rural health research center s outh c arolina forwarding public oral health with theoretically...

Rural Health Research CenterSouth Carolina

Forwarding Public Oral Health with Theoretically Framed Partnerships, Planning, Programs, and Policies

Amy Brock Martin, DrPHPresentation to Public Health Consortium

October 15. 2013

South CarolinaRural Health Research Center

Who we are…South Carolina Rural Health Research

Center 1 of 7 Rural Health Research Centers

funded by the Health Resources and Services Administration

Administratively located in the Arnold School of Public Health at the University of South Carolina

Mission: to increase knowledge of the persistent inequities in health status among populations of the rural US, with an emphasis on factors related to socioeconomic status, race and ethnicity, and access to healthcare services.


Presentation Overview Introduce South Carolina’s demonstration of the Academic

Health Department Model through the Division of Oral Health (DHEC) and SC Rural Health Research Center (SCRHRC) Guiding principles of partnership Theoretically-driven State Oral Health Plan Collaborative leadership model of SC Oral Health Advisory Council

and Coalition (SCOHACC) Results of AHD Model

Policy & practice achievements ROI (extramural funding) Scientific contributions Epidemiological impact Rural disparities & what we are doing about them


Why Public Oral Health Matters?Oral health disparities hurt everyone!

Martin, AB et al. Dental Health Access to Care Among Rural Children, 2008, included in CD, also available at http://rhr.sph.sc.edu/report/(7-2)%20Dental%20Health%20and%20Access%20to%20Care%20Among%20Rural%20Children.pdf

What are costly diagnoses to your states’ Medicaid programs?Those who come early…Preemies

Huck O, Tenenbaum H, Davideau JL. Relationship between periodontal diseases and preterm birth: recent epidemiological and biological data. Journal of Pregnancy, 2011, Article ID 164654.

Those who live long…Dementia/Alzheimer’sManczak M, Reddy, PH. Abnormal interaction of oliomeric amyloid-beta with

phosphorylated tau: Implications to synaptic disyfunction and neuronal damage. Journal of Alzheimer's Disease 36(2), 2013, DOI:10.3233/JAD-130275.

Those who with chronic disease…Diabetes & Cardiovascular DiseaseLeite RS, Marlow NM, Fernandes JK. Oral health and type 2 diabetes. American

Journal of Medical Science. 2013 Apr;245(4):271-3.


Dental Health Professional Shortage Areas, 2012


Persistent Whole County Dental Health Professional Shortage Areas, 2009 - 2012


Why Care About Safety Net Populations?


IOM Academic Health Department IOM called for agency/academic partnerships to ensure the

effectiveness of public health in 1988 and 2003. What is it?

According to ASPH, it is a “partnership between a school of public health (SPH) and a health department to create a dynamic academic-practice collaboration, which effectively pools assets of both institutions.”http://www.asph.org/UserFiles/AcademicHealthDepartments.pdf

HRSA determined poor responses by SPH & agencies to IOM call to action in 2005.


South Carolina’s SOHP Proof of Concept

DHEC and SCRHRC began partnership in 2006, facilitated by CDC Cooperative Agreement, Strengthen State Oral Disease Prevention Programs.

$15K contract codified relationship, which has leveraged $5.2 million in oral health grants and programs (excludes national research grants)

State Oral Health Plan (SOHP) as catalyst A collaborative leadership model with

SCOHACC used to develop 5-year SOHP PRECEDE-PROCEED was used to

facilitate the SOHP.


Health

Behavior & lifestyle

Environment

Predisposing Factors

Reinforcing Factors

Enabling Factors

Health Promotion

Health Education

Policy Regulation

Organization

Quality of Life

Phase 6Program

Implementation

Phase 7Process Evaluation

Phase 8Impact Evaluation

Phase 9Outcome Evaluation

Phase 5Administrative &

Policy Assessment

Phase 4Educational &

Ecological Assessment

Phase 3 Behavioral &

Environmental Assessment

Phase 2Epidemiological

Assessment

Phase 1 Social

Assessment

SOHP GENERAL THEORETICAL FRAMEWORK (Green and Kreuter, 1999)


Phase 6Program

Implementation

Phase 7Process Evaluation

Phase 8Impact Evaluation

Phase 9Outcome Evaluation

Phase 5Administrative &

Policy Assessment

Phase 4Educational &

Ecological Assessment

Phase 3 Behavioral &

Environmental Assessment

Phase 2Epidemiological

Assessment

Phase 1 Social

Assessment

SOHP GENERAL THEORETICAL FRAMEWORK (Green and Kreuter, 1999)

Improved oral health status of South Carolina

citizenry

•Changes in oral health behavior, knowledge & values

•Fluoridated Water•Educated, Strategic Dental Workforce•Public oral health infrastructure

•Workforce with public health competencies•Infrastructure & resources for change•Targeted outreach

•Workforce recruitment & incentive programs•Public demand for oral health improvements

•Availability of workforce & educators•Ability to pay for dental care•Political will for change

•Surveillance program•Interventions for special populations & chronic diseases

•Social marketing•Educational materials

•Effective Advisory Council & Coalition•Committed public leadership

Improved Quality of LifeFor All of SC


Partnership Guiding Principles Funding opportunities should not drive the mission of DOH or

SCOHACC Remain focused on SOHP goals and objectives to avoid mission

creep Disseminate lessons learned through peer-reviewed venues Focus on consensus building Small funding opportunities should be used for credibility-

building efforts that can be leveraged into larger, innovative grants

Respect partners’ expectations e.g. academic needs for scholarly output, DHEC needs for

epidemiological impact


Summary of Policy & Practice Achievements since 2006

Act 235 Pew Rankings Congressional testimony NCSL Presentation OB guidelines School nurse dental screenings Community water fluoridation advocacy

training Oral health integrated into Dept. of Ed.

Health and Safety Standards Early childhood guidelines Fluoride varnish reimbursement policy

(Medicaid) AAPD/Head Start Dental Home

Leadership State


Extramural Funding ($5,220,000)

Grant Funding Amount Time Period Grantee

CDC State Infrastructure

$1.5 million 2013-18 DHEC

HRSA Oral Health Workforce

$1.5 million 2012-15 USC

DentaQuest Foundation

$300,000 2012-14 USC

DQF Planning $100,000 2011-12 USC

CDC State Infrastructure

$1.75 million 2008-2013 DHEC

Head Start Dental Home

$10,000 2009-10 DHEC

ADA School Nurse Study

$50,000 2009 USC

ASTDD – Head Start Study

$2,500 2007 DHEC

ASTDD – CSHCN Study

$7,500 2006 & 2008 DHEC


Results:Scientific Contributions

Presented 12 posters and conducted 5 invited oral presentations at state and national conferences (APHA, Academy Health, Academy for Health Equity, NOHC, AAP, SCRHA, James E. Clyburn Health Disparities Lecture)

Published 2 manuscripts in peer-reviewed journals (Maternal & Child Health Journal and Pediatric Dentistry) with 1 in development and 1 in R&R (APHA & Public Health Dentistry).

Influenced 3 national studies funded through the core RHRC grant: National Rural Children’s Oral Health Disparities Chartbook (2008) State Policy Levers for Addressing Preventive dental Care Disparities

for Rural Children (2012) Dental Sealant Utilization Among Rural and Urban Children (2013)


OHNA Summary Results for 2012/2013Percent of Children by Indicator*

Weighted analysis for public schools in K and 3rd grade. Sealants only include children in 3rd grade.


Results: Epidemiology Impact


Percent of Caries Experiences by Race/Ethnicity

2007* (p<0.0001 for race; ethnicity not calculated due to low observations)2012* (p<0.0001 for race; p=0.01 for ethnicity)


Percent of Caries Experiences by Medicaid Member Status

20072012* (p<0.0001)


Percent of Caries Experiences by Free & Reduced Lunch Participation

2007* & 2012* (p<0.0001)


Percent of Caries Experiences by Rural vs. Urban School

2007* (p<0.0001)2012* (p=0.048)


Percent of Sealants by Race/Ethnicity

2007 (no race differences; not calculated for ethnicity due to low observations)2012* (no race differences; p=0.022 for ethnicity)


Percent of Sealants by Medicaid Member Status

2007* (p<0.0001)2012 No differences


Percent of Sealants by Free & Reduced Lunch Participation

2007 & 2012 (No differences)


Percent of Sealants by Rural vs. Urban School

2007 & 2012 (No differences)


Percent of Untreated Caries by Race/Ethnicity

2007* (p<0.0001 for race; not calculated for ethnicity due to low observations)2012* (No differences for race or ethnicity)


Percent of Untreated Caries by Medicaid Member Status

2007 (No differences)2012 (p=0.007)


Percent of Untreated Caries by Free & Reduced Lunch Participation

2007* (p<0.0001)2012 (No differences)


Percent of Untreated Caries by Rural vs. Urban School

2007* (p<0.0001)2012* (p=0.007)


Percent of Tx Urgency 1 by Race/Ethnicity



Percent of Tx Urgency 2 by Race/Ethnicity



Percent of Tx Urgency 1 and 2 by Medicaid Member Status

2007 (No differences)2012 (p=0.0111)


Percent of Tx Urgency 1 and 2 by Free & Reduced Lunch Participation

2007 (p<0.0001)2012 (No differences)


Percent of Tx Urgency 1 and 2 by Rural vs. Urban

2007 (p<0.0001)2012 (p=0.0083)


OHNA Takeaways…how do we see the glass?Half Full Caries experience has

declined but disparities continue to exist

Untreated caries & Tx urgencies drop is sizeable race, ethnicity, and F&RL

disparities disappear! Tx Urgency 2 is nearly

eliminated

Half Empty Sealants improve a little

with lots left to do Rural disparities remain

throughout the indicators, except sealants


Addressing the rural disparities….


South Carolina Act 235 (2010)

Created the Community Oral Health Coordinator program (COHC) within DHEC. work with school nurses in a targeted community program to improve dental health in the state’s

public schools. operate in three to five counties identified as dental health professional shortage areas. The

program will provide dental health education, screening, and treatment referral for public school students in kindergarten, third, seventh, and tenth grades; or upon entry into a South Carolina school.

provide community oral health education and training coordinate transportation and other non-clinical support to patients and their families link dentists who provide Medicaid services or would provide free or reduced-cost care to children

identified by the screening that do not have a dental home help ensure that parents understand the importance of not missing appointments and the need

for follow-up care provide a connection people in local communities with the tools they need to improve oral health NO FUNDING APPROPRIATED!


HRSA Oral Health Workforce Grant

Teledentistry feasibility study N=387 (21.5% response rate)

COHC Training Center Community Water Fluoridation Advocacy Rural Safety Net Expansion


“Perfect Storm” of Opportunity

1. Oral Health 2014 Planning Grant – Sustainability Workgroup

2. MIECHV Grant

3. HRSA Oral Health Workforce Grant


Oral Health 2014 – DentaQuest Foundation

System-Level Goals To increase the number of dentists who see children

aged 0 to 3 years To increase the number of physicians who apply

fluoride varnish To integrate community oral health coordination into

the SC Maternal, Infant, and Early Childhood Home

Visitation program Increase the knowledge of early childhood oral health

needs among the aforementioned providers using

Smiles for Life Increase the knowledge of COHC techniques among

existing care coordinators in community systems, e.g.

WIC, BabyNet, FQHCs etc.

Person-Level Goals Increase in the number of children aged 0

to 3 years with preventive dental services Increase in the number of children

receiving fluoride varnish from their

medical home Decrease in early childhood caries-

related treatment Increase parents’ perceived value of oral

health services of children aged 0 to 3


How does DQF ‘ask’ align with the SOHP? PRECEDE-PROCEED

Health

Behavior & lifestyle

Environment

Predisposing Factors

Reinforcing Factors

Enabling Factors

Health Promotion

Health Education

Policy Regulation

Organization

Quality of Life

Improved oral health for kids 0-3

Access to fluoridated water & affordable, high quality oral health services

Improved appropriate use of preventive oral health services

Local fluoridation advocacy teams; adequate care capacity for 0-3

Parents engaged in care & behaviors; med/dental interconnected

Parents, MDs, & DMDs value oral health services for 0-3

Engaged Stakeholder Collaboratives;COHC through MIECHV

Safety Net EdCOHC CtrFlu advocacy

DMD visit by 1; risk-based varnish received

Organized in the ‘Early Childhood’ Chapter


How does our DQF ‘ask’ align with Medicaid priorities? Triple Aim Model

Achievement of Triple Aim is contingent upon the following conditions:1. Focus on a specific population2. Consistency in approach/care for the specified population3. Use of an organization (an “integrator”) that accepts responsibility for all three aims for that population. Berwick et al states the integrator’s role includes at least five components:

• partnership with individuals and families,• redesign of primary care, (in our case, oral) • population health management,• financial management, and • macro system integration.

Improved population health: •Reduction in early childhood caries

Improved care experience: •DMD visit by age 1 with annual visits thereafter•Receipt of risk-based fluoride varnish

Decreased per capita costs:

•Increased overall savings to Medicaid due to increase in preventive service utilization

Source: Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, and Cost. Health Aff. May 2008. 27(3):759-69.


Unanticipated Benefit

Public Health Leadership Development Martin obtains public oral health practice

experience Former DOH Director (Veschusio) obtains technical

training by entering the HSPM DrPH program We have trained 7 graduate students with DOH

through public health practica and graduate assistantships.

Valeria Carlson (HPEB) works for CDC Gerta Ayers (HSPM) works for DOH and is currently

interim director


Summary – Facilitators of Success

Deliberate (usually) delivers! Theoretically-driven strategic plan Mutually agreed upon guiding principles and

expectations Data-driven solutions Leadership development


Contact information

Amy Brock Martin, [email protected]

SC Rural Health Research Center220 Stoneridge Drive, Suite 204Columbia, SC 29201803-251-6317 (telephone)http://rhr.sph.sc.edu

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