The TeleDentistry Project

1. The TeleDentistry Project Increasing Access to Dental Services for Georgia’s Children through Public Health Suleima Salgado, MBA Director of Telehealth & Telemedicine Office of the Chief of Staff Georgia Department of Public Health suleima.salgado@dph.ga.gov March 28, 2017

3. Some of Georgia’s DPH Telemedicine Initiatives High Risk OB Clinic Children’s Medical Services Developmental & Genetics Endocrinology Nephrology Neurosurgery Pulmonology Sickle Cell • Centering Pregnancy • Ultrasound / Colposcopy • Consult w/ Maternal Fetal Medicine Specialist WIC Nutrition Infectious Disease (HIV/AIDS) • Breastfeeding Support • Nutrition Education • Staff Training/Development • Patients at local clinics see DPH Infectious Disease specialist • Mobile presentations from home or community setting

4. Oral Health • Tooth decay is one of the most preventable childhood chronic disease among children • It accounts for persistent pain, trouble eating and sleeping, missed school days, and expensive emergency room visits for preventable dental problems yet oral health care remains the most prevalent unmet health care need for children, especially low income children • Early diagnosis and treatment are emphasized due to the progressive, destructive nature of caries and periodontal diseases

5. Oral Health • Yet, much of the reason dental disease persists comes down to the fact that underserved children and other vulnerable populations in Georgia lack access to routine dental care • Unfortunately, the traditional office-based dental care delivery system does not reach a large segment of Georgia’s population. • Because of the lack of providers, rural areas have additional barriers to dental care when compared to other locations. • The targeted counties are designated Health Professional Shortage Areas (HPSA) and dental HPSAs by the Health Resources and Services Administration (HRSA).

6. Oral Health Routine use of Oral Health services is driven by a variety of “access to care” issues including: • Dental Health Insurance • One dental practice in each county • Limited number of Medicaid/PeachCare patients seen in two of the practices, none in the third • Limited pediatric specialty services • Socio-economic Status • Workforce Issues • Oral Health Literacy • Individual and Cultural Health Behaviors • Geography

7. Why Dental Services in Schools? • DPH polled school nurses from four southeast Georgia counties, including Brantley and Charlton, and nurses reported back to us that dental related complaints surpassed asthma as the leading reason given for seeking school nurse services.

8. GEORGIA’S (2) TELEDENTISTRYINITIATIVES

9. Teledentistry Initiative Mission for DPH: • Provide dental screenings, preventive services, and oral health education for students who may not have access to dental care in rural, South Georgia.

10. Serving Brantley, Charlton, Clinch County Schools Teledentistry Initiative (1) Background/Funding: • Public Health Expansion Funds & HRSA OAT grant • Initial set-up in Head Start center 2008 – 2009 school year • Portable dental equipment from school-based clinics • Expansion grant began Sept 2010 • Network Development HRSA Grant in 2014

11. Innovative Partners

12. TeleDentistry Process Flow Dentist, from his or her office, makes a diagnosis and connects with dental hygienist to discuss findings with student and develops a treatment and follow up plan, if needed. For more advanced treatment needs, case management begins and referrals can be made. All results mailed to caregiver Caregivers provide prior consent. Student is called out of class and seen during school hours. A thorough medical/dental history is captured Hygienists provide cleaning, fluoride, x-rays and dental education Hygienist collects initial information about students oral health, uploads and submits X-rays to dentist for review New questions, responses, and updates

13. Patient Satisfaction • District has been providing care to high-risk children for nine years through this program. • Overwhelmingly positive results • Routine Customer Satisfaction Surveys conducted • Parents/Teachers express a high degree of satisfaction with the program, in large part because this program is designed in a way that makes accessing dental care easy and convenient for students. • Teachers and Administrators have made this a standard practice and recommend kids for referrals routinely

14. Health Outcomes • Children receive services they may not have gotten otherwise • Children learn how to care for teeth for lifetime • Children come to school ready to learn & experience less dental pain • School reduce absenteeism rates for dental related illnesses and appointments • Parents save w/ transportation costs, lost wages, & preventative care • Children are connected w/a dental home for future services • Dental providers receive information from screening and have payor source intact

16. Barriers: • Follow-up challenges • Pediatric providers • Transportation • Medicaid/PeachCare providers • Acceptance by local dental providers • Scope of practice regulations for Dental Hygienists • Payment for services/sustainability

17. TeleDentistry Initiative (2) South Central Health District: • Increase scope of network and the resources available to other health districts (Dublin, GA) • EX series desktop video conferencing system provided and access to all DPH provider sites. • Hygienist takes laptop into CHDs to serve young WIC clients with screenings and preventative oral health services • DMD oversees operations remotely from office using technology • Outfitted local mobile dental trailer to provide services in field • Community Elementary Schools to provide dental services

18. Next Steps: • Expansion of Service into Dental Office and Mobile Clinic in South Central Health District • Implementing mobile trailer (Early April, begin use next school year) • Continued Pursuit of Medicaid Reimbursement for Teledental Services to Improve Sustainability • New state law carve out from DCH for hygienist to practice outside of direct dentist supervision, which would allow us to bill for our teledental hygiene visits (Pending final legislative approval). • Recruitment of Part or Full-time Dentist to Expand Capacity of Treatment • Hire a new dentist. We continue to pursue increased client treatment capacity through the use of contracted services

19. Next Steps: • Further Development of Teledentistry Protocol for Adoption by the Georgia DPH • Work with state office of Oral Health • Implement University (GRU) Student Rotation of Teledentistry Services • Difficult process. Little interest from our partner dentist to act as preceptor for the program. • In lieu of this, we've decided to push for more community outreach in the form of continuing education classes to community providers, and using the forum to  assist with educating the members about our program.

20. Peebles, Heather G. "A Cost-Effectiveness Analysis of the Southeast Health District's Teledentistry Program." Thesis. Emory University, 2011. Print.

21. Contact Information Suleima Salgado, MBA Director of Telehealth & Telemedicine Office of the Chief of Staff suleima.salgado@dph.ga.gov Office: 404.657.2305 Georgia Department of Public Health Southeast Health District Office: 912.287.5884