviate fear • Provide assistance with medical card application • Determine their dental need and provide relief of pain as priority initially. • Provide support for General dentists who are willing to accept the patient referrals, by means of telephone and visits where necessary.

6. Identifying Objectives (SMART) • S- Assess 30 per week for level of need, medical card status/eligibility and Triage and refer to suitable GDP/MQ emergency • M- Recordnumber of patients attending screening sessions and number of patients attending for Emergency relief of pain. Follow up with dental practices with phone call to measure level of attendance for consultation and follow up treatment.

7. Identifying Objectives (SMART) • A- Success of screening, triage, referrals satisfaction of patients and GDPs • R- Target Number of patients per week is 30 Target number of GDPs in the referral pathway 8. Is this sustainable? Necessary? Other factors preventing us reaching target • T- Time frame of 6 months for a pilot with a 3 month reflection period

8. Programme Implementation • Identified 8 units to be targeted for screening chosen due to existing referral pathway with dental services and previous presence in these units • Units differed in type of homeless service day center/residential setting/methadone treatment center • Age profile and level of level of dependency differed in units

9. Meet Staff in Units Unit date Response • Orchid House 19/01/12 Positive • Sundial House 19/01/12 Positive • Focus George’s Hill 20/01/12 Positive • Focus Coffee Shop 24/01/12 Positive • Castle St. 26/01/12 Positive • Trinity Court Pearse24/01/12 Positive • Merchant’s Quay 31/01/12 Negative • City Clinic Amiens 07/02/12 Positive

10. Meeting Summary • Outline proposal to use premises for dental screenings for clients of the facility • Explain that clients should be assisted by units to apply for medical cards via the ‘Fast Track’ Online service • Clients will be listened to and examined to ascertain their need and matched with a suitable dentist • Emergency dental care available in MQ 2 days per week without medical card • Any Questions from staff answered

11. General Dental Practitioners • Contacted GDPs in the Dublin city center areas by phone for willingness to accept referrals from Homeless services • All clients eligible for treatment under Medical Card Exceptional/High Risk clause • Eight accepted proposal • Create positive relationship with reception staff/dental nurse and the senior dental nurse for Homeless services to ensure efficient referral pathway

12. Clinical Dental Technician • A Clinical Dental Technician or CDT is a registered Dental Care Professional who is trained and qualified to provide a range of denture services directly to patients. • Eight in Rep. Of Irl one of whom is close by in Dublin • Referrals made for all dentures in same manner as to GDPs with Medical Card subject to approval

13. Dental Screenings • January 2012 to June 2012 – 18 screenings carried out • Assess Med card status& provide support for medical card application • Examine using Denlight • Discuss patient needs and wants • Discuss suitable venue for treatment • Explain Exceptional/High Risk clause subject to approval • Get Patient details to contact later that day

14. Triage Form

15. Eligibility Form for GDP records

16. Administration • Back at base check Med Card status & PPSN (personal public service number) • Make best match with GDP & client • Make referral calls if not already done during screening • call client with details of referral • copy screening form & eligibility form and post to GDP • Follow up phone call 1 week later to GDP and client

17. Mid Point Reflection • At 3 month point in project • GDPs – 10 more requested to join the referral pathway • Units – positive response asking for sister satellite units to be screened in the future • Clients – suitable clients were referred by staff of units to GDPs with advice from Homeless unit • Information – Medical card eligibility, access to dental services more readily available to clients in their own units • Emergency treatment in MQ still heavily subscribed

18. Table 1: 6 month evaluation Number of clients screened and referred

19. Making sense of the figures Table 1 • Number of clinical sessions Jan-June 2012 Screening + MQ emergency = 48 • Total number of clients seen- 216 Screenings + 69 Emergency MQ = 285 • Av. Number of clients per session = 6 • Session is AM or PM

20. Table 2:Number of procedures carried out2008*,2007,2006,2005* week 9 2008 to week9 2009

21. Making sense of the figures Table 2 • Total number appointments annually- 839 Av. • 52 weeks in year minus 9 weeks Annual Leave/Bank hols/Sick leave etc = 43 weeks • 7 sessions per week x 43 = 301 sessions • Av. number of clients seen per session - 2.8 • Many of these clients were repeat visits. In 2008 there were 279 individuals treated over 946 appointments. Compare this with 289 in 6 months pilot 2012

22. Figure 1: Number of Clients catered to per session in 2012 compared with previous years

23. Figure 2:Referral outcomes with GDPs & CDT & Homeless Dental

24. Supported Medical Card Application

25. Discussion • The initial findings suggest more clients are being cared for • Administration - Labour intensive • Evident by the fact that there is a high number of clients in the ‘Don’t know’ category of the follow up data • Of the clients referred to GDPs 44% are non contactable for follow up • It is unrealistic to think that the service could move forward without the support of dedicated staff, at least a specialist dental nurse and ideally a specialist dental team

26. Discussion • Attendance at the Emergency drop-in in MQ is still heavily subscribed lending support to the belief that the chaotic nature of homelessness does not marry well with an appointment service • What the client ‘wants’ and what they are capable of is often at odds • The most successful referral pathway is to a GDP who operates a ‘walk in’ service in Dublin 1 • Sometimes the city needs a whole warehouse dedicated only to Bananas

27. References • Slide 1http://www.homelessagency.ie/Facts/Homeless-Figures.aspx ‘Measuring Homelessness’ accessed 12/01/12 • Slide 3 Holohan T (1997), “Health Status, Health Service Utilisation and Barriers to Health Service Utilisationamong the Adult Homeless Population of Dublin”, Dublin, Eastern Health Board • Slide 14 http://www.cdtai.ie/ Clinical Dental Technician Slide 23 HSE Special Needs Dental Report 2007, 2008