Community Oriented Primary Care Dental Services October 18, 2011 Avantika Nath, BDS, DDS - Director of Dental Services, COPC
Community Programs: COPC Administration
Outline I. Scope of Services II. School Based Prevention Programs III. Patient Visits & Demographic Data IV. Special Programs a) HIV Health Services b) Give Kids a Smile Day c) Project Homeless Connect V. Staff VI. Challenges
SFDPH Community Oriented Primary Care Dental Services Provided at: 1) CPHC 2) SAFHC Maxine Hall Health Center (MHHC) Medical Respite and Sobering Center (Polk St) (1) Chinatown Public Health Center (CPHC) CHPY Larkin Street Clinic 3) SEHC Housing & Urban Health Clinic (HUHC) 4) PHHC 5) TWHC + offsite Tenderloin Health 6) SPY Medical Respite and Sobering Center (Fell St) CHPY Cole Street Clinic Curry Senior Center (5) Tom Waddell Health Center (TWHC) Ocean Park Health Center (OPHC) Community Oriented Primary Care Administration San Francisco General Hospital Campus Clinics (SFGH PC) Castro Mission Health Center (CMHC) (4) Potrero Hill Health Center (PHHC) (6) Special Programs for Youth (SPY) (2) Silver Avenue Family Health Center (SAFHC) (3) Southeast Health Center (SEHC) CHPY Hip Hop to Health Clinic CHPY Balboa Teen Health Center CHPY Hawkins Clinic
Scope of Services Clinic Services Provided Priority Kids Pregnant women People Living with HIV/AIDS (PLWH/A) Homeless Population SPY Adults Triage Services
I. Scope of Services Dental Services are offered to the low income, under/uninsured people of SF by COPC, DPH. Priority populations receiving care: Kids (0 19 years) DentiCal, HK/HF initiative Pregnant women DentiCal, HF/HK Diagnostic, preventive and basic restorative dental services for infants, children, adolescents and pregnant women. In the past Denti Cal ( part of MediCal) was the primary source of revenue generation for services rendered by COPC. Since July 2009, Denti Cal cuts from the state whereby they only cover triage services for indigent Adults (extractions and emergency exams), has made it necessary for us to provide only emergency services for Adults. The Homeless dental services are supported by general fund and in a small part by the McKinney grant. The HIV clinic is supported in part by the Tenderloin Health Oral Health Collaboration (ended Aug 2011) and the HIV Health Services Grant (from the SF AIDS Office). The SPY services are supported by general fund. The dental clinics in the health centers are supported by general fund. The School based Kindergarten screening and sealant programs are supported by general fund. Healthy SF the medical insurance plan for the low imcome populations in the city does not cover dental services.
Clinical Services Provided: Oral examinations, X rays and diagnosis Oral hygiene instructions Prophylaxis (cleaning), fluoride Periodontal scaling and root planing Permanent and temporary fillings Endodontics; root canals anterior (front) teeth only Pulpotomy Uncomplicated extractions, minor tissue surgery and excisions Emergency care: Services necessary to relieve or control acute oral conditions, ie: pain, inflammation, infection, bleeding, trauma, etc. Clinical Services not provided: Orthodontics (braces) Cosmetic dentistry (bleaching, veneers) Treatment of advanced periodontal conditions Complicated extractions or impactions Nitrous oxide analgesia and sedation Surgical endodontics, root canals posterior (back) teeth Prosthetics (dentures, partials, crowns, bridges) Other SFDPH Dental Services include: providing and updating oral health education materials; providing educational trainings to health care students and professionals on oral health; developing innovative programs to increase access to dental care, and seeking policy changes to help increase access to dental care.
COPC Dental Clinics Potrero Hill Health Center Dental Clinic (adults, infants, children, adolescents and pregnant women) Southeast Health Center Dental Clinic (adults, infants, children, adolescents and pregnant women) Silver Ave. Family Health Center Dental Clinic (infants, children, adolescents and pregnant women) Chinatown Public Health Center (infants, children, adolescents and pregnant women) Tenderloin Health Center (HIV services) Tom Waddell Health Center (Homeless/HIV services)
II. School Based Prevention Programs Kindergarten Dental Screening Surveillance Program One of the three public health core function is Assessment through monitoring health status to identify community health problems. The Kindergarten Dental Screening Program is the Department s primary oral health surveillance activity. This program is a collaborative between the San Francisco Department of Public Health (SFDPH), San Francisco Dental Society (SFDS) and the San Francisco Unified School District (SFUSD) which provides a yearly oral health assessment to every kindergartener enrolled in the SFUSD. The program was created: To monitor and identify disease trends over time (level and demographic distribution) To provide data to develop and target appropriate interventions and resources To mobilize community partnerships to identify and solve oral health problems To develop policies and plans that support individual and community health To research for new insights and innovative solutions To demonstrate that public private partnership can improve health outcomes To assist children into a dental home a place where he or she receives continuous, comprehensive, coordinated and culturally competent oral health care
Kindergarten Dental Screening Surveillance Program, continued Since its inception during the 2000 school year, over 40,000 children have received an oral health assessment, the results of the assessment and information on insurance and dental care resources. The San Francisco program was one of the models used to support the development of Education Code Section 49452.8, legislation passed in passed in 2005 as AB 1433, which requires public school children to have their oral health assessed by a licensed dental professional (dentist or dental hygienist) by May 31 of their first year of school. During the 2010/2011 school year: 4,274 children received a dental screening in 72 schools. 22% had one or more actively decayed teeth (untreated caries) 41% had experienced decay (treated and/or untreated caries) Over the last ten years we have observed a 17% decrease in the percentage of SFUSD Kindergarteners with untreated caries. Comparing these results to national data is difficult because there is no exact national comparison. The closest may be the National Healthy People 2010 objectives for children ages 6 8. We have almost reached the Healthy People 2010 objective of no more than 21% of 6 8 year old children with untreated caries (22%). We have surpassed the National Healthy People 2010 target of 42% for caries experience in 6 8 year olds (41%).
Kindergarten Dental Screening Surveillance Program, continued There are multiple factors that may contribute to these improvements including: Community water fluoridation San Francisco s commitment to fund universal health care including dental services for children through the Healthy Kids program Small but significant number of private practice dentists accepting public insurance plans and willing to treat children ages 0 5 and two dental schools for advanced specialty care Priority of safety net dental providers (including SFDPH Dental Services) to see children ages 0 5 Various programs, collaborations and initiatives between SFDPH Dental Services and other DPH departments and community partners which provide case management, training of Pediatrics and Family Medicine residents on early childhood oral health, perinatal oral health services and pre school/head Start screenings
Seal San Francisco, Dental Sealant Program In 2007 the CDC s Task Force on Community Preventive Services released a report strongly recommending two community based interventions to prevent tooth decay community water fluoridation and school dental sealant programs. Dental sealants are a highly effective thin plastic coating painted on the chewing surfaces of the back teeth to seal out and prevent tooth decay. Although highly effective, national and state data show sealants are generally underutilized on children with both public and private dental insurance coverage. School based programs provide pit and fissure dental sealants to the permanent teeth of children in a school setting and generally target vulnerable populations less likely to receive dental care such as children eligible for free and reduced lunch programs. Our dental sealant program, Seal San Francisco, is a school based dental disease prevention program targeting second graders which: Helps to eliminate barriers that contribute to health disparities Prioritizes disease prevention and health promotion Provides oral health services in a non traditional setting Follows public health population based principles
Seal San Francisco, Dental Sealant Program, continued Seal San Francisco began in 1997 as a pilot program and grew with the help of a grant from the Dental Health Foundation. Mobile dental equipment is utilized to create a temporary clinic in the school. Approximately 12 14 schools are served per year. For the 2010 2011 school year: 917 children in grades 1 5 were screened 783 children received dental sealants
III. Patient Visits and Demographic Data Total Visits Patient Demographics Age distribution Age shift: 2008/2009 to 2010/2011 Adult visit distribution Increase in visits: pregnant women Dental visits by Payor source Dental Payor Sources FY 10/11 page, 14
Total Visits HC FY08/09 FY09/10 FY10/11 SAFHC 1,897 1,905 2,454 CPHC 1,566 1,675 1,913 YGC 743 607 419 SEHC 1,784 1,777 1,813 PHHC 1,742 1,378 1,167 TWHC 665 589 843 TLH 318 573 823 TOTAL: 8,715 8,504 9,432 page, 15
Patient Demographics: Age Distribution Age FY08/09 FY10/11 Total % Total % 0-5 1,237 17.0% 1,666 17.7% 6-11 1,208 16.5% 1,912 20.3% 12-17 1,538 21.1% 1,789 18.9% 18+ 3,316 45.4% 4,065 43.1% page, 16
Age Shift: 2008/2009 to 2010/2011 page, 17
Adult Visit Distribution Age FY08/09 FY10/11 Total % Total % 18+ 3,316 4,065 Pregnant 396 12% 917 22.5% Non-pregnant 2,920 88% 3,074 77.5%
Increase in Visits: Pregnant women page, 19
Patient Demographics: Dental Visits By Payor Source FY08/09 FY09/10 FY10/11 Denti-Cal 3,769 4,658 5,320 Private Insurance 56 33 32 GA 16 0 1 CHDP (children) 89 218 339 Sliding Scale (adult, preg) 547 702 770 Self Pay 76 80 28 Healthy Families 439 465 417 Healthy Kids 406 328 306 Healthy San Francisco 931 1254 1,468 page, 20
Dental Payor Sources FY 10-11 page, 21
IV. Special Programs: Service Grant with Research Component: 1) Special project of National Significance Oral Health Collaborative details in presentation 2) HIV Health Services Grant for providing Oral Health Care to PLWH/A, from SF Aids Office. Funding: $400,000 over 3 years Goals: Improve Access to Oral Health Care to PLWH/A who are under/uninsured, homeless or marginally housed, with high prevalence of medical & psychosocial and comorbidities. Innovative Approach: Use of extensive outreach and referral bases - Establishment of Dental Case Management - Holding focus groups to provide Oral hygiene and Oral Health education - Affiliation agreement with UCSF, GPR program to provide specialty services
Give Kids a Smile Day 2011 Give Kids a Smile Day Events at Southeast HC and SFGH Southeast Heath Center Feb. 4, 2011 SFGH WIC Feb. 10, 2011 Total Seen: 67 Total seen: 136 We screened 67 kids at SEHC All received FV Heard about event from: WIC 71, Flyer 18, Homeless Prenatal 5, School 15, Hospital/clinic 10 75% from WIC, 4% Homeless Prenatal, 13% school, 8% hospital/clinic Ages: Class 1: 87 44% with decay 0 5: 104 Class 2: 26 50% previous DDS 5 10: 21 Class 3: 12 124 children received FV at SFGH 10 20: 3 SF DPH participated in a nationwide effort to highlight the need to establish a dental home, on February 4, & 10, 2011, called Give Kids a Smile Day. We targeted our low income SF children ages 0 5years old, and advertised to the WIC sites, preschools and SFGH. Partnering with SFSU School of Nursing and the SF Dental Hygiene Society, we were able to provide not only dental screenings, exams, cleanings, and fluoride varnish, but also education for the parents, homecare toothbrushes and supplies, and healthy snacks. We also followed up the event with calls to parents to support them in making a dental appt. for their children.
Project Homeless Connect Since 2007, COPC Dental Services has been a key partner with PHC in bringing necessary services to the homeless. Dental care is one of top unmet needs of the homeless population. COPC partners with San Francisco Dental Society volunteers, UCSF and the University of Pacific School of Dentistry to provide comprehensive dental services for the homeless San Franciscans. It truly reflects a best practice model for collaboration. On any given PHC event, we provide screening to an average 165 patients and provide treatment to 98-100 patients. We continue to reshape our outreach strategy and improve available services.
Community Based Dental Partnerships - San Francisco Dental Society - San Francisco Dental Hygiene Society - San Francisco Unified School District - UCSF, General Practice Residency Program (GPR) - Western University, Pomona - Arthur A. Dugoni School of Dentistry, UOP - SF VA Medical Center
V. Licensed Staff: - Dentist 10 - Dental Hygienist 2 - Dental Aide 11
VI. Challenges Demand for dental services is high for all segments of the population, but is increasing for low-income populations. The loss of most Denti-Cal adult dental benefits in 2009 and private and public sector job losses with concurrent loss of private dental insurance is further taxing our already fragile dental safety-net system. The ongoing challenge for SFDPH Prevention Programs is to carry out our key public health surveillance functions and population-based programs to maintain and/or surpass gains made in oral health status for children given the current fiscal environment. Each year an Americorps member full-time position is hired to assist in managing the Prevention Program infrastructure and data at minimal cost. Strong relationships with the local private practice dental community, other dental safety-net providers and the school district have been forged. Quarterly meetings are attended with organizations tied to children s dental health to exchange ideas, ensure minimal duplicated efforts, share resources and assist in providing services that perhaps one organization is unable to provide alone.
VI. Challenges, continued A focus on prevention, education, early detection, community partnerships, accessibility to quality population-based services and establishing a dental home early in life are key to maintaining and improving the oral health status of the populations we serve. Challenges moving forward: Access to Oral Health Care limited due to multiple barriers Public Health Services poorly reimbursed Reliance on the General Fund Enhancing Quality of Care and cost-effective care Unknown impact of HealthCare Reform Conversion to new EMR