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Avenues to Access

Avenues to Access. A Primer in Initial Development of a Dental Safety Net System. In the Beginning :. Someone , somewhere has decided to look into access to oral health in a particular area. If the leader is new to the public health arena, it can be a little overwhelming. “Expert” Advice:.

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Avenues to Access

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  1. Avenues to Access A Primer in Initial Development of a Dental Safety Net System

  2. In the Beginning: • Someone, somewhere has decided to look into access to oral health in a particular area. • If the leader is new to the public health arena, it can be a little overwhelming.

  3. “Expert” Advice: “You got to be careful if you don’t know where you’re going, because you might not get there.” Yogi Berra

  4. What is the purposeof this presentation? The most important need on this trip is to figure out where you would like to this journey to end. This is best accomplished with a few simple, though time-consuming steps.

  5. Where does one begin? Just like eating an elephant, the job is best accomplished through small bites!

  6. What This Presentation CANNOT Do: • Answer all of the questions. • Provide anything more than a starting point for a community discussion on how to best provide services for unmet oral health care needs. • Pick the delivery method that will work best for a particular area.

  7. What This Presentation CAN Do: • Provide a very basic overview of different ways to create access to dental care. • Spell out the common acronyms. • Raise a few points to consider as one is developing a safety net system. • Provide some links to additional information on many of the ideas introduced.

  8. Overview • Do a quick assessment to get a sense of need. • Develop a team. • Investigate more deeply the existing conditions/resources and their growth potential, as well as the actual numbers and characteristics of those in need. • Understand the options available. • Create a plan: What will best address the needs the team have identified as top priority?

  9. Quick Assessment: What? • Gather and assess basic information that is readily available including: • Population • Overview of needs • Number of existing providers

  10. Quick Assessment: Why? • Go beyond anecdotal. • Helps in recruiting team. • Requires little time and effort.

  11. Quick Assessment: How? • U.S. Census Data available at www.census.gov • Health Resources and Services Administration (HRSA) • Medically Underserved Area (MUA) Data • Medically Underserved Population (MUP) Data • bhpr.hrsa.gov/shortage/ • State Department of Public Health • Association of State and Territorial Dental Directors (ASTDD) has links to all state programs • www.astdd.org/state-programs/ • County/Municipal Health Department • State licensing agency quantity of providers in area

  12. Developing a Team: Why? • Gain a better understanding of the needs and resources within the community. • Promotes buy-in, lends legitimacy. • Share the workload. • Sustain the operation over time.

  13. Developing a Team Who should be on board? Think of all the necessary aspects of bringing such a project to completion.

  14. Team Members: Who? • Provider Network • Governmental Units • Finance People • Social Services • Patient Representatives

  15. Team: How to Invite Onboard • A personal invitation is best. • Now is the time to share a story, some enthusiasm and define the problem as you see it. • Discuss why they’ve been included; why their view matters. • Be honest about the duration of commitment you expect at that point.

  16. Team: Provider Network • There MUST be a local dentist onboard: • Knowledge of community, delivery systems and a great resource for potential collaborative efforts • Serves as a conduit to the local dental society for information/idea exchange as well as a referral source

  17. Team: Provider Network • There SHOULD be a member of the County or Municipal Public Health Department: • Knowledge of the community and patient populations • Awareness of existing sources of care • Awareness of funding sources

  18. Team: Provider Network • If a local hospital exists, consider inviting the administrator or the ER supervisor to join. Urgent care clinic folks also have good information: • Great source of statistics for community need • Possible funding source • Familiar with many aspects of healthcare delivery, from governmental regulations on through inventory supply systems

  19. Team: Provider Network • Local dental schools and hygiene or assisting programs • Hygiene society • Community health workers • School Nurses

  20. Team: Governmental Representatives • State and local officials • County or municipal Board of Health • State dental director

  21. Team: Finance People • Foundations • Charitable civic organizations • Corporate donors • Bankers • Grant writers

  22. Team: Social Services • Agencies that work with special populations groups • Homeless • Aging • Children (Head Start, WIC, school systems) • Individuals with disabilities • Clergy • Other social service agencies (county, municipal, hospital)

  23. Team: Patient Representatives • Advocates for the homeless • Local AARP representative • Shelter residents • Uninsured “working poor”

  24. Investigate Existing Conditions/Resources How do you know what you NEED when you don’t know what you HAVE?

  25. Investigate Existing Resources • Look at existing safety net resources: • How many and who are they serving now? • Can they/will they grow? • Look at the unserved population: • Demographically • Geographically

  26. Investigate Existing Resources • Health Professional Shortage Area (HPSA)Designation? • Incentives (loan forgiveness) in recruiting providers. • HPSA determination: hpsafind.hrsa.gov • Other “scholarship” type incentives for providers in underserved areas • As an example, Illinois has “Bridge to Healthy Smiles”: www.bridgetohealthysmiles.com/

  27. Investigate Existing Resources • Clinics • Mobile Units • School Programs • Hospitals • Private Dentists Accepting Medicaid • Nursing Homes • Professional Schools

  28. InvestigateExisting Resources • Land • Buildings/Clinics with extra space • Nearby Federally Qualified Health Center (FQHC)—possibility of satellite? • Unused equipment or potential corporate donations of same • New school being built?

  29. Investigate Existing Resources • Ask your team and Use your team! • Where does the county refer patients? • Does the hospital have a referral base? • Current Provider Data: • CMS provides database of current Medicaid providers: www.insurekidsnow.gov/ • FreeDental.org is a searchable database that provides a breakdown of providers of free or sliding-scale care by state: www.freedental.org/ • Identify low-cost/free care providers by zip code: www.1dental.com/free-dental/

  30. Investigate Existing Resources • Geographical Information Systems (GIS) mapping • More accurate than “by county” analysis • See Kansas study data available at www.kdheks.gov.ohi/index.html • Hospitals: emergency room data • School Nurses: oral health-related absences

  31. Investigate Existing Resources • From census data: • Age • Ethnicity • Location • Languages spoken • Special Needs Populations

  32. Existing Conditions: Helpful Resources • “A Guide for Developing and Enhancing Community Oral Health Programs,” National Maternal and Oral Health Resources, Available at www.aacdp.com/Guide/ • “Assessing Oral Health Needs: ASTDD Seven-Step Model” The Association of State and Territorial Dental Directors, Available at www.astdd.org/index.php?template=sevensteps.html

  33. Systems Check • You’ve established need. • You’ve put together a team. • You assessed your existing resources. • You have taken a deeper look at your unserved population in order to better understand them. • What next?

  34. Congratulations!! If your existing resources fulfill yourexisting needs:

  35. However: IT SEEMS MORE LIKELY THAT THE NEED WILL OUTWEIGH THE EXISTING NUMBER OF CAREGIVERS! (The team needs to keep going.)

  36. Options to Address Needs • Bricks and mortar clinic • FQHC and “Lookalike” Clinic • Local Public Health Clinic • Hospital Clinic • Mobile Clinic • Portable Dental Unit • School-based Program • “Temporary” Fixes: • Mission of Mercy • Give Kids a Smile • Donated Dental Services • Indian Health Service

  37. FQHC and “Lookalikes” • WHAT are they? • HOW do they work? • WHOM do they serve? • WHY or why not? FQHC Madison, WI

  38. FQHC: What are they? • Federally Qualified Health Centers • Nonprofit healthcare centers located in a high need or high-risk area (most provide some dental care). • Provide comprehensive primary care to all. • Exceptions exist for FQHCs that target specific populations, such as the homeless or migrant farmworker communities. • Provide support/enabling services for patients.

  39. FQHC: What are they? (continued) • Governing board of community members with at least 51% of its members coming from within the patient ranks. • Meet other requirements regarding administrative, clinical and financial operations. • “Lookalikes” are much the same, except they do not receive federal funding from Section 330 grants nor do they qualify for malpractice protection under the Federal Tort Claims Act (FTCA).

  40. FQHC: How do they work? • Made possible under Authorizing Legislation of the Health Center Program • Section 330 of the Public Health Service Act; • bphc.hrsa.gov/about/legislation/section330.htm • Partially funded by Sec. 330 grants, estimated by Cong. Research Center to cover 20% of cost (lookalikes do not get this grant money) • “Federal Health Centers,” Elaine J. Heisler, Congressional Research Service, March 21,2012, p.2. Available at www.fas.org/sgp/crs/misc/R42433.pdf

  41. FQHC: How do they work? (continued) • Many other grant sources can be tapped for funding. For example: • Ryan White HIV/AIDS • Healthy Start program • State and local grants • Health Professional Shortage Area (HPSA) designation • Can help qualify for financial help by providing loan forgiveness assistance for providers; hpsafind.hrsa.gov/ • Can hire staff through Nat’l. Health Service Corp

  42. FQHC: How do they work? (continued) • Medicare, Medicaid, private pay and insurance also accepted • Federal Poverty Level = $22,350/family of four and is used as determinant in fees owed • Patients above 200% of the FPL pay a fee set by board to align with local prevailing fees. • A family at or below 200% of FPL is subject to sliding scale, though none refused if unable to pay. • Private or corporate funding also accepted

  43. FQHC: How do they work? (continued) • Can elect to receive funding through a Prospective Payment System (PPS). • Per visit payment rate determined by baseline rate/visit from previous years, with Medicare Economic Index adjustments. • Helps FQHC determine budget. • Quadrant dentistry is performance goal; want to avoid practice of “churning.” • Other Alternative Payment Methodologies (APM) exist.

  44. FQHC: Whom do they serve? • Designed to serve the community, absent of regard for personal resources (or lack thereof) with “required primary health services.” • By statute must provide “dental screenings for children” and “preventive dental services” as part of requirements. • “Preventive dental services” are defined in regulations to mean oral hygiene instruction, cleanings, topical fluoride and/or fluoride prescriptions. • If FQHC does not provide dental, must make these services available by referral or contracting with providers. • See 42 U.S.C. Sec. 254b(b)(1)(A)(i)(III)(ff) & (hh)

  45. FQHC: Whom do they serve? (continued) • May get approval to extend services beyond those provided as primary. • Health and Human Services gives approval for supplementing services. • See 42 C.F.R. Sec. 51c(102)(j)(6). • If so, then must offer this additional care to all residents of service area that fit the parameters defined.

  46. FQHC: Why or why not? • If an FQHC exists somewhere “in the area” consider a satellite office. • Access to medical staff within system. • Federal Tort Claims Act (FTCA): Centers are considered Federal employees and thus covered in malpractice lawsuits: bphc.hrsa.gov/policiesregulations/policies/pin201101.html (click on policy manual link) • FQHC can contract with private dentists in providing care. • A little more difficult to share space.

  47. FQHC: Helpful Resources • “Operations Manual for Health Center Oral Health Programs” National Network for Oral Health Access. Available at www.nnoha.org/practicemanagement/manual.html • “So You Want to Start A Health Center. . .? A Practical Guide to Starting a Federally Qualified Health Center” National Association of Community Health Centers. Available at www.nachc.com/hc-growth-development.cfm • “Safety Net Dental Clinic Manual” National Maternal and Child Oral Health Resource Center, available at www.dentalclinicmanual.com/ • “Increasing Access to Dental Care through Public Private Partnerships: Contracting between Private Dentists and FQHC” Children’s Dental Health Project. Available at www.cdhp.org/resource/FQHC_Handbook

  48. Local Public Health Clinic (LPHC) Northern Dental Access Center Bemidji, Minnesota

  49. LPHC: What are they? • Includes many county, municipal and foundation-based facilities that provide services • Regulation of each entity dependent on governing body—usually a board-type governance structure

  50. LPHC: How do they work? • Very broad spectrum of operational plans exist. • Funding sources: • Grants/donations: private, corporate and nonprofit • Governmental funding (but not Sec. 330 dollars) • Private pay, insurance, Medicaid • Donations of services often help defray costs

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