Integrating Oral Health and Primary Care Opportunities in Health Reform and Federal Policy

1. Grantmakers In Health Returning the Mouth to the Body: Integrating Oral Health and Primary Care Opportunities in Health Reform and Federal Policy Meg Booth, MPH National Maternal & Child Oral Health Policy Center Children’s Dental Health Project National Maternal & Child Oral Health Policy Center

2. National Maternal & Child Oral Health Policy Center • Goal 1: Enhance Knowledge. Identify, analyze, and promote new information for policymakers and key stakeholders to improve MCH oral health policies and practices. • Goal 2: Build Capacity. Build awareness, skills, and knowledge among policymakers and key stakeholders to actively promote new and effective oral health policies. • Goal 3: Expand the Community. Expand and diversify the audience engaged in promoting oral health of MCH populations. National Maternal & Child Oral Health Policy Center

3. W What do we mean by a “health home”? National Maternal & Child Oral Health Policy Center

4. Definitions • Medical Home: • a physician-directed medical practice that provides point-of-entry • enhanced primary care in a continuous fashion • across the health care spectrum, and • comprehensive, coordinated and delivered in the context of family and community. • Dental Home: • 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 • establishment of a dental home begins no later than 12 months of age and • includes referral to dental specialists when appropriate. • Health Home: • an approach to providing care within service delivery systems • integrated, comprehensive medical, dental and mental health care • focused on prevention and early intervention with reliance on specialists to help with disease management and provide more intensive care • Sources: Patient-Centered Primary Care Collaborative. Patient Centered Medical Home. Accessed 2/1/11 at: http://www.pcpcc.net/patient-centered-medical-homeDefinition of a Dental Home. Policy Statement. 2010. American Academy of Pediatric Dentistry. Reference Manual. Vol 32; No. 36. National Maternal & Child Oral Health Policy Center

5. What does a health home look like? Health home generally remains a vision as it relates to the integration of dental care, however there are opportunities for integration of medical and dental… • Full integration • Co-location • Shared financing • Virtual integration Systems considerations: • Lack of primary care provider training • Lack of dental care provider training • Lack of primary care provider time in well-child visits to provide services beyond physical health • Separate medical and dental financing strategies • Administrative barriers to sharing health information between providers Source: National Maternal and Child Oral Health Policy Center. Children’s Oral Health in the Health Home. May 2011. National Maternal & Child Oral Health Policy Center

6. Oral Health in Health Reform (ACA) National Maternal & Child Oral Health Policy Center

7. Quick Review: Systems Framework • Comprehensive systems approach, building on CHIPRA • Health coverage bill – estimated by 2019, 92% non-elderly will have health insurance (94% if exclude undocumented immigrants) • Provides dental coverage to nearly all children • Coverage is supported by numerous additional provisions • Unfortunately, many of these provisions still await funding National Maternal & Child Oral Health Policy Center

8. Prevention & Health Promotion National Maternal & Child Oral Health Policy Center

9. Effective Coverage National Maternal & Child Oral Health Policy Center

10. Workforce and Training National Maternal & Child Oral Health Policy Center

11. Delivery System National Maternal & Child Oral Health Policy Center

12. Infrastructure, Quality & Surveillance National Maternal & Child Oral Health Policy Center

13. What are the opportunities in ACA to move toward a health home? National Maternal & Child Oral Health Policy Center

14. ACA Opportunities • Essential Benefits • Early Childhood Caries Disease Management • Maternal, Infant, and Early Childhood Home Visiting Programs • Center for Medicare and Medicaid Innovation • School-based Health Centers • Dental Training programs National Maternal & Child Oral Health Policy Center

15. Essential Benefits Pediatric Dental Benefit – SEC.1302(b)(1)(J) “Pediatric services, including oral and vision care.” • Dental benefits can be provided through stand-alone dental plan or qualified health plan. • Recommendations to HHS signed by 50+ organizations • Effective and efficient dental care for children must be individualized according to their levels of disease risk and disease experience • Existing clinical diagnostic and preventive resources should be directed so that the intensity of care received by children is tailored to their levels of disease risk and disease experience in collaboration with the child’s medical home and other community health care agencies. • All children should receive pediatric dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions for the attainment and maintenance of oral health. National Maternal & Child Oral Health Policy Center

16. Early Childhood Caries Management Demos SEC. 4102 – Charges the Secretary to award grants to demonstrate the effectiveness of research-based dental caries disease management activities. • Building the evidence-based for dental caries management provides foundation for future efforts to control disease and dental expenditures. • Demonstrations would be provided through CDC • Eligible entities include community-based provider of dental services • Including FQHCs, hospital clinics, state or local health department, IHS dental program, private dental provider, medical provider, public health provider, nurse, nutrition education institution, or national organization • Currently authorized, not appropriated National Maternal & Child Oral Health Policy Center

17. Maternal, Infant, and Early Childhood Home Visiting SEC. 2951(SEC. 511 SSA) – amends Title V of Social Security Act to (1) strengthen and improve [Title V] programs and activities…(2)to improve coordination of services for at risk communities; and (3) to identify and provide comprehensive services to improve outcomes for families who reside in at risk communities • Statewide needs assessment and coordination with other need assessments and inventory of community-based prevention-focused programs • Nurse, social workers, or other professionals meet with at-risk families to evaluate family circumstances and connect families to health care, developmental services, early education, parenting skills, child abuse prevention, and nutrition education or assistance • $1.5 billion over five years ($88M awarded 7/11) National Maternal & Child Oral Health Policy Center

18. CMS Innovation Center (CMMI) • Established by the ACA to rapidly test innovative care and payment models and scale up successful models • Designed to be a public/private/consumer partnership to explore new payment and care delivery models in three main areas: • Improved Care for Individuals • Coordinating Care to Improve Health Outcomes for Patients • Community Care Models • Projects and initiatives still being developed, exiting initiatives include • Medicaid Health Home State Plan Option • FQHC Advanced Primary Care Practice Demonstration • Multi-Payer Advanced Primary Care Practice Demonstration • Appropriated $10 billion over the next 10 years National Maternal & Child Oral Health Policy Center

19. School-based Health Care • School-based health centers SEC. 4101(a) – One-time funding for facility construction, expansion, and equipment. $200 million ($50 million per year through FY2013) • Mandatory funding • School-based dental sealant program SEC. 4102(b) – Expands existing current school-based dental sealant funding to all 50 states • Currently authorized, not appropriated • Community Health Center Trust Fund • SEC. 10503(b) – Expand health centers’ operational capacity and enhance their medical, oral , and behavior health services. • $9.5 billion for health center operations (FY2011 through FY2015) • Plus,$1.5 billion for capital needs including new construction and renovation • Mandatory funding National Maternal & Child Oral Health Policy Center

20. Dental Training Programs • General, pediatric, and public health dentistry training SEC. 5303 – • Expands “Title VII” dental workforce training program to include training of dental students and practicing dentists as well as residents • Provides financial assistance to dental trainees (including dental hygienists) developing new training programs • Traineeships and fellowships for dentists committed to teaching; grants for faculty development • Faculty loan repayment programs • Advancing pre-doctoral training in primary care dentistry Current appropriated, partially funded through ARRA and FY10 funding • Primary Care Residency Programs SEC. 5508 – • Establishes three-year, $500,000 grants to establish new primary care residency programs, including dental programs. • Currently appropriated National Maternal & Child Oral Health Policy Center

21. Other Federal Opportunities • Children’s Health Insurance Program – • “…coverage of dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.” • regulations for the dental benefit are anticipated in spring/summer 2012 • benchmark plan for ACA • Perinatal Oral Health Services – • State guidelines professional guidelines for perinatal oral health services (NY, CA) • Upcoming national consensus statement (HRSA/MCHB) • Professional training programs National Maternal & Child Oral Health Policy Center

22. Policy Barriers to Integrating Medical & Dental • Insignificant support and/or opposition from the dental profession to integrate primary care and dental care • Little demand from the public to make changes to the dental delivery system • Inconsistent support from dental benefit and health insurers for integrating medical and dental care • Limited innovation and adoption of health information technology integrating medical and dental National Maternal & Child Oral Health Policy Center

23. What can philanthropy do influence policy change? National Maternal & Child Oral Health Policy Center

24. Policy Opportunities for Philanthropy • Support innovation that addresses system barriers • integrated models of prevention and disease management should drive the discussion about expanding access and quality rather than extensions of the current misdesigned system which will probably yield the same results • Build public or political will to make change • There is currently little public demand, provider motivation, or political will to change the dental delivery system • Furthermore, there are active strategies to keep the system the same • Encourage policy change that addresses systems barriers • Federal, state or local policy can be changed to encourage or allow integration as innovative models are being tested National Maternal & Child Oral Health Policy Center

25. Resources • National Maternal and Child Oral Health Policy Center – www.nmcohpc.org • Children’s Dental Health Project – www.cdhp.org Meg Booth National Maternal & Child Oral Health Policy Center Children’s Dental Health Project mbooth@cdhp.org Ph. 202.417.3598 National Maternal & Child Oral Health Policy Center