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Innovations in Oral Health Care for

People Living with HIV/AIDS

Speakers:Sara S. Bachman, Ph.D., Jane Fox, MPH, David Reznik, DDS, Carol Tobias, MMHS

Guest Editors of the May/June 2012 PHR Special Supplement on Innovations in Oral Health Care for People Living with HIV/AIDS

Moderator: CDR Mahyar Mofidi, Ph.D., DMD

Public Health Reports Special SupplementInnovations in Oral Health Care for

People Living with HIV/AIDS

Webinar Learning Objectives

• Present findings from the Special Projects of National Significance (SPNS) Innovations in Oral Health Care Initiative.

• Describe ways to improve access to oral health care and associated outcomes for people living with HIV.

• Discuss ways innovative strategies can be applied to other vulnerable populations.

• Fills research gaps related to oral health care for people living with HIV/AIDS.

• Special supplement to Public Health Reports presenting findings from the Special Projects of National Significance Innovations in Oral Health Care Initiative.

• The Oral Health Initiative encompassed 15 sites from around the country, about half in urban and half in rural communities.

• Results show innovative program models can engage and retain people who are living with HIV/AIDS into oral health-care.

• Articles in this special issue represent the most comprehensive additions to the body of knowledge about oral health care for people living with HIV/AIDS in a decade.

Innovations in Oral Health Care for People Living with HIV/AIDS

The Initiative and Evaluation at a Glance

• The purpose of the Oral Health Care Initiative was to develop and implement innovative models of oral health care.

• The multi-site evaluation was conducted by the Health and Disability Working Group at the Boston University School of Public Health.

• Goals of the Evaluation Center included:– Help sites improve access and adherence to high quality oral health

care for underserved populations.– Implement a mixed methods multi-site evaluation of the

demonstration projects.– Assist grantees in implementing both the multi-site evaluation and

their local evaluations.– Disseminate findings to a broad range of audiences including oral

health care providers, medical care providers, consumers and policy makers.

Evaluation Questions

• Do the demonstration programs increase access to oral health care for the target population?

• What are the main similarities and differences in strategies and program models to increase access to oral health care across programs?

• Are the oral health services performed in accordance with professional practice guidelines?

• Do clients experience improvements in health outcomes over time?• Are clients’ oral health care needs met?• Do clients experience improvements in oral health related quality of life

after enrollment in oral health care?• What strategies are most effective in furthering successful program

implementation: barriers, facilitators, key lessons learned?• What strategies to address the structural, policy and financing issues

can be replicated in other settings?

In this Webinar we will….

• Provide a brief overview of key results of the multi-site evaluation

• Highlight innovative practices• Describe lessons learned about sustainability

and financing • Identify applications to other vulnerable

populations

Study Sample Demographics (N=2469)

• 75% male• 40.3% black, 21.4% Latino• 32.8 % high school

education, 42.0% beyond high school

• 30.7% working • 54.4% monthly income

< $850• Mean age: 43.6 (18 – 81), • Years positive: 9.54

3%

12%

35%29%

21%

Last dental visit

Never

< 12 months

1 - 2 yrs

2 - 5 yrs

>5 yrs

Sample Baseline Characteristics

Prior Dental Care • Usual place for dental

care: 37.6% none; 30.4% private dentist

• 48.5% reported needing dental care since testing HIV+ but were unable to access it

• Of those who could not access dental care, 64.4% stated cost/affordability as the reason

Prior HIV Care• 97.3% reported a regular

place for HIV care and 95.5% had seen their HIV provider in the past 6 months

• 84.6% had an HIV case manager and 77.4% were taking ARTs

• 57.35% had a CD4 count over 350 and 44.2% had an undectable viral load

Increasing Access to Oral Health Care

By the end of the study:• Patients made over

15,000 clinic visits• They received over

37,000 services• 917 (42%)

completed a Phase 1 treatment plan

In the first 12months of oral health care # provided

Patients who received any

service n %

Clinic Visits 11,315 2178 100%

Phase 1 Treatment Plans Completed*

717 717 33%

Comprehensive Exams

2077 1944 89%

*Phase 1 Treatment Plan = Prevent and treat active disease

Program Models and Interventions

• Program models – AIDS service organizations– Hospital–based programs– Community Health Centers

• Interventions– Expansion of clinic space and/or services– Dental case management–Mobile dental units

Patient Perspectives on Innovation Impact

• Reasons for retention in oral health care– Staff and environment– HIV knowledgeable dentist– Dental case manager– Maintaining oral and overall health

• Impact of participation in oral health– Improved awareness about HIV health and oral health– Better oral health hygiene practices– Improved self-esteem and appearance

Innovative PracticesThe Rural Alliance

• Partnerships– HIV Alliance– Community Health Centers of Lane County– Lane Community College

• Service Delivery– Sites– Transportation– Staffing

• Dental hygiene students, dental assisting students, hygiene faculty, dentists, denturist, and a dental case manager.

Lessons learned about sustainability/financingMedicaid Adult Benefits

• Medicaid is a major source of health-care coverage, including oral health care, for PLWHA.

• Comprehensive adult dental coverage under Medicaid is only available in approximately 20% of states.

• More than half of the states offer emergency or highly restricted dental services only.

• Medicaid programs that offer some oral health benefits may not provide adequate coverage to eliminate oral disease.

Lessons learned about sustainability/financingMedicaid Adult Benefits

• Medicaid coverage for adult dental services has often been the victim of budgetary cuts during periods of fiscal retrenchment.

• A fiscal year 2010 survey of Medicaid programs reported a reduction in Medicaid adult dental benefits in 20 states, more than in any year in the past decade; 14 states planned to reduce benefits in FY 2012.

Limits of dental coverage for people living with HIV Medicaid Adult Benefits

• Most people with HIV who qualify for Medicaid do so by meeting the program’s income and disability standards. However, many PLWHA may not gain Medicaid coverage until their illness progresses to the point that they are determined to be eligible as a result of disability.

• Presently, 68% of PLWHA have incomes below 100% of the federal poverty level, yet only 34% qualify for Medicaid.

• Implementation of the Medicaid expansion contained in the Patient Protection and Affordable Care Act (ACA) would cover adults within 133% of the Federal Poverty Limit and would greatly benefit PLWHA.

• However, adult dental care is presently not included in the Medicaid expansion.

Lessons learned about sustainability/financingRyan White HIV/AIDS Programs

• The Ryan White HIV/AIDS program, administered by the Health Resources and Services Administration, is the third largest public financing program for HIV/AIDS care after Medicaid and Medicare.Of note: Medicare does not offer a dental benefit but does reimburse for oral pathology services including biopsies and destruction/removal of lesions (e.g. oral condylomas).

• Grants from the Ryan White program provide funds that function as a “payer of last resort” for more than 500,000 uninsured or underinsured people each year. The majority of these recipients live below the federal poverty level and are ethnic and racial minorities.

Lessons learned about sustainability/financingRyan White HIV/AIDS Programs

• The Ryan White program funds HIV-related health care and services through multiple grant opportunities called Parts.– Part A funds are awarded to eligible metropolitan areas

that are disproportionately affected by HIV/AIDS– Part B funds are awarded to States– Part C and Part D funds target primary care providers in the

community such as hospitals or community health centers. – Part F funds healthcare educational programs including the

Dental Reimbursement Program, the Community-Based Dental Partnership Program, AIDS Education and Training Center and the Special Projects of National Significance program.

Lessons learned about sustainability/financingRyan White HIV/AIDS Programs

• 75% of funding in Parts A, B and C must be spent on Core Services:– Primary Care– Medications– Oral Health Care– Mental Health Care– Substance Abuse Services– Medical case management/treatment adherence counseling

• Other services such as food, transportation, peer counseling, translation, etc. are considered support services

Program Sustainability

• Sustainability depends on several factors:– Medicaid dental coverage in the state– Leveraging multiple Ryan White Program funding

sources to sustain the delivery of care. – Applying for foundation grants and other sources

of funding outside of the Ryan White Program.– Leadership

• AIDS Service organization• Dental providers

Sustainability: An Example

• HIV Alliance in Oregon– The SPNS Oral Health Initiative helped the

program establish a dental clinic and hire a project coordinator.

– The Ryan White Dental Reimbursement Program (Part F) created an ongoing source of revenue for oral health services.

– Part B funding will fund the dental case manager, cover denture costs, and pay for transportation.

– Foundation grants to cover additional costs.

Sustainability: An Example

• Tenderloin Health Care– The SPNS Oral Health Initiative was instrumental in

establishing dental operatories in the same facility where clients received their HIV care.

– The Dental Director of the San Francisco Department of Health, Dr. Avi Nath, successfully applied for Part A funds to sustain the program once SPNS funding ended.

– Working with the University of California at San Francisco (UCSF) Dental School’s General Practice Residency Program (to manage some surgeries, endodontics and dentures) allowed UCSF the ability to apply for Part F Dental Reimbursement funds to help defray the costs.

Application to other vulnerable populations

• People with HIV, seniors, adults with disabilities are living longer:– More people, more teeth and more complex oral health care needs

• Self-perception of dental health is poor1 • 50% of seniors say their teeth are poor or very poor• Poor oral health is associated with weight loss, failure to thrive,

pneumonia

• Oral health remains a much greater need – more so than general health care2

1www.smilesforlifeoralhealth.org2 The national survey of children with special health care needs chartbook 2005-2006. Rockville, Maryland: DHHS 2007.

Similar Barriers to Care

Overall access barriers30-50% of adults with

disabilities have significant barriers to

dental care3

Only 43% of seniors visit the dentist in a year1

Financial barriers 70% of seniors lack dental insurance1

Adults with disabilities are twice as likely to

forgo dental care for cost reasons4

Other barriers Transportation Finding a dentist who will treat them

3 Drainoni M, Lee-Hood E, Tobias C, Bachman SS, Andrew J, Maisels L. Cross-disability experiences of barriers to health-care access. Journal of Disability Policy Studies Fall 2006 Fall 2006;17(2):101-15.4Rapalo DM, Davis JL, Burtner P, Bouldin ED. Cost as a barrier to dental care among people with disabilities: A report from the florida behavioral risk factor surveillance system. Spec Care Dentist 2010 Jul-Aug;30(4):133-9.

Care Facilitators

Dental provider education

Outreach and transportation to services

Care coordination, systems navigation, appt. follow up

Service integration with medical care and social services

Patient education

Outcomes beneficial for other vulnerable populations

Eliminate pain and infection

Improve overall oral health

Engage-ment in preventive care

Improving self-esteem

Interpro-fessional team

building

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