Iowa Plan: Dental Public Health in Iowa

1. Iowa Plan: Dental Public Health in Iowa Bob Russell, DDS, MPH Iowa Department of Public Health

2. Title V MCH Service Areas

3. Partners Within each county are multiple agencies (local public and private/non-private agencies) that serve families: • County health departments • Public health nursing services • Home health care agencies • Visiting nurse services • Community action programs

4. Assessment Examples • Open Mouth Surveys • Medicaid Services • Title V Databases & Reports • Public Health Supervision Reports http://www.idph.state.ia.us/hpcdp/oral_health_reports.asp

5. National Trends in Caries-Free Schoolchildren – Permanent Teeth Ages 5-17 years Ages 6-19 years

6. Iowa: Untreated decay is decreasing

7. Iowa: Adults

8. Penetration of Public Health Sealant Programs in Iowa • 79 elementary schools • Total: 990 elementary schools • 21 Junior High Schools • Total: 299 Junior High Schools • 9,941 Sealant placed on 1st molars in 2009-10 • 2,381 sealants placed on second molar teeth

9. Decay Positive and Decay Negative

10. Results Decay Negative Decay Positive • 37.8% from East Central Iowa • 22.2% Rural (Not adjacent to urban) • 70.5% white, 16% unknown race/ethnicity • 85.2% spoke English • 95.5% had a Medical Home • 61.2% had a Dental Home • 49.9% Males • 73.5% were younger than 5 • 29.9% from East Central Iowa • 29.1% Rural (Not adjacent to urban) • 66.7% white, 16% unknown race/ethnicity • 80.5% spoke English • 92.2% had a Medical Home • 69.3% had a Dental Home • 52.7% Males • 56.8% were younger than 5

12. Iowa: a State in Transition Demographic Trends Rapid Ethnic Diversification Aging white population Low fertility rates among whites Exodus of graduates to other states Higher birth rates among native minorities Large influx of immigrants, primarily Latinos, to work in labor shortage

13. IowaImplications of Changing Demographics • Need for increased outreach services • Need for new service hours • Child Care barriers • Geographic and transportation barriers • Different health care utilization patterns

15. Iowa Elderly in Assisted Living Centers

16. The Iowa Picture • We have stated that 92% of Iowans are receiving optimally fluoridated water. What does this % really mean? •  92% of Iowans who receive their water from a Community Water Supply are receiving optimally fluoridated water. •  Overall, approximately 83% of Iowa’s total population is receiving optimally fluoridated water.  • This percentage may actually be higher depending on if the population who receives their water by a private well has naturally fluoridated water or is adding fluoride to their water. • We have no system for tracking private wells or monitoring leaving over 248,205 estimated Iowans potentially lacking fluoridated water!

17. Trends are Troublesome

18. Iowa

19. I-SmileAn Overview of Iowa’s Dental Home Initiative for Children Bob Russell, DDS, MPH State Public Health Dental Director Iowa Department of Public Health

20. 2005 Legislative Mandate By July 1, 2008, every recipient of medical assistance who is a child 12 years of age or younger shall have a designated dental homeand shall be provided with the dental screenings and preventive care identified in the oral health standards under the EPSDT program.

21. Iowa Legislative Mandate Modified By December 31, 2010, every recipient of medical assistance who is a child 12 years of age or younger shall have a designated dental home and shall be provided with thedental screenings and preventive services, diagnostic services, treatment services, and emergency services as defined under the EPSDT program. * Language modified in 2008, HF2539

22. Conceptual Dental Home The dental home is a systemthat allows all children, even those often excluded from receiving dental care, to have early and regular care to ensure optimal oral health.

23. The I-Smile Dental Home DENTIST NURSE PHYSICIAN DENTAL HYGIENIST

24. I-SmileObjectives • Improve the dental support system for families. • Improve the dental Medicaid program. • Implement recruitment and retention strategies for underserved areas. • Integrate dental services into rural and critical access hospitals.

25. I-Smile Strategies • Partnerships and planning • Link with local board of health • Provide training for child health agency staff • Develop agency oral health protocols • Provide education and training for health care professionals • Ensure completion of screenings and risk assessment • Ensure care coordination services • Ensure provision of gap-filling preventive services

26. Improve Dental Support System for Families Strengthen Iowa’s Title V MCH System • Establish a dental hygienist within each Title V Child Health agency as the local I-Smile Oral Health Coordinator • Currently, Iowa has 24 dental hygienists working as regional I-Smile™ Coordinators • They create a system to assure optimal oral health for children.

27. I-Smile Referral System

28. I-Smile Dental Home Care Plan Diagram I-Smile Oral Health Coordinator Oral Screening and Risk Assessment Preventive Care Education Medicaid, uninsured, and underinsured children from birth-12 years Level 1Level 2Level 3 Low Risk No observable disease Moderate Risk No observable disease High Risk Observable disease High Risk Severe disease P L A N

32. Based on SFY2012 Medicaid paid claims, Iowa Department of Human Services

33. I-Smile--Challenges • Still too many children under the age of 3 who do not receive dental services. • Lack in dentists willing to see the very young child. • Low participation by dentists willing to see Medicaid children. • Low Medicaid reimbursement. • Decreasing and aging dental workforce • Mal-distribution of available dental providers

34. I-Smile--Sustainability • Promote children’s oral health to parent’s and caregivers. • Support gap-filling preventive services within public health and Title V agencies. • Maintain partnerships with early childhood programs. • Share information with stakeholders in anticipation of a changing health care system within Iowa. • Continue to support “health homes” by collaborating with medical providers to include oral health as part of well-child care. • Explore funding and collaborative opportunities with private organizations so that oral health becomes a priority statewide.

35. I-Smile™ Future Good oral health for all children beginning at birth Long-term savings in dental care costs Improved overall health of Iowa children and adults

36. Dental Screening Requirement (became effective July 1, 2008) A critical step in “closing the gap” in access to care for underserved children

37. Dental Screening Requirements • Elementary school • Prior to age 6, but no earlier than age 3 • Licensed physician, physician assistant, nurse, dental hygienist, dentist • High School: • Within one year of enrollment • Licensed dental hygienist or • dentist

38. Integration with I-Smile™ What if a child has a problem getting a screening? What if a problem is detected and a child doesn’t have a dentist? Contact local I-Smile Coordinator

39. Supervision Dental hygienist providing direct care services in Iowa must work under the supervision of a dentist. In public health settings, this would be either public health or general supervision. http://www.idph.state.ia.us/hpcdp/oral_health_resources.asp http://www.state.ia.us/dentalboard

40. Public Health Supervision • Recommended by IDPH, this allows hygienists working in a public health setting to provide services without the patient first being examined by a dentist. *Dentists providing public health supervision arenot required to provide future dental treatment to patients served by the hygienist.

41. Requirements for Practice as a Public Health Supervision Hygienist (PHSH) Requirements Settings Services Some services required to maintain Public Health Status:

42. Practice as Public Health Supervision Hygienist– What Else Do I Need to Know?

43. General Supervision • A dentist is required to see a patient prior to a dental hygienist providing certain services under general supervision • Sealants • Prophylaxis • Radiographs

44. Public Health Supervision Currently, a hygienist must have an Iowa license and a minimum of threeyearsof clinical experience to work under public health supervision.

45. Loan Repayment Two options: • National Health Service Corps – federal program • State Loan Repayment Program (called PRIMECARRE) Site criteria: • For PRIMECARRE, must be public or non-profit; NHSC also allows for-profit • Federal Health Professional Shortage Area (found at http://hpsafind.hrsa.gov/) • Sliding fee scale, accept Medicaid and Medicare

46. Applicant Eligibility Full-time or half-time (meet definition) U.S. citizen Education-related debts No unfulfilled practice obligation to federal, state, local government or other entity (such as employer) Certification or license to practice in Iowa Serve all patients regardless of ability to pay

47. Eligible Professions • Primary care physician • Dentist • Dental Hygienist • Physician Assistant • Nurse Practitioner • Certified nurse Midwife • Clinical Psychologist • Clinical Social Worker (LISW only) • Psychiatric nurse specialist • Mental Health Counselor • Marriage and Family Therapist

49. Thank you! Dr. Bob Russell, DDS, MPH Public Health Dental Director (515) 281-4916 Bob.Russell@idph.iowa.gov Iowa Department of Public Health Oral Health Center Lucas State Office Building 321 East 12th Street Des Moines, Iowa 50319 1-866-528-4020

50. References Institute of Medicine, National Academy of Sciences. The Future of Public Health. Washington DC; National Academy Press; 1988. Public Health Functions Steering Committee. Public Health in America. Washington, DC: PHS; 1995. CDC. Ten Great Public Health Achievements - United States, 1900-1999. MMWR. 1999;48(12); 241- 243. http://www.idph.state.ia.us/hpcdp/oral_health.asp http://www.ismiledentalhome.iowa.gov/