SD Collaborative Agreement

1. SD Collaborative Agreement ZonaHornstra, RDH, BS SDDHA Legislative Chair May 18, 2013 This is a Working Document and will be updated periodically with new information as it becomes available

2. OBJECTIVES • Describe Collaborative Supervision Practice • Awareness of Level of Supervision • Discuss Opportunities for Direct Access • Review Specifics of SD Collaborative Agreement • Laws and Regulations that regulate CS • Identify Treatment Settings and Roles of Providers • Documentation and Reporting Structures • Determine an Awareness of SD Provider Shortage Areas • Considerations for Business Planning and Tax Implications • Reimbursement of Services/ CDT Codes • Information of NPI numbers • Location and Contact Info of State Public Access Opportunities • Questions and Answers • References

3. INTRODUCTION Collaborative practice means that the dental hygienist has established a written agreement with a dentist who has agreed to monitor treatment of patients and consult as needed. The dental hygienist and dentist jointly establish a protocol that describes the services the hygienist may provide without the dentist’s supervision.

4. Academic definition • The science of the prevention and treatment of oral disease through the provision of education, assessment, preventive, clinical, and other therapeutic services in a cooperative working relationship with a consulting dentist, but without general supervision. Christine Nathe RDH MS, University of New Mexico

5. LEVELS OF SUPERVSION "Direct supervision," the supervision of a dental hygienist or dental assistant requiring that a dentist diagnose the condition to be treated, a dentist authorize the procedure to be performed, a dentist remain in the dental office while the procedures are performed, and before dismissal of the patient a dentist has approved the work performed by the dental hygienist or dental assistant; "General supervision," the supervision of a dental hygienist requiring that a dentist authorize the procedures to be carried out, and that the patient to be treated is a patient of record of the supervising dentist and has had a complete evaluation within the previous thirteen months of the delegation of procedures; "Indirect supervision," the supervision of a dental hygienist or dental assistant requiring that a dentist authorize the procedure and a dentist be in the dental office while the procedures are performed by the dental assistant or dental hygienist Source: SD Dental Practice Act p. pg. 12-13

6. OPPORTUNITY Direct access dental hygiene practice options are available that would offer you: • a professional challenge • open doors to new opportunities • provide unique satisfaction • Being able to provide services to people unable to obtain them Collaborative practice can be a new career option: • as a part-time vocation • on an occasional volunteer basis

8. The Career of Dental Hygiene Private dental office remains the primary place of employment. Career opportunities from alternative clinical setting to school sealant program. Career pathways in public health and career opportunities outside of private practice. ADHA give career opportunities in public health and `other opportunities. Information about specific job opportunities can be found in ADHA’s Career Center within the ADHA. org website

9. Historical Review Dental hygiene was created as a distinct profession positioned in dental public health model in schools. Wide access to preventive care is provided by educated dental hygiene professionals in public settings in Early 1900’s. Emphasis was placed on the dental hygienist as an outreach worker to bring patients in need of restorative dental care. The effectiveness of the care provided in communities and schools spread to the private dental practice. Nation's health care leaders are quickly realizing the important connection between oral health and total health. Emphasis by both dental hygienists and dentists is now wisely being placed on interdisciplinary health care delivery options. One of the top ten fastest growing health professions in the country, *** References: • *** American Dental Hygienists' Association. July 10, 2010. ADHA Offers Testimony at CMS National Dental Medicaid Dental Town Hall Forum. Accessed July 16, 2010 from http://www.adha.org/news/04062009-CMS.htm

10. SD HISTORY 2002 Oral Health Coalition recommended Limited Access Permit RDH. 2005 was brought in as a Bill and was not approved in Committee. 2009 Oral Health Coalition recommended investigation of a model of Public Health Supervision. Surgeon General mandates each state to have options for improved dental access. SDDHA brought forth House Bill 1045 which was Established by Statute in 2011 to allow dental hygienists to provide preventative services. Rules and statute put into SD Dental Practice Act July 2012.

11. INTENT • The intent of collaborative dental hygiene practice is to: • Extend dental hygiene services to those unable to access services • Offering services in locations where there are transportation barriers • There are many possibilities for a variety of locations and populations

12. SD Agreement • The process of Collaborative Supervision practice agreement is defined by South Dakota law. • Dental hygienists and dentists must enter into a written collaborative agreement. • Collaboration will negotiate all details and protocols (e.g., billing practices and where and when dental exams occur) • Purpose of the written agreement is to clarify and document mutual decisions regarding specific dental hygiene services. • Details discussed and direction given within the SD Dental Practice Act.

13. SD Law and Regulations DENTAL AND DENTAL HYGIENE • Knowing the laws governing dental hygiene and more specifically dental hygiene services in community settings is essential for all involved in Collaborative Supervision hygiene services. • The SD Dental Practice Act gives a complete picture of regulations addressing all aspects of dental care in South Dakota for regulations of dentists and dental hygienist, including Collaborative Supervision: http://www.sdboardofdentistry • Under Statutes and Rules Review: • Title 36 : 36-6A-26, 36-6A-31; 36-6A-40; 36-6A-40.1 • Title 20 Article 43/ 20:43:04:04; 20:43:10

14. SD Practice Act 36-6A-40. Employment of hygienist--Scope of permitted practice--Preventive and therapeutic services. Any licensed dentist, public institution, or school authority may use the services of a licensed dental hygienist. Such licensed dental hygienist may perform those services which are educational, diagnostic, therapeutic, or preventive in nature and are authorized by the Board of Dentistry, including those additional procedures authorized by subdivision 36-6A-14(10). As an employee of a public institution or school authority, functioning without the supervision of a licensed dentist, a licensed dental hygienist may only provide educational services. May not include the establishment of a final diagnosis or treatment plan for a dental patient. Services performed under supervision of a licensed dentist. and all care rendered by the hygienist is completed under the definition of patient of record. A dental hygienist may perform preventive and therapeutic services under collaborative supervision if the requirements of § 36-6A-40.1 are met. However, no dental hygienist may perform preventive and therapeutic services under collaborative supervision for more than thirteen months for any person who has not had a complete evaluation by the supervising dentist. • Source: SD Dental Practice Act

15. Practice Act Requirements 36-6A-40.1Hygienist requirements for preventative and therapeutic services under collaborative supervision. A dental hygienist may provide preventive and therapeutic services under collaborative supervision of a dentist if the dental hygienist has met the following requirements: (1) Possesses a license to practice in the state and has been actively engaged in the practice of clinical dental hygiene in two of the previous three years; (2) Has a written collaborative agreement with a licensed dentist; and (3) Has satisfactorily demonstrated knowledge of medical and dental emergencies and their management; infection control; pharmacology; disease transmission; management of early childhood caries; and management of special needs populations. • Source: SD Dental Practice Act pg. 19

16. Collaborative Supervision • The Collaborative Agreement is designed as a guide for dental hygienists, dentists and facilities that are establishing dental hygiene services in community settings. • Laws pertaining specifically to Collaborative Supervision for dental hygienists are found in Chapter 10 of the South Dakota Dental Practice Act.

17. SD PRACTICE ACT CHAPTER 20:43:10 COLLABORATIVE SUPERVISION 20:43:10:01. Practice settings. A dentist may provide collaborative supervision to a dental hygienist pursuant to a collaborative agreement if the dentist holds a license in good standing in the state of South Dakota and the following services are provided: In a school as defined in § 24:43:01:01(38); (2) In a nursing facility as defined in SDCL 34-12-1.1; (3) Under the auspices of a Head Start program or Early Head Start program being operated by an agency designated pursuant to section 641 or 645A of the Head Start Act; (4) Under the auspices of a mobile or portable dental unit operated by any nonprofit organization affiliated with a nonprofit dental service corporation organized under SDCL chapter 58-39; (5) Under the auspices of a community based primary health care delivery organization, which is operating as a community health center or migrant health center, receiving funding assistance pursuant to section 329 or 330 of the United States Public health Service Act; (6) Through a program administered by the South Dakota Department of Health; (7) Through a program administered by the South Dakota Department of Social Services; (8) Through a program administered by the South Dakota Department of Human Services; or (9) Through a program administered by the South Dakota Department of Corrections. Source: SD Dental Practice Act pg. 65

18. Settings Nursing home, home health agency Nursing facility as defined in SDCL 34-12-1.1 Group home serving the elderly, disabled, or juveniles State-operated facility licensed by the commissioner of human services or commissioner of corrections Federal, state, or local public health facility Community clinic United States Public Health Service Act section 329 or 330 Tribal clinics- have their own requirements and contractual agreements that need to be met School authority In a school as defined in § 24:43:01:01(38) Head Start programs Mobile Units SDCL chapter 58-39 NONPROFIT DENTAL SERVICE PLANS (Delta Dental Ronald McDonald bus, van)

19. Hygienists Requirements 24:43:10:02. Qualifications A dental hygienist providing services under collaborative supervision must hold a license in good standing in the state of South Dakota and meet the following requirements: (1) Completion of three years of clinical practice in dental hygiene; and (2) Completion of a minimum of 4,000 practice hours. A minimum of 2,000 of those hours must have been completed within two of the three years preceding application. 20:43:10:03. Application for registration. A dental hygienist registering to provide services under collaborative supervision must submit the following: (1) A completed application form; (2) A completed board approved collaborative agreement; (3) A fee of $20; (4) Verification of completion of three years of clinical practice in dental hygiene; (5) Verification of completion of a minimum of 4,000 practice hours; and (6) Verification of completion of a minimum of 2,000 practice hours within two of the three years preceding application. Source: SD Dental Practice Act pg. 67

24. Providing Treatment (2) A dental hygienist providing services under collaborative supervision may provide all preventative and therapeutic services that a hygienist is allowed to provide pursuant to SDCL chapter 36-6A and this chapter, except for the administration of local anesthesia and nitrous oxide inhalation analgesia, and must: (a) Maintain appropriate contact and communication with the dentist providing collaborative supervision; (b) Practice according to age and procedure specific standing orders as directed by the supervising dentist, unless otherwise directed by the dentist for a specific patient; (c) Provide to the patient, parent, or guardian a written plan for referral to a dentist land assessment of further dental treatment needs; (d) Have each patient sign a consent form that notifies the patient that the services that will be provided do not take the place of regular dental checkups at a dental office and are meant for people who otherwise would not have access to services; and (e) Specify a procedure for creating and maintaining dental records for patients that are treated by the dental hygienist, including where these records are to be located; Source: SD Dental Practice Act pg. 68

25. Maintaining the Agreement (3) A copy of the collaborative agreement shall be filed with the board. If any changes are made to the collaborative agreement, an updated copy of the agreement shall be filed with the board and must be approved; (4) If the agreement is terminated by the dentist or dental hygienist, the board shall be notified in writing within 30 days. A termination of the collaborative agreement constitutes a suspension of the registration (5) The collaborative agreement must be maintained by the dentist and the dental hygienist in each location where collaborative supervision is provided and must be made available to the board upon request. The dentist and dental hygienist must review the agreement annual 20:43:10:06. Termination of agreement. If any provision of the collaborative agreement is violated, the registration may be suspended or revoked by the Board. Source: SD Dental Practice Act pg. 68

26. CONSENT FORM EXAMPLE

27. Screening Referral Form Example

28. Role of Supervising Dentist 20:43:10:04. Collaborative agreement. A dentist and dental hygienist shall enter into a written board approved collaborative agreement that specifies the following responsibilities: Provide appropriate communication and consultation with the dental hygienist; Have age and procedure specific standing orders for the performance of dental hygiene services. Must include consideration for medically compromised patients and medical conditions for which a dental evaluation must occur prior to the provision of dental hygiene services; Specify no more than 13 months, examination must occur prior to providing further hygiene services. Limit the number of dental hygienists that he or she has a collaborative agreement with to four or less; S Source: SD Dental Practice Act: pg. 67

29. Extra Items The law does not require the dentist to examine or treat people The document formalizes the working relationship Hygienists may have more than one sponsoring dentist if they are providing services in different community sites . If hygienists change sponsoring dentists, they must complete a different form, and resubmit to the SD Board of Dentistry.

30. Reporting 20:43:10:05. Reporting requirements. Each dental hygienist must complete a summary report and submit the information to the board at the completion of a program or, in the case of an ongoing program, annually.

31. REPORTING FORM Form given to Collaborating Team after application is approved by State Board of Dentistry. SD Collaborative Supervision Reporting Form : Is an Annual requirement Requires begin and end dates of the Services provided. Requires a one specific location where treatment was given Requires tabulation of preventative treatment given per age group Requires tabulation of Regular or Urgent referral given per age group Form will specify and document one location per form. Form copy is to be maintained by Collaborating by Hygienist and Dentist and also sent to the SD State Board of Dentistry.

32. Forms and Applications https://www.sdboardofdentistry.org State Board of Dentistry site: Licensure tab Application/ Documentation General tab • Bottom of page • Collaborative Supervision Agreement Consideration to make this info more visible to Dentists

34. Collaborative Planning Utilize a public health programming model: Define the Target Population Formulate the Problem Statement Perform a “Needs Assessment” • % of people who need care, have teeth, neglected Access To oral health care Create a Logic Model • Collaborative Supervision Model

35. Planning Secure your collaboration with a dentist, discussing an effective referral and/ or follow through mechanism, i. e. dental home Design plans in collaboration with the intended agency/ facility/ population Interview dental hygienists and dentists currently involved with collaborative practice Formulate a business plan with Collaborating DDS Utilize the Dental Safety Net Clinic Manual http:// www.dentalclinicmanual.com/bottomFrame.Html

36. Safety Net Dental Clinic Manual

37. Identify Funding Opporunities Collaborating Dentist Facility Based Opportunity for Grants HRSA, ADHA

39. Details…options for financing acollaborative practice Q: How is a dental hygienist paid; how is a program financed? A. Various options, to include : As an employee of a dentist, submit claims through the dental office • Fee-for for-service; Sliding fee scale • Grant funding • Philanthropic donations; funding from Foundations • FUTURE POSSIBLITIES • Medicaid direct billing utilizing the RDH’s NPI numbers • Health plan billing utilizing the RDH’s NPI numbers

40. Reimbursement Private insurance companies may reimburse dental hygienists in some states. Need to consider coordinating billing through the Collaborating dentist. Some might limit the codes they will reimburse to dental hygienists. To order the CDT manual of dental codes see: http://www.ada.org/3836.aspx

41. Billing Codes CDT ADA determines CDT codes (Current Dental Terminology) Responsibility of a Code Maintenance Committee (CMC). Mission is to incorporate best practices from HIPAA, CDT, ICD-9 codes. Provisioned for Affordable Health Care Act

42. New CDT 2013 CODES FOR DIRECT ACCESS • Pre-diagnostic Services • D0190 Screening of a Patient to determine need to be seen by a Dentist • D0191 Assessment of Patient – a limited inspection to determine need for referral for diagnosis and treatment D0380-0386 Capturing radiographic image without interpretation • D0391 Image captured by practitioner not associated with interpretation or report. D1206 topical application of fluoride varnish • D1208 topical application of fluoride Source: Department of Human Services April 2013

43. CAMBRA Caries management by risk assessment • A methodology of identifying the cause of disease through the assessment of risk factors • This approach has been qualified through various experts, researchers and advocated by numerous professional organizations • Become a new standard of care which should be incorporated into the dental hygiene process of care ADA has approved 3 New CAMBRA CDT codes for 2014 book Source: http://carifree.com

44. 2014 CDT CODE/ CAMBRA CHANGES • Along with assessment forms, suggested management protocols and clinical guidelines: • 0-5 years of age: • • Frequency of periodic examination • • Frequency of radiographs • • Saliva testing • • Fluoride Utilization (in-office, daily use and care giver) • • Xylitol products • • Sealants • • Antibacterials • • Anticipatory guidance/counseling • • Self management goals • • White spot precavitated lesion management • • Restoration/Existing lesions • 5 through Adult(5): • • Frequency of radiographs • • Frequency of caries recall exams • • Saliva test (saliva flow & bacterial culture) • • Antibacterials, chlorhexidine & xylitol • • Fluoride (in-office & daily use) • • pH control • • Calcium phosphate topical supplements • • Sealants

45. SD Medicaid Expansion Governor Daugaard decided not to fund Medicaid Expansion this last legislative session But A task force developed to gather information determine the best decision for SD . Meetings to be held Spring/ Summer 2013 with a report to the Governor September 2013. Can Find more info at: www.sdbudgetandpolicyprojects

46. PEW CHARITABLE TRUST STATS Total individuals eligible in Fiscal Year 2010 = 96,781 38.6% of children enrolled in Medicaid accessed preventive dental services (37,353 eligible) 17.6% of children enrolled in Medicaid received dental treatment services (17,032 eligible) 5.1% of children enrolled in Medicaid received a sealant on a permanent molar tooth (4,951 eligible) Total eligible receiving any dental services= 41,271 (42.6%) Total eligible receiving dental diagnostic services= 34,815 (35.97%) Total eligible receiving oral health services provided by a non-dentist provider = 287 (0.3%) Total eligible receiving any dental or oral health services= 41,460 (42.8%)

47. PEW GRADES STATES ON SEALANTS Based on four indicators as a key part of any state’s prevention strategy: • having sealant programs in high-need schools, • allowing hygienists to place sealants in school-based programs without requiring a dentist’s exam, • collecting data regularly about the dental health of school-children and submitting it to a national oral health database, and • meeting a national health objective on sealants.

50. Reimbursement Each state Medicaid program is Federally mandated and identifies the types of procedures and providers it reimburses for services. Federal / State Medicaid Assistance Percentage is decided on matching funds based on 3yr income average of each state. SD Privatized Medicaid by contracting with Delta Dental to administrate the program. Medicaid in other states will reimburse dental hygienists who provide care if alternative settings for: prophylaxis, sealants, and fluoride with improvement on reimbursement due to new CDT codes. SD currently does not allow Medicaid reimbursement to dental hygienists but does reimburse medical providers and others for fluoride application. Many rules and stipulations dependent on age and inability to pay programs determine reimbursement under Medicaid program. Utilize Call center to determine eligibility: Call Center 877-841-1478 Fax Back 877-789-5241 or deltadentalsd.com