Getting a Head Start on Oral Health: An Overview of Oral Health Requirements and Programs

1. Getting a Head Start on Oral Health: An Overview of Oral Health Requirements and Programs The National Center on Health Reg Louie, DDS, MPH Harry Goodman, DMD, MPH Bev Isman, RDH, MPH, ELS (facilitator) UCSF Dental Public Health Seminar October 15, 2013

2. What is Head Start • Head Start (HS) is a federal program that promotes the school readiness of children ages birth to five from low-income families (living at 100% or below the federal poverty level) . • HS programs provide a learning environment that supports children's growth in the following domains: • Language and literacy • Cognition and general knowledge • Physical development and health • Social and emotional development • Approaches to learning • Source: Copied from ECLKC website: http://eclkc.ohs.acf.hhs.gov/hslc/hs/about

3. History of Head Start • HS began as a summer demonstration project in 1965 as part of Lyndon Johnson’s War on Poverty. • Since 1965, HS has served nearly 30 million children. Currently, HS is administered by the Admin. for Children and Families (ACF) within the Dept. of Health and Human Services (HHS) and serves over 1 million children annually in all 50 states, US territories, and AI/AN and Migrant communities. • HS was reauthorized in 2007 with several provisions to strengthen HS quality. The HS training and technical assistance system was redesigned to support programs through six National Centers and a state-based system to ensure success. • Source: Copied from ECLKC website: http://eclkc.ohs.acf.hhs.gov/hslc/hs/about/history

4. Head Start Services • HS programs provide comprehensive services to enrolled children and their families, which include: • Education and cognitive development services • Health, nutrition, social, and other services • HS emphasizes the role of parents as teachers, and programs build relationships with families that support: • Family well-being and positive parent-child relationships • Families as learners and lifelong educators • Family engagement in transitions • Family connections to peers and community • Families as advocates and leaders • Source: Copied from ECLKC website: http://eclkc.ohs.acf.hhs.gov/hslc/hs/about

5. Head Start Service Models • HS serves preschool-age children (3 – 5 years) and their families. Early Head Start (EHS) serves infants, toddlers (up to 36 months), pregnant women, and their families. • HS programs offer a variety of service models. Programs may be based in: • Centers or schools that children attend for part-day or full-day services • Family child care homes • Children's own homes (home-based model), where a HS staff person visits once a week and provides services • Source: Copied from ECLKC website: http://eclkc.ohs.acf.hhs.gov/hslc/hs/about

6. HS Program Performance Standards • The HS Program Performance Standards provide a standard definition of quality services that all EHS and HS grantees are required to follow. • HS performance standards related to oral health include: • Within the first 90 days of enrollment, HS must determine whether each child has an ongoing source of continuous, accessible care (“dental home”) • HS staff should ask the parents the following in order to determine if children have a “dental home” • Name of dental provider? • Date of last dental visit? • How often does the child visit the dentist?

7. HS Program Performance Standards • Within the first 90 days of enrollment, a health care professional must determine if a child is up to date on preventive and primary oral health care according to state Early and Periodic Screening, Diagnostic, and Treatment (EPSDT or Medicaid) schedule • Health care professionals and HS staff access their state's EPSDT schedule to ensure children's health and dental needs are met • http://eclkc.ohs.acf.hhs.gov/hslc/states/epsdt

8. HS Program Performance Standards • Dental follow-up and treatment must include topical fluoride treatments as recommended by a dental professional • Head Start must establish ongoing communication with parents of children with identified dental needs to facilitate the implementation of the plan • Education of HS staff, case management systems, and documentation are vital to this process

9. HS Program Performance Standards • If a child is not up to date on age-appropriate preventive and primary care (EPSDT), HS must help parents bring the child up to date within the first 90 days of enrollment • e.g., Assists with Medicaid/CHIP application, transportation, finding a dental provider, etc. • Head Start must obtain or arrange further diagnostic testing, examination, and treatment for each child with health/dental problem • Dental follow-up remains one of the biggest challenges for Head Start parents and staff

10. YES DentistName FOLLOWUPTREATMENTREQUIRED? Phone Appointment Date Time InsuranceProvider ACTION Determine Insurance Status NO CONGRATULATIONS! YES YES ACTION Enroll in ACTION MakeAppointment Medicaid/ Hawk-i/CHIP GiveParentFormtobeSignedbyDentist Dental Home ACTION OralExam ACTION Provide DentistList (seeI-Smile) ACTION Keep ACTION Parent NO NO MEETINGORALHEALTHREQUIREMENTS Appointment toSecure DentalHome ACTION GetSigned ACTION Document Form Dental Home • Toothbrushing • GumWiping • HealthyDrinks • HealthyFood • HealthySnacks • LifttheLip • Other • Reinforce or choosenew goal: FamilyOral HealthEducation • Secure Servicesin: • Dentalhome • Classroom PreventiveServices Homevisit DentalvisitDATE Parentconference Informalcontact Schoolmeeting ACTION NO DATE ToothbrushingGumWipingHealthyDrinksHealthyFoodHealthySnacksLifttheLip Other Reinforce or choose new goal: YES Homevisit DentalvisitDATE Parentconference Informalcontact Schoolmeeting ACTION • FluorideTreatment • FluorideTreatment • Toothbrushing • GumWiping • Sealants • ParentEducation • ProfessionalDentalCleaning • Other • FluorideTreatment • Toothbrushing • GumWiping • Sealants • ParentEducation • ProfessionalDentalCleaning • Other • Toothbrushing • GumWiping • HealthyDrinks • HealthyFood • HealthySnacks • LifttheLip • Other • Reinforce or choosenew goal: • Toothbrushing • GumWiping • Sealants Homevisit DentalvisitDATE Parentconference Informalcontact Schoolmeeting ACTION ACTION ACTION ACTION • ParentEducation • ProfessionalDental Cleaning ToothbrushingGumWipingHealthyDrinksHealthyFoodHealthySnacksLifttheLip Other Reinforce or choose new goal: • Other Date Date Date Homevisit DentalvisitDATE Parentconference Informalcontact Schoolmeeting ACTION CHILD’SNAME

11. US Children: Decay Trends for Primary (Baby) Teeth Caries in children aged 2 to 5 years increased from 24 percent to 28 percent between 1988-1994 and 1999-2004 (CDC - 2007)

12. HS Program Information Reports (PIR) • The PIR provides comprehensive data on the services, staff, children, and families served by EHS / HS programs nationwide. All grantees and delegates are required to submit PIR reports to the HHS OHS annually. • Self-reported data • The PIR data is compiled for use at the federal, regional, state, and local levels. • http://eclkc.ohs.acf.hhs.gov/hslc/mr/pir

13. HS Program Information Reports (PIR) Oral Health PIR data requirements: • Number of children age 3 and older who received preventive oral health care • Number of children age 3 and older who need dental treatment • Of those, how many children received or are receiving dental treatment • Reason children did not receive dental treatment

14. Program Information Reports (PIR) Oral Health PIR data requirements: • Number of children age 3 and older up-to-date on preventive and primary oral health care based on state EPSDT schedule (age varies by state) • Number of pregnant women who received an oral exam or treatment (EHS)

15. Program Information Reports (PIR) 2012 Statistics (Self-Reported Data) • 91% have a dental home • 87% receive dental exams • 20% are diagnosed as needing treatment • 81% are receiving or have received care • 85% receive preventive care • 79% children 0-2 Up-to-Date on DentalEPSDTSchedule • 40% pregnant women completed dental exam

16. Head Start and Oral Health Photo Credit: Jane September | Stock Free Images & Dreamstime Stock Head Startdirectors, staff, and parents report oral health issues as one of their biggest challenges • Finding dentists that • See young children • Accept Medicaid • Have extended hours • Following up on needed treatment

17. Head Start and Oral Health Dentists and their staff report the following issues: • Don’t feel comfortable treating young children • May not have received adequate education • Parents canceling or not keeping appointments • Inadequate Medicaid reimbursement to cover services • Believing that oral health is not important to parents

18. Head Start and Oral Health Parents report the following issues: • Dental office staff are not friendly or welcoming • Explanations and instructions are hard to understand • Too technical • Not in the language they speak • Transportation is difficult or impossible • Difficult to miss work for dental appointments • Oral health care is too expensive

19. Challenges • Maintaining open and clear communication between Head Start staff, oral health professionals, and parents • Debunking myths and misperceptions • Reducing barriers to accessing oral health care for children • Engaging parents in their child’s oral health, and increasing their confidence and skills • Preventing oral diseases and injuries

20. Dental Office Factors • Attitudes toward and experiences with Medicaid • Ability of dentists and dental office staff to effectively work with infants and young children • Compliance with Head Start oral-health-related program performance standards, including documentation • Communication with parents (e.g., explaining how to be a good oral health consumer)

21. Dental Home and the PIR • A dental home is defined as a continuous and accessible source of dental care. Families need to know where they would take their child if they had a dental emergency and also where they will take their child for dental services after they graduate from Head Start. • What if you provide dental exams at the center and some children don’t have to go to the dentist?

22. Mobile Dental Programs • Is a mobile dental program a dental home? • A few cautions…

23. Dental Exams:Different ways to get there • Work with families to schedule appointments and take their children individually to the dentist. • Provide dental exams onsite by inviting the local dental staff to the center • Arrange to take the children in groups to the dental clinic for their exams.

24. Preventive CareDifferent Ways to Get There • Daily brushing with fluoride toothpaste in the center • Fluoride Varnish applications 3-4 times a year • www.ihs.gov/headstart • www.ihs.gov/doh/ecc

25. Dental Treatment:Different Ways to Get There • Have families schedule treatment appointments and take their children to the dentist individually. • Work with families to obtain informed consent and then Head Start can transport children to the dental clinic for routine treatment. OR…thinking outside of the box • Discuss less invasive treatment options with your local dental staff so that more children can be treated quicker, avoiding referrals to pediatric dentists.

26. Effective Family Engagement • Most health education is overwhelming and endless information that may not be understood or remembered.

27. Office of Head Start

29. Office of Head Start National Centers

30. National Center on Health

31. OHS Priority Health Issues • Healthy active living • Developmental and behavioral health • Safety and injury prevention • Health literacy • Oral health and dental homes • Asthma prevention with special emphasis on tobacco exposure prevention

32. National Center on Health Partners • American Academy of Pediatrics • Education Development Center, Inc. • Center for Child and Human Development at Georgetown University • UCLA Health Care Institute at the UCLA Anderson School of Management • National Training Institute for Child Care Health Consultants at The University of North Carolina at Chapel Hill • National Maternal and Child Oral Health Resource Center at Georgetown University (OHRC) • Association of State and Territorial Dental Directors (ASTDD)

33. Association of State and Territorial Dental Directors (ASTDD) • National non-profit organization representing SOHPs and other partners • Assistance to state oral health programs (SOHP) in improving the oral health of all residents through: • Community focused disease prevention programs • Improved access to care • Development of competent dental public health infrastructure • Worked with Head Start programs from 2002-2008 through the OHS/HRSA IAA • Subcontractor to OHRC for Head Start Oral Health Project

34. State Oral Health Programs (SOHPs) • A unit of state government usually in the health dept. • Assess and track dental disease rates • Promote and support education, prevention and access to care services • Use evidence-based strategies to promote best oral health practices and policies • Build public and private partnerships to promote and support state and local programs and policies • Assure adequate & competent oral health workforce

35. What SOHPs and HS Programs Give Each Other • Best practices • Education of families, HS teachers/staff, dental and other health professionals • Workforce development • Data and surveillance • Insurance and access (Medicaid/SCHIP) • Coordination, collaboration, and leadership • Funding • Linkage to dental professionals and HS personnel

36. Oral Health Project Activities • Use a three-pronged approach targeting parents, programs, and providers within a framework for oral health activities that includes disease prevention and management, access to care, and systems integration. • Focus on the oral health needs of infants, children, and pregnant women enrolled in Head Start.

37. Oral Health Project Activities (continued) 3. Establish and maintain a communication network at the national, regional, and state levels to share information with national organizations, regional offices, Head Start state collaboration offices, state Head Start associations, state oral health programs, health professionals, and others about Head Start oral health issues. 4. Collaborate with the American Dental Hygienists’ Association to use volunteer dental hygienist contacts in each state to serve as primary information conduits between NCH and state contacts.

38. What is the Role of the Head Start-Dental Hygienist Liaison? • Dental hygienists in every state are serving in volunteer roles to: • Provide a communication link between NCH and Head Start oral health activities and programs. • Collaborate with state organizations and ongoing networks (e.g., Dental Home Initiatives), including state dental directors and Head State state collaboration office directors, to address prevention and access-to-care issues.

39. What is the Role of the Head Start-Dental Hygienist Liaison? • Dental hygienists in every state are serving in volunteer roles to: • Assist in promoting evidence-based preventive and educational services to Head Start statewide. • Share links to resources with Head Start and other partners to improve consistent messaging on oral health.

40. Oral Health Project Activities (continued) Seek guidance about ways to accomplish oral health program activities, with particular attention to the unique needs of American Indian and Alaska Native Head Start programs, Seasonal and Migrant Farmworker Head Start programs, and children with special health care needs.

41. Disease Prevention and Management • Collaborate with organizations to widely distribute NCH evidenced informed information and materials. • Assist in locating policy statements, guidelines, training materials, and new research, and disseminate these. • Present at national and regional trainings.

42. Access to Care • Contact key individuals in each state to determine their ability to assist with T/TA, linking programs to dental homes, and other Head Start activities. • Collaborate with organizations to increase the involvement of federally qualified health centers with Head Start programs.

43. Access to Care (continued) • Continue to gather input from the Office of Head Start, national organizations, and key informants on strategies to develop a system of oral health care and oral health services for Head Start, as well as methods of tracking outcomes. • Continue to collect, review, and share promising and successful state and local models and practices via the Early Childhood Learning & Knowledge Center, newsletters, and presentations.

44. Access to Care (continued) • Continue to collaborate with state Medicaid and Children’s Health Insurance Programs (CHIPs), state oral health programs, state dental associations, and others to support the Centers for Medicare & Medicaid’s Oral Health Initiative to increase the number of Head Start participants enrolled in Medicaid or CHIP who receive preventive oral health services. • Promote work force, case management, and reimbursement models that increase access to/completion of care.

45. Systems Integration • Summarize and analyze Head Start program information report oral health service data to identify national/regional trends, successful programs, and programs needing TA. • Promote T/TA on valid tools to collect data on the oral health of children enrolled in Head Start that will allow for comparisons across states and can be submitted to the National Oral Health Surveillance System.

46. Cross-Cutting Issues • Share links to resources, and promote inclusion of Head Start and perinatal/early childhood oral health information in learning modules for students and residents. • Encourage dental manufacturers, insurers, grantmakers, and others to contribute or leverage resources for Head Start activities.

47. Resources for Head Start Staff, Health Professionals, and Families • Resource guide • Curricula • Tip sheets • Newsletter • Booklet and poster • Orientation guides • Brochures • Website

48. Oral Health in Head Start: A Resource Guide • Journal articles • Material descriptions and contact information • National initiative and programs • Policy • Professionals education, tools, and training • Public education • Surveillance • Organization descriptions and contact information

49. National Center on Health Contact Information Toll-Free: 888-227-5125 Email: nchinfo@aap.org Website: http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/health/center

50. Dental Public Health Competencies • Plan OH Programs for populations • Select interventions and strategies for the prevention and control of oral diseases and promotion of oral health • Develop resources, implement and manage oral health programs for populations • Incorporate ethical OH standards in oral health programs and activities • Evaluate and monitor dental care delivery systems • Design and understand the importance the use of surveillance systems to monitor OH • Communicate and collaborate with groups and individuals on oral health issues • Advocate for, implement, and evaluate public health policy, legislation, and regulations to protect and promote the public's oral health • Critique and synthesize scientific literature • Design and conduct population-based studies to answer oral and public health questions