Community Oriented Primary CareDental Services

October 18, 2011

Avantika Nath, BDS, DDS - Director of Dental Services, COPC

Community Programs: COPC Administration

OutlineI. Scope of Services

II. School Based Prevention Programs

III. Patient Visits & Demographic Data

IV. Special Programs

a) HIV Health Services

b) Give Kids a Smile Day

c) Project Homeless Connect

V. Staff

VI. Challenges

SFDPH Community Oriented Primary Care Dental Services Provided at:1) CPHC

2) SAFHC

3) SEHC

4) PHHC

5) TWHC + offsite Tenderloin Health

6) SPY

Castro Mission Health Center (CMHC)

(4) Potrero Hill Health Center (PHHC)

(2)(2) Silver Avenue Family Health Center (SAFHC)

(3)(3) Southeast Health Center (SEHC)

(5)(5) Tom Waddell Health Center (TWHC)

(1)(1) Chinatown Public Health Center (CPHC)

Ocean Park Health Center (OPHC)

Maxine Hall Health Center (MHHC)

Housing & Urban Health Clinic (HUHC)

Curry Senior Center

Community Oriented Primary Care Administration

CHPY Cole Street Clinic

CHPY Hip Hop to Health Clinic

CHPY Balboa Teen Health Center

CHPY Hawkins Clinic

CHPY Larkin Street Clinic

Medical Respite and Sobering Center (Fell St)

(6)(6) Special Programs for Youth (SPY)

Medical Respite and Sobering Center (Polk St)

San Francisco General Hospital Campus Clinics (SFGH PC)

Priority

Kids

Pregnant women

People Living with HIV/AIDS (PLWH/A)

Homeless Population

SPY

Adults Triage Services

Scope of ServicesClinic Services Provided

Dental Services are offered to the low income, under/uninsured people of SF by COPC, DPH.  Priority populations receiving care:• Kids (0‐19 years)‐ DentiCal, HK/HF initiative• Pregnant women‐DentiCal, HF/HK• Diagnostic, preventive and basic restorative dental services for infants, children, 

adolescents and pregnant women. In the past Denti‐Cal ( part of MediCal)  was the primary source of revenue generation for services rendered by COPC.Since July 2009, Denti‐Cal cuts from the state whereby they only cover triage services for indigent Adults (extractions and emergency exams),  has made it necessary for us to provide only emergency services for Adults.The Homeless dental services are supported by general fund and in a small part by the McKinney grant.  The HIV clinic is supported in part by the Tenderloin Health Oral Health Collaboration (ended Aug 2011) and the HIV Health Services Grant (from the SF AIDS Office).  The SPY services are supported by general fund.  The dental clinics in the health centers are supported by general fund.  The School based Kindergarten screening and sealant programs are supported by general fund.  Healthy SF ‐ the medical insurance plan for the low imcome populations in the city does not cover dental services.

I. Scope of Services

Clinical Services Provided:• Oral examinations, X‐rays and diagnosis • Oral hygiene instructions• Prophylaxis (cleaning), fluoride • Periodontal scaling and root planing• Permanent  and temporary fillings• Endodontics; root canals anterior (front) teeth only• Pulpotomy• Uncomplicated extractions, minor tissue surgery and excisions• Emergency care: Services necessary to relieve or control acute oral conditions, ie: 

pain, inflammation, infection, bleeding, trauma, etc.Clinical Services not provided:• Orthodontics (braces) • Cosmetic dentistry (bleaching, veneers)• Treatment of advanced periodontal conditions • Complicated extractions or impactions • Nitrous oxide analgesia and sedation• Surgical endodontics, root canals posterior (back) teeth• Prosthetics (dentures, partials, crowns, bridges)

Other SFDPH Dental Services include: providing and updating oral health education materials; providing educational trainings to health care students and professionals on oral health; developing innovative programs to increase access to dental care, and seeking policy changes to help increase access to dental care.

• Potrero Hill Health Center Dental Clinic (adults, infants, children, adolescents and pregnant women)

• Southeast Health Center Dental Clinic (adults, infants, children, adolescents and pregnant women)

• Silver Ave. Family Health Center Dental Clinic (infants, children, adolescents and pregnant women)

• Chinatown Public Health Center (infants, children, adolescents and pregnant women)

• Tenderloin Health Center (HIV services)• Tom Waddell Health Center (Homeless/HIV services)

COPC Dental Clinics

Kindergarten Dental Screening Surveillance Program

One of the three public health core function is Assessment through monitoring health status to identify community health problems. The Kindergarten Dental Screening Program is the Department’s primary oral health surveillance activity.  This program is a collaborative between the San Francisco Department of Public Health (SFDPH), San Francisco Dental Society (SFDS) and the San Francisco Unified School District (SFUSD) which provides a yearly oral health assessment to every kindergartener enrolled in the SFUSD.  

The program was created:• To monitor and identify disease trends over time (level and demographic distribution)• To provide data to develop and target appropriate interventions and resources• To mobilize community partnerships to identify and solve oral health problems• To develop policies and plans that support individual and community health• To research for new insights and innovative solutions• To demonstrate that public‐private partnership can improve health outcomes• To assist children into a dental home – a place where he or she receives continuous, 

comprehensive, coordinated and culturally competent oral health care

II. School Based Prevention Programs

Since its inception during the 2000 school year, over 40,000 children have received an oral health assessment, the results of the assessment and information on insurance and dental care resources.  

The San Francisco program was one of the models used to support the development of Education Code Section 49452.8, legislation passed in passed in 2005 as AB 1433, which requires public school children to have their oral health assessed by a licensed dental professional (dentist or dental hygienist) by May 31 of their first year of school.  

During the 2010/2011 school year:• 4,274 children received a dental screening in 72 schools.  • 22% had one or more actively decayed teeth (untreated caries) • 41% had experienced decay (treated and/or untreated caries)  

Over the last ten years we have observed a 17% decrease in the percentage of SFUSD Kindergarteners with untreated caries.  Comparing these results to national data is difficult because there is no exact national comparison.  The closest may be the National Healthy People 2010 objectives for children ages 6‐8.  We have almost reached the Healthy People 2010 objective of no more than 21% of 6‐8 year old children with untreated caries (22%).  We have surpassed the National Healthy People 2010 target of 42% for caries experience in 6‐8 year olds (41%). 

Kindergarten Dental Screening Surveillance Program, continued

There are multiple factors that may contribute to these improvements including:

• Community water fluoridation• San Francisco’s commitment to fund universal health care including dental services 

for children through the Healthy Kids program• Small but significant number of private practice dentists accepting public insurance 

plans and willing to treat children ages 0‐5 and two dental schools for advanced specialty care

• Priority of safety‐net dental providers (including SFDPH Dental Services) to see children ages 0‐5 

• Various programs, collaborations and initiatives between SFDPH Dental Services and other DPH departments and community partners which provide case management, training of Pediatrics and Family Medicine residents on early childhood oral health, perinatal oral health services and pre‐school/Head Start screenings

Kindergarten Dental Screening Surveillance Program, continued

In 2007 the CDC’s Task Force on Community Preventive Services released a report strongly recommending two community‐based interventions to prevent tooth decay—community water fluoridation and school dental sealant programs.

Dental sealants are a highly effective thin plastic coating painted on the chewing surfaces of the back teeth to seal out and prevent tooth decay.  Although highly effective, national and state data show sealants are generally underutilized on children with both public and private dental insurance coverage.  School‐based programs provide pit and fissure dental sealants to the permanent teeth of children in a school setting and generally target vulnerable populations less likely to receive dental care such as children eligible for free and reduced lunch programs. 

Our dental sealant program, Seal San Francisco, is a school‐based dental disease prevention program targeting second graders which: • Helps to eliminate barriers that contribute to health disparities• Prioritizes disease prevention and health promotion• Provides oral health services in a non‐traditional setting• Follows public health population‐based principles

Seal San Francisco, Dental Sealant Program

Seal San Francisco began in 1997 as a pilot program and grew with the help of a grant from the Dental Health Foundation.  Mobile dental equipment is utilized to create a temporary “clinic” in the school.  Approximately 12‐14 schools are served per year.  

For the 2010‐2011 school year:• 917 children in grades 1‐5 were screened • 783 children received dental sealants

Seal San Francisco, Dental Sealant Program, continued

page, 14

III. Patient Visits and Demographic Data• Total Visits • Patient Demographics

– Age distribution– Age shift: 2008/2009 to 2010/2011– Adult visit distribution– Increase in visits: pregnant women– Dental visits by Payor source

• Dental Payor Sources FY 10/11

page, 15

Total Visits

HC FY08/09 FY09/10 FY10/11

SAFHC 1,897 1,905 2,454CPHC 1,566 1,675 1,913

YGC 743 607 419

SEHC 1,784 1,777 1,813

PHHC 1,742 1,378 1,167

TWHC 665 589 843

TLH 318 573 823TOTAL: 8,715 8,504 9,432

page, 16

Patient Demographics: Age Distribution

Age FY08/09 FY10/11

Total % Total %0-5 1,237 17.0% 1,666 17.7%

6-11 1,208 16.5% 1,912 20.3%

12-17 1,538 21.1% 1,789 18.9%

18+ 3,316 45.4% 4,065 43.1%

Age Shift: 2008/2009 to 2010/2011

page, 17

Adult Visit Distribution

Age FY08/09 FY10/11

Total % Total %

18+ 3,316 4,065

Pregnant 396 12% 917 22.5%

Non-pregnant 2,920 88% 3,074 77.5%

Increase in Visits: Pregnant women

page, 19

page, 20

Patient Demographics: Dental Visits By Payor Source

FY08/09 FY09/10 FY10/11

Denti-Cal 3,769 4,658 5,320Private Insurance 56 33 32GA 16 0 1CHDP (children) 89 218 339Sliding Scale (adult, preg) 547 702 770Self Pay 76 80 28Healthy Families 439 465 417Healthy Kids 406 328 306Healthy San Francisco 931 1254 1,468

Dental Payor Sources FY 10-11

page, 21

IV. Special Programs:Service Grant with Research Component:1) Special project of National Significance – Oral Health

Collaborative – details in presentation2) HIV Health Services Grant for providing Oral Health Care to

PLWH/A, from SF Aids Office.Funding: $400,000 over 3 yearsGoals: Improve Access to Oral Health Care to PLWH/A who are under/uninsured, homeless or marginally housed, with high prevalence of medical & psychosocial and co-morbidities.Innovative Approach: Use of extensive outreach and referral bases- Establishment of Dental Case Management- Holding focus groups to provide Oral hygiene and Oral

Health education- Affiliation agreement with UCSF, GPR program to

provide specialty services

“Give Kids a Smile Day”2011 Give Kids a Smile Day Events at Southeast HC and SFGH

Southeast Heath Center ‐ Feb. 4, 2011 SFGH WIC ‐ Feb. 10, 2011Total Seen:   67  Total seen: 136We screened 67 kids at SEHC All received FV  

Heard about event from:WIC – 71, Flyer – 18, Homeless Prenatal – 5, School – 15, Hospital/clinic – 10

75% from WIC, 4% Homeless Prenatal, 13% school, 8% hospital/clinic

Ages: Class 1: 87 44% with decay0‐5: 104 Class 2: 26 50% previous DDS5‐10: 21 Class 3: 12 124 children received FV at SFGH 10‐20: 3

SF DPH participated in a nationwide effort to highlight the need to establish a dental home, on February 4, & 10, 2011, called Give Kids a Smile Day.  We targeted our low‐income SF children ages 0‐5years old, and advertised to the WIC sites, preschools and SFGH.   Partnering with SFSU School of Nursing and the SF Dental Hygiene Society, we were able to provide not only dental screenings, exams, cleanings, and fluoride varnish, but also education for the parents, homecare toothbrushes and supplies, and healthy snacks.   We also followed up the event with calls to parents to support them in making a dental appt. for their children.

Project Homeless Connect

Since 2007, COPC Dental Services has been a key partner with PHC in bringing necessary services to the homeless.Dental care is one of top unmet needs of the homeless population. COPC partners with San Francisco Dental Society volunteers, UCSF and the University of Pacific School of Dentistry to provide comprehensive dental services for the homeless San Franciscans. It truly reflects a best practice model for collaboration. On any given PHC event, we provide screening to an average 165 patients and provide treatment to 98-100 patients.

We continue to reshape our outreach strategy and improve available services.

Community Based Dental Partnerships

- San Francisco Dental Society

- San Francisco Dental Hygiene Society

- San Francisco Unified School District

- UCSF, General Practice Residency Program (GPR)

- Western University, Pomona

- Arthur A. Dugoni School of Dentistry, UOP

- SF VA Medical Center

V. Licensed Staff:

- Dentist 10- Dental Hygienist 2- Dental Aide 11

Demand for dental services is high for all segments of the population, but is increasing for low-income populations. The loss of most Denti-Cal adult dental benefits in 2009 and private and public sector job losses with concurrent loss of private dental insurance is further taxing our already fragile dental safety-net system.

The ongoing challenge for SFDPH Prevention Programs is to carry out our key public health surveillance functions and population-based programs to maintain and/or surpass gains made in oral health status for children given the current fiscal environment. Each year an Americorps member full-time position is hired to assist in managing the Prevention Program infrastructure and data at minimal cost. Strong relationships with the local private practice dental community, other dental safety-net providers and the school district have been forged. Quarterly meetings are attended with organizations tied to children’s dental health to exchange ideas, ensure minimal duplicated efforts, share resources and assist in providing services that perhaps one organization is unable to provide alone.

VI. Challenges

A focus on prevention, education, early detection, community partnerships, accessibility to quality population-based services and establishing a dental home early in life are key to maintaining and improving the oral health status of the populations we serve.

Challenges moving forward:

• Access to Oral Health Care limited due to multiple barriers

• Public Health Services poorly reimbursed

• Reliance on the General Fund

• Enhancing Quality of Care and cost-effective care

• Unknown impact of HealthCare Reform

• Conversion to new EMR

VI. Challenges, continued