Expanding Dental Therapy in Tribal Communities

1. Expanding Dental Therapy in Tribal Communities Christina Peters Native Dental Therapy Initiative Project Director Northwest Portland Area Indian Health Board Andrew Shogren Tribal Health Director, Suquamish Tribe Tribal Self Governance Conference Travers City, MI April 1, 2019

2. Building a 21st Century Dental Team at Swinomish Indian Tribal Community -- and Beyond!

3. Topics of Discussion: • Swinomish Licensing - Christina • How Dental Therapy fits into the Community Health Aide Program – Andrew • Portland Area and National Update on CHAP expansion –Andrew and Christina • Ways to use Dental Therapists in your communities – Andrew and Christina

4. Our Board is interested in supporting long term sustainable solutions that build up our communities, create opportunities for our youth and tribal members, educate our healers and train the next generation of work force. Why?

5. Plays a significant role in shaping employment opportunities • Can increase capacity for better decision making regarding one’s health • Provide scope for increasing social and personal resources that are vital for physical and mental health Education Attainment

6. Employment Attainment • Living Wage • Access to insurance and other resources Economic Stability

7. Old I.H.S. Provided Dental TrailerSwinomish Indian Tribal Community

8. Swinomish Dental Clinic after Self Governance -Exercising Sovereignty

10. Adding a DHAT works for the Swinomish Community • Procedure review for FY 2012, 2013 and 2014 for Swinomish Clinic showed that over 50% of procedures and services could have been provided by trained dental therapist using the Alaska model • Analysis shows that the same procedures could have been covered with 50% personnel cost savings by replacing dentist time with dental therapist time • Analysis shows that dentist time could have been significantly re-oriented to more complex dentist-only procedures, i.e. such as prosthodontic, advanced restorative and surgical procedures, etc.

11. Increase in patients seen • Completing treatment plans faster • Dentists doing almost 50% more crown, bridge, and partials and have started an implant program • More efficient “urgent” care time • Daniel is out in the community every week • Wednesdays with Head Start Program brushing and flossing • Delivering meals to elders in the community • Two DHAT students set to graduate from the ADTEP class of 2019. Swinomish Today

12. Political Road to Sovereignty Solution • Swinomish worked for 7 years with the Northwest Portland Area Indian Health Board and a coalition of community advocates, public health organizations and dental professionals to pass a bill in the Washington Legislature authorizing dental therapists to practice in Washington in order to meet the requirement of the IHCIA limiting language • Swinomish worked for 3 years to pass a Tribal Specific DHAT Authorization Bill • Before 2016, no bill got out of House or Senate Committees in Washington State, blocked by legislators working on behalf of the Washington State Dental Association • Swinomish determined it has the power and obligation to address oral health systems change by exercising its Tribal Sovereignty

13. The Community Health Aide Program is nationalized through with the permanent reauthorization of the IHCIA However: IHCIA Title 25 §1616L(2)(B) shall exclude dental health aide therapist services from services covered under the program. AND IHCIA Title 25 §1616L(3)Election of Indian tribe or tribal organization (A) In general Subparagraph (B) of paragraph (2) shall not apply in the case of an election made by an Indian tribe or tribal organization located in a State (other than Alaska) in which the use of dental health aide therapist services or midlevel dental health provider services is authorized under State law to supply such services in accordance with State law.

14. Undaunted by the ADA, Swinomish decided to create the regulatory structure to license and employ a DHAT based on the Alaska CHAP Standards and Procedures. DHAT Daniel Kennedy at Swinomish on his first day with his first patient, Anthony Cladoosby

15. Sovereigntyin Action: Build Tribal Regulatory Framework • Swinomish created a Division of Licensing, bringing together existing Tribal licensing and regulatory functions: • including licensing/regulating child care services and on-Reservation businesses • Swinomish also self-certifies its mental health providers and regulates admission to practice in Swinomish Tribal Court • Swinomish adopted the first Tribal Dental Health Provider Licensing Code to license and regulate Dentists, Hygienists and Dental Therapists • This is a quintessential exercise of Tribal sovereignty: regulating Tribal providers who are employed by the Tribe, paid with Tribal funds, working in a Tribal clinic built on Tribal land, and improving the health of Tribal community members

16. Overview of Swinomish Dental Licensing Code • Established Dental Health Licensing Board of at least five (now expanded to six) members, with five year terms: • Chair of Swinomish Senate’s Health, Education and Social Services (HESS) Committee • Enrolled Member of the Tribe • Dentist or other individual with experience in oral health education and training • Individual with education, experience, interest in and commitment to improvement in oral health among Native Americans • Swinomish Chief Dental Officer

17. Overview of Swinomish Dental Licensing Code • Licensing Board duties: • Consult with and advise Swinomish Senate and Division of Licensing on technical and policy matters, and recommend Licensing Code amendments • Review and approve Division of Licensing procedures and forms • Conduct hearings and appeals from license or sanctions decisions • Division of Licensing duties: • Investigate license application and • Issue license, • impose conditions on license, • or deny application • Investigate complaints • Take action to protect public or sanction licensees

18. Overview of Swinomish Dental Licensing Code • License requirements include: • Must meet Tribal minimum standards of character for contact with Indian children or elders • Employed by Tribe or eligible for employment when licensed • Completed required training and continuing education • Demonstrate formal education, training and/or personal or professional experience that would reasonably be expected to result in cultural competence • If a Dentist, have experience supervising Dental Therapists or complete an acceptable course on supervision

19. Overview of Swinomish Dental Licensing Code • Robust investigative and appeal provisions to: • protect public safety • provide due process to license applicants or holders • Division of Licensing authority to impose range of sanctions: • Probation, with regular reporting, limited practice, continued education • Reprimand • License suspension • License revocation

20. Overview of Swinomish Dental Licensing Code • Creating a licensing code and an administrative process is resource intensive • Every Tribe may not need to replicate the Swinomish model • Swinomish worked with the NPAIHB to make its licensing system available to collaborating Tribes: • Swinomish amended its Dental Licensing Code to provide for licensing of dental providers employed by Washington and Oregon Tribes • NPAIHB prepared template Memorandum of Agreement and Tribal code documents for use by collaborating Tribes

21. Overview of Swinomish Dental Licensing Code Intertribal health care licensing fosters Tribal autonomy and independence from state regulation Intertribal licensing parallels state initiatives to expand professional license reciprocity and portability Intertribal health care licensing conserves limited Tribal resources and avoids needless duplication Intertribal licensing is a cooperative exercise of Tribal sovereignty that strengthens Tribal authority and governance

22. Overview of Swinomish Intertribal Licensing Process • Two step process for a Dental Therapist and Supervising Dentist to be licensed by Swinomish: • PHASE I – LEGAL INFRASTRUCTURE • Tribe employing the Dental Therapist must enter into a Memorandum of Agreement (MOA) with Swinomish: • Includes HIPAA compliant Business Associate Agreement • Adopt Dental Licensing Code • Provide Certificate of Insurance pursuant to MOA • Adopt Tort Claims Code (optional but recommended) • Needs to be in place before starting Phase II process

23. Overview of Swinomish Intertribal Licensing Process • PHASE II – LICENSING PROCESS • MOA requires Swinomish licensure of both the Dental Therapist and Supervising Dentist • Steps in seeking a Swinomish license: • Step 1 Complete Application, with attachments: • $450.00 Application Fee • Letter of Intent • Letter(s) of Reference • Resume • HIV/AIDS Education Completion Verification • Suicide Prevention Education Verification

24. Overview of Swinomish Intertribal Licensing Process • Step 2 Complete and sign background check form • Step 3 Provide letter of certification on cultural competency • Step 4 Complete/Sign Practice Agreement between Dental Therapist and Supervising Dentist • Step 5 For Dental Therapist application: complete Preceptorship (may be issued a Provisional License until Preceptorship is completed) • Step 6 For Supervising Dentist application: complete Supervisory Training & Provide Certificate of Completion

25. Overview of Swinomish Intertribal Licensing Process • Swinomish Intertribal Licensing is a new process. • As with any professional licensing protocol, Swinomish Department of Licensing’s due diligence to determine eligibility involves a number of steps, and each takes time. • Applicants may be requested to provide additional or explanatory information in the course of the review process. • As with any new process, Swinomish Intertribal Licensing will evolve over time.

26. WE ENCOURAGE YOUR PARTICIPATION Sovereignty in Action is aided by solidarity amongst all Tribes

27. February 2017: Tribal DHAT bill becomes law!

28. SWINOMISH INDIAN TRIBAL COMMUNITYDENTAL HEALTH PROVIDER LICENSING CODEHTTP://WWW.SWINOMISH.ORG/MEDIA/48067/1511DENTAL.PDF Tara Satushek, Senior Planner Division of Licensing tsatushek@swinomish.nsn.us 360-466-5318 Stephen LeCuyer, Director Office of Tribal Attorney slecuyer@swinomish.nsn.us 360-466-1058

29. CHAP in the Portland area Andrew

30. Tribal Health System Needs: Trisha Patton, DHAT, taking x-rays on patient • Effective prevention programs • Culturally competent care • Basic restorative services • Locally provided • Meeting our needs intelligently will lead to efficiencies

31. What is the Community Health Aide Program? (and how do DHATs fit?)

32. The Community Health Aide Program (CHAP) and CHR Program have key differences. • Legislative Authority- CHAP is authorized under 25 USC § 1616 a-d while the CHR Program is authorized under IHCIA PL. 100-713. • Funding Sources- The Alaska CHAP is funded through the hospital and health clinics (H&HC) line item in the IHS budget and CHRs are funded through a specific CHR line item. • Scopes of Work- While the “community health” portion of the names are similar, the scope of work for a Community Health Aide and Community Health Representative are vastly different. CHAs are mid-level primary medical providers who can provide basic medical attention and can connect a patient to clinical care. CHRs provide health promotion, prevention, and outreach to community members.

33. The AlaskaCommunity Health Aide Program Alaska Native Tribal Health Consortium web: www.akchap.org |www.anthc.org

34. Who do CHAs, BHAs, and DHAs provide services to? National Geographic Families Elders Individuals Youth Alaska Native Tribal Health Consortium The Blues & the News

35. Community’s Role in Selection • Culturally Competent Care • Competency based curriculum • Team-Based Care Health Aide Program Key Components CHAP Education center in Gambell, AK

36. CHA I • Body systems and approach • Basic medical history and basic exam • Patient Intake • Blood draw, urine dip, suturing and wound care, IV therapy, splinting, lab testing, med administration • Substance abuse • Emergency medical services and mental health • CHA II • Blood draw, urine dip, suturing and wound care, IV therapy, splinting, lab testing, med administration • Substance abuse • CHA III • Women’s health, STI, prenatal visit, emergency deliver • Well child • CHA IV • Follow up and management of chronic illnesses • Elder Care • Tobacco cessation and substance abuse prevention • CHA/P • Team leadership • Primary Care CHA/P Scope

37. BHA-I • Screening • Initial intake process • Case management • Community education, prevention, early intervention BHA-II • Substance abuse assessment & treatment BHA-III • Rehabilitative services for clients with co-occurring disorders • Quality assurance case reviews BHP • Team leadership • Mentor/support BHA-I, II, and III BHA Scope of Practice

38. Alaska’s Dental Therapists in action 35 dental therapists increased access to care for over 45,000 Alaska Natives Provide culturally competent care Produce high patient satisfaction rates Reduce amount of emergency care Increase preventive care Create jobs and generate economic impact Created 76 full time jobs per year with total personal income of $4.4 million Net economic effect of program is $9.7 million in Rural Alaska Swinomish Dentist Rachael Hogan observes DHAT Savannah Bonorden on a recent learning trip to Sitka, AK

39. Types of Dental Health Aides (DHA) • Primary DHA (CDHC) • Oral Health Educators • Expanded Function DHA • Restorations, cleanings, temporary fillings • DHA Hygienist • Local anesthesia • DHA Therapist (DHAT) • Prevention, operative, urgent Supervised providers Teams led by Licensed Dentists Chelsea Shoemaker, Bonnie Johnson, Corrina Cadzow (DHAT students) providing fluoride varnish treatment for a Head Start student.

40. DHATS scope and education tailored to address barriers in Indian Country Shortage of dentists in tribal communities Lack of Resources Coverage and Medicaid Acceptance Cost of care Historical Trauma Lack of culturally competent providers Geographic isolation Delivery system-Lack of a strong safety-net

41. Expand access to consistent, routine, high quality oral health care in tribal communities; • Grow the number of AI/AN oral health care providers available to tribal communities; • Bring culturally competent care into tribal communities; • Create a more efficient and effective oral health team that can meet the needs of the tribal communities; • Establish cost effective solutions to oral health challenges into tribal communities; • Bring care where it is needed most. Dental Health Aide Therapy Programs Chelsea Shoemaker, DHAT, with Patient

42. Daniel Kennedy, Swinomish Dental Clinic, WA Jason Mecum, Lower Elwha Klallam, WA There are 5 DHATs working in Washington and Oregon Naomi Petrie, CTCLUSI Dental Clinic, Oregon Marissa Gardner, CTCLUSI Dental Clinic, OR Rochelle Ferry, Pt Gamble S’Klallam, Washington

43. Pt Gamble S’Klallam Today • Wait time is almost gone • DHAT Rochelle Ferry is out in the community • Exams and sealants with head start program • Working with Home Health Nurse doing home visits targeting elders and diabetic population, doing exams and listening and bringing people BACK into care • Roz is the only full time provider at the clinic • The community is eager to see Roz • More elders than ever before are getting care.

44. CTCLUSI Today One DHAT has completed her preceptorship 2nd DHAT in preceptorship Increase in level 4 and 5 services Even with burden of preceptorship, there has been an increase in patients seen Two new dental chairs Plans for clinic expansion Now that Naomi has completed her preceptorship, she will begin community projects.

45. Tribes without medical, dental, or behavioral health facilities could partner with near by Tribes to share CHAP providers • Tribes with new health facilities could use CHAP providers to encourage continuity and to build program in the early stages • Tribes that lose their doctors/dentists can partner with other Tribes to utilize their workforce in the short term until new providers can be hired • Shared elder, child, and community programs • Home visits for vulnerable populations • Focus on chronic disease populations • Endless possibilities Government to Government Partnership opportunities through CHAP

46. What’s next?

47. Students from Washington, Oregon, and Idaho in the Alaska Dental Therapy Education Program, class of 2019 Angela Johnson (First Nations), Lummi, Class of 2019 Asiah Gonzalez, Swinomish, Class of 2019 Anna Degraffenreid, Coeur d’Alene, Class of 2019 Sarah Chagnon, Swinomish, Class of 2019 Inga Weddle, Tulalip, class of 2020 Kari Douglass (Chickasaw), NARA Dental Clinic, Class of 2019 Arielle Cawston, Colville, Class of 2019 Avena Finkbonner, Lummi, Class of 2019

48. What’s next for CHAP in the Portland Area? • DHAT Education program in partnership with Swinomish and Skagit Valley College • Dental Therapy Legislation in Idaho signed on March 25, 2019 • Dental Therapy Legislation in Oregon in 2021 • Portland Area CHAP Certification Board

49. IHS has formed CHAP TAG • Area Directors appointed two TAG members from each Area • First meeting of CHAP TAG was March 21-22, 2018 in Phoenix AZ • Second meeting was by phone on April 27, 2018 • Third meeting was in August in Seattle • Next meeting was in Washington DC on Oct 10th at IHS HQ • CHAP TAG met by phone with IHS twice in Jan/Feb • Next meeting is Wednesday April 3rd here from 9-11AM

50. The interim policy, once approved will provide a legal foundation for the CHAP CB being developed in the Portland Area • IHS is planning to roll out policies for DHAT and Behavioral Health Aides (BHA) with Community Health Aides (CHA) to come later