Identifying Vulnerable Populations: Who is Primary Care?

1. Identifying Vulnerable Populations: Who is Primary Care? Ginny Cathcart BA, Dip. DH, M.Ed. RDH gcathcart

2. Why “The Visioning Summit?” • Dental hygienists have much to offer the public in terms of education, health promotion, preventive & therapeutic care. • The public has few choices for service delivery models when it comes to accessing dental hygiene care. • The private system of dental care is often the only choice. • For many citizens this system is not an option due to financial, physical, psychological or other barriers. gcathcart

3. Alternative Service Delivery • To achieve improved levels of oral health for a broader segment of the population, new models of dental hygiene service delivery need to be developed. • You were invited to this Summit to begin the process of developing alternate service models which take full advantage of the dental hygienist’s broad range of skills to enhance the oral health of the public. • The focus will be on serving segments of the population who are currently underserved such as the poor, the dental phobic, the homebound and the institutionalized. gcathcart

4. Anticipated Outcomes • A vision of alternate service and its relevance to the future of the dental hygiene profession. • Identification of those clients and users who may access alternate service delivery. • Discussion of a range of potential alternate service models • Agreement on the next steps for BCDHA and the BC Dental Hygiene Educators to work cooperatively in actualizing proposals for alternate service delivery • Agreement on concrete responsibilities and timelines for implementing alternate delivery models. • The summit final report will be available to BCDHA members. gcathcart

5. Mapping the issues? • Who lacks access to dental hygiene services? • Who cares about “access to care?” • Why is access denied? • Is “primary care” a turf conflict? • Who is primary care? • Why vision alternatives? gcathcart

6. Dental Hygiene Process of Care? • Is primary care just the full process of care taught in current dental hygiene programs? • Is our current dental hygiene education sufficient for accessing vulnerable populations? (2) gcathcart

7. Primary care: Features and disciplines • Definitions of primary care are numerous and either more descriptive or normative, depending on the purpose they serve. • The normative approach has been closely connected with the WHO Alma Ata Declaration in 1978 on Primary Health Care, in which the focus was on solidarity and equitable access to care (1) gcathcart

8. Primary care: features and disciplines • on the protection and promotion of health rather than on curing illness • on more influence of the population on health care instead of professional dominance • and on broad intersectoral collaboration in dealing with community problems (WHO, 1978) (1) gcathcart

9. Who is Primary care? • One consistent thread within these variations is that primary care consists of the professional response when patients make first contact with the health care system. (1) gcathcart

10. The primary care process • The attributes or functions of primary care have been concisely summarized in the definition of the American Institute of Medicine (Donaldson et al., 1996) referring to • “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, • developing a sustained partnership with patients and practicing in the context of family and community” (1) gcathcart

11. Responsiveness to community needs is a key element of primary health care. • Therefore, the range and configuration of services may vary from one community to another. • There is no "one size fits all" model. • Similarly, there may be various governance and funding models. (1) gcathcart

12. Vision the Solutions • a greater emphasis on health promotion and illness/injury prevention; • voluntary participation by providers and patients alike; (2) gcathcart

13. Vision the Solutions • capacity-building in evaluation, so that system performance may be monitored; and • an explicit focus on change management activities to support all of the above. (2) gcathcart

14. Supports to primary health care • information technology (especially electronic health records); • governance and funding models which support team-based care; • links to public health; and • a culture of accountability, performance measurement, and quality improvement. (2) gcathcart

15. The “neglected epidemic” • Poor children, • the elderly, • developmentally disabled, • the medically compromised, • homebound and homeless people, • those with HIV, • uninsured, • institutionalized individuals, • as well as members of ethnic minorities, • remain most vulnerable to oral diseases. (3) gcathcart

16. The “neglected epidemic” • The U.S. Surgeon General goes so far as to refer to a “neglected epidemic” because of the failure to recognize oral disease as a health priority in the USA. • Report offers Canadian health officials and caregivers an unprecedented opportunity to learn…(3) gcathcart

17. Low Income Families • Many lack dental insurance and cannot afford to see private dentists. • Many have no regular source of care. (3) gcathcart

18. Low Income Families • Are less likely to have reliable private transportation • Are more likely to rely, where it’s available, on public transportation • Are more likely to have difficulties keeping appointments (3) gcathcart

19. Low Income Families • Children from low income families are 50% less likely to have their dental caries treated than children from middle-income families. • The consequences of untreated dental caries include: pain, loss of appetite, mental distraction, tooth loss, disfigured smiles, speech pathologies, emotional distress, academic problems and behavioral issues. (3) gcathcart

20. The Elderly • Often have income issues, transportation needs and care-giving conflicts. • Federal health insurance plan for the elderly, offers no dental benefits in many areas. • Institutionalized elderly have special access issues. (4) gcathcart

21. Canadian Seniors • The dental care needs of Canadian seniors are not being met because of economic & other barriers. • Only 34% of Canadians, aged 65 and older, reported having visited a dentist in the last year. • In contrast, 87.5% of them had visited a primary care physician — a 2.5 fold difference. • Alberta, the Yukon, and the Northwest Territories offer seniors dental care as part of their universal health care programs. • Ontario and eight other provinces do not (4) gcathcart

22. Non-English Speaking Families • Find it more difficult to learn about federally sponsored programs, get enrolled and locate participating providers • Have difficulty communicating needs and problems to providers, understanding self-care instructions (3) gcathcart

23. Persons with developmental & mental Disabilities • Have greater dental morbidity than general population, less well-developed self-care habits, difficulty in making and keeping dental appointments, less compliant with treatment advice • The mentally ill often use psychotropic drugs to manage their symptoms; such drugs cause Xerostomia (dry mouth), which increases incidence of tooth decay and gum disease. (3) gcathcart

24. Under-represented persons • First we need to address the needs of • Low-income Canadians • Seniors • Aboriginal peoples (5, 6) gcathcart

25. CDHA urges the federal government • to implement Medicare coverage for public dental hygiene programs for all low-income Canadians, particularly children and seniors, to narrow the ever widening gap in the oral health status between the rich and the poor. (5) gcathcart

26. CDHA & the Federal Government • needs to revise its reimbursement schedules for public oral health care services so that they are based on average market rates. • This will improve access to oral health services for the neediest Canadians, who are presently refused treatment by some dentists who are reluctant to participate in public programs that in some cases provide reimbursements that do not cover their overhead costs. (5) gcathcart

27. CDHA recommends • The federal government increase financial support for both the Community Health and the non-insured health benefits program (NIHB) of the First Nations and Inuit Health Branch of Health Canada, specifically for dental hygiene preventive programs, in order to reduce the gap in oral health between Aboriginal peoples and non-Aboriginal peoples. (5) gcathcart

28. The dental decay rates • for Aboriginal peoples, which are three to five times greater than the non-Aboriginal Canadian population, show that the present funding for these programs is woefully inadequate. • Poor access for aboriginal persons in Canada • More likely to have untreated dental disease and they experience more severe consequences from dental disease. (5) gcathcart

29. Closer to home: Cost to society to treat early childhood caries BC • Approx 1800 children are seen each year for dental treatment under general anesthesia at BC Children's Hospital (4-6 months wait time) • Private dental care ranges $400-$600 • The BC Dental Association advocates a private public partnership, where the health ministry pays the facility fee for displaced children in private clinics. (7) gcathcart

30. What This Means? • Much is written about minimal access to care once oral diseases are developed. • The panellists will assert that access to optimal, primary oral healthcare must occur before oral disease develops. • Review WHO definition of Primary Care (1) gcathcart

31. Fair Access to Oral Health • apply research outcomes & oral health policy on… • the protection and promotion of health rather than treating disease • more influence of the population on health care instead of professional dominance • On interprofessional collaborations in dealing with community problems (1) gcathcart

32. What This Means? • Panellists & keynote speaker will present alternative service delivery: • Population health • Social marketing • Mentoring applied research • Interprofessional collaborations • Expanded & full scope of practice • Dental hygiene primary care gcathcart

33. References • Saltman RB, Rico A & Boerma WGW (Eds). Primary Care in the driver’s seat? Organizational Reform in European Primary Care. Open University Press: McGraw-Hill Education; McGraw-Hill House. Berkshire, England, New York, NY. 2006 [cited 19-Apr-07] at: http://www.euro.who.int/InformationSources/Publications/Catalogue/20060403_3 • About Primary Care: Health Canada. [Cited 1-Apr-07] at: http://www.hc-sc.gc.ca/hcs-sss/prim/about-apropos/index_e.html • Herenia P. L. & James L. L., The U.S. Surgeon General’s Report on Oral Health in America: A Canadian Perspective. J Can Dent Assoc 2001; 67: (10) 587. [cited 19-Apr-07] at: http://www.cda-adc.ca/jadc/vol-72/issue-8/vol72_issue8.pdf gcathcart

34. References 4. Leake, JLThe History of Dental Programs for Older Adults. J Can Dent Assoc 2000; 66:316-9 [cited 15-Apr-07] at: http://www.cda-adc.ca/jcda/vol-66/issue-6/316.htm • Ziebarth S. Financing Canada’s Oral Health System. Oral Presentation to the House of Commons Standing Committee on Finance Pre-Budget Consultations. Canadian Dental Hygienists Association. 2002. [cited 19-Nov-06] at: http://www.cdha.ca/content/newsroom/pdf/Financing_Can_Oral_Health_Care_eng.pdf • Dental Benefits available at: http://www.hc-sc.gc.ca/fnih-spni/nihb-ssna/benefit-prestation/dent/index_e.html • BC Dental Association News Archive [cited 19-Apr-07] at: http://www.bcdental.org/bcda/news/mediaArchive-detail.jsp?item=22 gcathcart

35. Access to Oral Health Care On-line Resources • Access Angst: A CDHA Position Paper on Access to Oral Health Services 2003 at: http://www.cdha.ca/pdf/position_paper_access_angst.pdf • Access and Care: Towards a National Oral Health Strategy. Presentations. University of Toronto. 2004 at: http://individual.utoronto.ca/accessandcare/saunderson.html • Armstrong R. Access and Care: Towards a National Oral Health Strategy: Report of the Symposium. University of Toronto. 2004 at: http://individual.utoronto.ca/accessandcare/Report.pdf gcathcart

36. Access to Oral Health Care:On-line Resources • CDHA Newsroom: News Releases at: http://www.cdha.ca/content/newsroom/reports.asp • Dental Hygiene Focus on Advancing the Profession. ADHA. 2005 at: http://www.adha.org/downloads/ADHA_Focus_Report.pdf • Leake, JL. Access and Care: Reports from Canadian Dental Education and Care Agencies J Can Dent Assoc 2005; 71(7):469–71 at: http://www.cda-adc.ca/jcda/vol-71/issue-7/469.pdf • Main P, Leake J, Burman DOral Health Care in Canada: A View from the Trenches. J Can Dent Assoc 2006; 72(4):319 at: http://www.cda-adc.ca/jcda/vol-72/issue-4/319.pdf gcathcart