Welcome to 9/21/2014. Course Objectives. Lisa Greenshields, RDHAP, BS Susan McLearan, RDHAP, MA

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1 Welcome to 9/21/2014 Lisa Greenshields, RDHAP, BS Susan McLearan, RDHAP, MA Sacramento Dental Hygienists Association September 24, 2014 Course Objectives Be able to discuss the reasons behind the movement to expand the dental workforce Be able to define direct access and list four types existing in the U.S. Be able to discuss the most prominent workforce models currently being tested Be able to list the settings and scope of the RDHAP Be able to compare aspects of the VDH Project with the current roles of the RDH and RDHAP 1

2 The Surgeon General s Report Although there have been gains in oral health status for the population as a whole, they have not been evenly distributed across subpopulations. Profound health disparities exist among populations including: Racial and ethnic minorities Individuals with disabilities Elderly individuals Individuals with complicated medical and social conditions and situations Reports Dental Hygiene Workforce Registered Dental Hygienists in California: Regional Labor Market Chart Mertz and Bates Center for the Health Professions hppt:// Data from 2005 Reports Access, Quality Assurance, etc. 2

3 Governor s Report January 2014 National Governor s Association (NGA) Center for Best Practices Health Div. The Role of Dental Hygienist in Providing Access to Oral Health Care states can consider doing more to allow dental hygienists to fulfill these needs by freeing them to practice to the full extent of their education and training. UCLA Study Friday, September 5, 2014 Preventive care outreach programs in unorthodox settings are successful in getting underserved screened for health conditions. Population Categories Total Population 281,000,000 Note: The percentages are of the total population. Source: ADA 2006 CDHC Report, 2000 Census Institutionalized 4,000,000 (1.4%) Community Living 277,000,000 (98.6%) Severe Medical Co-morbidities 24,500,000 (8.7%) Generally Healthy 252,500,000 (89.9%) Economically Disadvantaged 43,000,000 (15.3%) Not Economically Disadvantaged 209,500,000 (74.6%) Remote 3,000,000 (1.1%) Non-remote 40,000,000 (14.2%) Remote 10,500,000 (3.7%) Non-remote 199,000,000 (70.8%) 82,000,000 = 29.18% 192,000,000 = 70.8% 3

4 Population Categories 70% Well Served 192 million 82 million 30% Underserved Complex medical, physical, and social conditions Culturally diverse Institutionalized Economically disadvantaged Rural Children s Use of Dental Care in California Among the findings: 24 percent of all children in California have never visited the dentist. Significant racial/ethnic differences in dental visit rates exist, even among Latino and Asian subgroups. 4

5 The Elderly and Infirm Suffer disproportionately from Active and untreated mouth infections Loss of teeth Old and ill-fitting dentures Impairments in salivary and masticatory function Source: Centers for Medicare and Medicaid Services 250, ,000 Number and Projections of General Dentists and Dental Hygienists 167, , , , , ,000 General Dentists Dental Hygienists 50, General Dentists = 9% increase, Dental Hygienists = 30% increase U.S. Dept. of Labor, Bureau of Labor Statistics: Occupational Outlook Handbook Projections data from the National Employment Matrix General Dentists: Dental Hygienists: 5

6 WHAT IS DIRECT ACCESS? What are Workforce Models? Direct Access Definition ADHA Direct access means that the dental hygienist can initiate treatment based on his or her assessment of patient s needs without the specific authorization of a dentist RDH may treat the patient without the presence of a dentist, and can maintain a provider-patient relationship Direct Access One way to address the gaps in workforce vs. need Patient does not have see the dentist first, they can go straight to the RDH May mean that the RDH may bill directly for services they render 6

7 All red states are not equal. General Supervision 8 states Public Health Hygienists 13 states Direct Access Collaborative Practice 12 states Independent Practice 6 states No Direct Access = 13 states General Supervision Hygienists can initiate patient care with a dentists authorization, in writing, such as seeing a patient of record in a nursing home Maryland New York (until 2015) Oklahoma Rhode Island South Carolina Tennessee Texas Vermont Note that none can direct bill for services rendered 7

8 Public Health Hygienists Hygienists work under the supervision of local state or federal programs Connecticut $ District of Columbia Florida Iowa Kentucky Massachusetts $ Missouri $ Montana $ Nebraska $ Nevada $ New Hampshire Pennsylvania Wisconsin $ $ = Direct billing allowed Collaborative Practice Hygienists may provide services outside of a dental practice according to the terms of a collaborative agreement. Pre-diagnosis/treatment plan not required. Alaska Arkansas Idaho Kansas Michigan $ Minnesota $ New Mexico $ Rx New York (2015) Ohio South Dakota Virginia-Pilot Project West Virginia Independent Practice Hygienist may practice without supervision in defined venues and receive direct reimbursement Arizona $ California $ Colorado $ DH Diagnosis Maine (2014) $, no programs yet Oregon $ Rx Washington $ 8

9 Collaborative & Independent Practice Some no special requirements Some require additional training Many have years of practice requirements Maine=Highest requirement is 6 years and 6,000 hrs California 3 yrs, 2,000 hours, Bachelor s or equivalent New(er) Workforce Models Mid-level Therapist (ADHA Model 2004) DHAT-Alaska DT and ADT- Minnesota Collaborative Practice Independent Practice (RDHAPs in California) Public Health Hygienists Community Health Aids Promatoras ADA Models (create new providers) Oral Preventive Assistant (OPA)- preventive and scaling dental assistant Community Dental Health Coordinator (CDHC) community based midlevel Apple Tree and other Mobile Dental Models* DHAT- Alaska Not ADHA s model Started in 2004-began practicing in month program administered by ANTHC in partnership with the University of Washington DENTEX program Remote general supervision by tele-dentistry DHAT providers are often Alaskan Natives who reside or grew up in the remote villages they serve 9

10 DHAT- Duties Oral health and nutrition education Sealant placement Fluoride treatments Coronal polishing Prophylaxis Expose radiographs Restorations Placement of pre formed crowns Pulpotomies Non surgical extractions Non surgical periodontal therapy Metropolitan State University Advanced Dental Therapist Apple Tree Model Modeled after Mayo Clinic 6 Free standing clinics Satellite site Equipment wheeled in Dental Director Utilize ADTs 10

11 Apple Tree San Mateo Scheduled to begin satellite services in 2015 ADA s Workforce Model American Dental Association New Providers Model Oral Preventive Assist. (OPA) Curriculum available thru ADA States decide duties Possibly sealants, fluoride and scaling Type I Is a certified dental assistant to work in an office or some community Comm. Dental Health Coord. (CDHC) Pilot Projects in 6 states New Mexico certificate program mo. program Can be an RDH or DA Oral health and nutrition education Sealant placement Fluoride treatments Coronal polishing Scaling for Type I Temporary fillings Development and implementation of community based programs 11

12 Community Oral Health Providers CDHC Promotoras DHAT ADHP RDHAP RDHAP Movement in California AB 1503 creates Health Manpower Pilot Projects 1981 CDHA submits proposal raise money 1986 HMPP #139 begins was closed down in HMPP #155 begins 1998 AB 560 passes after several failed attempts from initiation to legislation = 18 years ( ) 2003 First training program WLAC 2004 UOP On-line training 2010 HWPP # AB 1174 The RDHAP Model RDHAP a California Workforce Model Not a mid-level Restricted practice sites/populations Many clients do need a DDS Most need prevention and case management 12

13 RDHAP Practice Sites Residences of the homebound Schools Residential facilities and other institutions Dental health professional shortage areas RDHAP Practice This is what is seen every day More than a perio problem The Medical Home A.A. Pediatrics-1967 Care management over time Patient-centered Comprehensive and team based In pediatric medical home models, there is also an emphasis on access and early intervention services 13

14 The Dental Home The dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way Modeled after the medical home concept Articulated by the A.A. Pediatric Dentistry Virtual Dental Home Modified from Dental Home California Health Workforce Pilot Project HWPP #

15 HWPP #172 Steps Infrastructure, training, agreements Expand the duties of existing providers x-ray decision Interim Therapeutic Restorations Proof of concept demonstration Measure health improvement, economic modeling Advance legislation/ regulatory reform Stabilize and spread The Virtual Dental Home Sites Virtual Dental Home Sites VDH Pilots In Training 15

16 Quantifying and Collecting Data Training the Virtual Workforce Learning Laboratory VIRTUAL DENTAL HOME Equipment and Procedures 16

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19 Photographs- Intra and Extra Oral Cameras Photographs CAMBRA Risk Assessment 19

20 Basic Measures Basic Measures Performing Procedures in the Community Care management over time Preventive education Prevention procedures Teeth cleaning Medical treatments Interim Therapeutic Restorations 20

21 School Based Planning Pre-existing Treatment Plan 21

22 Quick Facts Preliminary results indicate that the Virtual Dental Home Project can currently keep 60% of the student population healthy at the school site, providing continued hygiene care, sealants, fluoride varnish and interim therapeutic restorations (ITR). Early Intervention White Spot Lesions and shallow cavitation Prevention Calculus removal Pit/fissure sealant Fluoride varnish 22

23 Radiographs Radiographs Intra- Oral Photographs 23

24 Photographs Sealants Sealant 24

25 Residence Based VDH Set-Up in Activity Room Virtual Dental Chart-X-Ray Set-Up X-ray Set-up 25

26 Resident with Mobile Oxygen Interim Therapeutic Restoration Set Up Interim Therapeutic Restoration 26

27 Interim Therapeutic Restoration Interim Therapeutic Restoration After Before I T R Glass Ionomer 27

28 DDS Intervention Results From here To here Prevention-More Than Restoration Risk assessment and evaluation Anti-bacterial regime Maintenance Re-Mineralization Combating effects of xerostomia Daily, effective oral hygiene Case Management Integration with medical and social services 28

29 Caregivers, a major challenge Demonstrating Pre and Post Brushing Training the Caregivers Training Program RNs, LVNs, CNAs,Others Educator/School Staff In-service Training Program School Nurses, Health Assistants, Teachers 29

30 Institutionalizing Prevention Developing understanding and appreciation for preventive products Oral Chemistry ph Testing ATP Testing Oral Chemistry Antimicrobials Fluorides 30

31 Oral Chemistry Xylitol Ca+ Phosphates Role of Nutrition School Lunch SNF Snack Cart Physical challenges in providing care Operator challenges: Visibility Back support Positioning with consideration to: Inability to swallow Head support Evacuation Fear Challenges 31

32 Challenges Product delivery, use and oversight Patient/caregiver Follow-through and accountability General lack of experience with special populations AB 1174 What is it? AB 1174 is a bill carried by Assemblymen Bocanegra and Logue intended to codify the duties proved safe by HWPP #172 Clarifies and codifies RDAEF/RDH/AP ability to determine which x-rays to take Allows trained RDAEF/RDH/APs to place Interim Therapeutic Restorations (ITRs) using glass ionomer filling material AB 1174 Where it is now AB 1174 has passed both the Assembly and the Senate (and subcommittees) Has been enrolled and sent to Governor Brown Governor Brown can sign it and it becomes law, not sign it and it still becomes law, or veto it and it is dead. 32

33 What happened it all worked out Author s View CDHA View Clarified x-ray decision Clarified responsibility and limited number of auxiliaries supervised Provided additional duties for RDAEF, RDH and APs Set out training guidelines CDHAs concern of potential misinterpretation unjustified Did not acknowledge current RDH x-ray duty Added RDH supervision where there had been none Went over the top and did not acknowledge the role of the DHCC to develop regulations Various elements could be misinterpreted and What might this mean for dental hygiene? Continuing steps to increase scope of practice which can Lead to more opportunities and Utilization in alternative settings References Oral Health In American accessed September 20, 2014 Registered Dental Hygienists in California: Regional Labor Market Chart, Resources.aspx, accessed September 20, 2014 Improving Access to Oral Health.. Underserved-Populations.aspx, Accessed September 20, 2014 Oral Health In the Era of Accountability, The Role of the Dental Hygienist in Providing Access to Oral Health Care, accessed September 20, 2014 The Have and Have Nots., Accessed September 20, 2014 Facts About California s Elderly accessed September 20,

34 References cont Direct Access Map and Chart accessed September 20, 2014 Alaska Dental Health Aid Therapists, Communities.pdf, accessed September 20, 2014 Advanced Dental Therapy, Metropolitan State University Accessed September 20, 2014 Apple Tree Dental accessed September 20, 2014 Apple Tree Dental San Mateo accessed September 20, 2014 Review of Proposed Oral Health Workforce Models: Part 1, Access, August 2008, pg Policy on the Dental Home, accessed September 20, 2014 References cont. The Virtual Dental Home Policy Brief 3.pdf, accessed September 20, 2014 HWPP #172 Application accessed September 20, 2014 Basic Screening Survey Tools, accessed September 20, 2014 Overcoming Obstacles To Oral Health, es.html, accessed September 20,