Maryann Bailey, DDS Director of Dental Services Westside Health Robert Arm, DMD

1. INCREASING DENTAL ACCESS:A COLLABORATION BETWEEN A COMMUNITY HEALTH CENTER AND A DENTAL RESIDENCY PROGRAM Maryann Bailey, DDS Director of Dental Services Westside Health Robert Arm, DMD Director General Practice Residency Program Christiana Care Health System James Baker, DDS Delaware Institute of Dental Education and Research, State of Delaware

2. Goals: Today: • Provide some practical information on dental residency programs and how to incorporate residents into a community clinic setting. • Demonstrate the value of a partnership with teaching hospital to increase access to care If time: • Provide a history of the Dental Program at Westside Health • Review difficulties recruiting dentists in the State

3. Design – Based on needs of both programs

5. Westside Health’s mission Respond with compassion and respect to the health care needs of vulnerable individuals and families by providing equal access to quality health care, with an emphasis on disease prevention and health promotion, regardless of ability to pay.

6. Westside Health • Federally Qualified Community Health Center with three locations in and around Wilmington, Delaware • Large organizational growth over the last 10 years • 17 FTE medical providers – MDs and NPs • Multicultural patient population, majority speak Spanish as their primary language

7. Westside Health Patients By Income Level, 2004 Westside Health Patients By Income Level, 2004 Figure 1 Westside Health Patients By Income Level, 2004

11. Identification of Need • Patient Satisfaction Survey performed in 1996 asked patients to write in their recommendations for increased services at Westside. • The resounding answer was: “Dental”

12. Linkage with CCHS • Gave input into equipment and staffing needed to adequately run a dental program. • Offered assistance in recruitment of dentist to Westside and would help prepare that person for the Delaware Clinical Exam. • Interested in resident rotations at our CHC once a qualified dentist in place. • Dr. Arm’s expertise helped us apply for another New Access Point Oral Health Grant in 2001.

14. Westside Dental Program • Opened December 2002 • 2,500 square foot space with four operatories. • Initial dentist was a NHSC Ready Responder placed at Westside for a short time to establish dental care. • Nationwide recruitment for a Director of Dental Services

15. Director of Dental Services Recruited • Westside covered my travel to Delaware to screen potential dental exam subjects. • This was an organization-wide effort, as staff and their families offered to be a test subject in exchange for free dental care and time off. • Dr. Arm coached me, a periodontist, on exam topics and refreshed my general dentistry skills before the exam in January 2003. • Westside provided transportation to Philadelphia for the exam subjects and dental supplies. • I chose to bring my own Dental Assistant for the exam.

16. Dental Program Expansion, 2004-Present

17. Westside’s Dental Program • March 2003-- 1 FTE dentist and 0.8 FTE hygienist • The need in the community far outweighed the capacity of our small dental clinic. • Met again with CCHS to discuss dental resident rotations.

18. 2004 Oral Health Expansion Grant Proposal • Fit out and equip another four operatories, bringing total to eight. • Add another fulltime dentist • Increase hygiene hours • Extend hours to include two evenings per week. • Establish dental residency rotation at Westside

19. Dental Resident Rotations At Westside • The final piece of the Oral Health Expansion Grant • Westside had experience working with Family Practice residents from CCHS. • Both partners committed to the realization of this plan with Senior Leader support.

20. Value of Dental Residency Affiliation • Increased access to care • residents can perform evaluations and treatment with oversight from dental preceptor. • Cost efficient • use of facility • cost of providers • Potential to help with future recruitment of dentists for Westside and the state • Contributes to the professional development of Westside dentists. • Referral source for difficult patients– oral surgery, patients requiring sedation, and medically compromised patients.

23. Residency Collaboration • Just started July 2005 • Westside hosted the new residents for an afternoon of orientation before start date. • Resident rotations will increase dental providers by 0.6 FTEs. • Thus far, staff impressed with professionalism of the residents and patients are pleased with care.

25. Christiana Care operates two acute-care teaching hospitals in New Castle County, DE • Christiana Hospital, in Newark, a 780-bed hospital, providing the highest capabilities in neonatal care, plus major regional, comprehensive, heart and cancer centers. • Wilmington Hospital,in Wilmington, a 291-bed, community hospital, providing emergency and acute care services to those who live and work in the city and its suburbs.

26. CCHS Mission To improve the health of all individuals in the communities we serve.

27. CCHS Vision To establish a strong, independent, coordinated healthcare system of unsurpassed excellence which is patient-focused and community-based.

28. CCHS’sAffiliation Requirements: • Facility must meet all accreditation standards • Space • Documentation • Quality assurance • Patient procedures, work-ups, etc • Support staff – 4 handed assisting - dental hygiene

29. CCHS’sAffiliation Requirements: • Must have an approved attending • Evaluate residents • Evaluate patients treatment • Have a desire to teach/mentor • Fill out evaluations, required forms • Be part of resident review committee

30. CCHS’sAffiliation Requirements: • Qualified Residents • Qualified candidates – can we recruit? • Spots must be filled • All residents must be accepted to rotations - • can’t refuse anyone • All must be part of any remediation plans • Residents must be team players • Diverse backgrounds/schools

31. CCHS’sAffiliation Requirements: • Distant Sites • Housing must be provided • Distant learning available

32. Requirements for Dental Resident Rotations - Met • Qualified dentist on staff to precept the residents • Enough physical space and equipment to support operations • 4 new operatories added • Fully staffed practice to efficiently assist dental care by the residents. • Establish policies, documentation guidelines, and quality improvement activities compatible with the standards of the Commission of Dental Accreditation.

33. Goals of Christiana Care Health System Affiliation with Westside • Increased opportunities for resident education • Educate residents on culturally effective care through exposure to a multicultural patient population. • Improve educational curriculum – 4 handed dentistry • Maintain accreditation • Increase access to dental care in the community – mission statement of both • Retain dentists in state after residency. Currently, over 80% stay in Delaware.

34. CCHS General Practice Residency Program - Changes • Goal – Increase the residency from six to eight residents per year • two added in 2005 to support Westside rotation • Problems recruiting residents • broken contracts, withdrawals • Even with only six to start WE STAYED COMMITTED TO THE PROGRAM • Seventh added late June • Eight to be added in September

35. Problems – Change Rotations: THIS YEAR • 24 blocks – ½ month but 8 residents 8+ months - General Dentistry • 1 1/2 months - OMFS • 1 1/2 Months - Consult Rotation • Wednesday AM- Endodontics • Wednesday PM – Implants • Thursday PM – Periodontics • Friday AM - Pediatrics

36. Implant Program – A Key to Attracting Residents Wednesday PM – Implant Team Drs. Zucker, Baker, Isaacs Drs. Rafetto, Granite - OMFS

37. Rotations • Consultations - Inpatient/ ambulatory • Emergency Department • Anesthesia • Other sitesProblems with scheduling

38. And Help From the State PROGRAM ANNOUNCEMENT Delaware State Loan Repayment Program For Physicians and Dentists June 2002 Appropriate access to health care services throughout the state requires an adequate number and appropriate geographic distribution of physicians and dentists. The documented shortage of physicians and dentists in certain parts of Delaware is a concern.

39. Challenges – Westside • Scheduling • Best for patients and scheduling same time each week • Seminars • Problems with last minute changes • Residents are slower • Orientation – takes chair side time away • Time from dentists schedule to supervise

40. Challenges - Christiana • Recruitment of residents • Making a rotation schedule for several sites • Meeting educational demands • Scheduling seminars • Continuity of Care

41. Challenges - CCHS Residents • Missing special clinics – • Pediatric Dentistry Friday AM’s • Endodontics Wednesday AM’s • Traveling • Returning for seminars • Length of session – • CCHS has different hours

42. Benefits - Westside • Increased Providers • Evening Coverage • Referral source for difficult case • Major Oral Surgery • Difficult Endodontics • Those who need sedation • Medically compromised

43. Benefits - CCHS Resident • Excellent 4-Handed Dentistry • One assistant assigned to residents • Better chair side set-up • Efficient patient care • More continuity of care – return casesALL SEVEN RESIDENTS STATED: • No problems • Enjoy the rotation

44. Plans for Program Evaluation • Did program improve access to dental care? • Were the educational standards met? • Did residents remain in Delaware? • Were any dental residents attracted to community dentistry through exposure to Westside? • Did this affiliation assist in recruitment of future dentists to Westside?

45. Outcome Assessment • Only time will tell– need a minimum of two years experience to track changes. • Hopefully, this program will help change the face of dental care in Delaware. • Delaware State Loan Repayment Program established in 2002 for dentists to help with recruitment. This is just a start. • Working together to increase access to care with the State and changing the requirements.

46. Starting NeedsChampions Westside Health Lolita Lopez, President and CEO Drs. Donohue, Bailey Christiana Care Drs. Arm, Granite, Administration Delaware Public Health, DIDER

47. Starting NeedsTaking a Chance • Willing to try, reevaluate, change • At least a two year commitment • Starting Funds • Building/expansion expense

48. Westside - Gaining Momentum • Evening hours added. • Final four operatories completed • Hygiene hours increased • Practice Management changes to limit new patient scheduling to one month at a time. • Establishment of same day or next day emergency appointments. • Development of an internal referral system to give priority to children, pregnant women, and adult patients with chronic disease.

49. Westside - Gaining Momentum (cont) • Integration of dental health into the Bureau of Primary Health Care sponsored Health Disparities Collaboratives • Diabetes Dental Sessions established to provide unique changes in Delivery System Design • CDE present in dental waiting room to provide education on dental health with diabetes • Private grant funding obtained to financially support initial diabetic dental appointment and hygiene • Patient gift bags as incentive to follow through with dental care.