Considerations for Program Development

1. Considerations for Program Development School-Based Dental Health By: Erica M. Allen Intern, Center for Health and Health Care in Schools Candidate for MPH, MCP Hahnemann University School of Public Health-Philadelphia

2. Preface The following is a power-point presentation summarizing current directions in school-based dental health. Recommendations and proposed strategies were obtained through personal interviews, published research, oral health conferences, personal observation of school-based dental centers and educational institutions. The presentation is intended to serve as guidance, based on best available information, for successful school-based dental health program development. This information is presented with the understanding that the oral health needs of children and adolescents are locality specific and will require flexibility in program design and implementation. We hope that you will find the following information useful for presenting dental health issues to partners in your community. EA

3. Why is Oral Health Important? • Good oral health means more than having healthy teeth • Oral health is integral to general health • Safe and effective prevention methods exist to improve oral health for everyone • About 51 million hours of school are lost due to dental problems • Poor dental health pain, infection, dysfunction, poor performance Systemic Systems (Nervous, Immune, Vascular) Craniofacial Tissue (Oral Tissue, Brain, Brain Tissue, Facial Tissue Mouth (Teeth+Gums+Tissues) + + Oral-Systemic Connection Quotes from text of: DHHS. U.S. Public Health Service. (2001, May). Oral Health in America: A Report of the Surgeon General.

4. Child & AdolescentOral Health The Problem • Tooth decay is the single most common chronic childhood disease • 5 times more common than asthma • 7 times more common than hay fever Nearly twice as many children with low-SES ages 2-9 years have at least three decayed or filled primary teeth than do children from families with higher income levels. National Institute of Dental and Craniofacial Research. (2001, Feb). A Plan to Eliminate Craniofacial, Oral, and Dental Health Disparities.

5. Child & Adolescent Oral Health Disparities Percent untreated tooth decay among poor children ages 2-9 years by Race/Ethnicity (primary teeth only) 71% 67% 57% DHHS. U.S. Public Health Service. (May, 2001, May). Oral Health in America: A Report of the Surgeon General, Chapter 4, p63.

6. Child & Adolescent Oral Health Disparities Percent untreated tooth decay among poor children ages 12-17 years by Race/Ethnicity (permanent teeth) 47% 44% 21% DHHS. U.S. Public Health Service. (May, 2001, May). Oral Health in America: A Report of the Surgeon General, Chapter 4, p64.

7. Percent of Total Dental School Enrollment by Underrepresented Minority Populations Percent Community Voices. (March 2001). The Big Cavity: Decreasing Enrollment of Minorities in Dental Schools. A series of Community Voices Publication.

8. Barriers in Access to Dental Health Services • Lack of awareness of seriousness of oral health • Lack of or insufficient dental insurance • Lack of transportation • Uncompensated time from work • Limited income • Low community-to-private provider ratio • Dentist non-participation with Medicaid/CHIP • Low Medicaid program reimbursement rates for dental services DHHS. U.S. Public Health Service. (May, 2001). Oral Health in America: A Report of the Surgeon General.

9. Cost and Utilization ofDental Services • $60,000 billionnational dental expenditure for fiscal year 20001 • 500 millionaverage number of dental visits in the U.S. annually2 • 39 millionnumberdental service beneficiaries through Medicaid and CHIP1 • 19%percent of total Medicaid & CHIP beneficiaries who received preventive dental services2 1 Health Care Finance Administration website: http://www.hcfa.gov. Date Accessed: July 10, 2001 2 U.S. DHHS. CDC. (2000). Improving Oral Health: Preventing Unnecessary Disease Among All Americans: At-A-Glance

10. Oral Health Problems: A Response “One proven strategy for reaching children at high-risk for dental disease is” providing oral and dental health services in school-based health centers… supporting linkages with health care professionals and other dental partners in the community” Grant Makers in Health Issue Dialogue.. (2001, May). Filling the Gap: Strategies for Improving Oral Health. Issue Brief.

11. Potential Objectives for a School-Based Dental Health Program • Increase the proportion of children who use the oral health system each year. • Increase the proportion of school-based health centers with an oral health component. • Increase the proportion of low-income children and adolescents who receive preventive dental services each year. • Reduce the prevalence of children and adolescents with untreated dental decay. • Reduce the proportion of children and adolescents who have dental caries in their primary or permanent teeth. Based on objectives for the Nation in Healthy People 2010.

12. Determinants of Good Oral Health“More than just having clean teeth” School-based health centers have the capacity to overcome barriers in access to dental care and to address each of these factors: Individual Factors (oral hygiene, fluoride rinse, diet/nutrition, personal risk, care seeking practices, etc.) Barriers to Oral/Dental Health Lack of Awareness Lack of Insurance Limited Income Lack of Transportation Physical Environment Social Environment (potential for unintentional injury/accidents) (dental insurance, community awareness)

13. Partnershipsfor Oral Health Programs in Schools School Personnel Schools of Dentistry Community Dental Practice PARENTS + KIDS Dental Health Organizations Policy Administrators Medicaid/SCHIP City Health Department

14. Evaluation School Based Oral/Dental Health Program ImplementationA Step-by-Step Process Program Implementation • Of goals • Of mission • Of outcomes • Of clinical services • …………... • Chart audits • Program modification • Parent/Child education • Staff training • On-going needs assessment Policy Context • Characteristics for success: • Flexibility • Motivation • Local/ state regulations • State licensure requirements • Medicaid provisions • Other dental insurance provisions Program Design Prior to start of school year • Needs assessment • Oral/dental service selection • Resource considerations • Staffing availability • Equipment availability • Supplies/electrical units • Outcomes measures • Quality assessment • Referral networks • Follow-up after referral • Data collection • Forms • Parental involvement Outcomes/Objectives • State/Local priorities • School priorities • Goals/mission • Short-term/long-term Infrastructure Development • Coalitions & Stakeholders • Planning process • Management structure 13

15. School-Based Health Centers, in PartnershipwithCommunity Dental Providers, Can: Enhanceeducation Enhance dentalservice Eliminate barriersto dental care Quotes from text of: DHHS. U.S. Public Health Service. (May, 2001, May). Oral Health in America: A Report of the Surgeon General.

16. A Proposed Oral/Dental Health Service Scheme Child Risk Assessment • Student Education • Video Presentation • Classroom Presentation • Individual Counseling • Parental Education & Consent • Back to school mailing • Emphasize importance • Increase awareness Low Risk Detection High Risk Detection • Coding Procedure • Standardized coding • Data collection • Data analysis • Proper documentation • Community member • Lay outreach • Health care receptionist • Dental hygienist • Health educator • Letter for parent signature • Phone calls Educate & Inform Parent Educate & Inform Parent On-site Service Service Referral Follow-Up Notice Exam Reminder Transportation Medicaid Enrollment Follow-Up Management

17. A Proposed School-Based Oral/Dental Health Service Scheme: Another View Medical or Dental Professional EPSDT 1. Risk Assessment 2. Establish Periodicity Family + Child 5. Education Individual/ Parent 3. Diagnosis/ Treatment 4. Guidance/ Referral Medical or Dental Professional EPSDT Adapted from text of Casamassimo P. (1996). Bright Futures in Practice: Oral Health in America. Arlington, VA: National Center for Education in Maternal and Child Health

18. Considerations in Implementing a School-Based Dental Program • Staff recruitment and retention • Sustainability –establishing a collaborative business plan • Electrical capacity- “dedicated line” for dental equipment • Potential use of portable equipment- (California and Oregon vendors) • Temperature sensitive equipment, AC/fans required • Availability of X-Ray machine- if unavailable, then referral service crucial • Emphasis on skills training for long-term oral health maintenance • Securing parent involvement for follow-up and family awareness • Securing support from dental school and oral health organizations • Securing support from local health providers involved in providing dental care to underserved populations

19. Encouraging Private Dentist Participation • Emphasize that school-based dental programs are not competitive • Involve private dental providers in planning for greater cooperation • Analysis of community-to-private provider ratio: • Number of dental providers available to Medicaid & CHIP beneficiaries • Number/Percent offices open to new patients • Private provider acknowledgement of inability to serve all children • Provides rationale/support for school-based services • More likely to support referrals for preventive/restorative care • Capacity to follow-up in school-linked programs is crucial • Requires referral, annual check-up, and re-assessment Adapted from text of: William Mercer Inc. (April, 2001). Geographic Managed Care Dental Program Evaluation: Executive Summary prepared for the Medi-Cal Policy Institute

20. Oral Health Service Outcome Measures 19 Adapted from text of Casamassimo, P. (1996). Bright Futures in Practice: Oral Health in America. Arlington, VA: National Center for Education in Maternal and Child Health