Cover

1 Acknowledgements

The Iowa/Nebraska Primary Care Association is indebted to Dr. Bob Russell, Iowa State Public Health Dental Director, Iowa Department of Public Health, for the development of this curriculum. We are appreciative of Dr. Russell’s willingness to share his expertise and commitment to our safety net dental programs. Development of this curriculum and training series for dental directors would not have been possible without the generous support of the Iowa Health Foundation.

Dr. Russell would like to thank the following for lending their expertise to this endeavor:

Jay Anderson, DMD, MHSA, Chief Dental Officer, Division of Clinical Quality, Clinical Quality Improvement Branch, HRSA Bureau of Primary Health Care

Steven Geiermann, DDS, CAPTAIN, U.S. Public Health Service, Office of Performance Review, HRSA Regional Dental Consultant Region V

David Rosenstein, DMD, MPH, Professor Emeritus, Department of Ommunity Dentistry, Oregon Health Sciences University

Raymond Kuthy, DDS, MPH, Professor and Chairperson, Department of Prevention and Community Dentistry, University of Iowa College of Dentistry

Raymond Lala, DDS, CAPTAIN, U.S. Public Health Service, Chief Dental Officer, HRSA Bureau of Health Professions

2

Dear Dental Directors:

It is with a great deal of pleasure and purpose that the Iowa Department of Public Health supports the development of this New Dental Director Training Program.

The Iowa Department of Public Health (IDPH) is pleased to collaborate with the Iowa/Nebraska Primary Care Association (IA/NEPCA) to bring this valuable training to the new dental directors of Iowa and Nebraska.

As dental directors in community health centers and other safety net settings, I know your challenges are many and varied. As our collective awareness of the lack of access to oral health care grows, we recognize that we are all responsible to address these critical issues. It is our hope that the information and knowledge you gain throughout the training series and from this curriculum will help provide clarity and equip you for the job ahead of you.

We are very fortunate to have Dr. Bob Russell in Iowa to bring public oral health issues to the spotlight. Dr. Russell brings with him years of practical and innovative experience from Michigan, and through this training and curriculum, is eager to share the lessons he has learned.

We are proud to partner with you in your very important work as you bring quality oral health care to our underserved populations. The Iowa Department of Public Health Oral Health Bureau stands at the ready to assist you in any way we can. Thank you for your very important work.

Sincerely,

Mary Mincer Hansen, RN, PhD Director

3 October 2005

Dental Directors:

IA/NEPCA is very proud of the partnership with the Iowa Department of Public Health, Oral Health Bureau, which has resulted in the development of this curriculum. This curriculum accompanies a four-part training series which is being conducted over the next eight months via both in-person and ICN presentations. The training will help develop competencies, increase clinic performance and enable you to provide the dental care Iowans and Nebraska’s underserved citizens need and deserve.

We are fortunate to be able to leverage the expertise and experience of Dr. Bob Russell, Iowa State Public Health Dental Director, who developed and will be presenting the four training sessions. Dr. Russell will explore the roles and challenges of the dental director throughout this training.

This training would not be possible without generous funding from the Iowa Health Foundation (IHF). IHF received a rural health outreach grant from the Health Resources and Services Administration (HRSA). IA/NEPCA has been able to utilize this funding to develop a variety of services, training, and technical assistance for our new and growing dental programs. We are very grateful to IHF for this support of our dental safety net providers.

We hope this curriculum and the training series are useful to you as you work to develop and improve the capacity of your dental programs. Thank you for your very important work.

Sincerely,

Theodore J. Boesen, Jr. Executive Director

4

Bob Russell, DDS, MPH Public Health Dental Director Iowa Department of Public Health 321 E. 12th Street Des Moines, IA 50319-0075

Dr. Russell; or “Dr. Bob” as many call him, comes to Iowa after serving as Dental Director of Hackley Community Care Center, a federally qualified health center located in the town of Muskegon Heights on the western shores of Michigan. After growing up in the once thriving automotive based industrial town, Dr. Russell saw the community degrade into poverty and despair with over 60% unemployment and little access for health care.

After attending Loyola University of Chicago’s School of Dentistry and working in various dental programs including migrant and rural dentistry, private practice and corrections based dentistry, Dr. Russell return to his home town and worked to start up the first community care center based dental practice in Muskegon County initially affiliated with the Hackley Hospital system of Muskegon. The center grew from a clinic of one dentist (Dr. Russell) to a large facility with over 4 dentists, 3 dental hygienists and a staff of 21 total employees responsible for the care of over 6,000 families and 15,000 annual dental visits. Dr. Russell has also recently completed a Masters of Public Health (MPH) program in Health Care Policy and Management at the University of Michigan’s School of Public Health.

Dr. Russell has represented oral health issues and the health care needs of the underserved before legislators and policy makers both nationally and on the state level. He is know by oral health leaders on many levels and brings that expertise to Iowa to help address the people’s oral health needs in the communities and across the state. It is Dr. Russell’s goal to champion the cause of increasing oral health care access and knowledge of proper oral health care for the citizens of Iowa to assure empowerment for achieving healthy communities.

5 Introduction

Federally Qualified Health Centers (FQHC) and Dentistry: History and Responsibilities The 1964 Economic Opportunity Act established Federally Qualified Health Centers, which provided a model program that combined local community resources with federal funds to reduce health care disparities and acute care access needs in hospital emergency rooms. The Health Center Consolidation Act of 1996 combined authority for various health center based clinics, such as migrant and community health centers, under Section 330 of the Public Health Service Act (PHSA). The PHSA firmly established health center programs as an extension of public health practice administered by the Health Resources and Services Administration (HRSA) Bureau of Primary Health Care. PHSA health centers have five core statutory requirements in common. They must: ƒ Be governed by a board of directors with a majority of board members from the patient community served by the health center; ƒ Be located in a federally-designated underserved area; ƒ Provide comprehensive primary health care services, referrals and other services needed to facilitate access to care, such as case management, translation and transportation; ƒ Have nonprofit, public, or tax-exempt status; and ƒ Provide services to all persons in the designated service area, regardless of ability to pay, and offer a sliding fee schedule that adjusts charges for care according to family income.

Health centers are charged to remove barriers to health care access by tailoring services to the special needs and priorities of their communities in a culturally and linguistically competent manner. Assistance services such as transportation, translation, case management, health education and home visitation must be offered in the community to help the health center reach its health care goals. In effect, health care center practice begins in the community. The dental program is an extension of the mission and primary care focus of the health center. The program must assume its role in developing and assuring the dental health of the community to achieve good clinical outcomes.

Dental Public Health Practice in the FQHC: A Working Definition “Dental public health is the science and art of preventing and controlling dental disease and promoting dental health through organized community effort. It is that form of dental practice which serves the community as a patient rather than the individual: It is concerned with dental education of the public, applied dental research, and administration of group dental care programs, as well as the prevention and control of dental disease in the community.”1

Public health dentistry in the FQHC is primarily focused on the collective dental health status of the community the health center serves. This perspective is not adequately taught in schools of dentistry, leaving the health center dentist unprepared to address it. The purpose of this training manual is to introduce the new FQHC dental director to the core competencies required to effectively manage a dental program within a community health center, consistent with standards and guidelines established by HRSA Bureau of Primary Health Care, which oversees the operations of all FQHC programs. This manual provides basic guidelines and instruction for the

1 Definition developed by the American Board of Public Health Dentists, and accepted by the American Dental Association, Dental Health Section of the American Public Health Association, and the American Association of Public Health Dentists 6 health center dental leader developing a dental workforce sufficiently equipped to face the challenges of a community-based dental practice and understand the core principles of the “safety net” concept and dental public health care practice.

The dental director and health center administrative leadership must be aware of the extreme adjustment staff face in transitioning from a “traditional” dental practice to the health center dental practice. The new health center provider may experience a period of “culture shock” and environmental adjustment for which the provider is not adequately prepared. This period of adjustment can significantly influence the health center’s financial viability, the provider’s long-term career satisfaction, and the public’s perception of the health center. The dental clinic should maintain its performance standards by guiding the new dental provider through the adjustment period.

This point cannot be overemphasized. A poorly prepared dental provider can devastate a health center dental program’s performance record. If the health center’s dental program falters because of poor personnel adaptation, it may take years to undo the damage, or it can even destroy the dental program altogether.

The most important lesson of this training manual for the dental director and clinic administrator is that adequate time should be focused on achieving staff buy-in to the health center’s mission and financial and environmental reality before they engage in the day-to-day delivery of dental services to the community.

Do not assume a new provider is ready for his or her role in public health dentistry because of previous professional education or practice experience. A community health center dental practice is not the same as a private dental practice, and each health center dental practice is different. “If you have seen one health center dental practice, you have seen one health center dental practice.”2

All FQHC dental programs should share certain guiding principles and objectives. The goal of this training manual is to identify common programmatic objectives and address decisional challenges each health center dental program leader will face. Dental directors should use the information contained within this document as a foundation and strive to build on these working guidelines to create a comprehensive health center dental program. This training document is not intended to provide an exhaustive review of everything a dental director or health center dental program administrator should know to manage a dental program. Additional resources are available to assist in developing and operating a health center dental program. Many of the available resources will be referenced throughout this document. One highly recommended resource used in developing this training guide is the Safety Net Training Manual. This free on-line resource can be accessed at: www.dentalclinicmanual.com.

New dental directors should become familiar with this on-line reference guide and refer to it often as they develop their dental clinic programs. Many details of the dental clinic planning process are contained in the Safety Net Training Manual to help the new director avoid common mistakes in public health dental practice set- up. A good start is essential to a good finish in health center dental practice. Additional valuable information is available under the Resources link at the American Association of Territorial Dental Director’s website: www.astdd.org.

2 Captain Steven Geiermann, PHS Officer, HRSA Region V Dental Consultant 7 By using this training manual and the reference sources listed throughout, a health center dental director should be well equipped to successfully operate a high-quality community health center dental program.

8 Table of Contents Introduction ...... 6 Federally Qualified Health Centers (FQHC) and Dentistry: History and Responsibilities...... 6 Dental Public Health Practice in the FQHC: A Working Definition ...... 6

Chapter 1 • Dental Public Health – Applications and Practice...... 10 Basic Dental Public Health Concepts: ...... 10 Common Misconceptions of New Health Center Dental Providers: ...... 10 Developing Cultural Competency:...... 11

Chapter 2 • Core Competencies of Sustainable Practice...... 15 Priority Setting in Dental Public Health Practice:...... 15 Community Based Dental Disease Prevention: ...... 16 Public Health Hygiene (PH) Contracts in Iowa: ...... 17 The Health Center Primary Care Advantage:...... 17 Prioritizing Dental Services:...... 17 Expectations of Successful Health Center Dental Practice:...... 21 Productivity in a Community Health Center Dental Practice:...... 24 Environmental Drift in Health Center Dental Practice Management: ...... 27

Chapter 3 • Role of the Dental Director in Health Center Administration...... 31 Qualifications and Responsibilities of a Health Center Dental Director:...... 31 Dental Director in Organizational Structure:...... 31

Chapter 4 • Dental Director’s Role in Health Center Financial Planning ...... 34 Working with the Chief Financial Officer (CFO):...... 35 Summary Considerations on Dental Directors in Health Center Financial Planning:...... 37

Chapter 5 • Basic Clinical Operations Guidelines ...... 39 Lifecycle Planning for Dental Clinics:...... 39 Data Management Systems:...... 42 Effective Scheduling Strategies:...... 43 Addressing “No shows” and Collections: ...... 45 Smoking Cessation Counseling in Dental Clinics:...... 46

Chapter 6 • Productivity Expectations and Evaluation...... 48 Practice Productivity Evaluation:...... 49 Productivity Reward Systems:...... 51

Chapter 7 • FTCA, Specialty Services Agreements, Volunteers, Recruitment and Provider Credentialing...... 54 Federal Tort Claims Act (FTCA):...... 54 Provider Credentialing:...... 57 Volunteer Dental Providers in Health Centers: ...... 64 Provider Health Center Agreements and Specialty Care:...... 64 Student Based Programs and Productivity:...... 65 Recruitment and Retention in Community Health Centers: ...... 69

Chapter 8 • Policies, Procedures, Quality Assessments, and Peer Reviews...... 71 Required Policies and Procedures:...... 74 Quality Assessments:...... 75

Chapter 9 • Strategic Planning ...... 80 Strategic Planning for Best Practices in CHC Dental Programs:...... 84

Chapter 10 • The Dental Director’s Role in Shaping Community, State and National Policy ...... 90 Community Partnerships and Collaborations:...... 92

9 Chapter 1 • Dental Public Health – Applications and Practice

Basic Dental Public Health Concepts: Health center dental practice is built upon the foundation of public health principles. These principles must be engrained in the dental provider undertaking the challenge of health center-based “safety net” dental practice. The essential principles are 1) Public health is “people health;” and 2) Public health’s focus is on the collective health status of a group of people. Traditional dental training and practice focus on the dental health of a particular patient, not the community as a whole. The public health dental practitioner must focus on the community environment and conditions that impact the dental health of the community. The goal of a public health dental program is to maintain or restore the public’s dental health by eliminating environmental causes of disease and restoring dental health to the population. Below are concepts a provider must consider in the practice of health center dentistry. ƒ Services provided must be based on the disease pattern of the target population rather than the individual patient. ƒ The target population demand and the resources available to address that demand must be considered. ƒ Continuous surveillance of the target population must assess the dental disease rate, perceived need for services, actual demand for services, and projected need for future services. ƒ While individual patients pay for private practice dental services, health centers and public health dental practices are financed through a budget approved by a public or private funding agency. ƒ Both individual patient treatment planning and surveillance of total population needs must be part of an efficient health center dental program. ƒ Service and treatment option priorities must be based on availability of resources, size of the target population, disease pattern and demand of the population, and a reasonable definition of dental health verses ideal restoration.

A new dental provider’s preparation should begin with an understanding of core public health concepts and competencies. The competencies should address specific needs and expectations of the target population, including variations in cultural norms about oral health. Competencies must address programmatic deliverables and communication requirements necessary to obtain optimum dental health outcomes. New health center dental providers must quickly develop sensitivity to the target population’s environment, potential language barriers, economic limitations and cultural practices. Sensitivity should be ensured through appropriate health center- based or facility-sponsored introductory training, if necessary. Limitations of the health center dental program to meet the target population’s needs must also be clearly understood.

Common Misconceptions of New Health Center Dental Providers: The following list, while not exhaustive, presents common assumptions many new dentists make on entering health center dental practice. ƒ All people have the same health care values, social expectations, money management abilities and language skills. ƒ Everyone must have the best and most expensive restorative dentistry money can buy to assure optimum oral health.

10 ƒ All patients value dental appointments and should be expected to show up when scheduled, no matter how long they have to wait. ƒ All patients feel the same way I do about the need for good dental care and define good dental health in the same way. ƒ Everyone in America understands English, so my words mean the same to my patients as they do to me. ƒ Patients listen to my words alone. How I feel or express my feelings through body language does not affect other’s perceptions of my intent. ƒ Everyone’s oral health practices should be judged by my standard of behavior. ƒ Health centers, like private practices, are funded based on the number and complexity of procedures performed per patient. ƒ Cost is not a factor in treatment if paying more makes possible the best technical dentistry.

New dentists entering health center practice with the above misconceptions may not adjust well and will be at a disadvantage in addressing the needs of the target population. They may face frustration and stress leading to dissatisfaction and burnout. Such providers are unprepared to assume a clinical role in a dental public health practice.

Developing Cultural Competency: Cultural competence is developed by acquiring and integrating knowledge, awareness, and skills about cultures and their differences. This will enable health care professionals to provide optimal care to patients of various racial, ethnic, and cultural backgrounds.3

Culture is the integration of patterns of human behavior that includes language, thoughts, communications, actions, customs, beliefs, values, and institutions of different racial, ethnic, religious and social groups.4

The easiest way for health centers to obtain cultural background data is by participating in community stakeholder coalitions to obtain community survey data. Health centers should conduct regular target population surveys. Health centers should also seek to engage community organizations representing cultural, racial, and ethnic groups to regularly evaluate the various cultural racial and ethnic groups making up the target population. This information should be stored in a database and shared with staff regularly. Clinical and educational materials should be developed with cultural relevance for the target community. Cultural characteristics are dynamic and subject to change. Information on cultures should be specific to the target community, not limited to generalizations from broad-based national data. This level of sensitivity can only be obtained through community-based stakeholders directly associated with the target population.

Regular provider and staff cultural sensitivity surveys should be conducted to determine areas of weakness that may need improvement. Table 1 is an example of a pre-employment questionnaire.

3 Cultural Competence in Cancer Care: A Health Care Professional Passport, HRSA Office of Minority Affairs, Rockville Maryland 4 ibid 11 Table 1. Pre-Employment Diversity Questionnaire Scale: 1 being strong disagreement, 5 being strong agreement Statements Circle One 1. I regularly assess my strengths and limitations, and consciously try to improve 1 2 3 4 5 myself. 2. I am interested in the ideas of people who do not think as I think, and I respect 1 2 3 4 5 their opinions even if they disagree with me. 3. I recognize that I am a product of my background and that is reflected in my 1 2 3 4 5 beliefs and attitudes. 4. Some of my friends or associates are diverse in age, race, gender, sexual 1 2 3 4 5 preference, economic status and education. 5. I am patient and flexible. I can accept different ways of getting a job done as long 1 2 3 4 5 as the results are good. 6. I have made mistakes. In addition, I have learned from them. 1 2 3 4 5 7. I allow extra time to communicate with someone whose first language is not mine. 1 2 3 4 5 8. I consider the effect of cultural differences on messages being transmitted, in 1 2 3 4 5 addition, I check my assumptions. 9. When experiencing frustration or sensing conflict in cross-cultural situations, I ask 1 2 3 4 5 myself, “What’s really going on here?” 10. I do not judge people on their accents or language fluency. 1 2 3 4 5 11. I make an effort to talk about differences. I try to include people in discussions 1 2 3 4 5 that affect them. 12. I never make ethnic jokes, and I object when others do so. 1 2 3 4 5 13. I never make remarks that are “hot buttons” for women, minorities, or any group. 1 2 3 4 5 14. When I do not understand what someone is saying, I ask for clarification before 1 2 3 4 5 responding. 15. I sincerely do not want to offend others. 1 2 3 4 5 16. I like people and accept them as they are. 1 2 3 4 5 17. I am aware of my prejudices and consciously try to control my assumptions about 1 2 3 4 5 other people. 18. I am effective in management of people who are different. 1 2 3 4 5 19. I am able to admit weaknesses and mistakes. 1 2 3 4 5 20. I am comfortable with heterogeneity at all levels. 1 2 3 4 5 21. I believe in empowering people. 1 2 3 4 5 22. I recognize and use people’s skills and abilities. 1 2 3 4 5 23. I create an environment that fosters learning and exchanging of ideas. 1 2 3 4 5 24. I am a flexible person and accept change easily. 1 2 3 4 5 ______Total : Less than 40 = A good place to start diversity training. 40 – 70 = Some knowledge, but need more education. Greater than 70 = Value diversity. Further education would be an enhancement.

Questionnaire from “Rural Health Care: Cultural Competency Training Workbook,” by Evelyn Harden, World of Culture, Kansas City, Missouri. This publication can be obtained from the National Rural Health Association Publications Department, One West Armour Blvd., Suite 203, Kansas City, MO. 64111. Questionnaires of this type should be obtained or developed to aid in evaluating the health center’s workforce cultural competency.

12 A good example of culturally sensitive communication with patients is found in the Indian Health Service’s Delivery of Dental Services Guide: “Patient Care Checklist,” reprinted below.

1. Greet and acknowledge the patient by name. ƒ Begin with a respectful greeting using the patient’s name including “hello,” “good morning,” or similar expressions in the culturally relevant language, if appropriate. Local norms should determine whether the first name is used or Mr., Mrs., or some other culturally appropriate title.

2. Introduce yourself. ƒ Providers should introduce themselves at the first meeting, or when it has been a long time since they have seen the patient. Provider name badges help patients remember names, but they should not replace introductions.

3. Provide support and reassurance. ƒ Recognize the patient’s non-verbal cues to pain or fear and respond to those cues through attentiveness, nonverbal expression, and reassurance. Culturally acceptable norms should be followed regarding touch, eye contact, etc.

4. Facilitate a dialogue. ƒ Dialogue sets the stage for developing a “negotiated relationship” between the provider and consumer. Issues of patient choice of care or willingness to comply with recommendations should be negotiated. Ask carefully considered non-judgmental questions, and listen attentively to determine the patient’s needs and expectations. Specific kinds of questions to consider include the following: o Why is the patient presenting for treatment? What is the patient’s request or problem? o What does the patient think is wrong or needed? Does the patient have an alternative or traditional belief about his or her needs? Is the patient seeking assistance with available traditional healing methods? o What does the patient expect from treatment? What level of responsibility is the patient assuming for the condition and/or follow-up care?

5. Respond and teach. ƒ Based on what is learned through the dialogue and clinical assessment, clarify the options for treatment, being careful not to “talk down” to the patient or use jargon and unfamiliar concepts. The intent is to respectfully respond to the patient’s perspective and how it differs from the clinical evidence. Inform the patient about the treatment you can provide and consider culturally relevant alternative remedies if available and desired. ƒ Actively teach the patient, informing and empowering him or her to assume appropriate responsibility for personal health or for his or her child’s health. ƒ Negotiate with the patient and/or family, involving them in appropriate care and follow-up decisions. ƒ Tailor treatment and follow-up, as much as possible, to the individual’s or family’s instruction.

6. Express a warm goodbye. ƒ Answer any final questions and close with a gesture of goodbye.

13 Regular use of patient satisfaction surveys is a good means of evaluating the effectiveness of your clinic’s cultural competency for communicating with patients and identifying problems early. The survey can help you make necessary improvements quickly, minimize discontent, and increase patient satisfaction. This will be discussed further under Quality Assessment and Peer Review in Chapter 8.

14 Chapter 2 • Core Competencies of Sustainable Practice

Priority Setting in Dental Public Health Practice: Dental public health is guided by the motto “doing the most good for the most people, at the lowest cost, in a manner that is acceptable to those served and those serving.” Meeting all the requirements of the motto, however, is challenging. The health center dental director and providers face the frustration of limited resources meeting the needs of underserved populations. Several presumptions common to dentistry make the challenge more difficult.

1. Regular dental care equals better health status.

2. All patients within the practice target area should have regular and timely access to dental care.

3. Optimal services on the cutting edge of dental technology render the “best” clinical outcomes and should be offered to everyone.

In practical terms, the lack of resources to accomplish optimal dental treatment means that the health center dental program must depend on multiple strategies to achieve access to oral health care and disease control for its underserved population. These strategies must identify and maximize services that influence the health status of the target population. Oral health and disease management activities must not be confined to the dental chair.

“Health center dental programs that limit their resources and dental care activities to dental chair procedures are doomed to an endless cycle of patient service over-utilization, recurrently disease- ravaged mouths, rapidly depleted resources, and minimal oral health impact on the target population.”5

Health center dental programs must learn to allocate clinical resources based on the following key guiding principles. ƒ The focus of a health center dental program must be to decrease the existing dental disease burden in the target population and prevent disease from starting in the youngest members of the population. ƒ A dental program’s ultimate clinical goal should be to provide access to basic services for all target population members. In practical terms, maintaining access for routine users while encouraging episodic or emergency users to become routine users. ƒ As routine users reach the maintenance level of care, treatment services and resource use (including costs) decrease, reducing the drain on health centers, and allowing re-allocation of resources to other potential users. ƒ It is generally easier and more efficient to treat new disease in patients at the maintenance level. The more patients that reach the maintenance level, the lower the overall clinical workload for the given population. While the above principles improve clinical operations, they address only half of the dental program’s needed strategies. A significant amount of time and resources must be allocated to controlling dental disease among the population outside the clinic chair. Dental disease must be reduced at the community level, or the balance of

5 Indian Health Service’s Delivery of Dental Services Guide 15 maintenance phase care and reduced resource consumption will never be achieved. The “source” of dental disease must be cut off or significantly reduced as early as possible in the patient population’s lifecycle. The goal of the health center dental program is not to fill the target population’s need for restorative care, but to prevent that need.

“The placement of a restoration statistically dooms a tooth to a future of repeated replacements, and ever larger and more invasive restorations. Restorative dentistry is a destructive process resulting in the loss of irreplaceable natural tooth structure.”6

Community Based Dental Disease Prevention: It is important for the health center dental program planner to understand the need for disease prevention activities in the target population. Most dental disease is caused by bacterial infections in the oral cavity. Dental disease, except traumatic accidents, can be addressed with prevention activities that reduce the risk of dental infection.

The health center dentist must zealously address dental disease in the target population through prevention more than at the chairside restoring damage caused by the disease process.

The limited resources available to a health center dental program and the large demand for restoring diseased oral tissues in long-neglected populations mean the dental clinic must both leverage and combine resources with other stakeholders, on local, state and national levels, to meet the challenge. Effective strategies include the following: ƒ Collaborating with state and local level public health organizations to deliver prevention services including community water fluoridation, school-based sealant, fluoride rinse and varnish programs, and parental education; ƒ Forming oral health collaborations with public and private organizations such as local health departments, WIC programs, maternal and child health agencies, Head Start programs, dental insurance foundations, urban and rural development councils, United Way, Rotary, Lion’s, Optimist and Kiwanis Clubs and other civic organizations, and business philanthropies; ƒ Collaborating with local health care providers across health disciplines to educate parents and children and provide basic prevention services, including early childhood screenings, fluoride varnish application programs, and interdisciplinary oral health training, study clubs, and continuing education opportunities for providers; and ƒ Integrating the health center’s oral health message with the messages of other community programs. The dental clinic will benefit from reduced time, effort, and resource drain. Patients will benefit from increased oral health care access in the community and increased availability of clinical services at the health center.

Establishing broad networks of community partners for disease prevention firmly links the health center dental clinic to state and national systems of public health dentistry.

6 Indian Health Service’s Delivery of Dental Services Guide 16 Public Health Hygiene (PH) Contracts in Iowa: Limited health center resources require dental directors to identify other community and state resources to accomplish the goal of preventing dental disease. This is especially true when on-site prevention resources and staff are limited or unavailable. Clinics in the early start-up phase often are staffed by a single dental provider and lack the resources or caseload to hire a dental hygienist. In 2004, the Iowa Board of Dental Examiners changed dental regulations to allow hygienists affiliated with public health agencies to provide prevention dental services including prophylaxis, fluoride treatments and education under the public health supervision of a dentist. Health centers lacking dental hygienists can now contract with hygienists employed or contracted with Title 5 Maternal and Child Health (MCH) Agencies, WIC, or Head Start. These relationships can be formed without additional cost to the health center program, since Title 5 agencies can directly bill Iowa Medicaid and Title 5 for dental hygiene services.

Public health hygiene contracts between health centers and Iowa Title 5 agency hygienists are advantageous to health centers. They increase the center’s potential to gain credit for a community oral health prevention activity without increasing health center dental program cost.

Contract and scope of practice information can be found in Appendix B (2-3). Dental directors and providers should be aware that under these contracts, only the first year of prevention services can be performed without a dental examination in advance. After the first prevention service cycle, additional services other than oral health education can only be provided following a dentist examination. This requirement attempts to ensure a dental home for regular, long-term dental care. After the annual dental examination, prevention services such as prophylaxis and fluoride treatments can continue to be provided outside the health center dental clinic through the PH supervision contract.

The Health Center Primary Care Advantage: Health center dental programs have a unique and wonderful partner in the Health Center Primary Care Medical Practice.

Effective interdepartmental collaboration with the medical clinic can be beneficial in a number of ways. Educating medical staff about important oral health promotion issues provides the dental practice an important ally and bridge to patients and the community medical network. Medical center resources, including case management, nurse assistance in emergency triage, medical consultation services, cross-practice referrals, and more eyes to monitor the oral health status of mutual patients, become more accessible to the dental clinic. In addition, the dental program gains an effective advocate to support the need for increasing oral health resources.

Prioritizing Dental Services: One of the most important tasks of the dental practice is prioritizing services. Without prioritizing, the dental clinic is likely to overextend its resources, fail to generate sufficient revenue, and ultimately fail to thrive. A dental director without service prioritizing skills becomes a liability to the administrative leadership of the health center. This cannot be overstated: Lack of dental director administrative skills can result in failure of the health center dental program.

Service priorities in a health center dental program are significantly different from those in private dental practices. This is mostly because of the different financial reimbursement structure of health centers, limited resources, and high treatment needs of the target population. This situation is like living on a fixed income in a 17 high-inflation economy. The spender must continuously adjust by spending less as costs increase by creatively stretching resources and maximizing purchase outcomes.

In health center dentistry, treatment services that alleviate pain or prevent disease are given higher priority than services that correct damage caused by disease.

The United States Indian Health Service in its Delivery of Dental Services Guide provides a “Levels of Care” listing that quantify dental services into ten graduated categories with each higher level receiving less priority in the practice. A simplified seven level version of this priority system follows:

Level One Emergency Care

Level Two Primary (Prevention) Care

Level Three Secondary Care

Level Four Limited Rehabilitation

Level Five Rehabilitation

Level Six Complex Rehabilitation

Level Seven Excluded Services

Level One – Emergency Care These are services necessary to relieve or control acute oral conditions, such as serious bleeding, a threat to life, maxillo-facial fractures, swelling, severe pain or other signs of infection. Prosthodontic repairs may also require urgent attention.

Examples of level one procedures: ƒ Emergency oral examination – problem focused ƒ Problem focused x-rays ƒ Simple tooth extractions ƒ Temporary or sedative restorations ƒ Palliative treatment ƒ Prescription medications for pain and infection ƒ Draining of oral abscesses ƒ Denture repairs and other urgent repairs

Level Two – Primary Preventive Dental Care Primary preventive services that prevent the onset of disease, clinical services to individual patients, and community health activities are included in this category.

18 Examples of level two procedures: ƒ Adult prophylaxis with or without topical fluoride ƒ Child prophylaxis with or without topical fluoride ƒ Sealant by tooth and quadrant ƒ Preventive self-care patient education ƒ Periodontal recall or maintenance procedures ƒ Athletic mouthguards ƒ Water fluoridation activities ƒ Group oral health education programs ƒ Surveys and tracking of oral disease in population ƒ Tracking number of children or adults receiving fluoride varnish applications and/or supplements ƒ Application of fluoride varnish and/or fluoride supplements ƒ Xylitol gum distribution and education activities ƒ Chlorohexidine rinse and therapeutic medicaments

Level Three – Secondary Prevention Dental Services Secondary prevention services are necessary for routine diagnosis and treatment to control the early stages of disease. These procedures are not considered complex, and are usually completed in one appointment.

Examples of level three services: ƒ Initial or periodic oral exam ƒ Full mouth x-rays, bitewings and panoramic radiographs ƒ Diagnostic casts ƒ Space maintainers ƒ Amalgam and composite restorations (up to 3 surfaces) ƒ Stainless steel crowns on primary teeth ƒ Therapeutic pulpotomy of primary teeth ƒ Anterior root canal (one canal) ƒ Periodontal scaling/root planing ƒ Biopsy, excision of small lesion

Level Four – Limited Rehabilitation Limited rehabilitative services restore oral structure after extensive disease damage. These services are more complex and costly to provide than level three services.

Examples of level four services: ƒ Complex amalgams (4 or more surfaces) ƒ Cast onlays, inlays or crowns with or without porcelain ƒ Post and core restorations ƒ Crown build-ups ƒ Laser and cryo dental applications ƒ Maryland type acid etch bridge ƒ Bicuspid two-canal root canals ƒ Apicoectomy and retrograde filling ƒ Gingivoplasty

19 ƒ Limited/interceptive orthodontics ƒ Surgical extraction, root recovery procedure - uncomplicated

Level Five – Rehabilitation Rehabilitation services require multiple appointments, complex treatment of extensive areas of the mouth, more clinical chair time, and higher service costs.

Examples of level five services: ƒ Molar root canals (3 or more canals) ƒ Periodontal surgery (mucogingival and osseous) ƒ Periodontal splints ƒ Complete and partial dentures ƒ Denture rebase (laboratory) ƒ Fixed bridgework (retainers and pontics) ƒ Multiple teeth surgical extractions and removal of soft tissue (impacted teeth)

Level Six – Complex Rehabilitation Complex rehabilitation services require advanced skill, usually involve specialty referral, and are costly. These services may not predictably improve a patients overall prognosis, and may be risky to perform. Careful patient selection is required.

Examples of level six services: ƒ Full mouth or quadrant occlusal adjustments ƒ Periodontal surgery (flap, osseous, soft tissue grafts) ƒ Overdentures ƒ Precision attachment prosthetics ƒ Comprehensive orthodontics ƒ Complex surgical extractions (boney impacted, sinus fistula closures, large excisions, osseous bone grafts) ƒ Intravenous sedation and general anesthesia ƒ Specialty service consultation ƒ Cephalometric and TMJ radiographs ƒ TMJ therapeutic procedures

Level Seven – Exclusions Services that are not evidence-based or unreliable, have highly variable success rates, are strictly cosmetic, non- billable services under Medicaid or insurance plans, controversial, and extremely costly to perform are considered level seven, or excluded services.

Examples of level seven services: ƒ Unbillable procedures per payment plan ƒ Direct pulp caps ƒ Endodontic implants ƒ Unilateral cast partial dentures ƒ Implants

20 ƒ Silicate restorations ƒ Caries susceptibility tests ƒ Sargenti root canals ƒ Pulpotomy in permanent teeth ƒ Porcelain veneers, full ceramic posterior crowns

Of the seven categories, levels one, two, and three are considered basic treatment services and are the most cost-effective services to provide routinely. If additional funding is available, higher levels of care can be included; however, during periods of low funding, priority should be given to basic services in categories one, two, and three.

The advantages of the basic three categories of service are as follows: 1. Shorter chair time requirements; 2. Most Medicaid plans reimburse for these services; 3. Higher revenue generating potential under “Prospective Payment Systems” (PPS) (Most health centers receive Medicaid funding that values clinic volume or visit encounters over the number or type of procedures performed.); 4. Low cost (minimizing charges against the health center’s 330 grant for sliding fee write-offs and uninsured patients); 5. Better patient outcomes and predictability; 6. Greatest health benefit provided to the greatest number of people for the longest time; and 7. Allows more adaptability to changes in economic environment cycles.

A health center dental director must demonstrate the ability to make economically reasonable service delivery decisions, considering the impact of services on the overall financial health of the organization.

Expectations of Successful Health Center Dental Practice: The Bureau of Primary Health Care (the federal agency that administers the PHS 330 health center program) has throughout the years, developed or sponsored documents to serve as general guidelines for successful operations of a health center dental clinic. One such publication written in 1988, Characteristics of Successful Dental Programs in Community and Migrant Health Centers,7 contains a wealth of information that all health center dental directors should know to successfully manage dental clinic operations. The document acknowledges the lack of a prior policy regarding dental clinic operations within health centers, even though the health centers were established 20 years prior to the 1988 publication. Few sources of programmatic guidance existed before this publication and little has been done since to update the 1988 document. An updated revision is urgently needed to focus on financial management of successful community health center dental practice.

The 1988 document highlighted characteristics of successful health center dental practices and common characteristics that contributed to their success. The document recognized that accounting inaccuracies and inconsistencies among the health centers studied limited the scope of the analysis. Current information and the

7 Characteristics of Successful Dental Programs in Community and Migrant Health Centers; Rosenstein, David I, et al July, 1988, Contract No HRSA 240- 86-0070, US Department of Health and Human Services 21 increased use of technology that was unavailable in 1988 would provide a better analysis and yield more useful information. The 1988 report did not include the following: ƒ Revenue/expenditures for dental services compared to other services; ƒ The percentage of dental services covered by grant funds compared to other grant-covered services; ƒ Support for dental services allocated by each payer source; and ƒ Marginal (expansion) cost of dental services.

The document summary noted that the lack of accurate financial information made analysis of dental center costs impossible. More will be said on this issue in Chapter 4.

A dental director must have access to relevant financial information to effectively plan dental operations in the health center setting.

Successful dental programs have the following characteristics. ƒ The health center dental program concentrates on levels one, two, and three dental services. ƒ If the program provides level four or higher services, patients are charged enough to cover the cost without using 330 grant revenues. ƒ Dentist productivity equals or exceeds 500 relative value units (RVU) per full time equivalent (FTE) dentist per month. ƒ Cost effectiveness (production value divided by total costs) is a factor greater than 0.8 with the ideal being 1.0 or slightly higher. ƒ Dental directors have a direct role in establishing and overseeing the dental department budget. ƒ The dental department has procedures in place for formal negotiations with vendors and dental laboratories, and contractual agreements for supplies and services. These procedures should save 10 to 20 percent of full costs for such services. ƒ The health center uses provider incentives based on productivity that are shown to decrease no-show rates compared to centers without such incentives. ƒ Patients are charged a small fee for broken appointments or no-shows before new appointments are scheduled. ƒ The health center dental programs have a set ceiling on patient past due balances (accounts receivable) that must be settled before future appointments can be scheduled. ƒ All patient referrals to specialists are tracked to ensure timely compliance with visits, and patient charts are flagged if they fail to keep referral appointments. ƒ The health center dental program has a defined mission statement. ƒ The health center dental program has measurable goals, with objectives that have timetables. ƒ The health center dental program has a process to evaluate program progress. ƒ The dental program protocols and procedures are written. ƒ The health center dental program has a quality assurance program and process. ƒ The health center dental program has demonstrated linkages with public and private organizations.

22 ƒ The health center dental program has an ongoing dental education program. ƒ The dental program has adequate facilities and equipment. ƒ Each dentist has a minimum of two operatories. ƒ The dental program provides adequate support staff. ƒ The dental program has written intra and inter-agency agreements. ƒ The dental department operates as an independent cost center within the health center budget. ƒ The dental program has defined billing and collection policies and procedures. ƒ The dental program has a process for addressing and resolving patient complaints. ƒ Staff conflict resolution policies are in place. ƒ The dental director reports to the executive director within the organizational structure. ƒ A staff exit interview policy is in place. ƒ After-hours policy and emergency services procedures are in place. ƒ The dental program has a new employee orientation program. ƒ The dental program focuses on cost effectiveness and has a good management information system. ƒ Each 1 FTE dentist has a minimum of 1.5 FTE dental chairside assistants. ƒ Less than 20 percent of all dental services performed by the clinic are level four services regardless of funding source. ƒ 50 percent or more of onsite dental treatment services are prevention and restorative services. ƒ The facility allows at least 400 square feet per FTE dental provider. ƒ Each 1 FTE dental provider has a minimum of 750 patients. ƒ The “no-show” rate is below 20 percent. ƒ The cost per dental patient is less than $340 per year (2005 adjusted). ƒ The patient encounter cost is less than $130 per visit per visit (2005 adjusted). ƒ The dental director has five or more years experience. ƒ Each 1 FTE dentist sees more than 11.3 patients per day (2,300 per year). ƒ The dental service filling to extracted teeth ratio should be between one and six. Lower than one indicates low emphasis on level two prevention based services and greater than six indicates neglect towards the needs of level one emergency patient service. ƒ The dental director carries a smaller patient load than staff dentists do. The director spends significant time on administrative duties and has opportunity for additional administrative training and technical support. ƒ There is a good line of communication between the dental director, medical director, and executive director for problem-solving. ƒ The dental director is a full-time position with no conflicts of interest.

23 While the 1988 Successful Programs document provides a good general model for health center dental programs, the Bureau of Primary Care has developed other general programmatic guidelines for evaluating the success of dental programs. One of these documents is the Primary Care Effectiveness Review or PCER. Appendix A-1 and A- 2 of this training manual contain the most current drafts of the dental PCER for health center dental program evaluations. While recent changes in HRSA quality review protocols no longer place emphasis on the PCER, a health center dental director should become familiar with the guidelines in the PCER document and determine whether their program meets PCER standards. A dental director should be able to answer “yes” to all statements in the PCER and demonstrate in the clinic performance record how the program meets those standards.

It should also be noted that the health center’s ability to meet the PCER standards and all BPHC general dental practice structural requirements impact the success a dental program has in receiving BPHC expansion grants. An example is found on the PCER module under “Clinical Facilities and Support,” questions XIII C and D. The question asks if the dental program has one and one-half dental assistant per FTE dentist and two dental chairs per FTE dentist. That question is in reality, an expectation for all dental clinics and considered necessary for efficient productivity. Health centers lacking these ratios on their expansion grant applications will not be favorably considered.

Health centers attempting to cut operational costs by reducing staff size and number of dental chairs below the standards considered acceptable by the Bureau of Primary Health Care will not be successful in receiving dental expansion grant dollars.

A complete summary of BPHC expectations on health center based dental clinic program criteria can be found in Appendix A-3.

Productivity in a Community Health Center Dental Practice: One especially important area a dental director and indeed, all dental practice staff within a community health center must understand, is what is considered “productivity” within a health center based practice. This is a difficult concept for most new dental providers to comprehend since it varies considerably from the traditional “Fee-For-Service” (FFS) principle that most private dental practices use to bill for services rendered. Under FFS, a dental practice receives reimbursement based on the number of ADA treatment coded (CDT) billable procedures performed on individual patients. In effect, the more treatment performed on a given patient, the more revenue the practice can potentially earn.

Community health centers that receive section 330 grantee status are classified as federally qualified health centers (FQHC) and are eligible to receive financial reimbursement from Title 19 or state Medicaid programs through a “Prospective Payment System” (PPS). For a better understanding on PPS, see Appendix A-4. The majority of health center based dental productivity revenue will be gained through PPS/Medicaid or drawn from the 330 federal grant. All Medicaid enrolled and eligible patient treatment performed within the health center dental program will be reimbursed either entirely or partially through the PPS reimbursement method.

The key point under the PPS reimbursement mechanism is that payment is negotiated between the state’s Medicaid program administration and the health center administration based on a “rate per patient volume” or “encounter” basis.

24 This implies that all treatment performed on Medicaid eligible patients within the dental practice are paid on a per patient visit basis not on the total treatment performed. The implication for this type of reimbursement mechanism is that no matter how much treatment or how many ADA treatment coded services are performed on an individual patient, the health center receives only one payment rate for that patient’s visit. This methodology utilizes an estimate of the average per unit treatment visit (encounter) cost of services based on available data including the financial history of the health center program and may not capture actual service costs. In addition, only Medicaid billable treatment codes under the state’s Medicaid guidelines are considered eligible for reimbursement. Under this reimbursement method, most health center financial administrators interpret productivity as daily patient encounters or visits, not the number of treatment services performed. The “per unit visit” or encounter standard is also used by the BPHC Uniform Data System or UDS reporting method as seen in the following statement from Appendix D-1.

Under the PPS reimbursement method, one patient encounter equals one payment and payment rate. This can present a further challenge to a dental practice that combines a dental hygiene prophylaxis visit with a dentist performing the dental examination. Two providers are actually serving the patient during the single patient visit; however, only one encounter is generated, as seen in the following BPHC guideline:

“The BPHC Uniform Data System (UDS) user manual defines an encounter to include a documented face- to-face contact between a user and a dentist or dental hygienist for the purpose of prevention, assessment, and or treatment of an oral health condition defined within the scope of practice of the health center. Note: A dental hygienist is credited with an encounter when the encounter is not combined with a dentist encounter. Only one encounter may be counted during a patient’s visit to the dental clinic in one day.”

A dental director might consider splitting the patient examination into a separate visit from the hygiene visit to gain the additional encounter and payment. However, this would double the patient visits necessary for the service and risk inconvenience for the patient and higher no-show rates for the dental practice. In addition, provider productivity evaluations and bonus criteria based on productivity may become a cause of provider dissatisfaction if encounters alone are used as standards for reward and accountability. Staff dentists and hygienists may feel insufficiently recognized for their individual contributions to patient care if only one encounter is generated when both providers provided time and service for the patient.

The philosophical and ethical implications for this type of reimbursement methodology can be challenging to both dental directors and dental staff members. The ethical dilemma to provide a reasonable level of care based on the needs presented at the time of service can conflict with the need to maximize patient volume and shorten patient treatment time to achieve financial goals.

The solution is to focus on patient convenience and ethical dental care; attempt to maintain clinical and fiscal balance, and reward provider productivity based on criteria other than patient encounter rates alone.

The requirements necessary to obtain this balance are complex and require a thorough understanding of the dental clinics financial structure, cost centers, budgetary requirements and minimal operational tolerances. An assessment of the health center’s scope of project service area and target patient population must be performed including oral health needs, general income (ability to pay), dental insurance availability, services covered by insurance based resources, and other financial resources within the community. The financial viability aspect of

25 the assessment process including other state and national resources should be ongoing by the health center’s financial and administrative team in collaboration with outside coalition partners.

The health center’s financial management, with guidance from the dental director, should develop a financial analysis and formula for the minimum ratios or percentage of payer mix needed to maintain operations. Table #2 contains an example of a tracking system of dental clinic revenue centers and percentage targets. In this example, the scope of the project includes a community with a high proportion of Medicaid eligible patients approaching 80% of the total population serviced by the health center.

Table 2. Dental Clinic Payer Source Breakout Medicaid CHS S-chip Medicare SFS Self Pay Other TOTAL

JAN 77.6% 0.0% 0.2% 0.0% 19.8% 0.2% 2.2% 100.0% FEB 75.9% 0.0% 0.1% 0.0% 20.5% 0.0% 3.5% 100.0% MAR 78.3% 0.0% 0.2% 0.0% 19.4% 0.0% 2.1% 100.0% APR 78.3% 0.0% 0.1% 0.0% 17.2% 0.1% 4.3% 100.0% MAY 75.6% 0.0% 0.2% 0.0% 20.5% 0.0% 3.7% 100.0% JUNE 75.1% 0.0% 0.3% 0.0% 20.4% 0.3% 3.9% 100.0% JULY 75.0% 0.0% 0.1% 0.0% 19.4% 0.4% 5.1% 100.0% AUG 76.2% 0.0% 0.0% 0.0% 19.8% 0.1% 3.8% 100.0% SEPT 81.0% 0.0% 0.1% 0.0% 15.9% 0.0% 3.0% 100.0% OCT 81.1% 0.0% 0.2% 0.0% 15.0% 0.1% 3.6% 100.0% NOV 79.6% 0.0% 0.4% 0.0% 16.5% 0.1% 3.4% 100.0% DEC 77.9% 0.0% 0.9% 0.0% 17.8% 0.2% 3.2% 100.0%

TOTAL 77.7% 0.0% 0.2% 0.0% 18.5% 0.1% 3.5% 100.0%

Target 75.0 % 0.0% 0.5% 0.0% 18.4% 0.1% 5.10% 100.0% 2003 YTD 75.8% 0.3% 19.5% 0.2% 4.3% 100.0% 2002 YTD 77.1% 0.3% 18.2% 0.3% 4.1% 100.0% 2001 YTD 80.7% 15.2% 0.1% 3.9% 100.0% 2000 YTD 76.2% 17.8% 0.6% 5.5% 100.0% 1999 YTD 78.0% 14.3% 1.1% 6.6% 100.0%

Chapter 4 will cover the dental director’s role in working with the health center’s financial management; however, the dental director needs clear guidance and an open line of communication with the health center’s financial administrator. Having clear financial targets and a time verses productivity evaluation system like relative value units (RVUs) gives the dental director and each provider the ability to monitor when and if adjustments are needed in treatment time intervals and/or ratios in payment sources. Focusing on basic services such as levels one, two and three also decrease time-intensive types of treatment options leaving only the number of treatment services required by the most comprehensive treatment need patients as the higher determinate of patient visit

26 time consumption. As these patients enter maintenance phase, the time requirements in recall appointments will also decrease.

The dental director is well-advised to warn health center administrative leaders that early on, after the dental clinical program start-up, the most time intensive services by the target patient population will be required due to long neglected oral health needs. The health center should seek to buffer the higher operational costs and limited daily encounters seen early on due to “train wreck” high restorative needs and adjust time per visit requirements downward over time as more patients complete restorative treatment and enter maintenance phase. This will vary considerably depending on the overall community needs and the transition of new high needs entrants into the patient population. An initial community needs survey may help administrators understand the magnitude of perceived needs within the target community population. Chapters 1 and 2 of the Safety Net Clinic Manual at www.dentalclinicmanual.com contains very useful information on how to evaluate community needs prior to starting a dental clinic program and will also be helpful to active programs that need to establish a baseline needs assessment for administrative guidance and strategic planning.

Environmental Drift in Health Center Dental Practice Management: As a final consideration in successful practice management, a dental clinic must manage the inflow of new patients entering the dental practice. While it is customary to allow “open access” and simply treat all potential patients walking into the practice, a successful practice must monitor and manage new patient activities in regards to chair time allocation, revenue generator ratios of uninsured to insured patients, emergency walk-ins verses comprehensive regular care seekers, after-hours coverage, and patient flow. A dental clinic that simply allows passive open access without management is like playing a game of dice and faces the risk of poor performance due to environmental drift that can threaten the longevity of the dental program.

Environmental drift is the reality that communities are vital entities in motion that change over time and sometimes suddenly in demographic make-up, employment, resources, and needs. The project scope and initial assessment taken when a health center opens may not reflect the reality of the service need, trends and projected revenue streams once the health center is up and running. Furthermore, unless the assessment of the community is thorough, accurate and taken from reliable sources, the real operating conditions faced by the health center when compared to the projected scope of practice may not be realistic.

What further complicates this situation is the BPHC standard of care, reprinted from Appendix D-1:

“It is a BPHC program expectation that health centers establish comprehensive primary oral health care as an integral component of primary health care services provided when resources are available to support such a program. Access to services defined within that scope must be made available to all health center users regardless of ability to pay. Health centers must be able to justify why services and/or populations are excluded from the scope of practice, if the scope of services is limited and/or less than comprehensive.”

Access to care must be available regardless of ability to pay, unless the health center is able to “justify” limits in care scope or population exclusions. An example of an environmental drift that could be used to justify a scope of service change or exclusion would be a sudden loss of a large portion of the eligible Medicaid population determined to exist based on previous scope of practice assessments of the service population. A state may determine that certain federal classified elective additions to Medicaid are excluded from coverage such as the

27 provision of dental services to all adults over age 18. Such a change would have a devastating impact on a health center with open access for all age groups. A health center may decide to exclude adult patients from their service population as a justified exclusion. The key principle is to justify necessary exclusions based on an acceptable standard according to federal rules and quality oversight. Justification can consist of extreme financial difficulty based on unusual shifts in non-controllable environmental changes or “drift” and must be supported by data, including demographic data of the health center’s target community, and needs analysis that can project proportions of payer types and resources along with general age, sex, race and ethnic classification.

Needs data can demonstrate and support the health center’s access policy and the general mix of patients seen. By combining the population financial profile and demographic data with the health center’s financial “bottom line” indicators necessary to sustain the practice, the dental director can manage patient access by essentially matching clinic access with the combined profile data. This process is considered adequate justification. The data helps the dental clinic avoid the potential of appearing selective or “cherry picking” for the sake of financial gain only. The BPHC expects initial and ongoing regular community assessments in order to evaluate needs, resources and program service potential as seen in the follow statement from Appendix D-1:

“The primary oral health care plan is an integral component of the overall primary health care plan, based upon what is feasible, taking into consideration the program’s projected revenue, other resources, and grant support.”

The primary elements of an oral health program needs/demand assessment that will justify project plans, prevention and treatment needs, service mix, organization of care, and staffing requirements include the following: 1. Estimates of number of users (specify critical mass of dental patients for the program); 2. Description of existing providers and resources in the community as well as an assessment of unmet needs; 3. Predominant characteristics of service population such as race, sex, age, ethnicity, primary language, income, etc; 4. Oral health status, prevention, and treatment needs of the population; 5. Barriers to access/availability to comprehensive oral health care services; and 6. Description of needs and treatment of special populations (e.g., HIV, homeless, migrants).

“Since oral health care needs in underserved communities are extensive and cannot be fully addressed by any one organization, it is important that programs actively solicit collaboration and linkages with dentists, dental schools, dental societies, and other health care providers in the community.”

Another example of environmental drift is a health center practice community facing a sharp rise in unemployment and/or uninsured patients. While the number of Medicaid patients in this community may still be substantial, the immediate crisis of rising uninsured patients begin to outnumber the demand of Medicaid and other revenue generator patients in the health center. Under “open access” the dental clinic will soon find eight out of ten patients seeking entrance into the practice are uninsured and unable to pay for services. In this scenario, there is still a viable Medicaid and other payer population in the community; however, the demand for services is highest among uninsured care seekers. The outcome in this scenario is that soon the health center

28 dental program will face declining revenue streams, rising costs, and depletion of 330 grant funds unless administrative leadership determines the reason behind the trend. The goal would then be to project future impact on program viability and develop an intervention to stop the negative flow if deemed necessary.

Management in this type of situation would require adjusting ratios of chair time or service mix availability based on shifting demographic data and patient categories such as age, type of service, payer source and percentage the practice can absorb and remain viable. As an example, a certain health center requires average monthly revenue proportions of 40% Medicaid, 30% SFS, 10% insured and 20% uncompensated care uninsured write- offs for minimum program viability. If the environmental assessment closely matches the proportion of revenue generators needed for minimum program viability as given above, chair time slots can be restricted to a specific patient age group (child, adult) and minimum payer category ratios. The restriction must closely match the population needs profile and be assigned by call-ins and appointments. This type of chair time control method requires electronic scheduling and integrated billing software along with close monitoring by the health center’s financial team. Once available patient type categories/ratio slots are filled, all others are placed on stand-by or next day fill-in with the exception of emergencies. Emergency care is not restricted by this methodology. Emergency access is limited only by the volume or numbers seen per day and can be applied against the 20% uncompensated care proportion if uninsured and uncollectible. This type of chair management system work best with three dental chairs per FTE dentist. One chair is unscheduled for emergencies and walk-ins while two chairs are scheduled. More detail regarding dental scheduling will be covered in Chapter 5.

The key point in addressing environmental drift in dental clinic practice is to manage all practice resources, scheduling, chair time and patient flow consistent with practice mission objectives and financial limitations based on support data that provides justification for exclusions and service limitations.

A health center dental program must be realistic and pragmatic in terms of resources and ability to meet the needs of the population. Decisions must not be limited to idealistic outcomes and wishful dreams. Federal grants are limited and fixed over several years without guarantees in adjustments. Decisions must be supported by good, data-driven evidence. While decisions to reduce programmatic services can and sometimes must be made, health centers should strive to use negative data to support the need for additional resources that if made available could increase the health center’s ability to meet the service population’s needs. Environmental drift can and often does outpace resources. These factors must be considered in daily operations and in future projections to be a successful dental program manager. This point is further illustrated in BPHC regulations:

“Health centers are required to maximize revenue from all sources of income to meet the needs of the patient population served. Health centers are expected to participate and collect reimbursements from state Medicaid programs, Medicaid Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Programs, Head Start programs, private insurers of health center users, and patient payments. Health centers are required to assure that services shall be available to the service population without regard to method of payment or health status. At the same time, health centers are expected to maximize revenue from third party payers and from patients to the extent they are able to pay.

Health centers should develop a financial plan for oral health delivery. The program should operate and be tracked as a cost center for analysis of cash flow, revenue generation, program costs, and utilization. The data should reflect the degree to which the budget and financial plan assures appropriate utilization

29 of resources, meets service objectives, and projects a likelihood that the program will remain viable. Principle elements of a financial plan should: ƒ Link the budget with the goals and objectives specified in the oral health program plan and overall health center plan. ƒ Identify specific cost such as salaries, equipment, supplies, rent, etc. ƒ Provide a budget forecast for future years which demonstrates increasing potential for program success.”

Health center dental clinics are in effect hybrid “managed care” programs that reward health maintenance and prevention-based activities more than intensive and costly restorative and repair services. This concept must be fully engaged by the dental clinic staff in order to be effective long term. While striving to provide “open access” to all, the dental program must manage the means necessary to accomplish practical open access goals and remain financially sound. It should also be stressed that changing demographic and needs data can be used to solicit other funding resources from charities and state, regional and national grants targeting specific need based groups. A health center dental director and health center program administrator should first seek these types of revenue enhancers before resorting to limiting patient services or exclusions.

Note: During a federal review audit, evidence of demographic support data and documented attempts to locate additional resources may be required to support justification in decisions involving service restrictions and exclusions. Two good reference sources for Iowa specific demographic and public health related information can be found at http://www.public-health.uiowa.edu/FACTBOOK and http://www.idph.state.is.us. Dental directors should regularly visit these sites for updates and links to information useful in making the case for justifiable programmatic changes. Additional resource links can be found in Appendix B-4.

30 Chapter 3 • Role of the Dental Director in Health Center Administration In the past, the most common organizational structure positioned the dental director under the health center medical director. This methodology assumed the chief medical administrator was the natural leader to address issues pertaining to all health care activities within the health center. The 1988 HRSA sponsored Characteristics of Successful Dental Programs report indicated this arrangement was unacceptable:

“A reporting system that provides a direct line between the executive director and the dental director rather than reporting to the medical director appears to be more favorable. Arbitrary dental program reductions were less likely to occur when the dental director reported to the executive director.”

In addition, the report indicated that several of the dental directors in the study did not have direct knowledge of their own department budgets and had not read portions of the health center’s grant applications pertaining to dental programs.

Current Bureau of Primary Health Care dental practice standards recognize the need for health center dental directors to report directly to the executive director and be part of the administrative management staff as illustrated under Section II Quality and Service Delivery in BPHC Dental Policy in Appendix A-3. The dental director is expected to be positioned within the health center’s administrative leadership team and have access to resources and provide program input in the health center’s budget and grant writing process. The dental director should also act as chief policy advocate on oral health before the health center’s board of directors.

Qualifications and Responsibilities of a Health Center Dental Director: A general guideline on the role and qualifications of a health center dental director can be found in Appendix B-1. Close communications with the health center’s operations and human resource manager can serve both the inexperienced and experienced dental director in addressing personnel related issues. These health center administrators can assist in hiring, termination and employment skill development for dental staff, and help administer the day-by-day complications of department operations. The dental director should regularly turn to these administrative team leaders, especially if the director lacks significant personnel and multi-departmental operational skills.

Dental Director in Organizational Structure: An example of a health center organizational structure is seen in Table #3 below.

31 Table 3. Board of Directors

Executive Director

Director-OB Medical Operations Dental Director Finance GYN Director Director Director

Certified Medical MSS/ISS Human Clerical Staff Dentists Billing Nurse Midwives Providers Supervisor Resource Supervisors Dental Supervisor Clinical Accountant Manager Hygienists Supervisors I/S

MSS/ISS Medical Clerical Dental Billing staff Staff Staff Assistants Medical Clinical Dental Clerical

Staff Staff

Dental directors with training in public health and practice management skills are better organized for leadership roles in larger health centers, especially those with large dental clinics and staff. Some BPHC experts recommend a dental director supervising clinics with four or more FTE dentists should have organizational skills equivalent to those learned through masters of public health (MPH) related programs. However, dental directors that maintain close relationships with executive directors and/or regional dental directors having such skills can gain additional support when lacking advanced organizational knowledge. Dental directors lacking specific skills may want to share responsibilities with other health center administrators in areas such as direct personnel supervision and dispute resolution. Table #3 illustrates a situation where direct supervision of dental auxiliary staff is assumed by the operations director. While retaining clinical oversight, the dental director does not administer employment policy and discipline.

The dental director’s role within the health center can be essentially summarized under the follow eight activities: ƒ Personnel; ƒ Daily operations; ƒ Financial analysis; ƒ Participation in management structure; ƒ Quality assessment/quality improvement; ƒ Strategic planning; ƒ Board of director reports and education; and ƒ Budget enhancement by seeking additional grants and resources.

32 The dental director must function as the “eyes and ears” of the executive director in all oral health related activities and constantly scan the environment for possible problems and opportunities for the health center.

The dental director should also serve on several community agencies and other state and national associations as a representative of the health center and oral health interests of the community. These activities also include scanning relevant oral health and health policy publications to track trends and updates in environmental and clinical practice knowledge. When possible, the dental director should be prepared to advocate for the health center and oral health policy issues. This will be covered in detail in Chapter 9.

Collaboration with the health center medical director is necessary and should happen on a regular basis. These collaborations can both educate the center’s medical team on relevant oral health issues and integrate oral health objectives into the overall clinical objectives of the health center. In addition, these collaborations open opportunities to expand oral health activities into the primary health care arena and form links with health care practitioners outside the health center. This is very critical in advancing oral health prevention efforts beyond the borders of the health center and into the communities.

33 Chapter 4 • Dental Director’s Role in Health Center Financial Planning The dental director must have a key role in addressing the financial operations of the health center dental program. While this does not require the dental director to assume an accountant level management of budgets, it does require direct knowledge of the health center’s financial profile and especially how dental services fit within the budget picture.

The dental director needs to be aware of how the dental department budget is carved out from the overall health center’s finances to assess the status of clinical operations and make changes if needed.

The type of minimal information that should be made available to the dental director is illustrated in Table #4.

Table 4. Dental Financial Statement

Revenue: Amount Percent of total revenues Governmental grant $ % Private grants $ % Other state or municipal funds $ % Patient payment revenues $ % Other (specify) $ % Total Revenues $ 100 %

Expenses: Amount Percent of total expenses Salaries: Dentists $ % Auxiliary staff $ % Reception and billing staff costs $ % Employee benefits $ % Employee taxes $ % Dental lab services $ % Facility costs (per sq. ft) $ % Equipment costs $ % Utilities $ % Dental referral costs $ % Bad debt collection expenses $ % Legal fees/professional services $ % Administrative overhead $ % Liability Insurance costs $ % Clinical supplies $ % Office supplies and services $ % Other $ % Total Expenses $ 100% Net Income (loss) $

34 A more complete financial and projection analysis method is given in Appendix C-1. However, as more information is provided, some experience reading financial statements and a level of accounting spreadsheet knowledge is required. A dental director that attends board of directors meetings should have access to a full range of financial analysis and accounting profiles of the health center.

Working with the Chief Financial Officer (CFO): Ideally, the dental director should regularly meet with the CFO of the health center to discuss department financial performance and future budget planning. The finance officer should seek the dental director’s expertise in setting fee schedules and production performance. The financial officer will likely attempt to push for greater levels of productivity. The dental director must serve as the regulator on realistic expectations based on provider abilities and expected rate of production given the various services within the practice. A significant tool in such situations is the relative value unit or RVU. The RVU is a standard of time allocated for performing a specific clinical treatment service. These units are usually set in ten- minute time intervals. A good source of updated information on the dental RVU is the Relative Value Studies Institute, Inc. This organization can be reached on line at: www.rvsdata.com.

The RVU allows the dental director a standard for productivity expectations in time relevant intervals. This also gives some direction to the financial officer regarding limitations on rate expectations for provider productivity and further allows for evaluation of the clinic’s costs for each unit of productivity. This information can be useful in evaluating the services performed and allowing adjustments if certain services prove too costly to perform given the time constraints required. An example of service charges and RVU time allocations for the services is found in Appendix C-2.

It is critical the dental director give realistic expectations to the financial officer regarding provider productivity such that achievable goals are set within the health center’s budgetary expectations.

The dental director must also keep abreast of the political and policy environment that may impact the health center’s financial future. Changes and forecasts on expected changes in state and federal Medicaid policy and 330 grant programs should be shared with the health center’s executive management team. These forecasts should be considered as future budgets and program planning take shape to ensure the health center’s mission does not become endangered due to poor future planning.

The health center dental director must be aware of the financial impact the dental program has on the overall operations of the health center. Sufficient information must be made available by the financial officer for this to take place. A summary of the health center’s financial profile can be obtained with simple information that clearly illustrates the impact of the dental operations on the health center as seen below in Table #5.

35 Table 5. Patients Treated 5,070 5,070 5,070

Medicaid $85,000 $350,400 $150,000

SCHIP $45,000 $75,700 $50,000

Self-Pay

Full Pay $1,000 $13,200 $7,500

Sliding Fee Schedule $25,000 $20,000 $62,000

Minimum Pay $10,000 $45,700 $41,000

Commercial Insurance $1,000 $10,700 $10,000

Revenue

Patient Care Revenue (Net) $167,000 $515,700 $320,500

$125,000 Non-Patient Care Revenue $0 $0 ($100,000 FQHC grant (Grants, Fundraising) + $25,000 state grant)

Total Revenue $167,000 $515,700 $445,500

Expenses $500,000 $500,000 $500,000

Bottom Line ($333,000) $15,700 ($55,500)

Other Subsidy $333,000 $0 $55,500 City Subsidy via Recurring Line from other cost centers at Item Health Center

Long Term This program relies on a line This clinic is in a This clinic relies on grants to item in the city budget to health center that offset the cost of subsidize the cost of requires it to be self- uncompensated care due to uncompensated care that results sufficient. Therefore, providing a sliding fee from maximizing access through the clinic turns away a schedule. The minimum fee of a sliding fee schedule that offers considerable number $20/visit still excludes some significant discounts. There is an of patients who can't patients. The waiting list in this extensive waiting list. As long as afford the minimum clinic has 200 names on it. the city's priority for this activity fee. The waiting list for Even with non-patient care holds, the clinic continues the clinic is very revenues, the clinic did not providing services. manageable. The clinic cover its costs last year. The operates in the black. health center budget, however, balanced due to positive balances in other cost centers.

Table #5 illustrates three financial scenarios given equal patient volume and expenses. Each center has some difference in revenue sources and amounts collected including patient payments. The revenues generated are based on the health center’s location, governing policy and income variations within the community, including patient willingness and ability to pay. Multiple factors impact the overall financial profile of each health center 36 program. Table #5 further illustrates that each health center has addressed their “unique” environment through various creative financial mechanisms. This is acceptable as long as the health center can compensate for lost revenues in a specific department.

The dental clinic illustrated in the third column from the left is clearly a “money loser” for the health center. However, other departments are able to offset the loss since those departments are creating higher revenues over expenses. Other revenue generating mechanisms, as seen in column one, are based on the ability to leverage a line item funding source in the target community city budget. It should be clear that if those special conditions did not exist within the health center’s financial profile, the dental clinics would not be able to sustain their current practice methods and would have to change or face elimination altogether. A dental director must be aware of the financial condition within the health center and adjust accordingly.

The important point for a health center dental director is to know where and how the health center receives its revenues and what methods are available to adjust to negative income balances if a department’s costs exceed revenues generated.

A health center is made up of multiple departments with multiple revenue and cost generators. As reported in the 1988 document, Characteristics of Successful Dental Programs, if that information is batched into a single profile, the dental program cannot determine if the dental clinic runs efficiently. These findings must be addressed within all health centers to accomplish positive dental program outcomes.

A dental program must be able to determine their portion of the health center’s 330 grant allocation and not consider it lost in the health center’s overall medical budget.

Summary Considerations on Dental Directors in Health Center Financial Planning: The financial goal of a health center dental director is to reduce the cost of the dental clinic to approximate the revenues generated. That will involve a careful analysis of the cost to benefit ratio of every treatment service, supply cost, staffing structure, overhead, and equipment allocations in the dental program. According to the 2002 BPHC Uniform Data System (UDS)8, the average dental cost per patient user was $117 (see Table #7). The 2003 UDS report indicates the average cost per dental visit was $124. While costs continue to rise, as seen in an increase of $17 per year from 2001 to 2003, a health center dental program with a 2005 average cost per user above $130 according to BPHC standards is likely headed for trouble. However, the volume of Medicaid and insured users to uninsured has a strong impact on the dental program’s ability to adjust to costs variations and program success. Current expectations according to the BPHC on average is 30 – 40% Medicaid users, 30% uninsured and sliding fee, and the remaining 20% insured, S-CHIP (hawk-i in Iowa), and other third party coverage systems.

A health center program must have a balance of patient users such that enough revenue generating encounters offset loses due to sliding fee write-offs and uninsured users.

Iowa health centers on average receive $12.5 million (January 2005) from the federal government as 330 base grant funding, or about 34% of the total Iowa health centers operational budgets of $36.6 million.9 With a sliding

8 Uniform Data System, US Bureau of Primary Health Care: http://bphc.hrsa.gov/uds/ 9 National and Iowa Specific Data on Funding Sources and Reimbursement for Federally Funded Community and Migrant Health Centers, Iowa Department of Public Health, January, 2005; additional information found at www.ianepca.org 37 fee utilization of 30%, which is the BPHC recommended ratio of utilization, the federal grant should be adequate for sliding fee/uninsured users all things being equal. However, each health center’s percentage of revenue sources differ based on the location and communities served. Of the current eight Iowa based health centers reported, the Medicaid /hawk-i proportion ranges from 48% to as low as 7%. Uninsured and sliding fee proportions range from 92% of users to as low as 35%. From these figures, the federal portion of the health center’s 330 grant revenues does not completely cover the expenses for services to the uninsured users.

Health centers and their health care department leaders must be creative in leveraging additional resources to make up the difference in revenues needed to cover the costs of treating the uninsured patients in their target communities. Dental directors must have sufficient financial information to know how their departments are performing in the overall health center operations and to position their service mix and scheduling to maximize resources to meet the needs of the health center’s operational budget. Selective advocacy for the oral health agenda of the community on a state and national level will help the dental director locate new resources and partners. This is one method of filling in the missing financial pieces for the dental department. In addition, leveraging new resources for the health center will strengthen the leadership role of the dental director in the health centers administrative structure.

Dental department operations as a national average percentage of the overall health center’s costs is 9% according to the 2003 UDS report.

38 Chapter 5 • Basic Clinical Operations Guidelines The practice standards of the BPHC for health center dental programs as seen in documents like the PCER module and general standards in Appendix A provide good working guidelines for minimum dental clinic expectations. However, a more thorough understanding of the BPHC guidelines and expectations for health center dental programs can be obtain by reading the BPHC statement on dental management and program definitions contained in Appendix D-1. A clear objective of the bureau for dental programs is to address the dental needs of a community based on specific life phases know as “lifecycles,” which is consistent with the objectives defined in Healthy People 2010.

Lifecycle Planning for Dental Clinics: Health center dental programs are expected to develop a protocol addressing the needs of patients and the community throughout the five stages of human lifecycles. In planning the services offered by the clinic, this concept is expected to be woven in the framework of all activities and integrated into the overall health center’s mission and methods of operations. An example of lifecycle related service planning is given in Table #6. The goal is to design activities to target oral health related problems that research demonstrates are associated with each lifecycle. These activities should be recorded and clearly identified with the specific lifecycle problem targeted.

Table 6. “DENTAL ISSUES ACROSS THE FIVE LIFECYCLES”

I. Prenatal 1. Oral care education for expecting mothers 2. Nutrition counseling II. Pediatric 1. Early childhood caries detection, prevention, and treatment 2. Fluoride utilization and sealants III. Adolescent 1. Mouth guards 2. Tongue piercing IV. Adult 1. Oral health and diabetes management 2. Cardiovascular disease and oral health 3. HIV and oral health V. Geriatric 1. Periodontal disease and root caries management 2. Medication effects on geriatric oral health

Appendix E-1 contains an example of a well-established FQHC based dental program with a complete practice profile, protocols, procedures, methods, and standards in place. Through prevention outreach, the Salud Clinic addresses lifecycle-based activities and targets how those interventions will be performed in their multi-site communities. The Salud Clinic example will be discussed further in Chapter 7 as a “best practice” of completeness in policies and procedure development. A well-developed lifecycle service approach recorded in the health center’s action plan and demonstrated within the health center dental service protocols is a BPHC standard for all health center programs.

39

A “Snap Shot” Summary of Dental Clinic Elements:

Table #7 illustrates the core elements necessary for a health center based dental practice and should be considered essential to meet BPHC standards.

40 Table 7.

Key Elements in New Program Development First Element: Community Partnerships ƒ Help in determining community profile and demographic areas of need ƒ Build local political goodwill and support ƒ Help sustain the clinic over time ƒ Provide local resources and referral networks

Second Element: Delivery System and Design ƒ Comprehensive services with community based needs, culture and family in mind ƒ Strong emphasis on prevention and education ƒ Public health emphasis should aim to maximize distribution of services toward a large population with extensive care needs ƒ Design should allow good traffic flow and volume based on expected local needs

Third Element: Design to Maximize Efficiency ƒ Proper staff / equipment ratios ƒ 2 chairs per dentist (3:1 ideal) ƒ 1.5 assistants per dentist (2:1 ideal) ƒ As preventive/recall volume increases to keep both providers busy without sharing patients add a hygienist ƒ Equipment of proven durability for large volume and repeat cycle use ƒ Waiting area appropriate for clinic size

Fourth Element: Computerize for Efficiency Management information systems ƒ Computerized financial systems ƒ Clinical applications ƒ Tracking ƒ Communications/medical-dental merging ƒ Reminders/letter generation ƒ Data collection ƒ Report generation

Design for Growth ƒ Expect a growing demand for services ƒ Portable/mobile equipment options ƒ School-based preventive programs ƒ Collaborations with private/public dental practices ƒ Location should be expandable both in clinic and patient waiting area

Fifth Element: Realistic Financial and Productivity Goals ƒ Services provided should be less than actual cost per patient/encounter ƒ Comprehensive mix of services should emphasize basic therapeutically acceptable care options: more “bang for the buck” ƒ Productivity goals based on practice objectives: services vs. time (encounters) ƒ 2,500 to 2,700 encounters/yr X FTE dentist ƒ 1,300 encounters/yr X FTE hygienist

41 New dental directors needing more guidance in developing basic clinical structure and design can find a useful online resource at: www.dentalclinicmanual.com. This resource provides an extensive amount of information on how to setup a community-based dental practice and practice design choices that best fit the objectives of the health center. Chapter 2 and 3 of the online Safety Net Clinic Manual is devoted to practice design and the fundamentals necessary to set up an efficient dental operation with step-by-step detail. The manual also helps dental program planners ask the right questions and avoid many mistakes that inexperienced dental practice administrators tend to make.

Only after a health center has established a well-planned and designed dental program can the dental director strive to meet the standards established by the BPHC. Failure to adequately design an efficient dental operation makes compliance very difficult and may hinder future growth in the dental program.

Getting a good start in setting up a health center dental practice is half the battle in achieving practice success. Once the practice is set up, the policies and procedures necessary to operate the practice are easier to develop since they reflect efficiencies built into the practice design. Productivity expectations and operations become more predictable with a well-developed practice design.

Data Management Systems: The heart of a well-designed dental clinic lies in data management. As a public health facility and governmental affiliate, health centers are responsible for extensive amounts of data to meet governmental requirements and operate efficiently. The higher the accuracy and speed in which data becomes available, the easier it is for both management and the dental director to make necessary changes in operations. Electronic data management systems are still relatively new and have a number of problems associated with them. Average software systems are specific towards a certain health care discipline. There are no comprehensive data management systems yet available that successfully integrate all health care disciplines in one package.

It is highly recommended that health centers select software packages that target specific health care applications and do not attempt to force applications across professional health care disciplines.

Chapter 3 of the Safety Net Clinic Manual provides an excellent reference on dental clinic operations and information management resources. Additional references on dental software systems can be found at www.ada.org/prof/prac/tools/software/vendor.asp and www.ada.org/prof/prac/tools/software/index.asp.

A good dental practice management software system has many advantages including electronic billing and coding capabilities. In addition, statistical information on practice service utilization and demographic information on the patient population can be easier to obtain. There are also software utilities that can merge one practice system with another such as medical management software and dental software. The potential for a truly integrated health system is just around the corner. The tracking features in most electronic dental software packages are extremely useful in making referrals and prescription writing. The mail-merge feature allows customized letters to be developed in short order thus freeing up more time for providers to treat patients.

Electronic charting has the potential of creating the “paperless” dental practice. This can also eliminate handwritten chart entries and the negative impact of poor penmanship that can result in poor outcomes in quality assessment chart reviews. Current trends in state Medicaid programs will require electronic billing potential in all participating dental practices in the future. Most commercial dental insurance plans also favor this method. While

42 there are a number of businesses that perform conversions of paper billing systems into electronic ones, these services add to overhead costs and slow down collections. Electronic billing has been shown to increase rates of collecting billing account receivables by decreasing payment-waiting time to less than 10 to 15 days in most third party based transactions.

Effective Scheduling Strategies: A dental clinic that meets BPHC standards in basic practice set-up with a minimum of two dental chairs per full time dentist and one and one-half full time equivalent dental assistant per dentist is ready for implementing effective scheduling strategies. New BPHC standards recommend two and one-half to three chairs for one FTE dentist and two FTE dental assistants per one FTE dentist for ideal efficiency. While there remains no “one” scheduling method that is ideal, there are fundamentals to effective scheduling that should be addressed: ƒ Keeping dental providers productive during the entire clinic operation time; ƒ Reducing or eliminating “no-show” appointments; ƒ Reducing or eliminating long patient waiting time; and ƒ Avoiding the need for long patient call-in lists.

According to the 2003 Uniform Data System Report,10 the average national individual patient visits per year in a health center dental clinic was 2.37 with 996 patient users per one FTE dentist. National productivity averages for dentists were 2,706 patients per FTE dentist at an average cost per visit of $124. The dental director should refer to annual UDS report averages to benchmark clinical performance while seeking to create more efficiency in both scheduling and patient flow.

Dental Appointment Scheduling: An Example With the dentist having access to at least two operatories and adequate support staffing, dental appointments can be standardized as one-hour intervals to allow for quadrant dentistry and efficient use of time. If the dentist has advance knowledge of the treatment process involved, an alternative method is to schedule the amount of time per visit per chair required for the specific treatment plus an additional 10 minutes for unit sterilization procedures. RVU data can serve as a template for allocating time units based on the CDT dental code for the procedure. Electronic dental software systems are set up in RVU-friendly 10 minute time intervals and work well with treatment specific time allocation methods.

Using the one-hour “block” scheduling method, assignments are two patients per hour per dentist. Appointments could be classified as either EXAM or OPERATIVE. An EXAM is an initial appointment, while OPERATIVE is used as a generic term covering all subsequent appointments after the initial one. An example of such a schedule follows.

DOCTOR A March 3, 2001 8:00 am XAM EXAM 9:00 am XAM OPERATIVE 10:00 am EXAM OPERATIVE 11:00 am EXAM OPERATIVE

1:00 pm OPEN OPERATIVE 2:00 pm EXAM OPERATIVE 3:00 pm EXAM OPERATIVE

10 http://bphc.hrsa.gov/uds/ 43 Upon entering the dental system with an EXAM appointment, the patient is given their next appointment before leaving. Strive to space appointments every two weeks for continuity of care and timely completion of treatment. Some patients, especially children, will not require additional appointments. Adjust the number of OPERATIVE appointments when necessary. Having an unscheduled third chair available shared between two FTE dentists would be ideal for emergencies and walk-ins. This would avoid interruptions in assigned chair visits if higher numbers of urgent care needs turn up. In addition, a no-show in assigned chairs can be filled from the urgent care unassigned chair.

If the one FTE dentist lacks a third unassigned chair, request emergency patients to present at the beginning of either the morning or afternoon session. EXAMS scheduled at 8:00 a.m. are most likely to no-show, thus freeing up time for emergencies. The OPEN 1:00 appointment is for those persons who call in distress during the morning. Unless an emergency patient is in a life-threatening condition, most understand that there are scheduled patients before them and they will wait knowing that they will be seen at the first available opportunity. Two patients scheduled per hour per dentist should allow emergencies to be seen in a timely manner. The dental assistant can triage the acuteness of the emergency and space these patients throughout the schedule striving for 8:00 a.m., 1:00 p.m. and the exceptional end of the day emergency. This should alleviate any tendency towards routine prescribing of analgesics and antibiotics in lieu of treatment.

Initial exam candidates should first be evaluated in the dental operatory by the dental assistant for home care, brushing knowledge and technique. If the patient is a very young child (one to four yrs), a toothbrush prophylaxis can be recommended. The assistant observes the child brushing at the sink and evaluates the thoroughness of the effort (disclosing solution may be helpful). Afterwards, the assistant educates the child in correct brushing technique. A rubber cup prophylaxis is only done if stain is present. This protocol of observed brushing technique stresses the point to the child, who is ultimately responsible for her dental health, along with the consistent help of the parents. Indiscriminate rubber cup use only serves to remove the outer-most layers of enamel, which happen to be the most fluoride rich and beneficial to the patient. The assistant obtains posterior bitewings and upper and lower anterior periapicals after the dentist completes the soft and hard tissue exam. Finish with topical fluoride if appropriate.

If the patient presenting is an adult with poor hygiene, barring no chief complaint, the dentist performs a gross scaling and instructs the patient on their home care responsibility. Radiographs and full examination can be completed at the next appointment when there is less bleeding. Subsequent periodontal procedures will be part of the overall treatment plan.

If a dental hygienist is available, the hygienist should have one scheduled patient per hour to allow adequate time for education and extensive procedures. Eventually, the hygienist may mix 45 and 60-minute appointments to better utilize time. The hygienist sees no initial patients, except possibly HIV+ and diabetic patients who routinely present with periodontal complications. No routine child prophylaxes or radiographs should be performed by the hygienist without dentist authorization. Initial periodontal gross scaling can be easily completed by the dentist or hygienist upon approval by the dentist, with Cavitron, Titan-S scaler, etc.

Stress progressive levels of prevention (one-step at a time). For example, discuss brushing at one appointment and flossing at the next. Evaluate periodontal progress at each subsequent visit. When the treatment plan is complete, the patient should at most require fine scaling. Patients should be routinely recalled at one-year intervals. Diabetics, HIV/AIDS, and other periodontally compromised patients would be recalled sooner. If treatment is completed in April 2005, a reminder card will be placed in the recall file to be mailed in March 2006. A six- month recall might be ideal, but may be unrealistic in a community oriented clinic where the demand far outweighs the resources. Recall with purpose…not blindly. If a patient’s oral hygiene looks good upon the initial examination and no remaining or new dental pathology is seen at the first six-month recall visit, a yearly recall cycle may be sufficient.

Schedule only three weeks to one month in advance. For example, schedule for February on the first Monday in January. There will be a finite number of new or EXAM appointments. When these are full, close the schedule until 44 the next four-week period. It should be possible to set a routine date for the next round of appointments, e.g., the first Monday of the month. Patients will eventually notice this. Schedule school and Headstart patients into definite blocks.

Explain to patients that due to limited personnel and space, a limited number of appointments are available. Considering that emergencies will have easier access and the new schedule should move patients through to completion in a timely manner, most individuals will acquiesce. Only allow two appointments per family at a time. This will help provide an equitable distribution of a limited number of appointments and for maintenance of the overall schedule in light of unexpected cancellations. In the interest of being sensitive to the needs of a large family who consistently keep their appointments, when one family member completes treatment, schedule the next family member immediately until all are completed.

When scheduling an appointment, request the patient’s name, birth date and phone number. Call and remind every patient the morning before their scheduled appointment. Call patients scheduled on Monday on Friday. If there is no answer, try again in the afternoon. Make a note in the scheduling book if appointment is confirmed. For those patients without phones, send a reminder note one week in advance.

Keep an updated list of no-show patients and refer to it whenever appointments are made. Call any previous no- show visits to the patient’s attention. Two unexplained absences generally indicate that the patient only desires urgent care. Consult with the dentist before any further appointments are scheduled. Cancellations and no-shows are to be documented in the patient record. Double booking patients is not recommended.

Keeping in mind the health center’s interdisciplinary approach to patient care, all referrals from medical colleagues should be given highest priority and scheduled as soon as possible.

Note: The revised BPHC Oral Health Guidelines recommend 2.5 operatories per dentist and 2 assistants per dentist for maximum productivity. This is based on an ideal 6-chair clinic with 2 dentists and 1 hygienist.

Addressing “No shows” and Collections: There are no set rules in addressing patient appointment no-shows or collecting a patient’s portion of the sliding fee for treatment. Among indigent populations, especially where significant cultural variations in health care access beliefs exist, these issues can be extremely exaggerated. Several strategies offer some control in these types of situations: ƒ Scheduling appointments out for only one month; ƒ Limiting no-shows to call-in/walk-in problem focused visits after two incidents of missing scheduled appointments; ƒ Charging a minimal fee for each no-show, payable before scheduling future appointments; and ƒ Allowing only one additional scheduled appointment if a payment balance is due and limiting future access to problem focused/call-in only until payment is received.

It is important that the health center assist in enabling the community to meet health care access standards through program assistance in childcare, transportation and case management. These types of issues are best addressed through forming collaborations with community and state empowering agencies and local infrastructure development groups.

If a health center dental program combines good scheduling practices and methods mentioned to control no- shows and payment resistance, the center should have minimum problems and meet BPHC recommendations of less than 20% no-show by volume. 45 Smoking Cessation Counseling in Dental Clinics: Iowa based health center dental programs have a unique opportunity to utilize a state sponsored resource as part of their prevention efforts known as “Quitline Iowa”. The performance of smoking cessation counseling in health center dental programs has historically been weak and is considered a time consuming process. The advantages of participating in the Quitline Iowa program follows.

Quitline Iowa Fax Referral Program Quitline Iowa is designed to help improve the health and well-being of Iowans by helping smokers quit and remain smoke free by increasing the number of individuals who receive smoking cessation counseling. Health care providers can play a critical role in this effort by referring their patients who smoke to Quitline Iowa, a statewide, toll-free telephone counseling service. The fax referral program gives health care practitioners a quick and easy method for referring their patients who smoke to effective cessation services. After identifying a patient’s tobacco use status, providers can have patients fill out a simple form indicating their consent to receive cessation services, then fax the form to Quitline Iowa for cessation counseling and follow-up.

Why Quitline Iowa? A study published in the October 2002 New England Journal of Medicine has shown that people who receive phone counseling are twice as likely to stay smoke free as those who try to quit on their own.

Quitline Iowa provides evidence-based, culturally competent smoking cessation services to all Iowans. The Quitline has a higher smoking cessation success rate (28% based on six month follow-up surveys) than the national average (19% according to the National Cancer Institute). The program also triage to other services, including local programs, if the Quitline is not the best option for an individual. The program performs a tobacco cessation screening and initial assessment, then connects patients with appropriate Quitline services or refers them to community services.

How Do Health Care Providers Benefit? The Agency for Health Care Policy and Research (AHCPR) guidelines for clinicians recommend that health care providers assess a patient’s smoking status and provide cessation assistance using the “5 A’s”: approach, ask, advise, assist and arrange follow-up. However, limited time and resources, as well as lack of information on available community services may pose barriers to health care provider’s ability to provide smoking cessation assistance. The fax referral program provides health care providers with an opportunity to outsource the time- consuming steps of assistance and follow-up in the “5 A’s” to a telephone smoking cessation service, which would alleviate some of the problems posed by lack of time and resources.

Why Fax Referral? Research indicates that physician referral of patients to smoking cessation programs is associated with a significantly higher participation rate than simply telling patients they should stop smoking. Using the fax referral form to refer patients to Quitline Iowa for smoking cessation counseling, information and referral to other resources provides health care providers with a quick and easy way to direct their patients who smoke to an effective smoking cessation program, while getting an immediate commitment from their patients to make an attempt to quit smoking.

46 Fax referral also will relieve patients of the responsibility of initiating services, as Quitline Iowa will make the initial contact after receiving the fax referral form. Such proactive counseling may increase participation rates, as patients will not have to take the difficult step of making the first call.

More information on the Iowa Quitline program can be found at www.quitlineiowa.org or by calling 319-384- 4847. The Iowa Quitline fax number is 319-384-4841.

Legal liability is a very important consideration for dental clinic program directors reviewing patient health histories. . Dental providers should be prepared to address all potential health-threatening indications listed on the health history form. A patient reporting tobacco or any substance abuse in their health history obligates the dental provider to recommend discontinuation of use and referral to appropriate counseling if not available within the health center program. Referral to the Iowa Quitline for patients with health histories confirming tobacco use serves as a good method to meet patient care legal and ethical responsibilities.

“Over one half of periodontal disease diagnosed patients and 90% of oral and pharyngeal cancer deaths involve the use of tobacco products.” 11

As of March 22, 2005, dentists may bill Medicare for dental services related to tobacco counseling for those clinical programs that provide on-site counseling services. The billing process involves the use of Medicare billing forms and billing codes such as:

G0375 – Intermediate cessation visit: counseling sessions lasting more than three minutes and no more than ten minutes per session, with a total of two sessions per year.

G0376 – Intensive cessation visit: greater than 10 minutes and no more than two sessions per year.

Guidelines for tobacco counseling can be found on-line at: http://www.surgeongeneral.gov/tobacco treating_tobacco_use.pdf and www.cms.hhs.gov/medlearn/drugcoverage.asp. Dental providers who wish to start billing for Medicare-approved dental services must acquire a National Provider Identifier (NPI). Information on the NPI can be found at https://nppes.cms.hhs.gov. Further information on how to use Medicare billing codes for approved dental procedures such as tobacco cessation counseling can be obtained by calling the toll free number 1-877-309-4290 or via the Centers for Medicare and Medicaid Services (CMS) Regional Offices for Part B Carriers at: http://www.cms.hhs.gov/contacts/.

11 www.cdc.gov/tobacco/sgr/sgr_2004/pdf/chapter2.pdf (see page 64) www.cdc.gov/tobacco/sgr/sgr_2004/pdf/chapter6.pdf (see page 736) 47 Chapter 6 • Productivity Expectations and Evaluation Throughout this training module general statements have been presented regarding provider productivity expectations in the health center dental clinic. A summary on productivity expectations from Dr. Jay Anderson, Chief Dental Officer, HRSA Bureau of Primary Health Care, for successful dental programs is seen in Table #8 below.

Table 8. Productivity

The BPHC's requirement for dental productivity is that the program be financially viable.

Based on UDS data, a health center program with one dentist needs to generate approximately $300,000 to break even. The average cost per encounter is $117; a health center would therefore need 2,564 annual encounters to break even. This is roughly 200 workdays per year (or 1,600 work hrs per year after holidays and vacations). The average number of encounters per dentist FTE per hour would be 1.7 patients per hour or 13.5 patients per day. The health center should benchmark the productivity of its current dental program to see if greater efficiency can occur that would allow an increase in new patient access. Based on 2002 UDS nationwide statistics, the average number of encounters per full time dentist were 2,700 per year or 1,100 patients.

A dentist should utilize a minimum of two chairs (2.5 chairs recommended) and one and one-half dental assistants (two dental assistants recommended) to achieve these productivity aims.

BPHC standards for encounter rates are as follows: <2,100 per fte dentist = poor; 2,100-2,400 = below average; 2,400-2,700 = average; 2,700-3,200 = above average; and 3,200 and above = outstanding. For a dental hygienist, the comparative 1.0 FTE annual encounters range from <800 = poor; 800-1,100 = below average; 1,100-1,400 = average; 1,400-1,800 = above average; >1,800 = outstanding. The workload for each assumes a 40 hr workweek and 200 work days.

A dental clinic program must have a means to evaluate productivity and encourage higher standards of productivity among its providers. It must be stressed that achieving efficient operations is possible. Chapters 2 and 5 presented information on efficient practice design. Table #8 contains the BPHC requirement that a dentist must have two dental chairs minimum and no less than one and one-half dental assistant per two chairs to be productive and efficient.

Dental clinics with below minimum practice set-up cannot produce BPHC expected production rates and may face diminished returns on resource investments by the health center.

48 Practice Productivity Evaluation: Table 9. JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL: Dentist X 105 135 150 168 81 131 149 131 171 166 153 1,540 total per day 8.9 11.1 11.7 10.6 9.2 10.0 10.8 11.6 13.5 12.5 13.9 2003 total per day 11.8 9.6 9.7 10.2 10.3 8.7 10.2 7.6 9.5 9.9 10.2 9.9 nonbillables 3 4 6 6 5 11 6 14 10 5 8 78 billables 102 131 144 162 76 120 143 117 161 161 145 0 1,462 billables per day 8.7 10.7 11.2 10.3 8.6 9.1 10.4 10.3 12.7 12.1 13.2 2003 billable per day 11.3 9.3 9.3 9.4 9.7 8.2 9.2 7.2 8.7 9.5 9.4 9.7 9.3 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL: Dentist A 32 47 54 35 47 49 53 55 66 42 45 525 total per day 10.7 11.8 13.5 11.7 11.8 9.0 13.3 13.8 13.2 14.0 15.0 2003 total per day 12.7 10.2 12.9 11.5 11.4 9.0 10.1 7.4 9.7 12.4 10.9 9.7 10.5 nonbillables 1 4 6 0 1 4 1 2 1 0 1 21 billables 31 43 48 35 46 45 52 53 65 42 44 0 504 billables per day 10.3 10.8 12.0 11.7 11.5 8.3 13.0 13.3 13.0 14.0 14.7 132.6 2003 billable per day 12.2 9.5 12.2 11.2 10.9 8.5 9.5 7.0 8.7 11.9 10.6 9.7 10.0 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL: Dentist Y 153 177 208 219 187 171 163 163 167 241 230 2,079 total per day 9.4 11.1 12.6 12.3 11.9 10.9 12.7 12.0 14.2 15.3 15.9 2003 total per day 10.9 11.5 11.9 12.1 11.2 10.8 10.0 11.1 11.4 10.5 11.2 9.8 11.0 nonbillables 1 11 4 0 4 4 4 0 3 2 4 37 billables 152 166 204 219 183 167 159 163 164 239 226 0 2,042 billables per day 9.3 10.4 12.4 12.3 11.6 10.6 12.5 12.0 13.9 15.2 15.6 2003 billable per day 10.8 11.3 11.6 11.6 10.6 10.5 10.0 10.9 11.1 10.4 10.9 9.8 10.8 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL: Dentist Z 125 182 266 232 213 281 193 277 217 281 308 2,575 total per day 11.4 13.2 14.9 13.6 14.9 17.0 12.5 16.5 13.9 18.7 18.8 2003 total per day 12.3 12.3 11.0 13.3 12.6 11.7 11.6 11.0 13.0 12.7 12.4 12.5 12.2 nonbillables 7 8 11 6 8 5 2 8 11 7 3 76 billables 118 174 255 226 205 276 191 269 206 274 305 0 2,499 billables per day 10.7 12.7 14.3 13.3 14.4 16.7 12.4 16.0 13.2 18.3 18.6 2003 billable per day 11.6 11.7 10.7 12.7 11.7 11.2 12.3 10.2 12.7 12.3 11.8 12.1 11.6 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL: Dentist B 37 157 212 214 125 745 total per day 9.4 10.5 11.9 12.7 13.5 2003 total per day 7.4 9.3 10.7 9.1 11.5 10.5 12.6 10.1 nonbillables 2 8 6 2 2 20 billables 35 149 206 212 123 725 billables per day 8.9 9.9 11.6 12.6 13.3 2003 billable per day 7.3 9.1 10.5 8.7 11.0 10.2 12.4 9.9

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL: Hygiene 1 99 120 168 150 155 176 127 163 167 155 158 1,638 total per day 7.2 8.0 9.1 10.0 10.6 10.1 9.7 10.4 11.1 9.8 11.6 2003 total per day 8.8 6.6 8.8 8.7 7.2 7.6 7.9 7.1 8.0 7.6 6.9 8.1 7.8 nonbillables 3 0 0 1 2 2 1 2 0 1 0 12 billables 96 120 168 149 153 174 126 161 167 154 158 0 1,626 billables per day 6.9 8.0 9.1 10.0 10.5 10.0 9.6 10.3 11.1 9.8 11.6 2003 billable per day 8.7 6.5 8.8 8.6 7.2 7.6 7.8 7.1 8.0 7.6 6.9 8.0 7.8

49 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL: Hygiene 2 118 133 119 164 153 156 163 122 155 146 167 1,596 total per day 7.4 8.3 9.1 10.3 9.6 10.7 10.2 11.0 10.6 9.7 10.8 2003 total per day 7.2 6.9 8.4 9.2 7.9 7.6 8.3 9.3 8.4 7.9 6.8 6.9 7.9 nonbillables 1 1 2 1 2 0 0 3 1 2 0 13 billables 117 132 117 163 151 156 163 119 154 144 167 0 1,583 billables per day 7.3 8.3 9.0 10.2 9.4 10.7 10.2 10.8 10.6 9.6 10.8 2003 billable per day 7.2 6.9 8.4 9.1 7.9 7.6 8.3 9.2 8.3 7.9 6.7 6.9 7.8 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL: Hygiene 3 107 107 167 153 123 89 112 159 99 99 113 1,328 total per day 6.8 7.1 9.0 9.6 8.2 6.8 7.0 9.2 6.8 7.1 7.3 2003 total per day 6.5 6.6 7.4 7.6 6.7 7.0 7.1 6.8 7.6 7.2 6.4 6.7 7.0 nonbillables 0 0 0 0 0 0 0 1 1 0 0 2 billables 107 107 167 153 123 89 112 158 98 99 113 0 1,326 billables per day 6.8 7.1 9.0 9.6 8.2 6.8 7.0 9.1 6.8 7.1 7.3 2003 billable per day 6.4 6.5 7.4 7.6 6.7 7.0 7.1 6.8 7.6 7.2 6.4 6.6 6.9 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL: Students (x2) 211 172 200 30 170 191 135 134 151 123 200 1,717 total per day 5.7 5.9 6.1 5.0 5.3 5.7 5.7 7.0 6.8 6.3 6.1 2003 total per day 7.2 5.3 6.3 5.3 6.1 5.3 6.4 6.4 5.7 6.0 5.2 6.0 5.9 nonbillables 3 4 1 0 0 1 3 4 4 4 1 25 billables 208 168 199 30 170 190 132 130 147 119 199 0 1,692 billables per day 5.6 5.7 6.1 5.0 5.3 5.7 5.6 6.8 6.6 6.1 6.0 2003 billable per day 7.1 5.1 6.0 5.3 6.0 5.3 6.3 6.2 5.6 6.0 5.1 5.9 5.8 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL: ALL 987 1,230 1,544 1,365 1,254 1,244 1,095 1,204 1,193 1,253 1,374 0 13,743 total per day 76.9 87.0 97.9 95.8 95.0 80.2 81.9 91.5 90.1 93.4 99.3 0.0 2003 total per day 77.4 69.0 76.4 77.9 73.4 75.1 80.9 77.4 82.4 85.7 80.5 82.4 82.3 nonbillables 21 40 36 16 24 27 17 34 31 21 17 215 billables 966 1,190 1,508 1,349 1,230 1,217 1,078 1,170 1,162 1,232 1,357 0 13,528 billables per day 74.5 83.6 94.7 95.0 92.8 77.9 80.7 88.6 87.9 92.1 97.8 0.0 2003 billable per day 75.3 66.8 74.4 75.5 70.7 73.2 77.9 75.1 79.4 83.8 78.0 81.1 79.9

Table #9 illustrates one method for tracking productivity based on total encounters. This method is often favored by accountants since health center reimbursements are based on patient volume in most states. This method does not recognize the complexity and time involved in each service performed. This method does recognize that some procedures performed are not reimbursed by payment plans and not chargeable to the sliding fee scale since most state Medicaid based Perspective Payment Systems (PPS) only recognize Medicaid chargeable services. Monthly billables are averaged out per day and all non-billable procedures are removed from the provider’s total procedure count. Only procedures that are billable are credited to the provider’s productivity totals. Also lacking in this type of data are the actual hours worked, whether a provider was full time or part time, interruptions due to vacations and holidays, and other conditions that may impact provider productivity. As the values are presented and lacking additional information, it is clear that the Table #9 example is below BPHC daily productivity standards of 13.5 patients a day average as seen in Table #8. However, more information might reveal the clinic has a high proportion of level three or above treatment services taking more time to perform. An RVU-based comparison could reveal this additional information.

Appendix D-2 demonstrates a blended dental clinic productivity tracking method with target goals and monthly variations. This method allows the dental director and administrative team to make program changes if necessary after a trend of negative variation is seen over time. This method alone does not give the dental director detailed 50 information on individual provider performance, type of procedures performed, hours of operations, provider work hour variations and billable service mix necessary to make changes based on proven performance deficiencies.

Appendix D-3 presents an example of an RVU-based evaluation system that compares encounters and time intervals based on dental procedure CDT codes. A calculation averages the total annual RVU value performed for all procedures performed in the dental clinic. In this case, the average RVU was 1.54 per encounter. The average RVU scale of 1.0 is equivalent to ten minutes; the average procedure in this scenario was slightly under 20 minutes. This clinic has a high volume of type one, two and three services, which is the preferred scope of services recommended for health center dental programs. However, significant information is missing from this type of system as well, including provider driven production variations and hours of operation. The dental operations as seen from this limited data may appear reasonable on a large scale, but may prove otherwise if breakout data on individual provider performance was available.

Appendix D-4 contains an example of a monthly production analysis that includes clinical hours each provider worked, the billing category for each visit encounter, and the daily production in encounter visits. While lacking RVU comparisons, this data gives the dental director a day-by-day snapshot of what each provider is actually doing in the clinic. The dental director can address productivity concerns readily with detailed information at hand. Each of the examples given was performed on an Excel spreadsheet from data readily available from dental information software systems.

Productivity Reward Systems: Various types of provider bonus programs are used in health center dental clinics. Some are based on total volume or aggregate encounters. Others are RVU driven in an attempt to recognize the time and effort a provider has invested in performing certain procedures over time. Both systems have advantages and disadvantages. From the accounting side, the only value a dental procedure has is the revenue potential the procedure generates. From that standard, it is insignificant how complex a procedure is or the time involved if the reimbursement system only recognizes volume or patients seen. This is a common complaint in PPS-based payment Medicaid programs.

Methods of combining encounters and RVU have been attempted with some success. Table #10 contains an example of how one such methodology works.

Table 10. Encounter/RVU Quarterly Bonus Program

Why? ƒ Fair system to providers ƒ Equalizes encounter value ƒ Decreases trend for selective procedure seeking “cherry picking” ƒ Gives a more realistic evaluation quality to patient/provider visits

Changes required to update old bonus system in RVU/encounter system: 1. Dentists are credited with all procedures requiring licensed dentists for Medicaid reimbursement, i.e. dental examinations. 2. Hygiene visits are separated into “two” encounters for tracking purposes when a dental exam is included 51 with preventive services (fluoride, prophy, x-rays); one for the dentist doing the exam, one for the hygienist providing treatment. 3. Encounters/visits are given a RVU value based on time and billing code. 4. Quarterly bonus reports give baseline encounter and RVU target scores. 5. When both target encounter and RVU baselines are reached, a bonus is awarded. 6. When baseline encounters are below target, yet the RVU score is higher than baseline target, a bonus is still awarded.

How does it work? ƒ Presently, the baseline encounter/time for dentists is 30 minutes ( for hygienists, 40 minutes) ƒ RVU = 10 minutes ƒ Baseline visit = 3 RVUs ƒ Two methods are possible. Per the RVSI institute of Denver, CO, all ADA coded procedures under CDT-4 have individual RVU expectation values. 1. Method one simply adds all billable coded procedure RVUs per visit. 2. Method two only recognizes a few criteria set by the dental practice beyond level three services that take more than the baseline of 30 minutes, i.e. root canals, surgical extractions, crowns and bridges. (More are possible, case-by-case.) ƒ If method two (the easier of the two) is used, only three types of level four and five procedures are allowed with RVU values above the baseline of three RVU per encounter. Root canals are six RVUs, surgical/wisdom teeth extractions are six RVUs, crowns (individual) are six RVUs and bridges are typically nine RVUs depending on length. ƒ Method two is preferred since it is easier to establish a baseline encounter/RVU average, i.e. daily production baseline of 11 encounters = 33 RVUs.

Formula: _____Encounter/quarter = _____x 3 RVU/quarter

ƒ Per quarterly calculations for provider baseline, simply multiply by “three” to get the equivalent RVU baseline per quarter. ƒ When a provider performs one of the three current double value RVU procedures, the actual RVU value will be higher than the encounter value times three. If significant numbers of double procedures are performed, the RVU totals will vary between three and six times the encounter value. ƒ In proportion, the encounter values may fall if double time or 60-minute (6 RVU) procedures are done in significant daily numbers. ƒ As long as the total RVUs per quarter exceed the baseline, the provider earns a bonus even if the encounter total is below the baseline cut-off.

52 Using the BPHC standard of 13.5 encounters per day and 200 working days per year (50 days per quarter) as seen in Table #8, a benchmark quarter encounter rate would consist of 675 encounters. Using method two as given in Table #10, the quarter RVU rate for 675 encounters would equal 2,025 RVUs. If the provider performs a significant number of procedures above type three that involve higher RVU values, the total RVU will exceed 2,025 per quarter. However, total encounters may drop below the benchmark in proportion to the increase in RVUs above the benchmark. As long as the provider maintains one of the two variables above the benchmark, productivity is considered acceptable.

Table #10 contains a formula that attempts to benchmark the RVU system with encounters to form an expectation standard. The accounting side gains the volume-based recognition that is revenue-friendly while the dental provider is recognized for time/work effort expected in provider productivity. In effect, both are rewarded if the provider exceeds the baseline provided for each (the RVU and the encounter.) The advantage of this system is that it recognizes that encounters fall as RVUs go up. Controlling abuse in an RVU-based productivity method requires setting a limit on both the number and category of procedures above level three that can be performed in the practice.

RVUs are time-relevant based on the procedures performed on individual patients. The number of patients seen (encounters) by the provider decrease as more work/time is concentrated on an individual patient’s treatment. However, the provider is productive and busy providing patient services. Another advantage of this type of system is that the pressure to avoid lengthy procedures and minimize patient services is reduced. The disadvantage of this system is that the health center is potentially rewarding providers with more money while the clinic’s revenue production actually falls. In a volume or encounter based reimbursement methodology, the RVU will likely face a secondary role in clinical evaluation if the health center’s focus is on revenue generation alone.

The critical role for the dental director is to achieve balance between good ethical patient care addressing the most individual patient needs per visit while remaining financially responsible through time and resource management.

Under the current “cost-based reimbursement” or PPS methodology utilized by most state Medicaid programs to reimburse health centers, this will be a difficult balance to achieve. The balance between more individual patient treatment services and more patients seen will always be a challenge and may face periodic swings as the health center readjusts to economic cycles. However, one of the dental director’s administrative duties is to advise the executive team on the need for balance in both treatment and volume to achieve the goals of improving the oral health of the community. A good health care outcome for the community is the primary care goal of the health center program. The BPHC is certainly expecting this as part of the center’s overall health plan objective.

53 Chapter 7 • FTCA, Specialty Services Agreements, Volunteers, Recruitment and Provider Credentialing Mastering the details involved in day-to-day dental clinic operations is critical for dental directors to avoid mistakes that can be harmful to their programs. Sometimes this information can be difficult to obtain or fully understand. One area where this difficulty is often experienced involves provider credentialing and the Federal Tort Claims Act (FTCA). FTCA is a federal service that provides medical malpractice defense for FQHC clinics and free health centers. The FTCA is administered under the Clinical Quality Systems Branch within the Bureau of Primary Health Care.

Federal Tort Claims Act (FTCA): The FTCA medical malpractice defense program for federally linked health centers began providing coverage in 1993. Since its inception, the program has been credited with saving up to one billion dollars for health center programs in reducing malpractice claim-related expenses. As a 330 PSA grant recipient, all health centers are eligible to participate in the program. As “employees” and “full-time contracted” dental care providers, dentists within a health center are eligible for coverage within health centers participating in the FTCA program. A health center dental director should confirm that their health center has applied and received confirmation of participation within the program.

The application process should be repeated with each competitive and non-competitive 330 grant application cycle to be valid.

However, a dental provider must be either a full time/part time employee or full time “contracted” dental provider and credentialed by the health center to be covered. This excludes part-time “contracted” dentists, hygienists and volunteers. A health center or the part-time contracted dental provider would have to purchase a separate dental malpractice policy for services within or outside the health center’s clinical site. Full-time is considered 32.5 hours per workweek or more.

Another critical point is that a health center must list “all” sites, including schools, public health agencies, mobile programs, etc., where the dental program will provide dental services and the complete scope of services provided on the 330 grant renewal application (Exhibit B) to be covered by the FTCA program.

The advantage of being covered under FTCA is that to “sue” a health center covered provider, a plaintiff (patient claiming harm) must be able to file a lawsuit against the federal government. This is a complicated process since it involves gaining “permission” from the government to bring a lawsuit against it. While complicated to explain, it provides an additional layer of defense to the dental provider, in that if the government legal advisory agency deems the complaint frivolous or lacking merit, the case stops at that point and the plaintiff has no other remedy. That presents a disincentive to lawyers seeking lawsuits where evidence is weak since settlements obtained on the “threat of a lawsuit” seldom take place.

Dental directors should review FTCA related information contained on the BPHC website at www.bphc.hrsa.gov.

54 The types of dental related complaints that are common and likely to result in successful judgments against a provider include the following: ƒ Improper performance of treatment/procedure; ƒ Errors due to an inadequate patient medical history; ƒ Failure to provide treatment to control infection or post-operative pain; ƒ Wrong tooth extractions and lack of pre-operative x-ray; ƒ Failure to document a diagnosis and obtain “informed consent” with explanation of associated risk factors before surgical treatment; ƒ Failure to document a health history and blood pressure reading prior to administering anesthesia; ƒ Failure to refer to a specialist; ƒ Failure to complete root canal therapy; ƒ Failure to inform a patient and document in patient record a treatment failure due to provider error; e.g. broken file retained in a failed root canal; ƒ Maxillary sinus perforation during treatment; and ƒ Failure to diagnose oral cancer.

Corrective action necessary to avoid most cases of successful claims involves the dental record. A good dental record must contain a thorough medical and health history protocol and adequate chart entry progress notes with enough information to clearly identify the procedure performed, purpose of the procedure, any extenuating or complicating factors, supporting diagnostic tests or x-rays, informed consent with written treatment alternatives, and risk factors. In addition, the chart entries must be legible and clearly written without confusing abbreviations that can be misleading.

Electronic records available with dental software systems can be a great advantage in meeting these objectives.

An example of good charting criteria is found in Appendix E-1 under Salud Clinic “Charting Protocol.” Additional resources on common patient consent forms utilized in health center dental practice can be found in Appendix E- 2 through E-9 and on line at www.cchn.org/activities/oral_health-forms.asp.

A health history questionnaire, like the one seen in Table #11, is essential for quality patient care and can save both the patient and the dental practitioner from serious errors. It is suggested the health history form leave space for unusual entries and modifiers since no questionnaire can account for every possible complication that can impact oral and general health care management. A system for regular updates should also be available.

55

Table 11.

HEALTH HISTORY English Patient Name: Patient Identification Number: Birth Date: I. CIRCLE APPROPRIATE ANSWER (leave blank if you do not understand question): 1. Yes No Is your general health good? 2. Yes No Has there been a change in your health within the last year? 3. Yes No Have you been hospitalized or had a serious illness in the last three years? If YES, why? 4. Yes No Are you being treated by a physician now? For what? Date of last medical exam? Date of last dental exam 5. Yes No Have you had problems with prior dental treatment? 6. Yes No Are you in pain now?

II. HAVE YOU EXPERIENCED: 7. Yes No Chest pain (angina)? 8. Yes No Swollen ankles? 9. Yes No Shortness of breath? 10. Yes No Recent weight loss, fever, night sweats? 11. Yes No Persistent cough, coughing up blood? 12. Yes No Bleeding problems, bruising easily? 13. Yes No Sinus problems? 14. Yes No Difficulty swallowing? 15. Yes No Diarrhea, constipation, blood in stools? 16. Yes No Frequent vomiting, nausea? 17. Yes No Difficulty urinating, blood in urine? 18. Yes No Dizziness? 19. Yes No Ringing in ears? 20. Yes No Headaches? 21. Yes No Fainting spells? 22. Yes No Blurred vision? 23. Yes No Seizures? 24. Yes No Excessive thirst? 25. Yes No Frequent urination? 26. Yes No Dry mouth? 27. Yes No Jaundice? 28. Yes No Joint pain, stiffness?

III. DO YOU HAVE OR HAVE YOU HAD: 29. Yes No Heart disease? 30. Yes No Heart attack, heart defects? 31. Yes No Heart murmurs? 32. Yes No Rheumatic fever? 33. Yes No Stroke, hardening of arteries? 34. Yes No High blood pressure? 35. Yes No Asthma, TB, emphysema, other lung diseases? 36. Yes No Hepatitis, other liver disease? 37. Yes No Stomach problems, ulcers? 38. Yes No Allergies to: drugs, foods, medications, latex? 39. Yes No Family history of diabetes, heart problems, tumors? 40. Yes No HIV/AIDS 41. Yes No Tumors, cancer? 42. Yes No Arthritis, rheumatism? 43. Yes No Eye diseases? 44. Yes No Skin diseases? 45. Yes No Anemia?

56 46. Yes No VD (syphilis or gonorrhea)? 47. Yes No Herpes? 48. Yes No Kidney, bladder disease? 49. Yes No Thyroid, adrenal disease? 50. Yes No Diabetes?

IV. DO YOU HAVE OR HAVE YOU HAD: 51. Yes No Psychiatric care? 52. Yes No Radiation treatments? 53. Yes No Chemotherapy? 54. Yes No Prosthetic heart valve? 55. Yes No Artificial joint? 56. Yes No Hospitalization? 57. Yes No Blood transfusions? 58. Yes No Surgeries? 59. Yes No Pacemaker? 60. Yes No Contact lenses?

V. ARE YOU TAKING: 61. Yes No Recreational drugs? 62. Yes No Drugs, medications, over-the-counter medicines (including aspirin), natural remedies? Please list:

63. Yes No Tobacco in any form? 64. Yes No Alcohol?

VI. WOMEN ONLY: 65. Yes No Are you or could you be pregnant or nursing? 66. Yes No Taking birth control pills?

VII. ALL PATIENTS: 67. Yes No Do you have or have you had any other diseases or medical problems NOT listed on this form? If so, please explain:

To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication.

Patient’s signature: Date: RECALL REVIEW: 1. Patient’s signature Date: 2. Patient’s signature Date: 3. Patient’s signature Date:

Cultural and linguistically appropriate health history questionnaires should be made available depending on the cultural diversity within the target population. Not all standard questions contained on a health history have the same meanings. Some questions may cause embarrassment and not be answered. In addition, some populations may not read their native language and may need interpretation assistance.

Provider Credentialing: For a dental clinic provider to become covered under FTCA, the provider must be credentialed. This process involves ensuring the provider is qualified to work within the health center and evaluating the scope of practice services the provider can competently perform. While the first part of the credentialing process is fairly straight- forward such as confirmation of the provider’s degree, license status, CPR certification, practice history including National Practitioner Database survey, and reference checks; the practice scope survey might be something new dental directors have little experience using. Scope of practice information is used to determine what procedures the provider is allowed to perform under the FTCA program. The accuracy of the information provided and the 57 assurance of the practitioner staying within the service framework provided on the scope of service competency form protects the dental clinic from malpractice claims.

Table #12 presents an example of a simple provider privileging checklist form. This form essentially records those ADA-approved CDT coded services a provider self-reports competently performing. Once approved, this form becomes a part of the provider’s employment record. The health center uses this information in the 330 grant application renewal process and upon acceptance by the BPHC; it becomes a record for FTCA coverage criteria.

Table 12.

Dental Privilege Code Dental Procedure Requested Approved Diagnostic 00110 Initial Oral Examination 00120 Periodic Oral Examination 00130 Emergency Oral Examination 00170 Periodontal Examination 00460 Pulp Vitality Tests 00470 Diagnostic Casts 09110 Palliative (Emergency) Treatment of Dental Pain-Minor Procedures 09430 Office Visit for Observation (During Regularly Scheduled Hours) – No Other Services Performed

Radiographs 00210 Intraoral – Complete Series 00220 Intraoral – Periapical – First Film 00230 Intraoral – Periapical – Each Additional Film 00240 Intraoral – Occlusal Film 00270 Bitewings – Single Film 00272 Bitewings – Two Films 00274 Bitewings – Four Films 00330 Panoramic Film

Preventive 01110 Prophylaxis – Adult 01120 Prophylaxis – Child 01203 Topical Application of Fluoride – Child 01204 Topical Application of Fluoride – Adult 01310 Nutritional Counseling for the Control of Dental Disease 01330 Oral Hygiene Instruction 01351 Sealant – Per Tooth 01510 Space Maintainer – Fixed – Unilateral 01515 Space Maintainer – Fixed - Bilateral 01550 Recementation of Space Maintainer

Restorative Amalgam Restorations 02110- Amalgam – Primary 02131 Amalgam – Permanent

58

Resin Restorations 02330- Resin - Anterior 02335 02336 Composite Resin Crown – Anterior – Primary 02380- Resin – Posterior – Primary 02382 02385- Resin – Posterior – Permanent 02387

Crown – Single Restorations Only 02710 Crown – Resin (Laboratory) 02720- Crown – Resin with Metal 02722 02740 Crown – Porcelain/Ceramic Substrate 02750- Crown- Porcelain Fused to Metal 02792 02810 Crown – ¾ Cast Metallic

Dental Privilege Code Dental Procedure Requested Approved Other Restorative Services 02915 Recement Inlay/Crown 02930 Prefabricated Stainless Steel Crown – Primary 02931 Prefabricated Stainless Steel Crown – Permanent 02932 Prefabricated Resin Crown 02933 Prefabricated Stainless Steel Crown w/ Resin Window 02940 Sedative Filling 02950 Core Buildup, Including Any Pins 02951 Pin Retention – Per tooth, in Addition to Restoration 02952 Cast Post and Core in Addition to Crown 02954 Prefabricated Post and Core in Addition to Crown 02960 Labial Veneer (Laminate) – Chairside 02970 Temporary Crown (Fractured Tooth) 02980 Crown Repair, By Report

Endodontics Pulp Capping 03110 Pulp Cap – Direct 03120 Pulp Cap – Indirect

59 Pulpotomy 03220 Therapeutic Pulpotomy Root Canal Therapy 03310 Anterior 03320 Bicuspid 03330 Molar 03351- Apexification/Recalcification – Initial, Interim and 03353 Final Visits

Periapical Services 03410 Apicoectomy/Periradicular Surgery 03430 Retrograde Filling – Per Root 03450 Root Amputation – Per Root 03470 Intentional Replantation (Including Splinting)

Other Endodontic Procedures 03910 Surgical Procedure for Isolation of Tooth with Rubber Dam 03960 Bleaching of Discolored Tooth 03999 Unspecified Endodontic Procedure, By Report (Pulpectomy)

Periodontics Surgical Services 04210- Gingivectomy or Gingivoplasty 04211 04220 Gingival Curettage, Surgical 04240 Gingival Flap Procedure, Including Root Planing 04249 Crown Lengthening, Hard and Soft Tissue

Adjunctive Periodontal Services 04341 Periodontal Scaling and Root Planing 04345 Periodontal Scaling Performed in the Presence of Gingival Inflammation 04910 Periodontal Maintenance Procedures (Following Active Therapy) Prosthodontics (Removable) Complete /Partial Dentures 05110 Complete Upper/Lower 05130 Immediate Upper/Lower 05211 Upper/Lower – Resin Base 05213 Upper/Lower Partial – Cast Metal Base with Resin Saddles 05410 Adjust Complete or Partial Denture

60 Repairs to Dentures 05510 Repair Broken Complete or Partial Denture Base 05520 Replacing Missing or Broken Teeth – Complete or Partial Denture 05620 Repair Cast Framework/Clasp 05650 Add Tooth to Existing Partial Denture 05660 Add Clasp to Existing Partial Denture 05710 Rebase Complete/Partial Denture 05730 Reline Complete/Partial Denture (Chairside) 05750 Reline Complete/Partial Denture (Laboratory)

Other Removable Prosthetic Services 05820 Interim Partial Denture 05850 Tissue Conditioning

Prosthodontics, Fixed Bridge Pontics 06210- Pontic – Cast Metal 06212 06240- Pontic – Porcelain Fused to Metal 06242 06250- Pontic – Resin with Metal 06252

Bridge Retainers – Crowns 06720- Crown – Resin with High Noble Metal 06722 06750- Crown – Porcelain Fused to Metal 06752 06780 Crown – ¾ Cast Metal 06790- Crown – Full Cast Metal 06792

Other Fixed Prosthetic Services 06930 Recement Bridge 06973 Core Build Up For Retainer 06980 Bridge Repair

Oral Surgery Extractions 07110- Simple Extractions 07120 07130 Root Removal – Exposed Roots

61 Surgical Extractions 07210 Surgical Removal of Erupted Tooth Requiring Elevation of Mucoperiosteal Flap and Removal of Bone and/or Section of Tooth 07220 Removal of Impacted Tooth – Soft Tissue 07230 Removal of Impacted Tooth – Partially Bony 07240 Removal of Impacted Tooth – Completely Bony 07241 Removal of Impacted Tooth – Completely Bony with Unusual Surgical Complications 07250 Surgical Removal of Residual Tooth Roots (Cutting Procedure)

Other Surgical Procedures 07270 Tooth Reimplantation and/or Stabilization of Accidentally Avulsed or Displaced Tooth and/or Alveolus 07271 Tooth Implantations 07281 Surgical Exposure of Impacted or Unerupted to Aid Eruption 07285 Biopsy of Oral Tissue – Hard 07286 Biopsy of Oral Tissue – Soft

Alveoplasty – Surgical Preparation of Ridge for Dentures 07310 Alveoplasty in Conjunction with Extractions 07320 Alveoplasty Not In Conjunction with Extractions

Surgical Excision of Reactive Inflammatory Lesions 07410 Radical Excision – Lesions Diameter up to 1.25cm

Removal of Tumors, Cysts and Neoplasms 07430 Excision of Benign Tumor – Lesion < 1.25cm 07450 Removal of Odontogenic Cyst or Tumor – Lesion Diameter up to 1.25cm 07460 Removal of Non-Odontogenic Cyst or Tumor – Lesion Diameter Up to 1.25cm

Excision of Bone Tissue 07470 Removal of Exostosis – Maxilla or Mandible

Surgical Incision 07510 Incision and Drainage of Abscess – Intraoral Soft Tissue 07520 Incision and Drainage of ABCs – Extraoral Soft Tissue

62 07530 Removal of Foreign Body, Skin, or Subcutaneous Tissue 07540 Removal of Reaction – Producing Foreign Bodies Musculoskeletal Systems 07550 Sequestrectomy for Osteomyelitis

Repair of Traumatic Wounds 07910 Suture of Recent Small Wounds up to 5cm

Complicated Suturing 07911 Complicated Suture – Up to 5 cm 07912 Complicated Suture – Greater than 5 cm

Other Repair Procedures 07960 Frenulectomy (Frenectomy or Frenotomy) – Separate Procedures 07970 Excision of Hyperplastic Tissue 07971 Excision of Pericoronal Gingiva

Orthodontics Minor Treatment for Tooth Guidance 08110 Removal Appliance Therapy

Minor Treatment to Control Harmful Habits 08210 Removal Appliance Therapy

Interactive Orthodontic Treatment 08360 Removal Appliance Therapy

Adjunctive General Services Anesthesia 09211 Regional Block Anesthesia 09230 Analgesia (N2O2)

Miscellaneous Services 09910 Application of Desensitizing Medicaments 09940 Occlusal Guards 09941 Fabrication of Athletic Mouthguards 09951 Occlusal Adjustment - Limited ______Signature of Requester Date

______Signature of Reviewer Date

63 The dental director must ensure the providers working within the health center’s dental program are credentialed for the services they are capable of performing and limit all providers to perform only those services they are credentialed and competent to do.

Volunteer Dental Providers in Health Centers: While the BPHC encourages and fully expects health centers to take advantage of volunteer health care providers willing to perform services on behalf of the center’s target population, the mechanism for these relationships are not fully in place. Volunteers are not covered under FTCA malpractice defense programs since they are not employed or contracted full time within the health center. Furthermore, billing for services performed by volunteer providers can be a problem for certain state Medicaid program guidelines since, according to certain statutes, volunteer provided services should not be billed. A dental director should check with their state Medicaid authorities on billing issues before using these providers to perform care in the center.

In the case that a volunteer provider is to perform “free” services within a health center, the volunteer would still have to have medical malpractice coverage and provide proof of coverage along with credentials before performing dental care in the clinic. In most cases, the credentialing process, while not as extensive as the employee or contracted provider process, would involve proof of licensure, malpractice coverage, CPR certification and National Practitioner Databank clearance.

The health center retains a responsibility to the population it serves to ensure that the providers performing care are qualified and will practice competent dentistry.

Iowa has a state program that provides malpractice immunity for volunteer health care providers. This program provides coverage for providers if the services are performed within a non-profit institution that is not billing for the services provided. This program is called the Volunteer Health Care Provider Program (VHCPP). The VHCPP requires submitting an application by the non-profit health center to the Iowa Department of Public Health to be recognized as a program participant. Appendix F-1 contains information on VHCPP. Appendix F-3 is a sample application for the program.

Provider Health Center Agreements and Specialty Care: Another great challenge for health center dental programs is locating adequate specialty referral providers for health center patients. Location of the health center, lack of nearby dental specialists, and the inability for health center patients to pay for services contribute to this challenge. Creative use of transportation services can address some of the distance issues; however, financial limitations and inability to pay for services are among the more common reasons for lack of access.

Appendix F-2 presents information on a project developed by the National Association of Community Health Centers (NACHC) and the American Dental Association (ADA) that promotes contracting with outside dental practices to provide services not available on-site within the health center dental program. Specialty services like oral surgery and less common services like orthodontics and periodontics are services that may benefit from such contracted arrangements. As described in the document, services that are contracted are billed by the health center program as standard practice billings. The scope of services on the 330 grant reapplication or amendment must reflect the increase in provided treatment services as soon as the contracted services start. A contracted fee is paid to the specialist or outside practice based on the volume of treatment services, number of patients

64 treated, or dental treatment coded procedures provided. The fee payment methodology is established as part of the contract.

A limitation with this program is that the health center has little control over the quality of care provided. In addition, the health center cannot pass on to the contracted provider the full revenues received for the services billed on behalf of the contracted services due to anti-kickback federal policies. A separate fee payment must be made, preferably lower than revenues received or based on the amount of costs the health center can absorb above revenues generated. It is best if the health center works out a reduced fee arrangement with the contracted provider. Such contracted arrangements require a full health center credentialing process in addition to proof of separate malpractice coverage since FTCA does not cover contracted part-time providers.

The primary benefit to the contracted provider is that they do not have to register with a state Medicaid program or bill for services through a separate third party payment plan. The health center performs the billing and pays the contracted provider from the collected billing revenues.

Student Based Programs and Productivity: Dental clinics may consider the addition of senior dental student providers as a means to increase productivity. While these programs are gaining popularity, both in dental schools as well as in public health circles, such arrangements can be costly and not very productive unless effectively managed. The critical areas that need to be thought out and addressed by the health center and the dental school before entering such relationships include the following: ƒ Time commitment required of the preceptor/supervising dentist; ƒ Types of services and complexity of those services performed by students; ƒ Number of service expectations and scheduling of students; ƒ Staff availability; ƒ Costs necessary to equip, supply, and set-up a student dental program; ƒ Student housing arrangements; ƒ Adequate number of chairs and equipment; ƒ Availability of electronic resources and internet access for student communications with the dental school; ƒ Ability to perform financial evaluation of student productivity, revenue generation, and costs associated with student activities within the health center; ƒ Responsibility in case of liability, accidents, or emergency protocols in case of exposure to environmental hazards; ƒ Patient approval protocols for students to perform dental services; ƒ Guidelines for introducing students to clinical protocols and preceptor responsibilities prior to starting clinical care; and ƒ Evaluation plan and protocol for reporting student progress to the dental school.

Students are not eligible for coverage under the FTCA malpractice program; however, students are covered under the dental school’s malpractice policy while performing services in a health center. This should be well 65 documented in any agreement negotiated by the health center and the dental school. While not exhaustive, the criteria listed above must be determined well in advance and are essential to the success of a student-based clinical program.

Some health center dental programs attempt to minimize the costs involved with student-based programs by pairing two students together in one dental operatory. These students alternate between chairside dental assisting and performing treatment daily or morning and afternoon shifts. This arrangement is not recommended and will reduce productivity below acceptable standards and result in minimal treatment access improvement for the dental practice.

Each dental student should have a minimum of one dedicated, experienced dental assistant and one and one-half dental chairs for efficient productivity.

While no BPHC standard currently exists for student health center arrangements, experienced centers find the above arrangement to be a good model for maximizing productivity. Services performed by students should be limited to levels one, two, and simple level three services. Students should not perform comprehensive examinations and treatment plans unless a preceptor monitors these activities directly. Multi-visit appointment procedures such as fixed and removable prosthetic procedures are usually not practical for students due to their limited time in the clinic. Most of these procedures will not be completed by the student starting the procedure.

Preceptors that monitor student activities will find that there is a considerable time commitment involved to properly monitor student activities. This is especially true the earlier in the student’s dental school clinical training program that the student is assigned to the clinic. Third year students and early fourth year students will require additional attention than students who are later in the fourth year curriculum.

A preceptor can effectively supervise up to two dental students. However, with each additional student, the preceptor’s time availability for routine dental services will be decreased proportionately. While there is no set structure on the time requirements regarding the preceptor’s student supervision activities due to variations in services performed, a good standard model for scheduling both student and preceptor is seen in Table #13.

Table 13. Guidelines for Preceptor-Dentist Checks for Dental Students

A. Restorative Procedures 1. Check to Begin 9 Visually check to verify tooth number and surfaces student will be preparing. 9 Have student point to tooth to be treated. 9 When primary teeth are present, be sure there is no confusion between primary second molar and permanent first molar. 9 After check, student will anesthetize and begin preparing tooth. 2. Prep Check 9 Dentist will check preparation. 9 Verify that all decay has been removed, and verify small fissurotomies. 9 If tooth needs further preparation, it will be at the dentist’s discretion whether to check again before restoring the tooth.

3. Final Check 66 9 Dentist will check to be certain that the restoration is acceptable. 9 Verify that route slip is correctly filled out, e.g., correct tooth number, surfaces, and student ID number. 4. Charting 9 Student will chart after patient is dismissed. Once the chart is complete and signed by the student, it is to be placed on the dentist’s desk to be reviewed and signed by the dentist.

B. Perio Procedures 9 Check case at start. 9 Check again at completion.

C. Oral Exams / Treatment Plans 9 Review all radiographic findings. 9 Review all clinical findings. 9 Confirm that radiographic and clinical findings coincide. 9 Review the students plan for treatment – encourage productivity and efficiency in line with the patient’s issues for treatment. D. Other Procedures 9 PRN as necessary.

Some final thoughts: 1. Encourage the student to solve problems/dilemmas on his/her own. There is a tendency for students to want the preceptor to provide the answer for them - challenge them and make them think. 2. For the first few encounters with a student, the preceptor should be diligent in checking often until confident with the student’s level of competence. Students all learn at different rates and come to the clinic with different levels of experience. 3. By the second and third week of rotations, significant increases in both quality and quantity of the student’s work should be evident.

Suggested Scheduling Times for Dental Students These recommendations apply to a student during his/her initial week of the rotation for fairly routine procedures. As the student progresses, you will most likely want to shorten the scheduled times.

Procedure Surfaces Time Allowed Amalgam 1-2 60 minutes 3+ 90 minutes Resin – posterior 1-2 60 minutes 3+ 90 minutes Resin – anterior 1 60 minutes 2+ 90 - 120 minutes Extractions 60 minutes Stainless steel crown 90 minutes

67 Pulpotomy 60 minutes Root canals – anteriors only 90 minutes Prophy 60 minutes Root planing 60 minutes per quadrant Patient exam 60 minutes

Scheduling Suggestions for the Preceptor-Dentists ƒ One dentist ought to be assigned to be the preceptor for a student on a particular day. ƒ The preceptor-dentist ought to be scheduled to see his/her own patients in one-hour blocks. ƒ Preceptor-dentist will then see four patients of his/her own in the a.m. and four in the p.m. ƒ Avoid over-booking or emergencies for the preceptor-dentist.

It is suggested to keep a log of the student’s attendance on a daily basis for the health center and dental school’s records. The next page contains a suggested format.

Dental Student Work Log Date Student Time In Time Out Total Hrs

Given the general guidelines provided, a dental clinic can expect student productivity to approximate between 6.0 to 7.5 daily encounters (see Table #9). This is equivalent to 0.4 FTE and 0.6 FTE respectively based on BPHC daily productivity standards of 13.5 encounters for experienced staff dentists as seen in Table #8.

68 Dental directors should evaluate the minimum productivity requirements given individual program costs and revenue funding streams before considering a student-based community rotation. However, there are other tangible factors and benefits to having students in health center dental clinics including the following: ƒ Exposes future dentists to alternative career possibilities other than private practice; ƒ Provides opportunity to expose students to the cultural realities of community-based practice and improve competencies in treating diverse populations; ƒ Provides a mechanism for recruitment of future providers for the health center; ƒ Opens dental school faculty appointments to dental clinic preceptors and opportunities for decreased rates in continuing dental education programs offered by the dental school; and ƒ Keeps dental staff current on dental-related information and new clinical methods taught in dental school.

While decisions regarding student provider programs tend to focus on productivity, there are other non- productivity considerations that should be weighed as dental programs evaluate adding a dental student to the practice. Many programs have successfully maintained their provider staffing through direct recruitment of new graduates who have rotated through the clinic, which can be very valuable for health centers facing difficulty recruiting providers when openings occur.

Recruitment and Retention in Community Health Centers: Student community care center rotation agreements with state schools of dentistry are good methods of recruiting new providers in a health center. The exposure of students to “real dentistry” that makes a real difference in the lives of patients plus the opportunity to experience interaction between dental and medical providers in true primary care management are some of the best recruitment tools available to health centers.

The opportunity to experience multi-disciplinary primary care health practice is one of the most powerful and underutilized tools of community health center dental programs.

Health center programs are often not financially positioned to offer competitive wages when compared to the average and above average private practice of general dentistry. This is especially true for dental specialists like oral surgeons and pedodontists. Yet, health center programs can be reasonably competitive when a full benefit package and near average salary is combined with a student loan repayment plan.

The extremely costly investment of a dental school education often leaves new graduates struggling to repay education expenses. This is also compounded by inexperience and low productivity. A new dentist will not generate sufficient revenues to sustain a new practice, finance student educational debt, sustain the cost of operational overhead, staff wages and a significant benefit package, and experience a significant net income at the same time. Many new dentists seek opportunities in the Armed Services if available or employment with an established practitioner willing to pay a substantial base salary plus percentage of earnings due to production. Most private practice agreements do not include benefits like health, life and malpractice insurance and membership packages in professional organizations. In addition, the student loan repayment burden alone can still reduce net income potential significantly.

However, the greatest recruitment marketing strategy underutilized by health center programs is the true potential of primary care practice. While most dental students target private practice as their ultimate idea of 69 dental practice, a significant number view dentistry as an alternative to medical practice. A significant number of dental school admissions are dual applicants seeking admissions to both medical school and dental school programs. While medical school admissions can be very competitive, most dental schools are somewhat less competitive. Therefore, dual applicants often find admission into dental school less restrictive.

The prospect of entering a community-based dental practice that involves the use of skills and knowledge of oral medicine in a group setting consisting of both medical and dental professionals is a powerful lure to dental students and new graduates inclined towards the general medical model of health care.

An effective recruitment strategy would suggest the following: ƒ Combine a reasonable salary with a student loan and generous benefit package. ƒ Develop and promote strong collaboration between the dental and medical departments of the health center program. ƒ Promote a strong combined primary care mission statement and marketing strategy for the health center. ƒ Develop a website for the health center with quality photos and examples of the center’s joint primary care health management mission. ƒ Clearly illustrate overlapping joint collaborations of the dental and medical program in patient care management (the team health care concept). ƒ Produce publications and handouts for distribution at professional conferences, publications, dental school recruitment offices and dental student based programs with the health center’s website listed. ƒ Participate in student community health center (dental, hygiene and assistant) training rotation programs, and develop a friendly, variety-filled experience for students with opportunities to interact with both the dental and medical sides of patient care management. ƒ Update and maintain a modern, clean environment and image in patient care, in regard to equipment, materials, and patient care services and the use of electronic patient records.

If a health center devotes significant time and resources to the above considerations, the center will be successful in sustaining a good supply of potential providers ready and willing to accept employment in the dental clinic program.

Retention is essentially focusing on and sustaining the same core values used in recruitment. A regular assessment of the health center’s internal environment should be performed by utilizing personnel satisfaction surveys. Also, the use of regional appropriate salaries, bonus and benefit packages will help the program remain competitive. The dental program should place strong emphasis on primary care collaborations and offer regular opportunities for continuing skill development. If these policies are followed, the health center will retain a viable and satisfied workforce.

70 Chapter 8 • Policies, Procedures, Quality Assessments, and Peer Reviews Good practice and operational policies and procedures can actually make a dental director’s job easier. These written guidelines can be referred to as authority for staff and provider guidance and for patient education on practice responsibilities and limitations. When addressing staff, provider, patient and even administrative complaints a well-written policy can aid the dental director in diffusing many disputes. However, the challenge in writing a good policy and procedure is writing too much detail and boxing the practice into such a tight regiment that new policies and procedures must be constantly written. This can easily happen if the practice includes such things as: ƒ Listing the brand name of reagents, medicaments, soaps or treatment material manufacturer as a standard of care in a policy; ƒ Restrictions to only one type of lab in name or supply vendor source as policy; or ƒ Restrictions that negate the ability of the practice to improve as new or better technology and materials become available.

Policies and procedures should be written that allow some limited flexibility for change while protecting operating standards that really impact quality of care and safety.

Dental directors must be aware that all policies and procedures must be reviewed by the health center’s board of directors and approved before the policy becomes official. This may take some time to accomplish. Some health centers limit approval and amending of policies and procedures to quarterly, semi-annual and annual cycles. If a new material or vendor with better features or prices becomes known, it could take up to a year to delete the old policy and allow a change of practice venue.

It is usually not necessary for “everything” to be spelled out in a policy and procedure like a cookbook. General wording and criteria is better unless the policy addresses specific practices that will not soon change and has evidence-based association with good outcomes. Appendix E-1 presents a good example of a well spelled out practice policy and procedure for most dental operations. General statements like: “Irrigation should be accomplished with sodium hypochlorite” are preferred over statements like: “Irrigation should be accomplished with Clorox Bleach.”

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Table 14.

“X” COMMUNITY CARE CENTER Policies/Procedures

Category: DENTAL Policy: No Show - Dental Dental Services

Desired Outcome: To define patient status following a failed appointment. Procedure: 1. All patients are expected to keep all appointments and be in the office on time. 2. If a patient fails to keep three consecutive appointments without notice whether the appointment could be confirmed or not, that patient will no longer be able to make another appointment for routine dental care. 3. The patient will be able to access dental care during “designated no show” times. 4. Once the patient fulfills the no show time requirement, another appointment can be made for the patient. The staff will explain to the patient that if he/she fails another appointment, then they will be placed on PERMANENT no show status, meaning they will no longer be eligible for any regular appointments. If the failed appointment was for a minor, this explanation will be given to the patient’s parent/guardian. 5. Documentation for steps two and four will be made in the dental chart by the staff member giving the information. 6. Exceptions can be made by the dental office coordinator or staff member based on individual circumstances.

Approved by:______Signature/Title Date

Reviewed:______Ints:_____ Reviewed:______Ints:______Reviewed:______Ints:______

Table #14 gives an example of a simple, to the point, no-show policy. This can be beneficial where volumes of policies and procedures are required. The larger the document, the larger the volume of the bound manual and the harder it will be for storage and reading.

Some policies and procedures must conform to standards established by a manufacture warranty for service of equipment. Table #15 presents a case where the policy complies with manufacturer warranty requirements. In those situations, you must record the procedure as recommended.

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Table 15.

Community Care Center Dental Services Maintenance Policy and Procedures

Policy: A/T2000 X-ray Developer Maintenance

Responsibility: Dental Assistant(s)

Outcome: Maintain equipment warranty and operational status.

Procedure: 1. At the start of each day of operation: A. Check fluid levels in chemistry bottles. B. Turn on water supply and power switch. C. After ready light illuminates, run a cleaning film through.

2. At the end of each day: A. Turn off power switch and water supply.

3. Weekly: clean rack assemblies. A. Remove rack assemblies. B. Use Spray 2000 (manufacture recommended materials) with warm running water and separate sponges to clean assemblies. C. Rotate gears while cleaning rollers. D. Rinse thoroughly.

4. Monthly: change chemistry. A. Remove and clean rack assemblies. B. Drain developer and fixer tanks. C. Rinse tanks with warm water three (3) times. D. Refill with water, replace cover, plug in, turn on and run processor and manual start for two (2) minutes, then drain, and wipe dry. E. Fill tanks with chemistry, replace assemblies. F. Process cleaning film.

5. Quarterly: clean with formula 2000(manufacture suggested cleaner). A. Remove and rinse rack assemblies. B. Drain and rinse tanks twice. C. Fill fixer tank with water, add Formula 2000 or manufacturer recommended cleanser to developer tank, replace rack assemblies. D. Press manual start and allow processor to run through cycle. E. Fill tanks with water, turn on power switch for two (2) minutes to purge replenishment lines. F. Drain and rinse twice and wipe dry. G. Fill tanks with chemistry, replace rack assemblies, developer is ready for operation.

73 A policy and procedure should be composed of: ƒ Subject matter of “policy” where or what will be affected; ƒ Outcome desired by implementing the procedure; ƒ Responsibility (if applicable); and ƒ “Procedure” describing the action steps involved.

Required Policies and Procedures: The Bureau of Primary Health Care’s standard regarding written policies and procedures for health centers as seen in Appendix A-3 is as follows:

“Health centers are expected to establish written clinical policies, protocols, and procedures i.e. principles of practice that are ratified by the center's board of directors. This documentation provides a systematic approach to the clinical management of oral health care services that include, but are not limited to the following elements: hours of operation, patient flow procedures, patient tracking systems (encounter data), the use of clinical protocols, risk management procedures, and patient grievance procedures.”

Health centers typically have a large variety of policies and procedures that cover a wide spectrum including: ƒ Organizational structure; ƒ Mission, values, and mission; ƒ Scope of services; ƒ Personnel /human resources, i.e. hiring procedures, position descriptions, credentialing and privileging, and employee and staff rules; ƒ Financial management procedures; ƒ Clinic insurance; ƒ Appointment and walk-in procedures; ƒ After-hours policy and emergency care protocols; ƒ Narcotic control policy; ƒ Patient’s rights policy; ƒ Patient record policy and HIPAA compliance; ƒ Informed consent procedures; ƒ Infection control procedures; ƒ Hazard communication program (federal requirement); ƒ Clinic safety protocols; ƒ Evacuation plan; ƒ Equipment use and maintenance protocols; ƒ Clinical procedure protocols; ƒ Patient management protocols; ƒ Referral protocols; and ƒ Inventory control protocols.

74 A useful online reference on policies and protocols can be found at: www.dentalclinicmanual.com . Chapter 4 of the safety net manual on the website addresses clinical operations and how to set up policies and procedures appropriate to dental clinical practice in a public health setting. Appendix E-12 includes an additional protocol for management of medically complex cases that would be a great addition to clinical management guidelines. However, the dental director must face the possibility of regular revisions as more evidence-based methods become available.

Dental directors should be aware that new policies and procedures may become necessary as new experiences in clinical practice and patient care occur. For example, policies on adults accompanying children into treatment rooms may need to change if experience shows that a large number of adult relatives and siblings want to accompany a minor child into the treatment area, restricting the operating space and presenting a safety issue. A policy may be required to limit the number (if any) family members or care givers that can be present in the treatment area.

Quality Assessments: Establishing a good clinical quality assessment plan is essential to good patient care management. Such a system can be as simple as a random chart audit to as advanced as a multi-clinic peer review process involving both chart audits, clinical inspection and selective patient treatment evaluations. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires a “peer” review process to be in place within a health care organization.

Often, a dental director will conduct their own random chart and treatment observation assessment in addition to a peer review process. The advantage of both is that in addition to the dental director having direct knowledge of the quality of care, the peer review process involves all clinical dental providers within the health center and engages them in the quality process.

Chapter 5 of the Safety Net Dental Clinic Manual (www.dentalclinicmanual.com) gives a good description of the purpose of health center accreditation programs like JCAHO including quality assessment protocols commonly used in health center and other public health based dental clinics. New and seasoned dental directors should consult this reference guide in developing protocols for their clinics.

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Table 16. Dental Provider Performance Evaluation

Dentist Primary (Bonus) Criteria: Clinical Productivity (individual) a. RVUs b. Encounters c. Revenue

Secondary (Merit Performance) Criteria: 1. Patient satisfaction survey 2. Work habits 3. Meeting attendance 4. Peer competency review* a. Treatment audits b. Chart audits 5. Staff evaluations 6. Continuing education 7. Overall attendance habit 8. Student preceptor participation

Method: 1. Monthly computerized production/RVU summaries 2. Quarterly/yearly audits 3. Staff/patient survey 4. Yearly CDE report 5. Meeting logs 6. Clinical director performance review 7. Chart reviews 8. Post treatment x-ray review 9. Clinical remake audits/lab receipts/expense reports 10. Attendance/hourly work reports

*not directly considered in merit increase

Table #16 contains a protocol for using dental provider assessments as an incentive tool in bonus rate increase evaluations. Multiple criteria are used in the evaluation process including a peer review component.

For a comprehensive clinical guideline on dental clinic protocols, quality assessment tools, and policies see Appendix D-5, E-1 or read Chapters 4 and 5 online at www.dentalclinicmanual.com.

The peer review process can be performed through rotating provider pair matches where one provider is assigned the charts of another provider in undisclosed covers or containers marked “peer review.” Once complete, the score forms are delivered to the dental director for summary and report generating. A composite score with benchmark identifying problem areas without identifying the provider can be made with corrective action given to

76 the entire team. Each peer provider is given policy-based instructions such as in the simplified example seen in Table #17 to use in reviewing peer charts.

Table 17. Quality Assessment Policy

Dental Records Audit Criteria Dental chart audits are performed to assess completeness of documentation, risk management issues, and appropriateness of care in order to assure the highest quality of care for our community.

Implementation Procedures Chart audits will be performed every six months on 20 selected charts for each dental provider of X clinic. These charts shall cover representative populations of the practice including pedodontic, geriatric, and adult care cases including emergency only services.

Results of the review will be shared with each provider in a timely manner. Effort will be made to select charts that fall between each six-month interval in order to assess improvement. Results of the audit may be used in performance evaluation reviews.

Chart Audit Index Emergency Exam Charts 1. Complete medical histories signed by the patient and initialed by dentist. 2. Properly labeled, diagnostic x-rays where appropriate. 3. “Emergency Exam” and date listed on the treatment notes. 4. Treatment notes to include chief complaint, patient symptoms, and tests performed if applicable. 5. Diagnosis and treatment indicated in treatment notes. 6. Medications given or prescribed, instructions to patient and follow up notes. 7. Warning labels attached to chart cover concerning allergies, SBE, dialysis patients, LATEX, and generic “alert” labels where indicated to preserve patient confidentiality. 8. Initials of provider on all treatment entries in the patient record and staff member making entries. 9. All entries should be legible. 10. Changes in medical history or status should be noted with patient signature and assistant initials on the treatment record date line for each successive dental visit. 11. Complete patient registration form with consenting patient/guardian signature and date. 12. Patient name clearly listed on each entry page of the treatment record. 13. All referral copies attached to file with provider signature when appropriate. 14. Consent forms and post extraction care forms attached to chart with appropriate provider, patient, and witness signatures. 15. Blood pressure listed for all emergency exams with assistant initial on treatment record for all adult patients. 16. All one-time visit patients shall be placed in a red emergency chart.

Established Patient Charts 1. All medical history, registration, consent information filled out and signed by patient/guardian. 2. Provider initial on the medical history form. 3. All x-rays mounted, labeled, and of diagnostic quality. 4. Protocol for all initial examinations should include “Initial Examination” listed on the treatment notes, adult blood 77 pressure, date, unusual findings, next appointment planned, provider initials, and assistant initials taking BP and listing treatment in computer. 5. Each medical entry form, treatment record page, examination record page, provider referral form and treatment consent form should have a provider signature and/or initial indicating the information has been reviewed. 6. Treatment plans are listed in the chart via computer printout summary and placed on the appointment planner sheet in per visit sequence. Effort should be made to list treatment sequence based on urgency of care with the most urgent needs starting at the top of the form in descending order. 7. Tooth charting should be completed in red pencil for decayed surfaces, infected root, abscessed areas and planned extractions. All other shading including filled teeth, missing teeth, and spacing areas should be in blue pencil. 8. Periodontal assessment should be complete including PSR scores in all adult cases, calculus, gumline inflammation index and PSR probing modifiers in sextant readings. 9. All identified oral risk factors should be checked off on the periodontal assessment sheet. 10. Educational literature should be given and discussed with the patient regarding oral risk factors. This is confirmed by checking the appropriate line item on the periodontal assessment sheet. 11. The initial oral assessment page is to be complete and initialed by the provider. All line items are to be filled unless certain conditions do not apply. A straight line through the item indicates “does not apply.” 12. Successive patient treatment record entries should include date, medical history update, assistant initials, treatment performed, medications administered or prescribed including dosage, materials utilized, listing of unusual findings, patient progress, patient concerns, follow up treatment planned and provider initials. 13. Referral letter responses are to be reviewed and initialed by the referring provider. 14. Periodic updating of tooth charting, periodontal assessment, oral assessment, medical history, and blood pressure should occur on a yearly basis when most patients are eligible for new bitewing x-rays. 15. Six-month periodic exams will include rubber stamp listing of PSR, soft tissue, plaque levels, calculus, caries development, and pertinent findings on the treatment record including provider initial and date. 16. All dental hygiene listings will be in purple ink. Dentists shall utilize black ink in chart entries. 17. All educational items, toothbrushes, floss, fluoride supplements, applications, and dental care items are to be listed in the patient’s progress notes including units and dosage when applicable. 18. When a PSR reading of three or more is encountered in at least two sextants or more with bleeding a complete periodontal probing and charting is to be performed. The results can be listed on a computer-generated form and attached to the chart. 19. All regularly seen patients shall have a blue general care chart.

Total Audit Criteria: 34 One point deduction per missing or erroneous entry .

The final scoring and report as seen in Table #18 is summarized in a non-identifying manner that prevents provider intimidation by peers and reduces the risk of retaliation.

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Table 18.

“X” Community Care Center Dental PEER Review Assessment – April, 2003 Summary Benchmark Score: 90% ƒ Continuous improvement in overall score seen ƒ Only two out of 34 categories deficient = 94 % ƒ Targets for improvement include patient education chart entries and patient name clearly highlighted on each page of diagnostic assessment page of treatment record ƒ Audit limiting factors include multiple providers treating and listing in charts randomly pulled ƒ Multiple providers responsible for yearly and periodic assessments

Only the dental director retains the charts and identities of each provider involved, both in the charting and performing the review. The dental director checks for accuracy and assigns a note in the record of each provider quality assessment file. This confidential log is maintained in a secure place and can be used in incentive-based evaluations.

While the use of a chart-based audit is standard in clinical practice, a random patient screening based on treatment recorded during the chart review adds real quality determinants to the review process and gives more information on actual quality of care. This is the preferred method for quality assessment programs. For a comprehensive model of a multi-clinic peer review/quality assessment tool, see Appendices B-5, B-6, B-7 and B-8 or go to the Clinical Director’s Network website at www.cdnetwork.org. This organization provides training and tools in conducting high quality clinical assessments.

79 Chapter 9 • Strategic Planning Dental directors must be prepared to serve their health center through participating in the health center’s strategic planning process. This process is usually performed annually and involves members of the health center board of directors, executive leadership team, health center stakeholders and members of the community. Strategic planning consists of: ƒ Performing an environmental analysis; ƒ Conducting internal and operational analysis; ƒ Defining the mission and core values of the health center; ƒ Evaluating the needs of the population; ƒ Projecting future needs and trends of the environment; ƒ Developing strategies to address future needs and trends; and ƒ Finalizing the process to implement the strategies.

The dental director’s role is to scan the oral health environment utilizing various survey tools including patient/customer satisfaction feedback to assess the dental programmatic impact in the community. From these analyses, the dental director provides informational support to the board and administrative team in the strategic planning process. A simple example of a patient satisfaction survey is seen in Table #19. This type of survey tool can be given to random patients during check out process after a dental visit and given on quarterly or semi- annual basis.

Additional surveys of the population environment are critical to understanding the trends and conditions that may impact the program. Linkages with state public health programs and local community collaborations are helpful obtaining the necessary information needed to make strategic program decisions.

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Table 19. Dental Patient Satisfaction Survey

We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for your time.

Date:______

Who did you see today?:______

My appointment today was: (circle one) I am a: (circle one) Walk - in New patient Scheduled Returning Patient

Please circle how satisfied you are in the following areas: VERY NOT SATISFIED SATISFIED SATISFIED N/A 3 2 1 0

Ease of getting care: Ability to get in to be seen 3 2 1 0 Hours center is open 3 2 1 0 Prompt return on calls 3 2 1 0 After hours contact service 3 2 1 0

Your provider:

Listens to you 3 2 1 0

Takes enough time with you 3 2 1 0 Answers your questions 3 2 1 0 Encourages you to participate in your treatment 3 2 1 0 decisions 3 2 1 0 Provides educational materials

Clinical Support Staff: 3 2 1 0 Answers your questions Friendly and helpful to you 3 2 1 0

81 Front Office: Friendly and helpful to you 3 2 1 0 Answers your questions 3 2 1 0 TURN OVER

Please circle how satisfied you are with: VERY SATISFIED NOT N/A SATISFIED 2 SATISFIED 0 3 1

Facility: Neat and clean office 3 2 1 0 Comfort and safety while waiting 3 2 1 0 Privacy 3 2 1 0

60 min 15-30 min 30-45 min 45-60 min or How long did you sit in the waiting room? more 1 hour or 1 – 2 hours 2 – 3 hours What was the total time you were at the center? 3 hrs. less or more

Would you refer your friends or relatives to us? YES NO

How can we do things better? ______

______

______

Thank you for completing our survey!

82 The dental director in cooperation with community public health organizations and health care service coordinators might elect to conduct a regular phone or mail survey to obtain information on the needs and care access perception of the local population. This information can be useful in evaluating the impact of the dental program and other resources addressing oral health in the clinic’s target community. These quarterly or semi- annual surveys vary in design and content based on the purpose of the survey. An example in Table #20 provides some insight into community oral health habits, knowledge, and dental care experience of local families

Table 20. Iowa Quarterly Oral Health Risk Questionnaire (Information must be obtained from parent or adult caregiver)

1. Does your child have caries (cavities)? Yes No 2. Can you (parent) describe your child’s oral health status? Yes No 3. Does the mother/father have caries? Yes No 4. Do siblings have caries? Yes No 5. Can parents identify three causes of cavities? Yes No 6. Do you (parent) conduct “Lift the Lip” screening monthly? Yes No 7. Does the child receive fluoride varnish treatments? Yes No 8. Do you (parent) clean/brush child’s teeth morning and night? Yes No 9. Do family members brush their teeth morning and night? Yes No 10. Does the family use fluoridated toothpaste? Yes No 11. Does the family drink fluoridated water? Yes No 12. Does/did family practice appropriate nursing/bottle feeding? Yes No 13. Does/did family practice appropriate “teething” practices? Yes No 14. Does family avoid grazing, for example on chips and cookies? Yes No 15. Does family provide child only 4-6 oz. of juice per day? Yes No 16. Does family avoid continually drinking sugar-laden carbonated beverages? Yes No 17. Does family sit at tables for meals and snacks? Yes No 18. Does the family have a community dentist who sees children? Yes No Initial Assessment; 3-month Assessment; 6-month Assessment; Final Assessment

Oral health surveys can offer important information. National and state survey data can supplement local efforts and provide a broader perspective on how the community data fits into the experience of a regional level. Shared concerns that span across a large region can form additional leverage for combining resources and increasing the size of potential collaborative advocacy with other stakeholders sharing common concerns and interests.

Dental directors should monitor ongoing prevention-based activities with their communities such as water fluoridation and regular evaluations on level of fluoridation the public is receiving. This may include surveys on bottled water use and percentage of population that uses municipal water as their drinking source. Collaborating

83 with state and county fluoridation officials will also prove helpful in knowing the community’s resources and ability to modernize fluoridation equipment and obtain optimum levels for the community.

A very useful and innovative collaboration is to work with local hospitals to monitor emergency room admissions based on oral-related complications. The patterns and numbers can be very useful in determining what types of services are missed by the health center or to develop strategies to be more effective in meeting emergency dental needs. Hospital administrators can become strong advocates for dental programs if they see efforts made to reduce emergency room over-utilization, especially with large volumes of uninsured patients. Hospitals are also very appreciative of efforts to prevent admissions of children requiring operating room services due to extensive dental decay. Health center dental programs can gain additional support and resources through forming close relationships with hospitals. For more information on types of useful surveys and how to design surveys, consult the American Association of State and Territorial Dental Directors (ASTDD) website at www.astdd.org.

Strategic Planning for Best Practices in CHC Dental Programs: One of the core purposes behind the BPHC primary care focus for health center-based dental programs is the integration of oral health and general health care practice. Having both a medical and dental practice under one roof or within one program offers great opportunity to investigate how both can be merged into a single primary care unit. Health centers are strategically established with that objective in mind. The collaboration between dental director, medical director and staff providers opens opportunity for joint learning initiatives and sharing of information. This is also the most attractive aspect of community health center-based practice. In a CHC, a dental provider has the potential of practicing oral medicine as part of the overall medical team. This aspect of community health center practice is very marketable to new dentists entering practice, but is currently underutilized.

One aspect of integrated primary care is shown in Appendix E-12. This example considers medical management from the dental provider’s perspective in providing treatment for medically compromised patients. A dental provider must collaborate with medical providers to determine safe parameters for treating high-risk patients and clearly demonstrate that having a medical clinic nearby is very convenient. Also, such cases give dental providers opportunity to exchange information with medical colleagues. Another aspect comes from the medical provider’s perspective when dental providers are consulted on management of dentally challenged patients such as in organ transplant cases and prosthetic joint repair where dental conditions like severe periodontal disease can compromise surgical outcomes. Physicians seek out dental advice and treatment to manage these situations, and having an on-site dental clinic can be advantageous.

However, there are opportunities for greater integration in primary care patient management. On another level, opportunities exists where routine patient evaluations can serve as screening procedures for both medical and dental management. The taking of a routine blood pressure and general vital signs like heart rates, breathing rate, levels of consciousness, and temperature readings taken in a dental clinic can be shared with medical providers as a means of screening and referral. On the medical side, routine oral screening of children and adult pregnant women by medical providers with referral of suspect dental disease is very valuable in a primary approach to health care. However, for both of these situations to occur effectively a routine opportunity for joint provider education must be part of the health center’s provider development protocol.

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Regular joint medical and dental provider training sessions should take place. A quarterly session with dental and medical providers alternating the presentation of information that cuts across both dental and medical disciplines is suggested. Table #21 gives an example of a dental presentation that can be shared during a joint session. Since periodontal disease has research-supported medical implications in disease management ranging from premature birth to diabetic management. The health center’s medical providers will be engaged to learn about management techniques from a dental perspective.

Table 21.

Periodontal Complications of Diabetes Health Disparities Collaborative Bureau of Primary Health Care Changing Practice, Changing Lives

Script Provided by National Institute of Dental and Craniofacial Research 1. * TITLE/LOGO 2. DETECTION AND PREVENTION OF PERIODONTAL DISEASE IN DIABETES: Periodontal problems can complicate the management of diabetes, and uncontrolled diabetes may aggravate periodontal disease. Recent studies indicate that the majority of the U.S. population has some periodontal disease including the most common form, chronic adult periodontitis, formerly known as pyorrhea. 3. Because the prevalence of both chronic periodontitis and diabetes increases with age, establishing a relationship between these diseases in older age groups is difficult. Recent studies in which the age relationship of periodontal disease is accounted for show that in persons with noninsulin-dependent diabetes mellitus (NIDDM), also called Type-2 Diabetes, periodontal disease is more severe and more prevalent than in people without diabetes (normal glucose tolerance or NGT). 4. Periodontal tissue loss, measured in millimeters along the tooth root, is a key indicator of periodontal disease severity. In the Pima Indians of Arizona, a population with the highest prevalence of Type-2 Diabetes in the world, periodontal infection and tooth loss are significant complications of the disease. These studies further show that adults with diabetes have a greater tooth loss from periodontal disease than people of a comparable age who do not have diabetes. 5. Diabetes and periodontal disease are also related in children and adolescents. Gingivitis is more frequent and severe in prepubertal children with diabetes, especially when metabolic control is poor. Among adolescents, approximately 16 percent of 11- to 18-year olds with insulin-dependent diabetes mellitus have periodontitis. 6. Classic studies in the late 1960s demonstrated that young adults with IDDM (Insulin Dependent Diabetes Mellitus) showed a significant increase in periodontal tissue breakdown compared to persons without diabetes. 7. These studies further showed that individuals with Type-1 diabetes with retinal changes experienced greater loss of periodontal attachment than those without this eye complication. 8. Normal periodontium includes gingival, periodontal ligament, cementum, and alveolar bone. It is supplied by the vasculature and is affected by bacterial plaque that accumulates at the junction between the teeth and 85 the gingivia. 9. Major tooth components: ƒ Enamel, the hardest substance in the body, forms the outer covering of the tooth. ƒ Dentin is the hard tissue that comprises the bulk of the inner tooth. ƒ Pulp, the soft tissue of the tooth, contains the blood vascular system and nerve tissue. ƒ Cementum is a hard tissue that covers the tooth root. ƒ Periodontal ligament tissue is composed primarily of collagen fibers, which attach the tooth root to the supporting alveolar bone and gingival tissues. 10. In addition to elevated glucose levels, other changes in diabetes may predispose individuals to periodontal disease. These include impaired leukocyte chemotaxis, phagocytosis and bactericidal activity. Impaired neutrophil function may reduce resistance to periodontal infection during periods of poor diabetic control and local relative insulin insufficiency. Other factors contributing to periodontal disease in persons with diabetes may be altered collagen metabolism and vascular changes, including stasis in the microcirculation. 11. Periodontal disease can best be described as a three-stage process starting with gingivitis, progressing to periodontitis, and finally to advanced periodontal disease. These stages are associated with bacterial accumulations, or plaque, at and below the gum line. As with other types of infections, these dental infections may worsen the diabetic state, resulting in hyperglycemia, fatty acid mobilization, and acidosis. Exacerbation of dental infection may undermine good diabetic control, and initial control may be difficult or impossible in a person newly diagnosed with diabetes who has active dental infection. Severe periodontal disease may also hamper systemic management by making chewing painful or difficult, leading the person to select foods that are easier to chew but which may not be nutritionally appropriate. 12. DETECTION AND MONITORING: Primary care providers and dental professionals can detect diabetes if they are aware of the periodontal manifestations of the disease. These include severe gingival inflammation, acute gingival or periodontal abscesses (which may be multiple and recurrent), and rapidly advancing periodontal disease. 13. Signs and symptoms related to dental structures may furnish clues about the presence of diabetes. In screening for periodontal disease, the gums adjacent to the teeth should be examined for bright red or magenta tissue or purulence emanating from the margins. Severe recession of gum tissues may be indicative of alveolar bone loss, and acute or multiple periodontal abscesses may suggest the presence of undiagnosed or uncontrolled diabetes. 14. Persons with diabetes may have elevated glucose levels in oral fluids when blood glucose is high, which can encourage the growth of Candida albicans, the causative agent in thrush. 15. Oral Candida albicans counts have been reported to be higher in individuals with diabetes. Local factors, such as smoking and wearing dentures, may promote candidal colonization of the mouth. 16. Gingivitis, a reversible condition, is characterized by inflamed and bleeding gums. Since it can be a precursor to chronic periodontitis, gingivitis requires treatment. 17. In gingivitis, periodontal disease is confined to the gingiva with no loss of junctional epithelial attachment. Gingivitis results from bacterial plaque accumulation at the gum margin and in the sulcus between the margin of the tooth. 18. These bacteria and their products have direct inflammatory effects and also evoke an immunological response.

86 19. The response to plaque leads to progressive destruction of the connective tissue fibers, resorption of the alveolar bone around the tooth, and deepening of the gingival sulcus or socket. The resulting condition is called periodontitis. 20. The periodontium (the tissues surrounding, supporting, and attaching to the teeth) is affected by the toxicity of the bacterial plaque as well as the resistance of the tissue. The microvasculature of the periodontium in diabetes shows microangiopathic changes that may reduce the resistance of the tissue and allow more severe periodontal disease. If untreated, periodontitis may result in rapid destruction of the tooth support and eventual tooth loss. 21. An increased susceptibility to acute periodontal abscesses has been reported in uncontrolled diabetes mellitus. 22. Periodontal abscesses also occur in individuals without diabetes, but their presence should alert the examiner to the possibility of undiagnosed diabetes or a change in diabetic control. 23. Granulomatous growths from the wall of the gingival sulcus can result from periodontal disease. 24. Oral hygiene measures (prophy and scaling) carried out by professionals are extremely important in controlling periodontal disease. 25. A dramatic response can occur in a short time with professional removal of calculus and plaque and diligent daily home care. 26. As periodontal disease advances, there is increasing resorption of the alveolar bone and loss of tooth attachment, making extraction necessary if the disease remains untreated. 27. An x-ray at the time of diagnosis of NIDDM may illustrate severe destruction of the alveolar bone that can lead to rapid migration of the teeth and severe involvement of the molar teeth. 28. Periodontal disease is correlated with diabetic control. 29. Although highly prevalent, not everyone has periodontitis. Elderly individuals with diabetes can retain their natural dentition and healthy periodontium, due in large part to a team effort of the patient and professional. 30. PRINCIPLES IN PREVENTION: CONTROL DIABETES: Dental infection in diabetes can cause a series of adverse metabolic consequences, including coma. Rapidly progressive periodontitis is less responsive to conventional dental treatment such as subgingival scaling and plaque control. With continuing bone loss around the teeth, exacerbations may occur. Therefore, preventing infection through local measures and reducing susceptibility to infection by maintaining good control of diabetes are primary steps in preventing periodontal complications.

PRESERVE NATURAL TEETH: Most people with diabetes who lose their teeth do so because of periodontal disease. Dentures may not be completely satisfactory replacements because the size and form of the remaining alveolar ridge may not allow proper fit. People who have diabetes may not tolerate full dentures well, especially when diabetic control is poor, because of mucosal soreness. Every effort should be made to preserve healthy, functional, natural dentition so that persons with diabetes may chew proper foods efficiently and comfortably. 31. When the base upon which dentures sit is destroyed, dentures will not have the necessary support. 32. MAINTAIN GOOD ORAL HYGIENE: Periodontitis is a bacterial infection strongly correlated with poor oral hygiene. It can be prevented or arrested by local treatment aimed at plaque and calculus removal and 87 improved oral hygiene, all of which are directed towards eradicating the pathogenic bacteria that cause periodontal disease. 33. TREATMENT AND REFERRAL: Persons with diabetes should be evaluated by their physician before scheduling treatment for periodontal disease. The dental practitioner should also consult the physician before gum surgery to be aware of the patient’s general condition. Knowledge of the patient’s medical history helps the dentist and physician determine the need for pretreatment with antibiotics. The decision whether or not to pre-treat with antibiotics should be based on the special needs of each patient and the type of dental procedure planned. 34. ACUTE INFECTIONS: Surgical treatment of advanced periodontal disease should be deferred in favor of conservative nonsurgical therapy, including adjunctive use of antibiotics, until diabetes is reasonably controlled. Acute infections, however, require immediate attention, including draining acute abscesses and administering broad-spectrum antibiotics. Complete metabolic control of diabetes may not be possible while dental infection is still present. However, if blood glucose can be reduced, the acute periodontal infection may improve. 35a. ORAL SURGERY: Once infection has subsided, necessary tooth extractions or other treatment can be performed. When diabetes is under good control, oral surgery can be carried out as in a nondiabetic patient. 35b. SCHEDULING APPOINTMENTS Dental appointments should be scheduled in the morning generally about an hour and a half after breakfast and the morning insulin. Persons with more severe diabetes should have surgery in a hospital where they can be more easily monitored during and after the procedure. 36. PATIENT EDUCATION PRINCIPLES: ƒ Inform patients that periodontal infection may make it more difficult to control diabetes and conversely, that poor diabetic control may increase susceptibility to infection. ƒ Patients who have diabetes should know that they may be more likely to get gum infections and that the infection may take longer to heal. Long-standing infection may lead to loss of teeth. ƒ Because of the importance of proper diet in helping control diabetes, the desirability of maintaining natural dentition should be emphasized. Persons with diabetes may have problems wearing dentures. ƒ Good oral hygiene will help prevent many periodontal problems. Patients should be counseled to carry out regular self-examinations of the mouth. Bleeding gums may be a sign of infection, and patients who notice this or other unusual lesions in the mouth should see a dentist. ƒ Because persons with diabetes may often be unaware that they have periodontal disease, they should have a dental checkup at least every six months and make certain that the dentist knows about their diabetes.

Further innovative integrations of primary care dental and medical practice are possible. Some of the potential collaborations include the following: ƒ Provision of dental hygiene prevention services within the health center’s pediatric clinic during well-child clinical exam visits; ƒ Routine blood monitoring of diagnosed diabetics in the dental clinic during recall and emergency dental visits; ƒ Psychological depression questionnaire given to suspect patients exhibiting signs of clinical depression;

88 ƒ Establishing joint clinical protocols in diabetic patient management including periodontal management and dietary counseling; ƒ Smoking cessation protocols with medical and psychological referral criteria and management included with cancer screening; ƒ Prenatal protocols for new pregnancy diagnosis including an oral health education and dental management plan; ƒ Narcotic and addiction management plan for suspect abuse patients; and ƒ Assignment of a midlevel medical provider to the dental clinic to screen adults and children for diabetes and weight management during routine recall appointments.

A health center’s strategic planning process should include advancing means to further integrate the health center’s health practice collaborations with the goal to completely integrate services into a single primary care practice program. The dental director must become a catalyst for promoting this objective within the health center’s administrative team.

In September 2005, the HRSA Bureau of Primary Health Care will pilot a new oral health collaborative as the next phase of the Health Disparities Collaborative (see http://www.healthdisparities.net). This new collaborative will focus on integrated management of diabetes, maternal and prenatal care, and early childhood development to target reductions in glycohemoglobin levels and improve diabetic management, decrease low birth weight babies and reduce incidence of early childhood caries in children between the ages of one to four. Protocols involving medical and dental management of patients presenting with the diagnosis of diabetes, pregnancy, and high caries-risk young children will be targeted for intervention and tracked. Evidence-based research has shown improved outcomes in these cases when medical and dental interventions are combined. Health centers will become the proving stage where research meets practical application and results are evaluated over time. The future of health care finance will involve a results-based or performance measure. If the new oral health collaboration shows improved disease management outcomes, health center programs will lead the way.

It should also be noted that among the most difficult dental appointments to schedule that have the highest no- show rates are preventive recall appointments. Strategically combining recall dental services with medical recall evaluations as in well-child exams and maternal prenatal checks with a preventive dentistry service and exam can reduce multiple appointment requirements and increase overall compliance.

Electronic health records open a new potential within health centers: the ability to integrate medical and dental health histories into a single joint access patient history profile. Patients having both medical and dental homes within the health center practice can benefit from both medical and dental providers sharing patient histories and collaborating in health management activities. This is a benefit to dental providers since having access to medical information can shorten patient treatment visits and reduce the need for time-intensive medical history report requests and consultations. Furthermore, combined patient histories make innovative ventures between medical and dental providers more meaningful in “real-time” learning experiences. It also promotes communication across the isolation of departmental and discipline barriers.

89 Chapter 10 • The Dental Director’s Role in Shaping Community, State and National Policy Managing a health center-based dental program can seem like a juggling act at times. The dental director and associate dental providers are caught between the dimensions of: ƒ Concern for patient services and ƒ Concern for the health center’s fiscal health.

Over time, this can lead to frustration and burnout unless the dental leader has a means to express the tensions involved in the split world of caring for the indigent. One effective method to address the tension is through effective advocacy. The disconnect between policy shapers that impact the environment of health center practice and providers of care that experience the tensions within the environment can be enormous. It is very important that policy-makers remain connected to the decisions they make and understand the impact of those decisions. No one else can be more effective in making that case than the front-line dental leader.

When it comes to oral health care, you are the expert!

Being a clinician, manager, advisor, coalition builder, team leader, and advocate can be a real challenge. Many executive directors and administrators fail to see the need for advocacy activities by their dental directors. The intense demand of clinical affairs can leave precious little time to make the critical contacts necessary to be an effective advocate. However, the availability of modern electronic communications like special interests listservs, e-mail, and provider-based web forums and governmental contact web servers make advocacy much easier and less time-consuming than in the past.

Many web and e-mail based communication activities can occur between patient visits and during anesthesia onset. You can send an e-mail message while a patient is getting numb.

Joining selective public health advocacy groups on a local, state and national level can open opportunities to utilize various means of communications. The National Association of Community Health Centers (NACHC) sends out a regular e-mail “Advocacy Alert” for member health center administrators and staff that chooses to join as basic individual members. NACHC also provides up to three complimentary memberships to CHC staff. The Advocacy Alerts allow a member direct access pre-written statements on issues impacting health centers, which they may use in communicating with federal legislators representing their voting district. These letters actually get responses.

Other organizations that provide advocacy alerts include state primary care associations, the American Dental Education Association (ADEA), the American Dental Association (ADA), the Association of State and Territorial Dental Directors (ASTDD), and the National Network for Oral Health Access (NNOHA). State oral health coalitions and public health associations also often have state advocacy listservs (See Appendix G 1-3) with links to state legislators and policy makers.

The key factor is to have a means to express knowledge and concerns to policy-makers who have the power to impact programs.

90 Effective advocacy requires a strategy that includes objectives and collaboration with other individuals and organizations seeking common goals. Table #22 contains an advocacy plan developed by NACHC for health centers, which illustrates components in an effective advocacy plan.

Table 22. 10 Action Steps That Every Health Center Needs to Take

1) Fully Inform Your Board and Key Staff on the Issue – to develop a thorough understanding on the threats facing your health center and what can be done to counter those threats.

2) Designate a Health Center Advocacy Coordinator – to stay on top of developments affecting Medicaid and other vital federal funding, and to marshal the efforts of health center advocates in the fight to preserve these programs .

3) Sign Up Health Center Advocates – this fight will require an army of advocates to make a difference, including board and staff members and active, committed patients.

4) Get Your Board of Directors to Pass a Local Resolution - stressing the importance of Medicaid and Health Center grant funding to your health center’s ability to care for your patients, and pledging to fight to preserve these all-important programs; and Establish a Health Center Board Advocacy Committee - to meet regularly to keep up with the proposed changes in Medicaid or other federal funding proposed by the White House and Congress, and also by your Governor’s office and the state legislature, to organize a plan of action for responding to those proposed changes, and to report to the full board at each meeting on what is happening on this all-important issue.

5) Plan to Attend the Special Medicaid Advocacy Training Session Sponsored by Your PCA - with presentations by NACHC Medicaid experts, and develop a statewide advocacy plan to fight against harmful Medicaid cuts in your state capitol.

6) Schedule a Meeting With Your U.S. House Member, or Get Him/Her to Visit Your Center - prior to January, when he/her will return to Washington for the new Congressional session, and when they do, stress the importance of Medicaid and other federal funding to your health center.

7) Seek an Editorial in Your Local Newspaper(s), or Write a Letter to the Editor(s) - about the importance of Medicaid, not just to your health center, but also to hard-working low-income people, who make up the vast majority of the 50+ million people that Medicaid covers, and to many other providers like local hospitals.

8) Stay in Touch with Your PCA and NACHC – visit the website, www.savethesafetynet.org for more information, and keep NACHC and your PCA informed of developments, events, and efforts that affect the issues at hand.

9) Become or Remain a Full Member of NACHC and of Your State PCA – while membership costs money, your dues payments will be needed more than ever to carry on this fight.

10) Make Plans to Attend P&I Forums in Washington – including at least one board member and at least one of your doctors/clinicians, to visit with your Congressional Representative and Senators to talk about this issue.

91 While much advocacy can be accomplished through electronic means, eventually effective advocacy will require a face-to-face encounter.

Policy-makers may request a health center presence during state legislative hearings and during special committee meetings. Effective advocates may also face appointments to local, state, and national policy review committees and forums. It is vital that health center administrators support these efforts and allow dental directors the time to participate in these opportunities. The dental director’s presence will give additional clout to the health center’s credibility and visibility among policy leaders. Best practice guidelines for successful health center dental programs, as seen in Chapter 2 of the 1988 “Successful Practice” report, contain the following observation:

The dental director should not carry the same clinical load as staff dentists. A dental director devotes a significant amount of time toward administrative duties and has the opportunity for additional administrative training and technical support.

Administrative duties also include an appropriate amount of time for community involvement and advocacy. The lack of community involvement and advocacy, especially in matters pertaining to oral health care, leaves the health center vulnerable to policy drift and unforeseen environmental changes that could threaten future program viability.

Community Partnerships and Collaborations: Effective advocacy and environmental analysis is best accomplished through establishing multi-spectrum collaborations not limited only to oral health providers and general health care practitioners. A good working coalition is a means to obtain information and target resources that will assist in the health center mission to improve health care outcomes and empower the community to meet the needs of the population. The American Association of Territorial Dental Directors (ASTDD) has established a “7-Step Model” for developing needs assessments for the community and establishing successful collaborations and can be viewed in Appendix-H.

The use of coalitions to help develop health center dental program priorities and assess the community’s needs is invaluable for a successful dental clinic program. Having multiple “eyes” or perspectives within the community and a ready community volunteer workforce can assist the dental director in collecting data needed for program planning. An example of a useful organization to have at the collaboration table is the community Head Start program. The combination of home visit follow-up, care coordination, and transportation capacity within many Head Start programs is nearly unequaled in other pre-school and early child-centered community programs. While many dental clinics complain about no-show appointments and poor patient compliance, Head Start-affiliated children are among the most reliable patients and the dental clinic can be assured of parents receiving appropriate instruction on oral health care and follow-up on their children’s needs.

Advocating for change should not be limited to outside concerns that impact health center programs. Dental directors need to take the lead on addressing programmatic policies impacting their dental clinics both inside the health center and among health center support organizations, like state primary care associations (PCAs), NACHC, and HRSA. Policy changes are needed in dental program financial structure to change Perspective Payment System (PPS) reimbursement methods into those that favor quality over quantity. Also, policies are needed to establish more HRSA regional dental consultants who would provide direct technical support to health centers.

92 These are just a few of the challenges that need to be addressed. Only health center dental directors and dental providers can give credible voice to these challenges before policy-makers.

Dental directors in various regions and states should seek to organize as a group and establish a forum within NACHC to address mutual issues and concerns, given the presidential directive to multiply the number of existing health centers across the nation. The plan is robust in scope and seeks to establish health centers as the primary care centers for indigent and underserved populations throughout America given the following facts.

Health Centers: Fulfilling the Pledge The Bush Administration is building on its aggressive efforts to improve the safety net for all Americans. √ The president’s budget completes his five-year commitment to create 1,200 new or expanded sites to serve an additional 6.1 million people by 2006. √ The president’s budget requests $2 billion, a $304 million increase from FY 05, to fund health centers. √ Through FY 06, health centers will deliver care to over 16 million patients at more than 4,000 sites. √ An additional than 2.4 million people will receive health care in 2006 through 578 new or expanded sites in rural and underserved urban communities. √ Health centers deliver preventive and primary care to patients regardless of their ability to pay. √ Nearly 40% of health center patients have no health insurance and 64 % come from racial or ethnic minorities. √ These health centers will serve an estimated 16% of the nation’s population who are at or below 200% of the poverty level. √ Health Centers employ 33% more physicians and dentists than in FY 01.

Health Centers: A New Goal √ In addition, the president has established a new goal to help every poor county in America that lacks a health center and can support one. √ The budget includes $26 million to fund 40 new health centers in high poverty counties.

It becomes all the more critical that health center dental directors start to organize and advocate for the quality of their programs as resources become more scarce. The popular statement, “The early bird gets the worm,” is true when it comes to securing scarce resources. These challenging times demand dental directors to take action.

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