The State of Oral Health & Access to Care in North Dakota

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1 The State of Oral Health & Access to Care in North Dakota North Dakota Dental Hygienists Association September 16, 2016 Shawnda Schroeder, PhD Assistant Professor, Research Center for Rural Health

2 Established in 1980, at The University of North Dakota (UND) School of Medicine and Health Sciences in Grand Forks, ND One of the country s most experienced state rural health offices UND Center of Excellence in Research, Scholarship, and Creative Activity Home to seven national programs Recipient of the UND Award for Departmental Excellence in Research Focus on Educating and Informing Policy Research and Evaluation Working with Communities American Indians Health Workforce Hospitals and Facilities ruralhealth.und.edu 2

3 Background & Funding Senate Concurrent Resolution no Continue to study dental services in the state Pew Charitable Trusts Year One Identify needs and stakeholder solutions Year Two Update need and disseminate findings North Dakota Department of Health, Oral Health Program Subcontracts CDC: Varnish application in primary care settings DentaQuest: Long term care oral health services 3

4 Current Resources Fact Sheets Varnish application in primary care settings Oral health policies and procedures in long term care Pediatric oral health social determinants Pediatric oral health outcomes Dental workforce Allied dental professional education Legislative requirements for dental therapy Policy Brief Oral health services in FQHCs ND oral health programs Chartbooks

5 Workforce 5

6 Dentist per 100,000 Population * Number of CODA Accredited Dental Schools South Dakota Wyoming North Dakota Idaho Montana Utah** Oregon* Colorado* Washington* Alaska Total U.S Source: American Dental Association, Health Policy Institute analysis of ADA masterfile. Copyright 2016 American Dental Association.

7 Dental HPSAs in Northwest Region D-HPSA Counties Total Counties Percent of D-HPSA Counties Idaho % Oregon* % Washington* % Utah** % Colorado* % Montana % Alaska % South Dakota % Wyoming % North Dakota %

8 Dental Health Professional Shortage Designations: Single Counties, April

9 2016 State Oral Health Workforce Number of Providers with an Active License & Practicing in ND, March Licensed in ND Employed in ND Dentists Dental Hygienists Dental Assistants Data provided by the North Dakota Board of Dental Examiners

10 Number of Dentists in Each County, 2016 Data provided by the North Dakota Board of Dental Examiners

11 North Dakota Dispersion of Oral Health Workforce, % 70% 60% 61% 60% 68% Dentists Dental Hygienists Dental Assistants 50% 40% 30% 20% 10% 22% 21% 20% 5% 8% 4% 12% 11% 8% 0% Urban Large Rural Small Rural Isolated Rural The red line ( ) indicates the percent of the state population within that geographic category Data provided by the North Dakota Board of Dental Examiners

12 Retirement Projections: ND Dentists 30% 25% 25% Percent of Dentist 20% 15% 10% 5% 19% 10% 6% 19% 8% 0% Undecided Not Applicable Years until Retirement The North Dakota Dental Workforce Survey data were collected through a Cooperative Agreement between the Centers for Disease Control and Prevention and the North Dakota Department of Health (CDC-RFA- DP ). The content of this publication is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control and Prevention or the official views of the North Dakota Department of Health

13 Dental Vacancy Projections: Five Years During the last 5 years, ND has had an average 3% increase in DDS National average annual DDS increase: 1.3% Projection: 65 new ND DDS within 5 years Roughly 19% ND DDS self-report plan to retire in 1-5 years Projection: 80 DDS will retire within 5 years The North Dakota Dental Workforce Survey data were collected through a Cooperative Agreement between the Centers for Disease Control and Prevention and the North Dakota Department of Health (CDC-RFA- DP ). The content of this publication is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control and Prevention or the official views of the North Dakota Department of Health

14 Allied Dental Professional Vacancies in ND 25% 20% 20% DA DH % of DDS Reporting Vacancies 15% 10% 5% 0% 8% 4% 4% Full-time Part-time The North Dakota Dental Workforce Survey data were collected through a Cooperative Agreement between the Centers for Disease Control and Prevention and the North Dakota Department of Health (CDC-RFA- DP ). The content of this publication is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control and Prevention or the official views of the North Dakota Department of Health

15 Dental Education Top Five Dental Schools Producing Licensed ND Dentists (n=438) U. of Colorado 12 Marquette (WI) 24 72% U. of Nebraska (Lincoln) Creighton (NE) Percent of licensed ND DDS graduating from one of only five dental schools U. of Minnesota Number of Licensed ND Dentists Data provided by the North Dakota Board of Dental Examiners

16 Dental Hygiene Education Top Three Dental Hygiene Schools Producing Licensed ND Hygienists (n=776) Other MN Tech. MN State Comm. & Tech. College % Percent of licensed ND DHs graduating from NDSCS ND State College of Science Number of Licensed ND Hygienists

17 Dental Assisting Education Top Three Dental Assisting Schools Producing Licensed ND Assistants (n=682) Other Regional/Boarder Colleges MN State Comm. & Tech. College % Percent of licensed ND DAs graduating from Regional Colleges ND State College of Science Number of Licensed ND Assistants

18 18 Oral Health Workforce: Summary More than 50,000 ND residents live in counties with no dental practice Inadequate geographic dispersion especially among DDS and DH High vacancy rates for DAs Dental vacancies projected in five years A majority of oral health providers are located in the 4 most urban counties

19 Oral Health Status in North Dakota 19

20 Oral Health Access for Medicaid Enrollees In 2013, 249 dental practices billed for at least one Medicaid patient in the calendar year 65 (26%) of those practices saw more than 100 Medicaid patients 58% of Providers seeing Medicaid patients only accounted for 11% of Medicaid patients seen 8% of the dental practices billing Medicaid in 2013 provided care to 52% of the Medicaid enrollees accessing dental services Data provided by the North Dakota Department of Health & Human Services, State Medicaid

21 Pediatric Oral Health: Social Determinants North Dakota Third Grade Students by Race 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 96% 97% 96% 92% 93% 90% White, Non-Hispanic American Indian 89% Other Minorities Total 66% 64% 64% 49% 32% 10% 11% 7% 4% Have Toothbrush Brushed Today Flossed Today Have Visited Dentist Data provided by the North Dakota Department of Health, Basic Screening Survey of Third Grade Students

22 Pediatric Oral Health: Social Determinants North Dakota Third Grade Students by National School Lunch Program Status 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 98% 95% 79% 93% 71% < 25% on NSLP % on NSLP > 50% on NSLP Total 65% 48% 64% Have Toothbrush Brushed Today Flossed Today Have Visited Dentist 11% 10% 10% 11% 97% 96% 92% 96% Data provided by the North Dakota Department of Health, Basic Screening Survey of Third Grade Students

23 Pediatric Oral Health: Social Determinants Percent of ND High School Students Drinking 1 or more Cans of Soda/day by Race, % 90% 80% White, Non-Hispanic American Indian Other Minorities 84% 82% 82% 70% 65% 60% 50% 40% 35% 30% 20% 17% 18% 18% 10% 0% Yes No Data were taken from the Youth Risk Behavior Surveillance System,

24 North Dakota Third Grade Students Oral Health Status of North Dakota Third Grade Students: Racial Disparities Percent of 3rd Grade Students 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 70% 91% 74% 73% Decay Experience White, Non-Hispanic American Indian Other Minorities Total 59% 74% 60% 56% Treated Decay 24% 51% 41% 28% Untreated Decay 28% 57% 34% 31% Rampant Decay 56% 39% 53% 46% Dental Sealants 24% 52% 40% 28% Need Treatment Data provided by the North Dakota Department of Health, Basic Screening Survey of Third Grade Students

25 Number of Cavities by Race ND Middle School Students ND High School Students 60% 50% 40% White, Non-Hispanic American Indian Other Minorities Total 60% 50% 40% White, Non-Hispanic American Indian Other Minorities Total 30% 30% 20% 20% 10% 10% 0% 0 Cavities 1 Cavity 2 or 3 Cavities 4 or More 0% 0 Cavities 1 Cavity 2 or 3 Cavities 4 or More Data were taken from the Youth Risk Behavior Surveillance System,

26 26 Oral Health Status: Summary Access to, and utilization of, dental care is a significant concern for: Medicaid recipients Low-income American Indian Rural Populations with poor oral health status: Medicaid recipients Low-income American Indian Rural

27 Dental Care within the Larger Health System 27

28 Community Health Centers: Oral Health 5 Federally funded CHCs at 18 sites in North Dakota Oral health services are provided directly by 3 CHCs in a total of 6 satellite locations Turtle Lake Rolette Minot Fargo Moorhead, Minnesota Grand Forks Northland Health Centers Northland Health Centers Northland Health Centers Family Healthcare Center Family Healthcare Center Valley Community Health Centers 28

29 Who do CHCs Serve in North Dakota? ND CHC Population ND Population Health Insurance Uninsured 34% 9% Medicaid 23% 9% Medicare 10% 13% Race/Ethnicity Hispanic 6% 3% African American 10% 2% Asian/Pacific Islander 5% 1% American Indian/Alaska Native 7% 5% White 73% 89% Income Status 100% FPL 61% 10% <200% FPL 91% 24% CHCs located in rural areas also served 58% of the total CHC patient population in North Dakota

30 Varnish Application in Clinical Settings Percent of Practices where Providers Conduct Oral Health Risk Assessments 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 40% 23% 15% 15% Yes, all Pediatric Yes, High-Risk Only No Do Not Know Conduct Oral Health Risk Assessment in Clinic 30 Data provided by the North Dakota Center for Rural Health, Varnish Survey 2015

31 Primary Care Varnish Application A majority of pediatricians (60%) and family practice physicians (82%) replied that no one within the clinic provided varnish. Only 31% believed that other physicians were aware that it was a reimbursable service. 90% of pediatricians and 82% of family practice physicians either agreed or strongly agreed that fluoride varnish was an effective preventative oral health care measure. Providers agreed/strongly agreed that well-child visits were an appropriate time for both varnish application (60%) and the oral health risk assessment (86%). If required as part of the well-child checklist, many also believed they would be done. 31 Data provided by the North Dakota Center for Rural Health, Varnish Survey 2015

32 Long Term Care: Oral Health Policies & Procedures Resident oral health was a high or essential priority for 72% of all North Dakota LTC facilities. However: Only 50% had a written plan of care for dental needs A dental professional reviewed/assisted with the written plan of care among only 3 facilities Only 6% of facilities indicated the initial oral health exam was completed by a dental professional

33 Percent of Facilities with List of Dental Providers for Referral by Rural-Urban Status (n = 42) % of Facilities 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 80% 59% 35% 20% Rural Urban 6% Yes No Do Not Know Active List of Dental Providers for Resident Referral Data provided by the North Dakota Center for Rural Health, LTC Survey 2015

34 34 Provider Responsible for Initial Oral Health Exam of New LTC Residents Dentist, 7% No Exam Given, 28% Unit Charge Nurse, 30% Do not Know/Other, 15% DoN/RN/LPN, 20% Data provided by the North Dakota Center for Rural Health, LTC Survey 2015

35 Improving Oral Health in North Dakota

36 Improving Oral Health in North Dakota Sealant programs Varnish application and oral health screening in primary care offices Public health hygienists Mobile oral health care services Strong referral networks in rural Indirect supervision for dental hygienists for preventative services Rural dental student residencies Loan repayment programs for rural/underserved practice Oral health literacy

37 Case Management: Senate Concurrent Resolution 4004 Case Management Outreach (CMO) to target highrisk patients in community settings utilizing current workforce Services provided by dental assistants and hygienists and reimbursed through collaborative dental offices to link high-risk patients to dental homes Need to create service reimbursement: Medicaid 37

38 Dental Therapy in the United States 38

39 New Provider Types Dental Health Aide Therapists (DHATs) Advanced Dental Therapists Dental Therapists 39

40 For recent publications and past presentations, visit the CRH Oral Health webpage at:

41 Contact us for more information! Shawnda Schroeder, PhD Center for Rural Health 501 North Columbia Road, Stop 9037 Grand Forks, North Dakota ruralhealth.und.edu 41