Capacity ofdental Clinics in San Franciscoto ServeChildren Ages 0-5 years With Denti-Cal Insurance in Summer 2018: A Cross sectional survey San Francisco Department of Public Health (SFDPH) Mimansa Cholera, Margaret Fisher, Jodi Stookey 1
BACKGROUND: Children's oral health is an important part of a child's overall health 1 Tooth decay is the most common chronic childhood disease. 1 Worldwide, 60 90 percent of school children have dental cavities 2 Low-income children and race-ethnic minorities have disproportionately higher tooth decay rates 1 Dental pain related to tooth decay is also a major reason for school abseentism 3 Children with untreated decay have more missed school days and lower academic performance 3 Tooth decay is largely preventable with relatively inexpensive and efficient intervention Once a cavity is formed it can only be healed by treatment Developing preventive oral health habits early in life such as regular dental care and oral hygiene practices including: daily tooth brushing with fluoridated toothpaste, drinking fluoridated tap water, eating a healthy diet, low in fermentable sugars, lead to better oral and overall health later in life 1, 2 1. Centers for Disease Control and Prevention (CDC). Children's Oral Health. https://www.cdc.gov/oralhealth/children_adults/child.htm 2. World Health Organization (WHO). Oral health fact sheet. http://www.who.int/oral_health/publications/factsheet/en/ 3. Jackson SL, Vann WF, Kotch JB, Pahel BT, Lee JY. Impact of Poor Oral Health on Children s School Attendance and Performance. American Journal of Public Health. 2011;101(10):1900-1906. doi:10.2105/ajph.2010.200915 2
BACKGROUND: SFUSD - SFDPH* data show that by the time children have reached Kindergarten: 1/3 rd have experienced dental decay 1/5 th have untreated decay *SFUSD: San Francisco Unified School District *SFDPH: Oral Health Screening Program Number of children screened Percentage of children with caries experience Percentage of children with untreated decay Percentage of SFUSD Kindergarteners with caries experience and untreated decay in San Francisco, 2007-2017 Total Kindergarteners Screened = 4,140 With Caries experience = 33.3% With Untreated decay= 18.1% 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 2016-2017 3
BACKGROUND: San Francisco Community Health Needs Assessment, in Spring and Summer 2018, identified limited access to dental care as a prevalent risk factor for children under age 5 A list from the California Department of Health Care Services (DHCS), accessed in Summer 2018, indicated that 37 dental clinics in San Francisco accepted Denti-Cal eligible children. The clinics were unevenly distributed across San Francisco 1 An estimated 18,342 Denti-Cal eligible, 0 to 5 year old, children live in San Francisco; 9,179 children ages 3 to 5 years and 9,163 children ages 0 to 2 years 2, 3 Not all 37 dental clinics on the DHCS list serve Denti-Cal eligible children ages 0 to 5 years Data Source: 1. https://www.denti-cal.ca.gov/beneficiaries/denti-cal/provider_referral_list/ 2. https://data.chhs.ca.gov/dataset/test-dhcs-utilization-measures-and-sealant-data-by-county-calendar-year-2013-to-2015 3. http://in-sfghtableau/#/views/mcahpilotdenti-caldentalproceduressfage0-20/denti-calbycustomage?:iid=1 4
OBJECTIVE: To describe the capacity of dental clinics in San Francisco to provide dental care to 0 to 5 year old Denti-Cal eligible children Dental care includes oral health education, clinical preventive care and clinical dental treatment. SPECIFIC AIMS: To answer 19 survey questions including : How many Full Time Equivalent (FTE) dentists treat children 0 to 5 year old in San Francisco? (1 FTE = 4days/week, 1/2 FTE = 2 days/week) Describe shortage of FTE dentists by Zip Code What are the wait-times to get an appointment to see a dentist for a regular dental check-up? How many children ages 0-2 and 3-5 years are seen per week? What preventive services are offered? For what treatments are children referred out to other specialized dental clinics? 5
METHODS: Study Design: Cross-sectional survey Eligibility: Managers of dental clinics that accept Denti-Cal patients, according to the list maintained by the California Department of Health Care Services (DHCS) 1 Exclusion criteria: Clinics that serve adults only Procedure: A questionnaire was sent out to the manager of each eligible dental clinic via online survey in the last week of May, 2018. Reminders were sent out twice via email in each month, June and July. Reminders phone calls were made in the first week of August and survey was closed in the second week of August to meet the Community Health Needs Assessment deadline. A $50 Safeway Gift card was offered as an incentive to non-anonymous participants. Participants could choose to remain anonymous Data collection: The questionnaire included 19 questions, which are each described in the following slides. The managers self-reported answers to all 19 questions Estimated time to completion: 7 minutes Analysis: Simple descriptive statistics for each question are described 1. https://www.denti-cal.ca.gov/beneficiaries/denti-cal/provider_referral_list/ 6
SURVEY RESULTS 7
RESPONSE RATE Clinics on DHCS list = 37 dental clinics Excluded = 2 adult clinics Eligible = 32 clinic managers at 35 dental clinics Note: Some clinic managers represent multiple clinics Responses = 21 clinic managers representing 24 dental clinics Unable to reach = 1 clinic manager Response rate: 66% of managers, regarding 69% of clinics 8
Question 1 66% of the dental clinics saw less than 10 Denti-Cal eligible children ages 0 to 2 years per week 40% In the past month about how many 0 to 2 year old children with Denti-Cal did your dental office serve (including preventive services and/or restorative services) every week? Percentage of Dental clinics 20% 0% 33% 33% 14% 10% 10% 0% < 5 5 to 10 10 to 20 20 to 30 30 to 50 > 50 Number of Denti-Cal eligible children served per week 9
Question 2 62% of the dental clinics saw less than 10 Denti-Cal eligible children ages 3 to 5 years per week In the past month about how many 3 to 5year old children with Denti-Cal did your dental office serve (including preventive services and/or restorative services) every week? Percentage of Dental clinics 40% 20% 0% 33% 29% 14% 10% 10% 5% < 5 5 to 10 10 to 20 20 to 30 30 to 50 > 50 Number of Denti-Cal eligible children served per week 10
Question 3 There were 48 FTE dentists at clinics that accepted Denti-Cal eligible children 6 FTE dentists were not currently accepting new patients 42 FTE dentists were available to serve 18,342 Denti-Cal eligible children ages 0 to 5 years in San Francisco How many FTE (Full Time Equivalent) Dentists treat children in your clinic? (1 FTE = 4 days/week; 1/2 FTE = 2 days/ week) Each bar represents one dental clinic 0 0.1250.5 1 1 1 1 1 1 1 1 2 2 2 2 1.5 1.82 1.5 3 4 0 2 4 6 8 10 12 Number of FTE dentists 8 10 11
Question 4 The number of FTE dentists who accepted Denti-Cal eligible children ages 0 to 5 years varied by zip code Zip code 94133 and 94143 had the most number of FTE dentists What is your dental office zip code? Number of FTE dentists 12 8 4 0 11 10 7 6 5 3.8 1 1 1 1 1 0.5 0.125 94108 94118 94122 94121 94132 94127 94107 94134 94103 94124 94110 94143 94133 Zip Codes 12
FTE dentists serving Denti-Cal eligible children were unevenly distributed across San Francisco Bubbles in blue represent the number of FTEs per zip code. Larger bubble size means more FTEs in that zip code. Zip codes in orange color represent zip codes that have dental providers treating Denti-CaI eligible children 0 to 5 year old. Zip codes in white do not have dental providers accepting Denti-Cal eligible children 13
CALCULATION TO ESTIMATE THE NUMBER OF PEDIATRIC DENTISTS NEEDED TO SERVE 18,342 DENTI-CAL ELIGIBLE CHILDREN AGES 0 TO 5 YEARS CONSERVATIVE APPROACH 1: Working days in US = 208 (1FTE = 4 days/week) 1 Average working weeks in US = 208/7 = 30 weeks/year 1 week = 8 patients/dentist (from slide 10 and 11) 30 weeks (1 year) = 240 patients/dentist 240 patients/year = 1 dentist 18342 patients/year = 76.4 dentists We are short by 76-42 = 34 dentists 1. https://explorehealthcareers.org/career/dentistry/dentist/ 2. http://www.aapd.org/resources/frequently_asked_questions/ CONSERVATIVE APPROACH 2: Working days in US = 208 (1FTE = 4 days/week) 1 Average working weeks in US = 208/7 = 30 weeks/year 1 dentist = 8 patients/week 42 dentists = 336 patients/week. 42 dentists = 10080 patients, in 30 weeks (1 year). 10080 patients/year = 42 dentists 18342 patients/year = 76.4 dentists We are short by 76-42 = 34 dentists Assumptions for this conservative approach: 1. Only 1 visit per year (AAPD recommends twice per year) 2 2. FTEs represent dentists only serving children 0 to 5 year old In reality the Denti-Cal population includes older children, teens and adults 14
Question 5 67% of the dental clinics referred out children for orthodontic care 48% of the dental clinics referred out for complicated cases Percentage of Dental clinics 100% 50% 0% 10% Examination For what treatments do you refer your child patients out to other offices? 14% Prophylaxis 19% 19% 19% X rays Fillings Extractions Treatments 33% Space Maintainers 38% Other (please specify) 43% Pulp Therapy/Root Canal therapy 48% Complicated cases only 67% Orthodontic care Others included: 1. Sedation Tx 2. Specialty 3. uncooperative/app rehensive patients who may need nitrous or sedation 4. GA 5. uncooperative 6. Behavior management 7. wisdom teeth extraction, behavioral management 15
Question 6 95% of the dental clinics offered fluoride Varnish, prophylaxis and teach brushing technique Percentage of Dental clinics 100% 50% What preventive services do youoffer for children under age 5 at your office? (Check all that apply) 95% 95% 95% 90% 90% 43% 0% Silver Diamine Fluoride Sealants Oral health education to parents Fluoride Varnish Teaching tooth brushing technique Prophylaxis Preventive Services 16
Question 7 81% (17 clinics) of the dental clinics were accepting new Denti-Cal patients 0 to 5 year old 4 clinics were not accepting Denti-Cal patients at the time of survey 100% Are you accepting New Denti-Cal Patients (0 to 5 year old children) at this time? Percentage of Dental clinics 50% 81% 19% 0% Yes No 17
Question 8 39% of the dental clinics had a wait time of 2 weeks or greater for the 1 st available appointment Half of the clinics had a wait time of more than one month for the 3 rd available appointment Days 75 50 25 0 0 1 2 5 5 6 How many days until the 1st, 2nd and 3rd available appointment for a check up for 0 to 2 year old Denti-Cal eligible children? 1415 1314 9 1011 12 1011 12 7 22 19 12 1213 11 29 50 36 22 23 15 15 16 30 29 2021 21 35 34 35 35 35 28 29 27 Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5 Clinic 6 Clinic 7 Clinic 8 Clinic 9 Clinic 10 Clinic 11 Clinic 12 Clinic 13 Clinic 14 Clinic 15 Clinic 16 Clinic 17 Clinic 18 Number of days to first available appointment Number of days to second available appointment Number of days to third available appointment Clinics in grey were not accepting new patients at the time of the survey 38 47 54 45 52 5960 56 18
Question 9 39% of the dental clinics had a wait time of 2 weeks or greater for the 1 st available appointment Half of the clinics had a wait time of more than one month for the 3 rd available appointment 100 How many days until the 1st, 2nd and 3rd available appointment for a check up for 3 to 5 year old Denti-Cal eligible children? 99 85 80 Days 60 40 20 0 64 5960 56 54 52 44 47 45 35 38 34 35 35 35 27 30 30 29 28 29 27 22 23 2021 21 19 19 18 16 16 16 1314 12 13 14 14 1415 9 101112 101112 1 2 3 Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5 Clinic 6 Clinic 7 Clinic 8 Clinic 9 Clinic 10 Clinic 11 Clinic 12 Clinic 13 Clinic 14 Clinic 15 Clinic 16 Clinic 17 Clinic 18 Number of days to first available appointment Number of days to second available appointment Number of days to third available appointment Clinics in grey were not accepting new patients at the time of the survey 19
Question 10 55% of the referrals to dental clinics came from Medical providers 40% come from preschools and 45% came from schools 60% Who refers children to your dental office? (Check all that apply) 55% Percentage of Dental clinics 30% 40% 45% 0% Preschools Schools Medical Providers Referrals 20
Question 11 75% of the referrals for difficult cases went to one Dental clinic in San Francisco Percentage of Dental clinics 80% 40% If you cannot treat a child at your office, where do you refer them to? (Check all that apply) 75% 55% 50% 5% 5% 5% 0% FQHC 1 FQHC 2 Other (please specify) Private Pediatric Dental clinic Others included: Insurance List Dental Clinics Pediatric Dental Clinic of Dental School 1 Pediatric Dental Clinic of Dental School 2 21
Question 12 33% of the dental clinics treated some patients with special health care needs Only one dental clinic treated patients with all types of special health care needs 1/4 th of the dental clinics do not treat patients with special health care needs 50% Do you treat patients with special health care needs? Percentage of Dental clinics 25% 33% 24% 43% Types of special health care needs addressed: - Autism - Down Syndrome - Vision impaired - Physically challenged - Wheel Treat - Cognitive Challenges - ADHD - All special health care needs patients 0% Yes No Sometimes Treating special health care needs 22
Question 13 90% of the dental clinics had wheel chair access Do you have wheel chair access? 100% 90% Percentage of Dental clinics 50% 10% 0% Yes Dental clinics with wheel chair access No 23
Question 14 24% of the dental clinics used Nitrous oxide in their offices 80% Do you use Nitrous oxide in your office? 76% Percentage of Dental clinics 40% 0% 24% Yes Nitrous oxide in office Nitrous oxide: Nitrous oxide is a safe and effective sedative agent that is mixed with oxygen and inhaled through a small mask that fits over nose to help patient relax. Nitrous oxide, also called laughing gas, is one option dentist may offer to help make patients more comfortable during certain procedures. It is not intended to put patient to sleep. Patient will be able to hear and respond to any requests or directions the dentist may have. https://www.mouthhealthy.org/en/az-topics/n/nitrous-oxide No 24
Question 15 24% of the dental clinics used protective stabilization device (papoose) in their practice when needed Percentage of Dental clinics 80% 40% 0% Do you use protective stabilization devices (papoose) in your practice when needed? 76% 24% Yes No Use of protective stabilization device (papoose) Protective stabilization is the term utilized in dentistry for the physical limitation of a patient s movement by a person or restrictive equipment, materials or devices for a finite period of time in order to safely provide examination, diagnosis, and/or treatment. A. (2017). Protective Stabilization for Pediatric Dental Patients. Accessed 8/29/18. 25
Question 16 81% of the dental clinics accepted pregnant women with Denti-Cal insurance 100% Do you accept pregnant women with Denti-Cal insurance? 81% Percentage of Dental clinics 50% 19% 0% Yes Dental clinics accepting pregnant women No 26
Question 17 All (100%) of the dental clinics provided prophylaxis to pregnant women 94% provided examination 72% provided restorations 100% What services do you provide to pregnant women? (Check all that apply) 94% 100% Percentage of Dental clinics 50% 0% 67% 67% 67% Local Anesthesia Extractions Oral Hygiene education for Mom and Baby Restoration Examination Prophylaxis Services for pregnant women 72% 27
Question 18 76% of the dental clinics had a No-Show Policy Do you have a "No Show Policy"? 80% 76% Percentage of Dental clinics 40% 24% 0% Yes No Show Policy No 28
Question 19 81% of the dental clinics had 24 hours required notice for appointment cancellation 100% Required Notice for Appointment Cancellation Percentage of Dental clinics 50% 0% 81% 5% 10% 5% 0% 24 hours 48 hours 72 hours None Other (please Notice for cancellation specify) Others included: - Up to time of appointment - Requested but not required 29
No Show Policy description of each individual clinics When a Patient misses 3 appointments, they need to wait for 2 months to be seen again 3 times no show will be placed on a 6 months probation period. During probation, the patient must check in one hour early to all appointments. Three strikes and you are out (with exceptions of course). If 3 N/S in any 12 month period we will counsel the client 3 consecutive broken appointments, patient need to meet in person with lead dentist to discuss future appointments 3 no shows members are put on "stand By" cannot schedule another appointment until 3 stand by visits are completed We have patient call us for same-day appointments only after they "No Show" many times. We try to hold them accountable 3 no shows patient is deactivate 2 consecutives no show appointment result in close file After the second no show appointment we close field If patient misses 1 appointment then patient is discontinued from the clinic. no show without any calls, next apt will be 3 months later Charge $50.00 It is our procedure that patient call 24 hrs prior to cancel appointment or there will be a charge of $50 for broken appointment Missed appointment fee applied Charge 30
SUMMARY: There were only 42 reported FTE dentists for about 18,342 Denti-Cal eligible 0 to 5 year old children The estimated shortage of FTE dentists in San Francisco was 34 dentists Half of the clinics had a wait time of more than one month for the 3 rd available appointment 66% of the dental clinics saw fewer than 10 Denti-Cal eligible children ages 0 to 2 years per week 62% of the dental clinics saw fewer than 10 Denti-Cal eligible children ages 3 to 5 years per week 95% of the dental clinics provided preventive services such as fluoride varnish, teaching brushing technique and prophylaxis; 90% clinics provided sealants and oral health education to parents and 40% provided SDF (Silver Diamine Fluoride) Only a quarter of clinics were equipped with tools (nitrous oxide and protective stabilization devices) to treat precooperative young children (0 to 5) Patients were referred out mostly for Orthodontic treatment, complicated cases, pulp therapy, behavior management and uncooperative child 75% of the referrals for difficult cases go to one Dental clinic in San Francisco Only 33% clinics treat special health care needs patients Only one dental clinic in San Francisco treats all patients with special health care needs 31
CONCLUSION: San Francisco has a shortfall of greater than 34 FTE dentists who will serve Denti-Cal eligible children 0 to 5 year old FTE dentists are particularly needed in zip codes 94112 and 94132 San Francisco lacks services for Denti-Cal eligible children with special health care needs 32
LIMITATIONS: Cross-sectional survey The results are based on self-reported information from clinic managers Managers reported estimated counts of patients served, not prospectively documented The survey was done in the summer, so may not reflect conditions at other times of year Our survey did not capture parents perspective on dental care access and utilization All the numbers should be considered approximate given the 66% response rate, the data may not represent all dental clinics in San Francisco. 33
ACKNOWLEDGEMENT: Christina Nip, Dental Transformation Initiative (DTI) Coordinator Irene Hilton, Interim director of Dental Services, San Francisco Health Network (SFHN), San Francisco Department of Public Health (SFDPH) Winnie Tse, Manager, Lean and Performance, San Francisco Health Network (SFHN) 34
THANK YOU For questions contact Mimansa Cholera at mimansa.cholera@sfdph.org 35