Public Health Dentistry in New Mexico

1. Public Health Dentistry in New Mexico State of New Mexico Office of Oral Health

2. What is Public Health? • Winslow’s definition of public health is “the science and art of preventing disease, prolonging life, and promoting physical and efficiency through organized community efforts” [Burt and Eklund, 2005:36]. • Concerned with the health of the population

3. What is Dental Public Health? Defined by the American Board of Dental Public Health, AAPHD, ADA, and APHA Oral Health Section- “Dental public health is the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts. It is that form of dental practice which serves the community as a patient rather than an individual. It is concerned with the dental education of the public, with applied dental research, and with the administration of group dental care programs as well as the prevention and control of dental diseases on a community basis” [Burt and Eklund, 2005:40].

4. 1988 Institute of Medicine (IOM) Core Functions of Public Health • Assessment: the regular collection and dissemination of data on health status, community health needs and epidemiologic issues • Policy Development: promotion of the use of the base of scientific knowledge in decision making on policy matters affecting the public’s health • Assurance: the provision of services necessary to achieve mutually agreed-upon goals, either directly, by encouraging other entities to supply them or by regulation [Burt and Eklund, 2005:37]

5. Cultural Competency • 1996 Archbold M. definition of Cultural Competency: “ A set of academic and personal skills that allow us to increase our understanding and appreciation of cultural differences between groups.” [Bilingual Advantage, Inc., 2006]

6. Social Determinants of Health • Socioeconomic position • Race and Ethnicity • Social Networks and Social Support • Work Conditions [IOM, 2003]

7. Factors that Play a Role in Determining Oral Health • Genetic • Biological • Culture • Environment • Socioeconomic Status • Can have interaction among themselves • May influence one another [Kwan and Peterson, 2010]

8. Prevention • Primary Prevention- Prevention of disease School based or school linked programs. • Secondary Prevention- Identify and control disease process in early stages • Tertiary Prevention- Prevent disability by restoring to optimal level of functioning after the damage is done [Turnock, 2009]

10. New Mexico Department of Health Oral Health Programs Office of Oral Health Office of Primary Care and Rural Health Office of School and Adolescent Health

11. New Mexico • 121, 356 square miles • In excess of 2 million persons (2011) • Asian– 1.6% (2011) • Black/African American—2.5% (2011) • American Indian– 10.1% (2011) • Hispanic Latino origin– 45% (2011) • White– 41% (2011) • Approximately 34% of the population live in rural areas • Approximate poverty rate in rural areas—24% (2011)

12. Dental Access to Care in NM • 32.8% adults reported no dental visit within the past year in 2010 DOH survey • New Mexico ranks 49th in the number of dentists per 100,000 • 23% had no insurance coverage in 2010 [NM State of Health, 2012]

13. New Mexico Continued: • 33 counties in New Mexico • 32 are considered Health Professional Shortage Areas (HPSAs) • 26 are considered dental HPSAs • 2 rural counties do not have dentists NM Office of Primary Care and Rural Health

14. New Mexico

15. Barriers to Accessing Health Care • Long travel distances [Bushy, 2009:26] • Lack of public transportation [Bushy, 2009:26] • Cannot take time off from work [Burt and Eklund, 2005] • Unreasonable office hours [Burt and Eklund, 2005] • Limited telephone and internet services [Bushy, 2009:26] • Shortage of health care providers [Bushy, 2009:26] • Inability to seek or obtain entitlements [Bushy, 2009:26] • Limited economic resources– income and insurance [Bushy, 2009:26] • Challenging roles and unpredictable weather conditions [Bushy, 2009:26]

17. New Mexico Dental Providers Licensed dental providers in 2011 • 1,326 dentists • 1,320 hygienists • 1,471 assistants [NM State of Health, 2011] Licensed dental providers in 2009 • 1,326 dentists • 1,132 hygienists • 1,878 assistants [NM Dental Health Care Board 2011] • 743 dentists provided services to a Medicaid patient. Licensed does not mean practicing!

18. Office of Oral Health

19. Office of Oral Health • Budget $3.1 million general fund • Staffing • 8 FTE: 3 dental hygienists, 3 dental assistants, 2 dental case managers*, 1 dentist*, and 1 financial operations specialist. 1 DCM and 1 dentist under contract • Preventive material and operating supplies • Supports operating dental vans, purchase of preventive material, educational material, portable equipment, and screening supplies. • Contractor support • School based dental sealant and restorative care contractors. • Basic preventive and treatment services for indigent New Mexicans. • Contractors reimbursed for services based on current NM Medicaid rates. • * contract employee

20. New Mexico Primary Prevention Dental Sealant Program 3 state teams services 50% F&RSLP elementary schools 3 private contractors State Fluoride Varnish Program Santa Fe and Rio Arriba Counties State wide: Head Start, Pre-K, Cleft Palate Dental Case Manager (2 county) State contractors

21. New Mexico Preventive and Restorative Care Under Contract (Uninsured) Mira Consultants – screening, dental sealants and treatment (children) El Centro Family Health – preventive and treatment UNM Dental Sciences – preventive and treatment Community Dental Services – preventive and treatment Sandoval Health Commons (WIC preventive/referral)

23. Office of Oral Health • State Fiscal Year 12 Total Population Served • # of unduplicated indigent persons 0-4 1797 • # of unduplicated indigent persons 5-19 11068 • # of unduplicated indigent persons 20-64 4825 • # of unduplicated indigent persons 65+ 806 • 18496 Dental Sealants Screening 7,724 Child receiving 6,524 Fluoride Varnish Screening 1,243* Child receiving 2,722** * Children receiving general screening vs. X-ray. ** Total children receiving an application.

24. Office of Primary Care • FY 2013 • Program allocated over $12.6 million general fund for the operation of 97 Primary Care Clinics • 37 clinics provide dental services • FY 2012 • 196,000 dental encounters were reported by the clinics

25. New Mexico Dental Support Center (NMDSC) • In 2009, NMDOH received a three-year workforce grant to establish a New Mexico Dental Support Center (NMDSC) to provide a wide range of support to dental professionals who work in rural areas and in community health centers, as well as a center of professional support and network of communication for dental educators throughout the state. • During the past three years, the NMDSC has provided communication networks for providers and educators, new provider orientations, face-to-face meeting with providers, continuing education opportunities, provider meetings, direct assistance, funding for community-based prevention projects, educator meetings and professional development for educators. • The NMDSC has established and maintained a database and electronic distribution list of NM dental providers who work in rural areas and community health centers, and a database and electronic distribution list of NM dental educators. The NMDSC has provided quarterly provider meetings and monthly newsletters in partnership with the New Mexico Primary Care Association, and coordination and facilitation of dental educator annual meetings and periodic conference calls. Over 80 dental providers have received technical assistance and over 37 have received scholarships. • Since funding ended in August 2012, the NMDSC is unable to sponsor continuing education events, provide scholarships and professional development, and fund prevention projects, however, it will continue with all other activities and remain a valuable resource for NM dental providers and educators.

26. Important dates in NM Dental Public Health • 1942- full-time dental consultant in PH Dept [Special Feature Public Health, n.d.] • 1948- clinic for indigent children [Greenfield, 1962] • 1953- Public Health Dept. Div. of Dental Health [Special Feature Public Health, n.d.] • 1962- 2nd mobile dental clinic [Greenfield, 1962] • 1963- mobile units reach 22 communities [Special Feature Public Health, n.d.] • 1975- 3 mobile units & 3 fixed facilities [J. Calderone, personal communication, 6/23/2010] • 1979- school based sealant program- 15 teams [J.Calderone, personal communication, 6/23/2010]

27. Important Dates Continued: • 1983- RDH can apply sealants under general supervision [J. Calderone, personal communication, 6/23/2010] • 1985- sealant program only [J. Calderone, personal communication, 6/23/2010] • 1997- Special Needs Code [R. Lyons, personal communication, 7/12/2010] • 2005- WICHE awardees must practice in NM [J. Harrison, personal communication, 6/23/2010] • 2010- NM Board of Dental Health Care accepts all dental exams for licensing [J. Harrison, personal communication, 6/23/2010] • 2012 Legislature expands scope of practice for dental hygienists.

28. Characteristics of the Frontier and Rural Lifestyle and Culture • Extensive distances between people and services • Work and recreational activities are often cyclic and seasonal in nature • Prominence of high-risk land oriented occupations and activities • Social interactions that facilitate, frequent, informal, face-to-face contacts • Close social or kinship relationships among community members • Preference for informal support systems in time of need

29. Characteristics of the Rural and FrontierLifestyle and Culture Continued • Individual and community self-reliance • Small towns as centers of trade • Churches and schools are centers of socialization for residents • Importance of local health systems, especially hospital and long-term care facilities, to the economy • Overlapping roles and relationships for clinicians as community members [Bushy, 2009:21]

30. Features Encountered by the Rural Provider • Limited health care services and resources • Geographic barriers to health care services • Conflicts between community values and professional guidelines • Challenges to privacy and confidentiality • A clinician providing care to a neighbor, a friend, or family member • A provider trying to deliver quality care, despite being professionally isolated, with limited access to peers and specialists • Overlapping professional and personal boundaries • Community expectations and professional stress [Bushy, 2009:16]

31. Difference between Rural and Non Rural Populations • Less dentists in rural areas • Less dental care in rural areas • Higher caries rate in rural areas • Higher tooth loss in rural areas [Rural Health Research Center, 2009]

32. What are the sources of patient care revenue? • Medicaid- dental insurance for low income patients- fee-for-service or capitation; can be main source of reimbursement for “safety-net clinics” • State Children’s Health Insurance Program (SCHIP)- Medicaid expansion program • Fee-per-visit- FQHC • Fee-per-covered member- managed care • Insurance- indemnity; possible deductible and co-payment • Full Pay- Not eligible for Medicaid/No insurance • Sliding Fee Scale- “safety-net” clinic reduced fees in accordance to ability to pay • Minimum- may be offered to people below the poverty level [Safety Net Dental Clinic Manual, 2009]

33. Community Health Centers • Economic Opportunity Act of 1964—add federal funds to community resources • Provide services to populations with limited health care access • Federally Qualified Health Centers (FQHCs)—Receive Section 330 grant funding • Must adhere to certain federal regulations • Outpatient health programs/facilities operated by tribal organizations • Board of Directors, Executive Director, and Key Management Team • 734 FQHCs offered dental services as of 2007 [National Network for Oral Health Access, 2009]

34. All Levels of Services • 1. Emergency Dental Services • 2. Prevention & Diagnosis 4 • 3. Basic Dental Care 3 • 4. Rehabilitative Services- 2 includes crown, bridge, 1 dentures [National Network for Oral Health Access 2009]

35. Quality Assurance and Improvement • Quality—IOM 1990 definition— “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” • Quality Assurance—reactive—examine after—focus on provider competence • Quality Improvement—proactive—quality built into work—preventive—focus on systems and processes [Safety Net Clinic Manual, 2009:2]

36. NM Programs available for Dental Professionals • New Mexico Health Service Corps • Health Professional Loan Repayment • Western Interstate Commission Higher Education (WICHE) Loan- for- service • Graduate Scholarship • Rural Health Provider Tax Credit [NM State of Health, 2009]

37. New Mexico • What is the NM State Tax Credit? What are the requirements to qualify? How do I apply?—Eligible dentists and hygienists who practice in a designated rural health care underserved area can apply for an income tax credit. Maximum tax credit for dentists is $ 5000/yr, for hygienists it is $ 3000/yr. There is a list of approved rural practice locations. For additional information and to apply visit-- http://www.health.state.nm.us/ Click on Rural Health. The Provider Tax Credit is at the bottom.

39. DOH STRATEGIC PLANNINGTurning the CurveIndicator: Increasing oral health access to care for adults.How much did we do?How well did we do?Is any one better off? State and local community partners. 5 Regional Planning meetings. Develop strategies to turn the curve for the local community.

40. Water Fluoridation • In New Mexico, community water fluoridation has come under attack by the local and national anti-fluoridation movement. • The Albuquerque Water Authority ceased water fluoridation to its customers without public notice. • The city of Santa Fe has proposed to stop fluoridating but the matter has been put on the shelf. • Santa Fe Oral Health Coalition formed to promote fluoridation and to improve the oral health status of pre-school and school aged children within the city and county. • Coalition will partner with the city of Santa Fe to promote oral health with the various school systems. • The city of Farmington will be the next community to be targeted by the anti-fluoridation movement . • The city of Espanola will be considering fluoridating its water. Office of Nutrition and Physical Activity OOH partners with the ONPA to promote child nutrition, physical activity and general health. ONPA has integrated in its educational material oral health specifically the consumption of fluoridated water. ONPA is funded by CDC and the Commuity Transformation Grant

41. Strategic Plan & Partnerships + Tools + Support = More Direct Path to Improved Oral Health for the people of New Mexico

42. References: • Burt, B.A. & Eklund, S.A. (2005). Dentistry, Dental Practice, and the Community (6th ed.). St. Louis: Elsevier Saunders. • Bilingual Advantage, Inc. (2006). Cultural Competence/CLAS Training for Healthcare Workers. NMDOH. • Bushy, A. (2009). A Landscape View of Life and Health Care in Rural Settings. In W.A. Nelson (Ed.), Handbook for Rural Healthcare Ethics: A Practical Guide for Professionals. Retrieved from http://dms.dartmouth.edu/cfm/resources/ethics • CDC (Centers for Disease Control and Prevention). (2010). Community Water Fluoridation. Retrieved from http://www.cdc.gov/fluoridation • Doescher, M.P., Keppel, G.A., Skillman, S.M., & Rosenblatt, R.R. (2009). The Crisis in Rural Dentistry. Rural Health Research Center. Retrieved from www.ruralhealthresearch.org • GADS Report. (2009). New Mexico Health Policy Commission. • Greenfield, M. (1962). A History of Public Health in New Mexico. Albuquerque: University of NM Press • Institute of Medicine. (2003). The Future of the Public’s Health in the 21st Century. Washington DC: The National Academies Press.

43. References Continued: • Kwan, S. & Peterson, P.E. (2010). Oral Health: Equity and Social Determinants. In E. Bias & A.S. Kurup (Eds.), Equity, Social Determinants and Public Health Programmes. Geneva: WHO Press. Retrieved from http://whqlibdoc.who.int/publications/2010/9789241563970_eng.pdf • New Mexico State of Health. Oral Health. (2009). Retrieved on February 19, 2010, from http://nmhealth.org/pdf/SoHiNM%202009%20(12-21-08)pdf. • National Network for Oral Health Access. (2009). Operational Manual for Health Center Oral Health Programs: Chapter One—Health Center Fundamentals. • New Mexico Office of Oral Health. (2009). • Office of Disease Prevention & Health Promotion. (2009). Public Comment – Healthy People 2020. Retrieved on June 24, 2010, from http://healthypeople.gov/hp2020/Objectives/TopicArea.aspx?id=38&TopicArea=Oral+Health • Rural Health and Rural Human Services Resources for New Mexico. Retrieved on June 10, 2010, from http://www.raconline.org/states/newmexico.php. • Safety Net Clinic Manual. Retrieved from http://www.dentalclinicmanual.com. • Special Feature: Public Health in New Mexico 1919-1979. (n.d.) • Turnock, B.J. (2009). Public Health What It Is and How It Works (4th ed.). Sudbury: Jones and Bartlett.

44. Acknowledgments Carol Hanson RDH, MPH Bill Burns, DDS, MPH Rick Champany, DDS Wendy Churchill, DDS Cindy Cullen, RDH