Community health care programs are a feature of the current scene. A case history is presented of the way in which an existing dental clinic for welfare clients was changed into a facility for community dental care. DENTAL CARE IN A VOLUNTARY AGENCY: THE M. J. LOEB DENTAL CLINIC Milton Lisansky, D.D.S., M.P.H., F.A.P.H.A. N 1934, the Dental Clinic Society, Inc., was organized by Dr. Morton J. Loeb, a prominent New Haven dentist to "provide through the practical application of dentistry, the benefit of necessary dental care only to persons who are referred to the clinic from recognized welfare agencies." In that year, at the depth of the depression and even today, the magnitude of the problems in terms of need for treatment, availability of personnel, and financial requirements has both stimulated and discouraged those who would plan dental clinical treatment programs. The impetus for the creation of the clinic came from within the dental profession despite the opposition of the membership of dental societies both local and state, an opposition which created personal animosities and hostilities which have cast their persistent shadows down to the present day. Assisting Dr. Loeb were Dr. Bert G. Anderson, chief of Dental Surgery at Yale University, Dr. Ira V. Hiscock of the Yale School of Public Health, other community-minded dentists, and social welfare agencies. Yale University provided rent-free quarters in the old dispensary building of the medical school. The staff consisted of three dentists, recently having established practice in 892 the area, one executive secretary, one chair assistant, and one laboratory technician for the completion of all prosthetic work. The clinic was open five week-day mornings until noon. An appraisal of the clinic with many details of its early operation was prepared by the author as a master's thesis at Yale in 1952 and is of passing interest except for certain conclusions and recommendations which have rested quietly until recent years when an awakened New Haven community beginning an attack on the urban ills of society provided fertile ground for the seeds of change. Program Development The community development program begun in New Haven in 1962 involved the expenditure of six million dollars annually by public and voluntary, local, state, and national agencies as part of the antipoverty program; this, in addition to the 25 million dollars spent annually for the community's health, welfare, and recreation services. Unfortunately, concern for the dental health needs of the poor was totally lacking. One of the recommendations which the author made in his appraisal of the clinic in 1952 was that "the directorate keep themselves constantly aware of the goals and purposes of the clinic, make VON. 58. NO. 5. A.J.P.H.
DENTAL CARE IN A VOLUNTARY AGENCY evaluations of the clinic's effectiveness, and be ready at all times to adapt the program of the clinic to the changing needs of the community." In the early years before World War II, the clinic served to meet the urgent dental needs of indigent people. Competition for positions was keen and staff dentists were selected with care. During the war, the clinic closed for several years due to lack of personnel. During the boom following the war the private dentist had less time to divert to clinic activities, and dental staff was recruited with difficulty, on many occasions from abroad and with less than adequate training. The clinic's financial base failed to expand with the economy, and the directorate was trapped by a "do not rock the boat" inertia. With minor changes the program was the same as it had been when the clinic was started; the equipment was antiquated, being replaced only with slightly less antiquated equipment when it failed; salary levels were low; recruitment of staff difficult and strong administrative direction lacking. The executive secretary, who had been with the clinic for many years on a half-time basis, fulfilled her minimal duties well, but these duties never did include proper liaison with other community civic organizations and health agencies nor did her qualifications include the necessary feeling for, and understanding of, the administration of health services for the poor. The fault, if fault there be, lay directly with the directorate and with the lack of attention by the community health planners to the importance of adequate dental care in community health services. In 1962, Yale University which had provided rent-free quarters for 28 years under an agreement which originally was for one or two years, requested that the clinic give up its space to make way for expanding medical school needs. The search for new quarters, the reality of the clinic's inadequate finances, and the beginning of the New Haven antipoverty program initiated some serious thinking among the directors about the clinic's future role in the community. Cessation of operations was one considered alternative. The city of New Haven provided the clinic with an abandoned firehouse in the center of town for temporary quarters where operations continued with the same antique equipment. The following year, 1963, the author having long been active in clinic affairs, originally on the dental staff and subsequently a member of the Board of Directors, was elected president which carried over-all responsibility for clinic operation. At the annual meeting in 1964, the name of the clinic was changed in honor of Dr. Morton J. Loeb. At that time, a federally financed research program in Dental Care for the Chronically Ill and Aged, jointly sponsored by the clinic and the Connecticut State Dental Association, was utilizing the clinic as a base for operations. A new health planner, Mr. Dean Maberry, had joined the staff of the United Fund and Community Council of New Haven. He was interested in dental care or the lack of it in the community and as a dental patient of the author was subjected to undue influence concerning dental public health problems. A new Community Services Building was being planned to meet the housing needs of the New Haven Health Department and many other community agencies and the clinic was invited to enter negotiations for housing in the new building. These factors stimulated a discussion between the clinic leadership and the Community Council to relate the need for dental care to the whole framework of New Haven's comprehensive human renewal program. It was decided that total administrative reorganization was necessary to strengthen the basic clinic program before any supplementary service areas could be developed. New goals had MAY, 1968 893
to be defined and the necessary community support achieved for these goals. Evaluation of Dental Services Dr. Sherman L. Cox of the Dental Health Branch of the United States Public Health Service was invited to make an administrative survey and evaluation of dental services in the New Haven community. He recommended that the clinic operate on a full-time basis under the direction of a full-time business manager and that new equipment be purchased when the clinic moved to its new quarters. He also recommended that the Board of Directors, particularly the Executive Committee, review the clinic's over-all mission and objectives, taking into consideration present concepts of dental public health practices and that the operation be sufficiently flexible to initiate new services and procedures. In addition, he suggested that the research project for dental care of the chronically ill and aged when completed be added to the clinic's program; that dental auxiliary personnel be fully utilized; that professional salaries be made more realistic; that we employ a commercial laboratory for our prosthetic work and that, in general, there be a tighter control over administrative records and details. Dr. Cox's report served as a working document for a clinic reorganization committee which included representatives from the Community Council, the United Fund Budget Committee, and the Clinic Executive Committee. The Reorganization Committee began meeting in the fall of 1965. Another factor influencing the thinking of the Reorganization Committee was a report on the Evaluation of the Health Status of Community Progress Incorporated Work Crew Members which indicated that their poor oral health was a major part of their general physical and psychological debility. The Community Council and United Fund responded almost immediately to 894 the evidences of ferment and growth within the clinic by granting a request for a 50 per cent increase in funds. The Reorganization Committee met regularly during the fall of 1965 and the spring of 1966, assisted by Mr. Anthony J. Suchy, vice-president and treasurer of Connecticut Blue Cross, Inc., who provided medical systems and accounting consultation. All aspects of the clinic operation were evaluated and revised to produce a bookkeeping and clinical record system which would be an accurate index of clinic operations at any time. The position of executive secretary was expanded to a full-time basis with extended supervisory and record-keeping duties and with added responsibilities for public relations and liaison with community civic organizations and health agencies. A graduate dental hygienist with keen sensitivity to the public health aspects of dental care was hired for this position and was involved immediately with the planning work of the Reorganization Committee. The research project on Dental Care for the Chronically Ill and Aged was incorporated into the clinic and is at present being financed by the annual contribution of $200 from each of 17 local convalescent hospitals. Additional dental auxiliary personnel were made available from the Eli Whitney Technical Training School which has a course for training dental assistants. Patient intake procedures and methods of payment for service have been adjusted to eliminate long waiting periods and delays in treatment. All laboratory work was transferred to a commercial dental laboratory with resultant improvements in the appliances constructed and elimination of delays in treatment completion. Finally, the clinic agreed to provide dental service for a comprehensive Family Medical Care Project at Yale University School of Medicine. VOL. 583 NO. 5, A.J.P.H.
DENTAL CARE IN A VOLUNTARY AGENCY Development of Community Services Building The Reorganization Committee planned to continue its study of the structure and function of the clinic and to begin planning for the new clinic in the new Community Services Building which would be ready in the early part of 1967. It also planned to establish an active associate supervisory staff of interested community dentists who would attend the clinic regularly. The purpose of this move was twofold. The more community dentists directly involved in clinic activities the easier it would be to recruit support from the professional community. Secondly, the professional willing to give his time to attend the clinic would undoubtedly be helpful in maintaining high quality dental care. The effect of these various changes in clinic organization was almost immediately apparent. The monthly intake of new patients began to rise and there was a dramatic change in patients' attitudes. The executive secretary became a familiar face to community agencies, interpreting administrative procedures, forms, and the new flexible fee schedule. She began to learn about the programs of other agencies and how to relate needed dental care to them. None of the foregoing activities of evaluation and program planning could really have had much meaning without the goal of appropriate housing for the clinic. The development of the central services building concept and the rapid movement toward completion of a million dollar building housing at least ten of the major New Haven health and welfare agencies was really the most meaningful stimulus to the creation of a totally new Morton J. Loeb Dental Clinic. The Community Services Building developed from the expressed housing needs of many agencies in New Haven including the Health Department. It received financial support through a grant from the New Haven Foundation, and those agencies with sufficient capital funds were able to buy space in the building on a condominium basis. Preliminary planning placed the Loeb Clinic adjacent to the City Health Department, thus allowing the clinic to avail itself of the large Health Department waiting room facilities and also to have access to the Health Department's three dental operating rooms. The Loeb Clinic has an administrative office of approximately 190 square feet with an open window to the waiting room. There are three operating rooms and one laboratory each 9 x 10 feet and a director's office or conference room of 140 square feet. All rooms except the laboratory have one solid glass wall with vertical blinds. The building is very modern and completely air conditioned. On May 1, 1967, the Morton J. Loeb Clinic moved into its new home at No. 1 State Street, New Haven, Conn. In addition to the problems of planning space requirements in the new building, the architectural layout, and the utilities the clinic was faced with a major concern of finances for new equipment. Dr. Loeb had bequeathed enough money for one room of equipment, New Haven Kiwanis Club contributed toward another, and the local dental profession contributed $6,000 by unanimous vote at an open meeting of the New Haven Dental Association. The presence of the Morton J. Loeb Dental Clinic in the Community Services Building represents a demonstration of responsible citizenship by the dental profession and is an advance toward achieving the goals of interagency coordination, communication, and concerted services, as well as providing facilities designed to enhance the quality of dental service. The process of planning for the clinic's future must include constant reevaluation of its program in terms of chang- MAY, 1968 895
ing social needs, new legislation, and new emphasis in the health fields. For the immediate future, we need to be concerned with the maximum use of the present facility and coordination among all those agencies and projects in the community concerned with dental health. The dental profession must continue to be actively involved in shaping clinic direction and maintaining a high quality of service, quality as measured by technical excellence, and quality as measured by appropriateness of programs in the community. Dr. Lisansky is Clinical Instructor, Dental Surgery and Public Health (Dentistry), Yale University School of Medicine (315 Whitney Avenue), New Haven, Conn. 06511. This paper was presented before the Dental Health Section of the American Public Health Association at the Ninety-Fifth Annual Meeting in Miami Beach, Fla., October 24, 1967. Medical Research Grants and Fellowships The Life Insurance Medical Research Fund has announced September 15, 1968, as the deadline for receipt of applications for grants in aid of medical research, effective July 1, 1969. Grants are made to nonprofit institutions for support of basic research in physiology, biochemistry, and other fields related to medicine. Further information and application forms may be obtained by interested investigators from the Scientific Director, Life Insurance Medical Research Fund, 1030 East Lancaster Ave., Rosemont, Pa. 19010. The fund also offers Medical Scientist Fellowships to medical students planning to prepare for careers in teaching and research by securing both the M.D. and the Ph.D. or its equivalent. Fellowships offer a maximum of six years of aid and may be activated at various stages of M.D.-Ph.D. training. Each school of medicine is invited to make two nominations for aid to begin July 1, 1969. Deadline for receipt of applications from deans' offices is October 15, 1968. 896 VOL. 58, NO. 5. A.J.P.H.