Improving the Oral Health Health of Rural Communities

1. Improving the Oral Health Health of Rural Communities Jack Dillenberg, DDS, MPH Dean, Arizona School of Dentistry & Oral Health Some slides provided by Allen Finkelstein, DDS and Michael Glick, DDS

2. Access to Care for Rural Americans • There are 62 million Americans currently residing in rural areas. • It is estimated that 20 percent of the rural population is uninsured, and this number is projected to increase to 25 percent by 2019. • The need for increased access to care and insurance coverage is especially crucial for rural populations because they receive less preventive care and have higher rates of all chronic diseases than their urban counterparts (Bailey, 2010)

3. Access to Care for Rural Americans A national survey places access to quality health services as the top-ranking priority among rural health care stakeholders and leaders (Nelson & Gingrich, 2010).

4. Substance Abuse In Rural America • There has been a dramatic increase in reported substance abuse cases over the last decade. • A 2002-05 national survey on drug use and health found that rural residents are more likely to use cocaine, methamphetamines and stimulants compared to residents of small and large metropolitan areas (Thomas & Compton, 2007).

5. Oral Health in Rural Areas • In rural areas fewer residents have access to health care and health insurance compared to urban areas, especially for specialty services such as dental care.

6. Decreased Dental Insurance

7. Oral Health in Rural Areas • Overall, rural residents are less likely to receive an annual dental exam than urban residents (Bennett, Olatosi & Probst, 2008). • Rural residents are at higher risk of having gum or tooth disease due to: • Higher rates of smoking or use of other tobacco products, • Lack of access to fluoride-treated water systems, • Poverty (Skillman, Doescher, Mouradian & Brunson, 2010)

8. Oral Health in Rural Areas • Despite the need for dental services, 72 percent of rural residents reported not having any dental insurance coverage (Ettinger, 2004), and only 55 percent of rural adults reported having a dental checkup in 2001 (AHRQ, 2005). • Children in rural areas, especially those with special health care needs, are more likely to have unmet dental needs, lack of dental insurance, and a perceived worse dental health status than children in urban areas (Skinner, Slifkin & Mayer, 2006).

9. Contributors to Poor Access • Increased geographic isolation • High levels of poverty • Concentration of elderly residents • Shortages of dental care providers (Shortridge & Moore, 2010).

10. Poverty – Influence on Oral Health • Work of Dr. Chrisophe Bedos and colleagues in Canada: • Why the poor do not have good oral health • Difficult relationships with oral health professionals • Feel they are perceived negatively – shame • Professionals admit frustration with their behaviors and lifestyle

11. Attitude is Everything! • Value appearance – more social than “biomedical” (white straight, teeth), employability, sociability, self-image • Feel powerless – envision extractions – dentures as a solution.

12. Oral Health in Rural Areas • In order to curb this trend, more dental hygienists and dentists need to be recruited to rural areas. Unfortunately, dentists are in demand but not available to rural residents. • In 2008 there were only 22 general dentists per 100,000 rural residents compared to 30 general dentists per 100,000 urban residents. • Additionally, 42 percent of dentists practicing in rural areas are age 56 or older (Doescher, Keppel, Skillman & Rosenblatt, 2009)

13. 1%

14. Only 1% of professionally active dentists in the U.S. dedicate their career to serve Health Center patients Source: Numbers based on 2006 data; report by the National Association of Community Health Centers (NACHC)

15. 2010 Health Center Oral Health Data • 3.75 Million Dental Patients Served • 9.23 Million Dental Visits • An increase of 2 million visits per year since 2008 Source: http://bphc.hrsa.gov/uds/view.aspx?year=2010

16. Dentist Vacancy Rate at Health Centers Source: Rosenblatt R, Andrilla H, Curtin T, and Hart G. Shortages of Medical Personnel at Community Health Centers. JAMA, 2006 –Vol. 295, No. 9: 1042-1049.

17. 48% of Health Centers reported at least one dentist vacancy • Almost half of all rural Health Centers have had a vacant dentist position for 7 months or more. Source: August 2007, Health Centers’ Role in Addressing the Oral Health Needs of the Medically Underserved, Ginger Ruddy, MD, Georgetown University Medical Center and National Association of Community Health Centers, Inc.

18. 17%

19. Indian Health Services 2010 vacancy rate was 17% http://www.ihs.gov/PublicAffairs/IHSBrochure/Workforce.asp

20. Surgeon General’s Report on Oral Health • Oral diseases common and consequential • Linked to overall health and well-being • Profound disparities in oral health status • Disparities • SES • Rural areas • Minorities www.nidcr.nih.gov/sgr/sgr.htm

21. Oral Health Facts • Dental disease is the most common unmet health need in U.S. • General public more likely to lack dental insurance • Access to dental care limited under Medicaid • 52 million school hours lost annually to dental issues www.nidcr.nih.gov/sgr/sgr.htm

22. Societal Changes • Emergence of older population • Need exists to coordinate chronic disease management and oral healthcare • Physicians, dentists, physician assistants , nurse practitioners and nutritionists must provide care in a collaborative manner • Need a more systematic approach to coordinating chronic disease care The Future of Primary Care, Editorial. Feb. 2003, 230-231

23. Institutionalized Elderly • Rapidly growing group • Increased rates of chronic disease • Increased demands for personal care homes

25. Paradigm Shift • A move from primary care • To comprehensive care… • To interprofessional care

26. Need to change “Homes” • Medical Home • Dental Home • HEALTH HOME

27. The “Health Home” • Not just a physical place • Accessible • Continuous and comprehensive • Family centered • Coordinated • Compassionate • Culturally effective • Inter Professional The Future of Primary Care, www.cbsnews.com/stories/2006/06/20/health/printable1735729.shtml

28. “Dentists are not the optimal provider of intensive disease management services: Lower cost cognitive disciplines proven to be effective in chronic disease management must include social workers, health educators, behavioral nutritionist, physician assistants and nurse practitioners.” “The medical and dental home of today must transform into The Health Home of the future.” Allen Finkelstein, DDS

29. Role of the PCP - The Facts • Tooth decay is the most common chronic disease – 5x more than asthma. • Over 51 million hours are missed annually from preschool through high school due to dental illness. • Oral health issues affect children in poverty and racial minorities far more than other groups. • 40 to 50% of children are affected with caries by age 5. • By age 2, children have seen a Primary Care Physician on the average of 7 times but few, if any, have had a well child dental visit.

30. Barriers • Oral health absent from radar screen of non-dental faculty, residents, staff • Providers busy – oral health not a priority • Confusion about PCP’s role as related to dentistry because of a lack of oral health training • Reimbursement absent

31. Integrated Insurance Provider Partnerships • To create an integrated medical dental program. • To communicate to the member through the medical and dental providers the importance of comprehensive integrated care. • To create a provider reimbursement (incentive) methodology that will support this program. • To identify medical dental opportunities for the convergence of these services in a cost effective manner.

32. Who to Engage in Making the Changes? • Health care system, Health insurance executives • Health Profession school deans • Legislators/Policy makers • The public The Future of Primary Care, Editorial. Feb. 2003, 230-231

33. Cross-Cutting Competencies for Health Professionals • Provide patient-centered care • Work in inter-professional teams • Employ evidence-based practices • Apply quality-improvement approaches • Utilize informatics • Health Professions Education: A Bridge To Quality

34. Role of Social Workers in a Health System • Provide counseling and education regarding behaviors that promote health and wellness • Provide information and referrals to community resources and assist with application process when indicated • Engage patient’s support system in facilitating problem resolution • Provide emotional support and counseling in relationship to difficulties imposed by illness • Assist patients in developing coping skills necessary to prevent relapse Doris JM, Davis E, Dumont C, Holdaway B. Social Work in Dentistry: The CARES Model for Improving Patient Retention and Access to Care. Dental Clinics of North America (2009);53 549-559.

35. Role of a Social Worker in a Dental School Setting • Act as a liaison between patients and dental providers • Provide services to patients that reduce barriers to dental care • Provide crisis intervention in the event of a mental health emergency • Provide training and education to dental providers regarding communication skills in the patient-dentist relationship • Educate dental providers regarding psychosocial issues that impact patient care • Evaluate effectiveness of social services provided Doris JM, Davis E, Dumont C, Holdaway B. Social Work in Dentistry: The CARES Model for Improving Patient Retention and Access to Care. Dental Clinics of North America (2009);53 549-559.

37. Future of Dentistry • Need for more comprehensive care in special and medically complex patients • Treating patients with/without teeth – not just teeth! • Integration, integration, integration….

38. Leadership is Required • Leadership Style & Success • “Servant leaders” • Compassionate, humble, reverent, open, teachable, respectful, caring • They model authority through: • Service, humility, contribution

39. Jack’s Suggestions for Good Leadership • Work at something you enjoy and that’s worthy of your time and talent. • Give people more than they expect and do it cheerfully. • Become the most positive and enthusiastic person you know.

40. Jack’s Suggestions for Good Leadership Grateful Be forgiving of yourself and others. Be generous. Have a grateful heart.

41. Jack’s Suggestions for Good Leadership Image from: http://showmeyourindies.com/indieflix/indieflix-blog/the-tortoise-and-the-hare-being-a-filmmaker-in-an-ever-changing-world/ • Persistence, persistence, persistence.

42. Jack’s Suggestions for Good Leadership • Be loyal. • Be honest. • Be bold and courageous. When you look back on your life, you’ll regret the things you didn’t do more than the ones you did.

43. Confidence Builds Effective Leaders

44. The Future of Our Profession

45. Arizona School of Dentistry & Oral Health • Our Purpose: • To educate caring, technologically adept dentists who become community and educational leaders, serving those in need

46. 4th Year External Rotations • Goals: • To make a difference in the oral health of those we serve • To change the face of dental education, and in the process, improve access to oral health care across the nation • Students are provided with the following: • Exposure to a variety of community and public health based clinical environments • An opportunity to be taught and mentored by excellent clinicians • A deeper understanding of the unique oral health challenges faced by many communities

47. 4th Year External Rotations • Community-Based Clinical Rotations • Examples of the 60+ sites: • Arctic Slope, Alaska Native Association • Penobscot, Maine CHC • Phoenix Indian Medical Center • High Plains, Colorado CHC • Hopi Healthcare Clinic • Redwoods Rural Health Center

48. Certificate in Core Concepts of Public Health • Online coursework begun 2nd year • Biostatistics • Epidemiology • Health Policy & Administration • Health Behavior & Health Education • Environmental Health Sciences

49. Hometown Project • Hometown aids aspiring dental students by linking with a CHC: • Locating a CHC needing volunteers • Gaining ASDOH application endorsement • Understanding the CHC working environment • Learning from a CHC mentor • Assistance in seeking employment pathways in a CHC • Identifying loan assistance and repayment programs

50. ASDOH Graduates • 78% of graduates serve Underserved patients • 94% of graduates strongly agree that ASDOH prepared them to treat patients from socio-economically disadvantaged backgrounds • 83% of graduates strongly agree that ASDOH prepared them to treat patients with disabilities